Managed Health Care (confusing?)
One thing, and only one thing that everyone seems to agree to when discussing Managed Health Care is its complexity. So to simplify: In June, the Board voted on a Resolution that allows Ramsey County to purchase medical services for those individuals enrolled in the Prepaid Medical Assistant Program (PMAP). Presently, the State is responsible for the purchase of these services statewide. The changeover is to take place by January 1, 2000, unless the State rejects the proposal or the County Board reconsiders the decision. PMAP represents 104 million Federal and State dollars which are dedicated to providing medical services for General Assistance (GA) and General Assistance Medical Care (GAMC). To start up these services by January 1, 2000, 3½ million dollars will be spent on Administrative and Computer expenses. Proponents contend these dollars will be reimbursed from Federal and State dollars. To Janice, its still your tax dollars. During the interim, the State will continue purchasing medical services under the "enhanced" PMAP legislation; i.e., PMAP with more County staff involvement.
Opponents, and Commissioner Rettman is one, see taking over the purchasing as not worth the risk; it is a duplication of administrative expenditures; Ramsey County residents could be left holding the bag; and that the County is not in the insurance business. The Countys goal is the delivery of services. To think that PMAP dollars can be expanded to be used for case management or even better health services beyond the benefit set by the legislature (those health services agreed to contractually) is a bit naive to say the least. HMOs may generate revenue in this good economy; but, they reserve those dollars for bad economic times.
Proponents see this decision as the opportunity to be innovative, an opportunity for change, an opportunity to combine case management with health services, and a risk worth taking. The County Manager said that 45,000 people will be impacted by this action: "The County is used to taking risk, without risk the insurance companies wouldnt want to do this."
The "For" and the "Against" argue back and forth, and present positives from their perspective. Assistant to the Commissioner, Gene Haselmann has jokingly said, "Janice, I have been persuaded For and Against County Based Purchasing (CBP)it all depends on who is the last person I talked to."
As an elected official, Janice likes to view issues from 1) how much does it cost; 2) what are we buying with your tax dollars; 3) what is the public purpose; and 4) how do we balance need with limited dollars. The following are excerpts of Janices statement that she made on June 10, just prior to the vote on County Based Purchasing. This statement is based on Janices 15 months on the County Board which included a year of policy discussions ( 6 full Board Meetings), two Advisory Committee reports, a review of a mountain of reading material from "stakeholders" and meetings of Janices Assistant with all interested parties; i.e., HMOs, Providers, Human Services and Health Services Staff, Consultants and Lobbyists "For" and "Against" CBP.
Janice said, "As I see it, we have at least four customers: Clients, Staff, Taxpayers, and the Board.
The Pros, if we stay with enhanced PMAP, the Clients in Minnesota continues to be blessed by good guaranteed health care. Some would say great health care. I DO NOT SUGGEST reducing these options, and I do believe in prevention and case management. I believe that under enhanced PMAP, all these goals could be achieved in PARTNERSHIP with the Statebetter health care, greater prevention, and more coordinated case management. We could instruct the Human Services staff right now to do more piloting of the case management activities, and use the 2 million dollars to buy the gap fillers when they are identified.
The Cons, if we vote to go with County Based Purchasing: 1) if the state does not approve the plan or if at some point the County decides NOT to continue this process, we lose 2-4 million non-reimbursable dollars; 2) we stand the risk with an economy swing or State changes of funding that we will have set in motion additional services which could come to the taxpayers to make up any shortages; and 3) we are sending "rainmaking" signals that we can offer even better benefits for those on MA, GMAC, and disability which government and bureaucracy has historically not been able to do without MORE dollars.
The Staff has put over 5 years into this concept. They truly believe the STATE cant change. And I appreciate that candor. But, I submit that feeling cannot be the foundation for this public policy. I suggest strongly that its always easier to see leadership as the sparkling/sexy new program rather than to go internally to the root of the problem. To prune a bush makes the root and limbs and fruit grow stronger. To ASSUME Managed Health Care is to be a part of the problem, not a part of the solution of cleaning up government (yes, Janice was in VISTA). Instead, it is creating more government. The leadership Id rather do is spotlight the State Health problems with Managed Health Care, get the Hennepin Lobbyist to help us, and to give enhanced PMAP a try with renewed vigor and with no perceived failure anticipation. Remember enhanced PMAP hasnt been tried.
