In a change that will dramatically affect the way poor people receive health care in Maryland, Medicaid patients will soon be teamed with their own personal physicians.
The move is designed to improve overall health care and cut down on unnecessary visits to hospital emergency rooms, saving the state millions of dollars a year.
The state is preparing a "managed care" system for two-thirds of its 343,000 Medicaid recipients, most of them women and children. The new system, dubbed Maryland Access to Care, will be phased in beginning this fall.
Medicaid now pays for a recipient to regularly be seen and treated by a doctor, but many people choose not to take advantage of such care. Instead, they rely on hospital emergency rooms, going there for treatment for even minor ailments. The new managed care program is the government's equivalent of a private health maintenance organization, in which the health care provider assigned to a patient decides when they need to see a specialist and when they need costly emergency care.
"A hospital will have to get authorization from the provider if the patient shows up with something that is not an emergency," said Nelson Sabatini, deputy director of the state health department. "Similar programs are under way in other states as well as in the private sector, but I think we may be one of the first to go on a statewide system of managed care."
Maryland's managed care program is starting when some area hospitals -- among them George Washington and Howard University hospitals in the District -- are staggering under the costs they must absorb in caring for Medicaid recipients and other poor people. The two hospitals laid off more than 400 workers this month to cut costs. Last week, the U.S. Supreme Court ruled that hospitals could sue states to get higher Medicaid reimbursements, a move expected to swamp the Medicaid system across the country with lawsuits.
While Maryland's managed care program is expected to get doctors and Medicaid patients together more often, it was designed to save money in the long run.
In addition to cutting down on unnecessary visits to emergency rooms and specialists, the program is meant to head off some acute health problems by ensuring continuous, rather than episodic, treatment.
Sabatini is estimating that the new program will cut the state's annual $1.2 billion Medicaid budget by $8 million. Most of the total budget -- 75 percent -- now goes to caring for people who are very ill, either in nursing homes or in hospitals.
Mary Mussman, a physician adviser to Sabatini, said many Medicaid patients are not aware that the program will cover the cost of regular visits to a doctor's office.
Under the new program, patients will be given the opportunity to choose a physician who accepts Medicaid patients. If they fail to do so, they will be assigned one.
Mussman said the program will allow patients to change doctors if they are not happy with the care they are receiving.
During the first six months of participation, the patient can simply call to request a change; later, she said, a written request will likely be required.
"That's a key issue, because there are lots of mismatches," said Sidney Wolfe, of Public Citizen Health Research Group.
"A patient should easily be able to switch to another doctor."
Providers in the managed care program will include not only private physicians, but also health maintenance organizations, community clinics and hospital outpatient centers.
Key to the program's success will be getting their participation.
Medicaid currently reimburses doctors at 25 to 30 percent of what the doctor would charge a regular paying patient.
The state is planning to raise that reimbursement level by half to get more doctors to agree to see Medicaid patients. Currently only about 20 percent will see Medicaid patients.
That number is sufficient now, but many more doctors will be needed under the managed care program.
"We're a thousand percent behind it," said Gerard Evans, a spokesman for the state medical society. "We have been saying we can find the doctors to take care of the Medicaid patients if we have relief in red tape and reimbursements." The state is doing that, he said. "Now we have to put up or shut up."
Under the new program, primary care providers will have to be available or have someone else available 24 hours a day, seven days a week to authorize emergency care for their patients who need it. Mussman said that while that is also the medical society's current standard of care, it is often not provided to Medicaid patients.
The program will cover two-thirds of the state's Medicaid recipients. Excluded will be persons in nursing homes, foster care and institutions.