THE VIRGINIAN-PILOT
Copyright (c) 1996, Landmark Communications, Inc.
DATE: Wednesday, January 3, 1996 TAG: 9601030005
SECTION: FRONT PAGE: A8 EDITION: FINAL
TYPE: Editorial
LENGTH: Medium: 61 lines
As of Monday, nearly 92,000 Hampton Roads Medicaid recipients became members of health-maintenance organizations. They face new rules and language - primary-care doctor, co-payment, referrals - but could receive better, cheaper care.
HMOs are nothing new in the marketplace. These health-care plans rely on stringent oversight and regulation along with a prevention-oriented emphasis to control health-care costs. They've been gaining popularity for a decade.
As private-sector results showed that HMOs actually could save money, the public sector grew interested. Hence, Virginia's experiment with mandatory HMO membership for much of its Medicaid population.
Since 1980, the state's Medicaid bill has quintupled to more than $1 billion a year. And with the federal government planning to block-grant and reduce Medicaid funds to the states, cost-saving measures are required medicine. Thus, the marriage of managed care and Medicaid.
The concept is a good one. With its emphasis on preventive medicine, managed care brings a much-needed focus on health instead of sickness to a population that typically has more than its share of chronic health conditions.
But those who promise major financial savings gloss over a crucial fact: More than half of the state's Medicaid costs come not from the poor who will be covered under HMOs, but from nursing-home residents who won't be affected by the new plan. Yet that's where much of the cost increase has come.
Still, Medicaid HMOs have a good chance at succeeding if Virginia can work through a period of transition. Consider:
For years, Medicaid recipients, unable or unwilling to find their own primary-care physician, have received much of their health care in expensive emergency rooms.
Now, if they head to the ER for an ear infection, they may find themselves footing the bill. Changing a lifelong habit isn't going to be easy.
The paperwork and rules of an HMO can be confusing - even to longtime members. Want to see an obstetrician when you're pregnant? You need a referral from your primary-care doctor. Need a blood test? Make sure you go to an ``approved'' lab. Entering the hospital? The visit must be ``pre-authorized.''
Members must choose a primary-care physician to provide most of their health care. Establishing relationships with these physicians - who have avoided Medicaid patients because of poor reimbursement rates - will take time.
Nearly half of the region's Medicaid recipients didn't choose their own HMO - they were assigned one. That may be a sign of how uninterested - or uninformed - this population is.
Even Pam Brunner, director of managed care for Children's Hospital of The King's Daughters, which relies on Medicaid for 50 percent of its revenues, admitted that ``there are some logistical problems the Medicaid population is not used to dealing with.''
How the four companies now providing medical services to this population overcome those obstacles will be crucial to the program's overall success. by CNB