As to the Taxpayer, last night on NBC, Managed Health Care was discussed. It was stated that in the past 10 years over 8 million Americans have lost part or all of their health coverage because of spiraling costs. Within the next 5 years, an additional 8 million Americans will lose part or all of their health coverage. This is in addition to those who have never had health insurance coverage at their jobs. This plan is asking the taxpayer to risk paying even more for some when they themselves may have little or none. If the issue today was that, I would welcome that discussion.
And remember, right now the benefits for the clients are already set. When I was in the Housing Office, I met a woman whose two children had physical problems. She lost them both to Child Protection because she had no house. She came to me and said, I need a house. And I said, How are you going to pay for it? She said, Ill get a job. She didnt have a GED. She asked me to help. She figured out that I got into my office early and shed beat me there. We would study together, and within a few months she got her GED and her beloved children back, lost weight, and got a new apartment. She needed a mentor, and time and hope. It costs the taxpayers no more than just my time. The "Roof" program that Victoria (Commissioner Reinhardt) spoke about, spoke of comradeship and mentorship. Management of getting kids to get their shots, having their teeth checked, and managing signs of chemical abuse, etc.; I believe we can do that now, if we make an integrated work plan.
We can do that as a Board, as a Community. I dont want us wanting to be the first in taking this (Managed Health Care) on and the glory it may bring to blind us to the sweaty, tedious work that must be done up at the State. We and County staff can achieve the same quality managed health care. There is a role for us to play and lead in that doesnt put Ramsey County at RISK."
The Board voted 5-2 (Janice and Commissioner Guerin against) to implement County Based Purchasing.
Fortunately, implementation is a year and a half away. This may be enough time for all things to fall into place. Or is it? The data needed to set capitation rates and do risk analysis is on schedulethats good. Human Services and State Human Services staff will proceed with enhanced PMAP for next yearthats good. But what about the negotiating skills needed to be in the health services market place? Does the County have them? At the May 19 meeting, Janice suggested that "we are a little fish swimming in a pool of sharks, folks." It appears that the County will have to contract for these skills.
And this may sound "Henny Penny"the millennium question. The May/June 1998 Modern Maturity magazine interviewed Adam Smith and asked about the Millennium issue. Following is a portion of the interview.
M.M.: Whats our greatest challenge in the new millennium?
Smith: The year 2000 itself. If Union Pacific lost half its freight cars just by trying to integrate the Southern Pacific computer system, think what will happen on January 1, 2000, when all the computers that dont have the "19" in their code cant make sense of the double zero. Social Security checks may not go out on time to some of your readers.
M.M: I keep asking bankers about it, and the ratio doesnt change: Two thirds of them think its a very big problem and one third think somebodys going to find a
Smith: Silver bullet? People think Bill Gates will come out with a package that fixes it. But he wont. You have to rip out the old code line by line. And with each passing day, the penalty for not finding that silver bullet increases because you need a year to test these things.
Think of it as a winter with ten blizzards. Car sales will go down because the highways wont be plowed. House sales will go down. Goods wont move. Well get some real GNP drop while we work our way out of it. But in 2001 we ought to have a boom as we rebuild from the computer glitches, and a lot of companies will have learned a lot fixing them. Itll be a good time to be an American .
"Henny Penny, the sky is falling" or a real problem that has to be addressed? January 1, 2000, will be an interesting start up time for County Based Purchasing.
One final note. An interesting call to our Office was from a present medical assistant recipient. "I dont think it is a good idea taking over medical assistance from the State. I have MA from the County right now and its a big procedure and there is a lot of work that needs to be done to clean up their (Human Services) act before they can take over. I hope you can talk with your Commissioners & not go forward with this because they (Human Services) are not ready."
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