The District of Columbia government is drawing up rules that would make it easier for Medicaid recipients to enroll in health maintenance organizations and other prepaid health plans.
The regulations would establish financial and other guidelines that an HMO or other prepaid health plan would have to meet to serve Medicaid patients. Currently, the vast majority of care for Medicaid recipients in the District is paid for on a traditional basis, with doctors and hospitals reimbursed for each service they provide.
The intent of the rules is to encourage Medicaid enrollees to use HMOs and similar organizations, which stress preventive care and seek to cut costs by more closely reviewing expensive hospital and doctor services. Most HMOs, which have been rapidly growing in popularity, require enrollees to choose from a select group of doctors and hospitals.
D.C. health officials hope patients, by enrolling in HMOs or similar groups, will take a more systematic approach to their health care.
"For years, our doctors and hospitals have been saying that too many of our people have been getting their care in the emergency room," said Lee Partridge, the director of the District's Health Care Financing Administration, which administers the D.C. Medicaid program. "This is a way of trying to reduce that somewhat," she said.
"If Medicaid patients had an ongoing medical relationship with a group of people they trusted, they could probably catch some health problems earlier," added Partridge, whose office has been working on the regulations for several months.
Preliminary regulations are scheduled for release in August, and final rules should be in place by fall, Partridge said.
Medicaid pays for the health care of roughly 100,000 low-income District residents. The $350 million yearly budget is shared by the city and federal government, and the program is administered by the District government, subject to federal guidelines.
Since the 1970s, those guidelines have permitted the states to enroll Medicaid recipients in HMOs, or similar groups, as long as the organizations meet federal rules guaranteeing certain services and financial solvency.
These guidelines were liberalized five years ago to permit the states to set up their own qualifications for HMOs that wanted to serve Medicaid patients. A number of District HMOs and similar groups qualify under the federal regulations, but only Kaiser Permanente serves any Medicaid patients -- about 100.
But, Partridge said, the new regulations would permit other groups, which are not federally qualified but have expressed growing interest in offering pre-paid health care, to serve Medicaid recipients. Without the city guidelines, many of the other groups, including community health centers and hospitals, would not be eligible to serve Medicaid patients on a pre-paid basis.
A number of groups contacted last week said they are studying the idea of participating in the new program, including officials with the Greater Southeast Community Hospital, which offers a pre-paid health plan, and Washington Hospital Center, which is planning to establish an HMO.
One of the main differences between the District and a number of states that have moved to place Medicaid recipients in HMOs is that under the D.C. proposal, enrollment will be voluntary.
A number of HMO experts said Friday that this would limit the ability of HMOs to sign up Medicaid patients. Partridge said she expected no more than 2,000 people to enroll in the first year. This number should increase with growing publicity about pre-paid options, she said.
Alan Silverstone, who is in charge of the area Kaiser Permanente health plan, said his group would examine the guidelines closely. But one of the problems HMOs traditionally have had with the Medicaid program, he said, is that enrollees drop in and out at a much faster rate than the general population.
To address this concern, one early draft of the D.C. regulations said that patients who choose a pre-paid option would be "locked in" for five months after they had been with a plan for a month.