The state's plan to move hundreds of thousands of Medicaid recipients into health maintenance organizations is bringing the debate over how to take care of the poor to a head this week. After months of packed meetings from Frederick to Chestertown, a draft proposal goes to the state health secretary Wednesday.
Eagerly awaiting the details of that massive plan are patients, doctors, clinics and hospitals, who for months have been lobbying to achieve favorable positions in the new system.
More than 1,000 Marylanders jammed 11 public hearings held across the state this summer. About 125 others serve on an advisory committee that held three-hour weekly sessions, trying to work out changes in the way medical services will be delivered to the state's 467,000 Medicaid recipients. About a quarter of those are in HMOs.
Key questions include which pa-tients will be in the new system, what benefits they will get and how they will be enrolled. At its heart, the plan will dictate how low-income pregnant women and their children and the chronically ill and disabled get health care.
As the issues were debated, psychologists, pharmacists, podiatrists and nutritionists demanded a say. Everyone from people with hemophilia and diabetes to educators who work with disabled students pleaded their cases. Many advocates asked that their areas be "carved out," which means they would be exempt from managed care and its restrictions.
The trouble is the new system is managed care, in which a health plan is paid a flat fee per month to take care of every aspect of a person's medical care.
"Towards the end of each meeting, I would be so depressed and think, 'God, they just don't really appreciate the good things we do,' " said Lorraine Doo, manager of Blue Cross and Blue Shield's two Medicaid health maintenance organizations.
Nationwide, as states struggle to control exploding Medicaid costs, they have begun the difficult task of moving poor people into managed care plans.
The goal is to hold down costs and give patients better access to preventive and other services.
Most Americans with private insurance are in some type of managed care.
But in the government health programs of Medicaid and Medicare, 80 percent of recipients still are in fee-for-service, the traditional system.
These populations are seen as the last holdouts.
Five states have begun the experiment of moving Medicaid recipients into managed care by receiving federal permission through a waiver. Fourteen states have been approved or have submitted proposals.
Six others, including Maryland, are preparing proposals.
"We think we've created the most extensive public input process of any state in the country to this point in evaluating and helping to shape our Medicaid delivery system," said Dr. Martin P. Wasserman, state health secretary.
Dr. Wasserman will receive the proposal from the team of consultants at University of Maryland Baltimore County who are putting it together.
In developing a plan, designers must balance the needs of an often sickly population with the reality of shrinking dollars.
Grass-roots clinics and physicians who have traditionally cared for these people worry there won't be a place for them in the new system.
On the other hand, HMO officials worry that community clinics and other providers which are beginning to form their own small health plans won't be required to meet the rigorous standards on data, quality and solvency that HMOs must meet to be licensed in the state.
'Something' has to be done
"I know they have to do something," said Melodye Fulton, 39, a Baltimore woman so grateful for the help she has gotten through Medicaid that she volunteered to serve on the advisory committee. "There just isn't the money. But let's not go to the other end of the pendulum."
Like many others, Ms. Fulton wants to make sure Medicaid recipients will get quality care and some choice of doctor.
She said she's afraid if physicians aren't paid enough, patients will be treated like "cattle."
Almost all Marylanders will be affected in some way, since the players in the health care field are reorganizing in an effort to survive the coming shakedown.
In a tumultuous process, ranging from angry exchanges and accusations to confidential meetings to explore alliances, community clinics, doctors and hospitals are scrambling to link up to avoid losing patients.
"It's berserk," said Jay Wolvovsky, president of the Mid-Atlantic Association of Community Health Centers, a group considering forming its own managed care network. "You could be working 24 hours a day and not have talked to everybody who you think you need to talk to. It's wild, and the competition is just crazy. You're either in our camp or in somebody else's camp"
It's unclear how all of this will affect the state's 600,000 uninsured people. Originally, the idea behind seeking a federal waiver was that savings from putting patients into managed care would pay to cover some uninsured.
However, with state officials estimating a $2.5 billion loss over the next seven years in federal Medicaid money, experts said covering more people will be difficult.
Dr. Peter Beilenson, health commissioner of Baltimore, where half the state's Medicaid recipients live, isn't optimistic about the new shape of health care for the poor.
"It's just so complicated," said Dr. Beilenson.
"I just can't imagine it's going to be any better, even with accountability built in."