There is no method to the madness of Maryland Medicaid

August 31, 2011

Gene Ransom, CEO of the Maryland State Medical Society, writes in his article to the Sun ("Don't cut services first," Aug 29) that thousands of vulnerable Marylanders stand to receive inadequate, substandard health care for years to come if the state's Medicaid Advisory Committee and the Department of Health and Mental Hygiene are forced to implement a series of radical cost cutting measures for the state's Medicaid program. According to Mr. Ransom, proposals on the desk include eliminating the kidney disease program, charging co-pays for emergency room visits and placing limits on outpatient hospital visits.

What Mr. Ransom does not mention is that thousands of poor Marylanders are already receiving substandard, inadequate care. The state has placed a lot of Marylanders, sick with dire ailments, on the PAC program, where they are not allowed to see specialists and are allowed only to have limited lab tests and investigations. One of my patients with severe insulin dependent diabetes, sarcoidosis, adrenal gland failure, sleep apnea and other problems, for whom specialist care was vital, was suddenly switched to the PAC program from regular medical assistance. Regular medical assistance was bad enough, but when this switch happened, I had to play along, give him a type of insulin to which he was not accustomed, beg for samples of medicines for him from pharmaceutical representatives, and write so many letters on his behalf to inane Maryland Medicaid, telling them he was total misfit for the program to which he had been designated.

Although this patient was ultimately assigned to the right program, things did not go that well for others. One of my Type 1 diabetics quit taking insulin on the PAC program and stopped seeing me, his diabetologist, who actually got him on the road to better regulation and control of his rather recalcitrant blood sugars.

There is no method to the madness of Maryland Medicaid. Several patients 65 years and older have Maryland Medicaid as their supplemental insurance. While the federal government meets 80 percent of a doctor's charges through the Medicare program, Maryland Medicaid is supposed to pick up the rest, but has not been meeting its 20 percent obligation for one and a half years. Gov. Martin O'Malley blamed the recession for this default and announced it with a peremptory letter to doctors in early 2010. He has treated private doctors like state workers and has docked them and there is no ray of hope in the offing to show this will change any time soon.

The CEO of MedChi, an advocacy organization for the state's doctors, has not said a thing about any of these outrages perpetrated on the state's Medicaid providers in his article. Instead he has written about high tech cures for what ails Maryland Medicaid. He would like to see Maryland's outdated Management Information System supplanted by a shiny new one that would be conducive to innovative payment models like the Medical Home Network, expected to improve care and rake in savings.

Mr. Ransom seems to think that doctors, including the rural ones, will flock to the idea of reward for cost savings and better care management. The people who are enamored with these payment models are mostly lawyers, journalists, politicians, medicolegal pundits, bureaucrats and software companies, especially the last that endlessly inundate the medical profession with ideas that neither materialize in enhanced care for patients nor in increased income for doctors. Instead these ideas have resulted in jobs and increased income for government auditors, care deniers and people who connect doctors to the care deniers, paper pushers and bean counters; folks who will never set eyes on a patient in their lifetime.

Doctors are not fools. They know that even as government is cutting reimbursements it is increasing demands for this or that. Accountability, increased savings, efficient care delivery, electronic medical records, transparency, control of multiple complex medical conditions with limited drug formularies, diagnosis of the same conditions with cheap lab tests and even cheaper radiological interventions are all the tall orders coming down from politicians, their minions and the lawyers who write the rules for the rulers to hand down to the sitting ducks.

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