Washington's 120,000 Medicaid patients should be "locked in" to one doctor of their choice and should not be al w0123 ----- r d BC-05/02/83-HDAWAY 2takes 05-02 0001 Health Chief Seeks Change In Attitudes By Sandra Evans Teeley Washington Post Staff Writer
Washington's 120,000 Medicaid patients should be "locked in" to one doctor of their choice and should not be allowed to switch from one to another at will as they do now, the city's new public health commissioner says.
This restriction would prevent "doctor shopping," in which a patient goes from physician to physician with a Medicaid card and may get a variety of treatments without anyone coordinating them, according to Dr. Ernest Hardaway, the city's new health chief. At the same time, he said, such a rule would hold down the city's Medicaid costs, which are rising faster than anything else in the Department of Human Services budget.
"I want to change the attitude that people have toward taking responsibility for their own health care," said Hardaway, who became the District's public health commissioner in January, in a recent wide-ranging interview.
This change also would be in line with an overall shift by the city government this year toward promoting self-sufficiency and discouraging dependence on public support.
Hardaway, 44, went to the public health commission as a deputy commissioner in 1981 after a series of health jobs with the federal government, most recently as deputy director of the U.S. Bureau of Medical Services and chief dental officer at the U.S. Health Services Administration.
Trained as an oral surgeon, with degrees from Howard University and Johns Hopkins University, he last practiced full time in 1972 when he was chief resident of oral surgery at Howard University Medical Center.
He heads the city's public health commission, part of the D.C. Department of Human Services, at a time when it is caught between an increasing caseload and shrinking resources. The commission is projected to lose about 200 positions in the fiscal 1984 budget, dropping to a total of 2,110. The commission's budget is to rise from $280 million in fiscal 1983 to $306.6 million in fiscal 1984, with the increase eaten up by higher Medicaid costs and pay raises for employes.
To operate within this hold-the-line budget, among other things, Hardaway will be overseeing the establishment of fees at city clinics for previously free services, and is in charge of putting together a plan for "consolidating" the District's 15 clinics--in other words, closing some while having the remaining ones pick up more clients.
Proposals can be designed that save the city money and are better for citizens' health at the same time, Hardaway said. He sees the proposed change in Medicaid rules as one such idea.
He expects community resistance and says he has a "selling job" to do on the idea. "Some people will complain that I'm trying to treat nonprivileged people in a way I wouldn't do with private people."
While shopping for doctors is a favorite method of drug abusers to get multiple prescriptions for drugs, it also is practiced by a number of patients with legitimate needs who have no incentive to stay with only one doctor, Hardaway said.
Restricting patients' access to doctors would help those who unwittingly may be taking drugs or getting treatments that should not be used together, Hardaway said.
Under the proposal, the patient's chosen physician would be responsible for keeping track of the patient's medical history and records.
That doctor's referral would be needed for the patient to be admitted to a hospital for nonemergency treatment, under the plan Hardaway envisions. This would mean more control and better use of the city's hospital resources, because people would not be using emergency rooms for routine care, he said. No one would be denied admission or treatment for emergencies.
City clinics also would try to have the same doctor treat a patient each time if possible, though another physician could take the individual if the first is not available.
A 1981 federal law basically left it up to the states whether they would "lock in" patients to a particular doctor, though federal approval of the change technically would be required, according to a spokeswoman for the U.S. Department of Health and Human Services.
Imposing fees at city clinics also would be better for individuals' health in the long run, Hardaway contended.
Clinic fees, recently authorized by the D.C. City Council, were proposed as a cost saver in Mayor Marion Barry's fiscal 1984 budget. But Hardaway said they will prove to be more important in forcing people to pay more attention to protecting their own health.
"People . . . will have a different attitude if they have to pay something," he said.
Community advocates involved with health care strenuously disagree with this theory and say instead that fees will discourage people from getting routine preventive health care or care for ailments without major symptoms, such as hypertension.
The City Council gave the executive branch broad authority to determine what the fees will be but specified they must be on a sliding scale based on ability to pay and that the mayor should designate services that will continue to be free to everyone because they are in the public interest.
Fees at the city clinics will not go as high as those paid to private physicians in any event, Hardaway said. If a private physician charges $40 for a service, the clinics might set a maximum of $35 for the highest income levels, for example, he said.
"We're not trying to discourage people from coming," Hardaway said.
Another proposal bound to generate controversy when it is completed is the city's pending effort to consolidate public clinics, included by the mayor in his fiscal 1984 budget. Hardaway said he is trying to balance "justice and mercy" in determining how to institute the cost-saving measure.
Some of the most underused clinics are those for senior citizens, but at the same time those people need clinics near to them more than others do, he said.
For example, the Regency House geriatric clinic is open only half a day a week, "but if I went to take it out of there, they the older patients would go bananas," Hardaway said.
In another part of town, the community already has reacted sharply to a city proposal to end funding for a Children's Hospital contract to run two children's clinics in Adams-Morgan and Shaw. In the wake of that angry response, Hardaway says, the city wants to continue funding the clinics but is negotiating with Children's Hospital on ways to hold down the costs.
Hardaway acknowledges that a number of the proposals he is in charge of implementing will be controversial and may make his tenure as head of the commission short-lived.
"I don't intend to stay in this job," he said. "You can't turn the system around and stay in the job for long.
"Sometimes I think I can stay two years; sometimes I'm not sure I can stay one year. It gets to be overwhelming."