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AFFORDABLE HOUSING
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Equality of Opportunity
COUNTY GOVERNMENT STUDY
HEALTH CARE STUDY
HEALTH CARE APPEALS
COMPARISON CHART
MEDICARE FRAUD AND REWARD
HEALTH CARE
STUDY
LOCAL PROGRAM REPORT - HEALTH CARE COMMITTEE
By Elaine Naper
In recent months the League's Health Care committee has
concentrated on studying services available to younger Kent Countians,
those ranging in age from infancy through the high school years. Our focus was
centered primarily on publicly funded services, since it was assumed that
individuals with private health care insurance enjoy access to necessary care.
We are grateful to Drs. Freddy Araujo and Mark Langitt, physicians in private pediatric practice, to
Superintendent Lorraine Costella, Ph.D. and Barbara
Kraal of the public school system, and to Mary Ad da
Moore and Dr. John Grant of the Board of Health who gave generously of their
time to make this report possible.
The past decade has brought significant changes in the organization, funding
and delivery of the programs administered by the Board of Health, chiefly as a
consequence of State and Federal reprogramming. The Board of Health's total
budget for 1998 is $3,964,000. Of this two State-mandated services--Mental
Health and Addictions--together absorb a total of $1,810,000 and are entirely
funded by the State. The remaining programs (some of which are also
State-mandated) are known as the Corefund programs
and are financed with 60% State grants and 40% County appropriations. Of the
$2,154,000 remaining for Corefund programs, roughly
$300,000 is budgeted exclusively for the 0 to 29 years of age segment of the
population--approximately 14% of the budget for slightly over 25% of the
citizenry.
CHAD (The Child Health Assurance Database program) begins with conception
and serves the entire child population of the county up to the age of two. It
assures every newborn a home visit by a nurse within two week of birth. Besides
monitoring the infant's progress, this visit offers new mothers assurance and,
if needed, guidance in developing parenting skills. In the course of the visit
ever baby receives a booklet of coupons outlining a schedule of the well-baby
check-ups and immunizations the child should receive by age 2. A recently
established electronic birth certificate database permits the Board of Health
to track compliance with the services covered in the coupon book. The Healthy
Start program assures appropriate care for Medicaid recipient s; the WIC
program provides nutritional assistance to very low income pregnant women,
infants and young children.
Special services are available for severely disabled infants and toddlers
and include consultation visits during the 18 yearly visits of specialists from
the Kennedy-Kreiger Institute, John Hopkins. From age
2 until school age there are no formal publicly-funded programs for healthy
children. However, funds have been available to provide insurance for those
uninsured children (approximately 17% of the under 19 population) who do not
qualify for Medicaid and whose families are unable to provide private health
insurance. This provision can be phased out as Maryland's new CHIPS*
(Maryland's Children's Health Program) extending medical coverage to all
children at up to 180% of the poverty level takes affect on July 1, 1998.
At present, there are six nurses (one of whom also serves as administrator)
rotating among the public elementary, middle and high schools. In addition to
providing basic student health appraisals and first aid, they are responsible
for health education, sports physicals (in cooperation with Dr. Grant,
specialty nurses average 30,000 contacts with students in the course of the school
year. The Board's request for additional funding to permit a nurse for every
school in the system was recently denied.
For their part, the physicians interviewed praised the school health
screening programs but would like see the referral system made stronger.
Procedures for follow-ups need to be improved particularly where vision and
dental problems are detected. Indeed the lack of adequate dental care is
perceived as a statewide concern. The Kent County Board of Health is hopeful
that this need may be met if a recent grant application for funds to cover
necessary dental care for children in low income families is approved.
It is also felt that more mental health workers are needed in the school
system. The anti-drug DARE program run by the state police has been effective
for the fifth and ninth grades, but programs and counseling are needed to help
all school age children deal with a variety of stressful pressures. Schools and
physicians report increasing instances of stress-related illness, of asthma,
attention deficit syndrome and hyperactivity.
In discussing the overall picture with those we interviewed, we had the
general impression that the county has most of the resources needed to assure
good health care for our children and youths. When asked what would make an
adequate system better, our informants had two replies: greater emphasis on
preventive medicine (an area in which the school nurses are our major
resource), and persuading more family practice physicians to emphasize
preventive medicine.
The following is taken from a Maryland Department of Health and Mental
Health publication.
The Maryland Children's Health Program
HEALTH INSURANCE COVERAGE FOR CHILDREN AND
PREGNANT WOMEN
On April 26, 1998 Governor Parris N. Glendening
signed a law that created the Maryland Children's Health program, a program
that provides health insurance coverage for average to low-income children and
pregnant women. Those eligible for the new program will be included in Health
Choice--an existing state-wide managed care program.
