THE VIRGINIAN-PILOT
Copyright (c) 1996, Landmark Communications, Inc.
DATE: Friday, July 26, 1996 TAG: 9607260010
SECTION: FRONT PAGE: A19 EDITION: FINAL
TYPE: OPINION
SOURCE: Keith Monroe
LENGTH: 82 lines
If you enroll the Medicaid population in an HMO, what do you get? According to a team from Sentara's Family Care plan, you get a win-win situation. Taxpayers save money, the HMO makes money and patients get better care focused on staying healthy. Is this too good to be true?
When Virginia decided to HMOize Medicaid, Sentara decided to get in the game. A few weeks ago several of the important players, including CEO David Bernd, paid the editorial board of The Pilot a visit to make a progress report.
Sentara was already serving Medicare and Medicaid patients, but when the playing field changed, the huge health-care company studied what a major push for Medicaid business would entail before deciding to proceed.
The research led Sentara to conclude that enrolling and retaining patients wouldn't work if traditional marketing methods were employed. Instead, Sentara set out to recruit enrollees less through a sales pitch than through education and community outreach.
The company also studied the kinds of health problems it would most frequently encounter. A stereotype of the poor could lead one to expect Skid Row ills - substance abuse, malnutrition, the results of violence. In fact, the demographics of the Medicaid population produce an entirely different set of health-care needs.
A high percentage of Medicaid enrollees turn out to be young mothers and their children. And the top issues Sentara has had to address have been a lack of childhood immunization, inadequate and inefficient treatment of asthma and poor delivery of neonatal and obstetrical care, particularly an over-reliance on Caesarean section births.
Dr. David Gundlach, Quality Medical Management director, presented data showing that by better educating asthma patients about their disease and the need for a consistent-treatment regimen, startling improvement has occurred. In the 12 months prior to the introduction of the program, patients missed 394 days of school. In the six months after the program was rolled out, only 24.5 days were missed. Equally dramatic decreases in ER visits, hospitals days and doctor visits also resulted.
Immunization rates have improved, and the aim is to achieve an 80 percent rate this year and a 90 percent rate next year, better than that for the general population. Getting neonatal care for mothers-to-be is another way to prevent expensive and harmful problems before they occur.
Many of those steps have required patients to change their behaviors, but in the case of Caesarean sections, it is the doctors who have had to change their ways. Under a fee-for-service model, there was an incentive for physicians to do the more-expensive C-sections. Under the managed-care model, there's less incentive for choosing Caesarean birth, and the rate for Sentara Family Care patients has dropped by a third.
According to some critics, there can be a dark side to embracing market incentives. If, in the past, doctors tended to treat too much, they may now feel pressure to treat too little. Sentara says there are countervailing market forces that make that unlikely. Enrollees can change plans if they aren't satisfied with the care. Furthermore, if saving money today can cause more expensive health problems later, it's not in the long-term interest of Sentara to adopt the cheap fix.
To keep patients happy and well-treated, Sentara is providing several services Medicaid did not, including an after-hours program that permits patients to consult with nurses over the phone. The service is logging 1,000 calls a month.
The change from a social-welfare model to a private-enterprise model hasn't been simple. Some Medicaid recipients are difficult patients; some doctors resist treating them. Sentara has had to worry about issues it's never confronted before - transporting patients to and from appointments, for example. Doctors and nurses have had to do more to educate patients about their ills, the importance of preventive medicine, the use of medications.
But most Medicaid patients have welcomed the change. Indeed, the most-heartening part of the report concerned patient reactions. After years of feeling like second-class citizens caught in a bureaucratic tangle, many feel they are getting the same care as anyone else and appreciate it.
Research by the company shows 72 percent of those enrolled had seen a family doctor, 75 percent had gotten an appointment in less than a week and 95 percent reported following a nurse's advice.
Not all the results are in. Challenges remain. But the experiment suggests there are other and possibly better models for providing health care to the population served by Medicaid. Since we're all paying for it, we all have a stake in the outcome. MEMO: Mr. Monroe is editor of the editorial page of The Virginian-Pilot. by CNB