Medicaid patients would get an expanded benefit package and a way to keep their longtime doctors, under a sweeping proposal released yesterday that lays the foundation for putting hundreds of thousands of Maryland's poor into managed care.
The proposal outlines how three-quarters of the state's 467,000 Medicaid patients will soon get their health care.
While managed care has long been considered the answer, the big question has been how to quickly shift a sick, vulnerable population into plans that have tight controls on medical services. Almost every state in the country is working on similar changes or has already made them to hold down exploding costs and give patients better access to health care.
The report, presented to State Health Secretary Martin P. Wasserman by a team of consultants at the University of Maryland Baltimore County, contains the long-awaited details -- details that will dictate what happens to hundreds of millions of dollars, a list of special interests and the patients.
Among the recommendations:
* The benefit package would go beyond the current Medicaid benefits to include emergency and preventive dental care for adults and children.
* Health maintenance organizations would no longer market directly to patients, a practice that has led to many abuses. The state would handle enrollment.
* Patients would be able to remain with their current physicians, as long as the doctors join one of the managed-care plans that contracts with Medicaid.
* Managed-care plans would have to meet standards to ensure that they are taking good care of people with special needs, like the homeless and those with HIV/AIDS.
* The chronically mentally ill would be be cared for in a separate, managed-care system.
The fine print -- and even the broad strokes -- may change after a public-input process and consideration by Dr. Wasserman and a committee appointed to advise him. In January, the plan will be submitted to the legislature.
One of the original goals was to use savings from managed care to cover some of the state's 600,000 uninsured. As the Republican Congress has moved to limit the Medicaid dollars sent to states, prospects for expansion have dimmed. Yesterday, financial projections made that even more doubtful.
But there were hopeful signs for many who have passionate concerns about turning over a population that faces transportation, cultural and other barriers to health maintenance organizations that are often for-profit.
From doctors and nurses to patient advocates, there seemed to be conditional approval of much of the plan and its consumer protections. "This group has really listened. I think you did a great job," said Marcia Pines of the Alliance for the Mentally Ill.
In one provision, managed-care plans would have to pay school-based clinics for the services they provide to students. Baltimore's school-based clinics have already lost significant revenue because many of their students are signed up with HMOs but can't get their care and wind up in school clinics.
The recommendations have particular import for Baltimore because half of the state's Medicaid population lives here.
About a quarter of the 467,000 Medicaid recipients are already enrolled in HMOs. Roughly half are enrolled in a plan that assigns primary-care doctors but does not use the same financing system and is therefore less restrictive than managed care. The remaining quarter may see any doctors.
But since many of the patients targeted by the proposal are mothers and their children, whose health care is relatively cheap, the plan will affect only half of the state's $2.2 billion Medicaid budget. The most expensive part of Medicaid is the care of the disabled and those in nursing homes, which will be addressed next.
Health secretary is pleased
"On balance, this is a pretty good proposal," said Dr. Wasserman of yesterday's report. However, he had some questions about whether certain mandates for HMOs overlap with existing duties of local health departments.
The road to putting Medicaid people -- who are the sickest of the sick and the poorest of the poor -- in managed care is complicated and difficult. Many other states have experienced abuses and massive dislocation because of inadequate preparation. In Maryland, the extensive public-input process has gone far toward working out problems early.
Dr. Lenox Dingle of the Monumental City Medical Society called the plan "progressive" because of its consumer protections. He was also glad to see that physicians who have treated Medicaid patients for many years -- yet have not joined managed care -- may continue. Those doctors would have to join HMOs.
Other concerns include how the state will prevent the HMOs already serving the Medicaid population from gobbling up the market before new ventures get off the ground.
Officials at Johns Hopkins Health System, which gets about 20 percent of its revenue from Medicaid, are worried about how the high-risk patients they have traditionally served will be managed.
State Sen. Larry Young, a Baltimore Democrat, said he was expecting something bolder from the proposal.
"I think managed care is key, but it should not be the sole vehicle utilized," said Mr. Young, who suggested that the state could be divided up, with individually tailored plans for each region.
Louis Hayes and A. Michael Collins, the leaders of the UMBC team, acknowledged that even though Maryland has one of the highest rates of managed care of any state, some areas, like the Eastern Shore and Western Maryland, are lagging.
Six public meetings will be held on the Medicaid proposal, all at 7 p.m. For information, call (410) 455-6853 or the meeting site. PTC A TTY line is available for the hearing impaired at (410) 455-3233. Here is the schedule:
* Monday, Oct. 23, Allegany County Health Department, Cumberland, (301) 777-5600
* Wednesday, Oct. 25, Deer's Head Center, Salisbury, (410) 543-4000
* Monday, Oct. 30, Werner Council Office Building, Rockville, (301) 217-1714
* Wednesday, Nov. 1, Joint Hearing Room, 90 State Circle, Annapolis, (410) 222-7375
* Thursday, Nov. 2, Prince George's Community College, Queen Anne Fine Arts, (301) 386-0132
* Monday, Nov. 6, Morgan State University, McKeldin Center Ballroom, (410) 455-6853 or 455-6854