Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, July 24, 1995 TAG: 9507240117
SECTION: VIRGINIA PAGE: A1 EDITION: METRO
SOURCE: LESLIE TAYLOR STAFF WRITER
DATELINE: LENGTH: Long
It looked official, printed on Virginia Department of Medical Assistance Services letterhead.
"Linda Poindexter is being enrolled in Medallion, a managed care Medicaid plan. You must choose a [physician] from the attached list of Medallion providers," the letter read.
Poindexter, a seven-year Medicaid recipient, crumpled the letter. Her physician was not on the list.
"I thought, `Here they are trying to tell me what doctor I'm going to see. What am I going to do?''' she said.
For most of her 43 years, Poindexter, of Roanoke, has battled a rare form of cancer called Von Hippel Lindau Syndrome. She lost her left eye to the disease. A tumor sits on the optic nerve behind the right one.
She has had four back surgeries, a left kidney removed and a brain tumor. She has a tumor on her spinal cord. She has CAT scans and MRIs every six months.
Since 1988, Medicaid - federal-state health coverage for the needy, aged, blind and disabled - has footed Poindexter's medical bills. She'd found a doctor at the Lewis-Gale Clinic at Valley View who was willing to learn about her disease and who had referred her to specialists close to home.
"How can they take my doctor away from me and give me who they want?" Poindexter asked. "These doctors are in my life for a reason. To me, poor people don't stand a chance."
Poindexter is one of 48,000 blind, elderly or disabled Medicaid clients in Virginia who were notified this month that in October they must enroll in Medallion, a primary-care provider group for Medicaid recipients.
Poindexter's reaction was likely no different from that of people whose private health insurers have moved into managed care and who have been forced to switch doctors or pay medical costs themselves.
But people on Medicaid rely on the subsidy because they earn too little or nothing at all. Most, like Poindexter, have no safety net.
As the state eases Medicaid into managed care and privatization, many clients are pushing the panic button. Karen Cullen, program consultant for the Virginia Department of Social Services, understands why.
"It's a pretty big change," she said. "It's especially disconcerting when the physician you have been seeing chooses not to enroll in Medallion."
And it is particularly troubling for people on Medicaid who want to stay with the same physician but don't have the option of paying out-of-pocket if their physician is not a Medallion participant.
But managed care and privatization for Medicaid is the future - a way to rein in out-of-control costs and ensure controlled, coordinated medical care for clients, say program administrators.
The Virginia General Assembly this year approved expansion of the Medicaid Medallion program to aged, blind and disabled clients. In October, they will join 320,000 of the state's 500,000 Medicaid clients who have been brought into Medallion over the past three years, most of them women and children who are on or qualify for Aid to Families with Dependent Children.
"One of the big concerns we've had is that this population had difficulty finding primary-care physicians," said Tom McGraw, director of program delivery system for the state Department of Medical Assistance Services. "I think with Medallion, physicians feel they have better control of clients."
Virginia's Medicaid budget is about $2 billion a year, or about 12 percent of the total state budget. It is the fastest-growing area of state expenditures.
Managed care "gets some control behind Medicaid, which is growing by leaps and bounds," Cullen said. "Medicaid needs to maintain a little control just like every other private insurance company that is facing ever-expanding costs."
But Poindexter calls it "government gatekeeping."
"The government is running my life, trying to control me, control my health, letting me in and letting me out," she said. "Now they're coming into my life and controlling my doctors."
The state has tried to recruit as many of the physicians of aged, blind and disabled Medicaid clients as possible. Though doctors are paid $3 a month per patient in addition to fees for their services, not all have jumped aboard.
Cullen said she doesn't know why doctors have been slow to sign on. Some might fear that enrolling would open them up to an infinite number of patients, though that is not likely to happen, she said.
Poindexter found out last week that neither her physician nor those who practice with him would be participating in Medallion.
Dr. Bruce Hagadorn, Lewis-Gale Clinic's medical director, said the clinic is not mandating that its primary-care physicians participate in Medallion. That decision is left up to the physician, he said.
He noted that some Lewis-Gale pediatricians are participating in Medallion and have been since the first wave of Roanoke-area Medicaid clients joined the program in 1992. Physicians at Lewis-Gale's satellite clinic in Shawsville also are participating. Physicians at two other satellite clinics have requested applications, he said.
About 2,300 physicians statewide are participating in Medallion, Tom McGraw said. Of those, 153 are in the Roanoke and New River valleys and the Bedford and Franklin county areas.
"We've instructed staff to work with the client to try to find a physician that works for them," he said. "If we can't, we've given staff authority to exempt the client. We don't want the program to be a hindrance to access to care."
The state Department of Medical Assistance Services must submit a long-term plan by September for making Medicaid managed care statewide. That plan also will include a time frame for Medallion 2 - a program requiring Medicaid clients to join a private health maintenance organization - to be extended statewide.
The plan likely will reflect an easing into change, McGraw said.
"We're not going to try to do this overnight," he said. "States like Tennessee went from nothing to everybody into HMOs overnight. We haven't done that. We're not trying to force fit."
Medallion 2 will be tested in Hampton Roads beginning Jan. 1. The pilot program is a prelude to the statewide privatization of Medicaid. In three or four years, Medicaid recipients throughout Virginia are expected to be receiving their care through HMOs or related managed-care organizations.
by CNB