Children up to the age of 19 and pregnant women of any age may be eligible
for the new program if they have a family income that is at or below $21,700
for a family of two; or $27,300 for a family of three; or $32,000 for a family
of four.
Among the health services to be provided to eligible children and pregnant
women are hospital care, prescription medicines, doctors visits and hospital
delivery bill, shots lab work and tests, mental health, drug and alcohol abuse
services, home health.
Applications for the program are readily available at local health
departments, schools and departments of social services. Those found eligible
will receive an enrollment packet in the mail so that they can choose a managed
care organization.
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HEALTH
CARE APPEALS STUDY
COMPARISON CHART
Following is a chart showing the present governmental
requirements (both federal and state for managed care and Medicare appeals.
This chart makes it possible to compare appeals processes and may point to
changes we might support in current Maryland legislation.
INFORMATION
|
MARYLAND LAW
Effective 1/1/99
|
MEDICAID MANAGED CARE
ORGANIZATIONS
MCOs
|
MEDICARE
|
CONGRESSIONAL PROPOSALS
|
|
Health
insurer to provide written information about internal and external review
process, at the time a person becomes insured and when the insurer makes an
adverse decision.
|
Same, plus
description of MCO and Department of Health and Mental Hygiene (DHMH)
"hotlines", available staff assistance and the role of the DHMH and
its ombudsmen.
|
Same as
Maryland Law.
|
Same as Maryland Law, plus
issued annually.
|
|
Information must be clear,
understandable, include the reviewer's name and how to contact him. Must also
contain a list of all participating providers.
|
Same, plus
"culturally sensitive", at suitable reading comprehension level, and
in native tongue if member of a substantial minority.
|
Same as Maryland law, plus
written in "culturally competent" manner.
|
Written in
"lay person's" language.
|
REVIEWS
|
MARYLAND LAW
Effective 1/1/99
|
MEDICAID MANAGED CARE
ORGANIZATIONS
MCOs
|
MEDICARE
|
CONGRESSIONAL PROPOSALS
|
|
Health
insurer determines whether services medically necessary and covered.
Authorizes payments or makes adverse decision.
|
Same.
|
Same.
|
Same.
|
|
If appeals, health insurer
review the case using established criteria which are objective, clinically
valid, and flexible. May then authorize payment or uphold adverse decision.
|
If appeal, internal review
per DHMH-approved plan with assistance of MCO staff and ombudsmen.
|
Internal review per
contract with Health Care Financing Administration (HCFA). Must provide
Interpreter when appropriate.
|
Internal review must
include oral and written appeals.
|
|
If adverse decision
upheld, appeal to Insurance Commissioner for decision. He may use medical
experts or Independent Review Organizations(IROs).
|
If adverse decision
upheld, appeal to DHMH.
|
If adverse decision
upheld, appeals to HCFA for review by independent contractor.
|
External
review: only if monetary threshold met or life or health are jeopardized.
|
TIMING
|
MARYLAND LAW
Effective 1/1/99
|
MEDICAID MANAGED CARE
ORGANIZATIONS
MCOs
|
MEDICARE
|
CONGRESSIONAL PROPOSALS
|
|
Internal
review: emergency cases reviewed within 24 hours of filing appeal; others
within 30 working days. Written decision within 1 calendar day for
emergencies. 5 working days for others.
|
Internal
review: same for emergency cases, within 5 days for others. Decision and
notice, per DHMH rules.
|
Internal
review within 72 hours for "urgent" cases: within 30 days for
others.
|
Internal review: not later
than 72 hours if life or health are jeopardized; 15 days for others.
|
|
External review: request
must be filed with the Insurance Commissioner within 30 days of the insurer's
notice. Review completed in same time frames as for insurer.
|
External review: no
legislative or regulatory time frames.
|
External review within 30
days.
|
External
review: 72 hours for life or health jeopardy, 60 days for others.
|
WHO DECIDES
|
MARYLAND LAW
Effective 1/1/99
|
MEDICAID MANAGED CARE
ORGANIZATIONS
MCOs
|
MEDICARE
|
CONGRESSIONAL PROPOSALS
|
|
Internal
review: at least one reviewer board certified (eligible) in specialty under
review. Phys-reviewer must be actively practicing, with no financial interest
in the case.
|
Internal review:
review by CEO, or designee, who has power to require corrective action.
|
Internal
review, per terms of contract with HCFA
|
Internal
review in accordance with approved plan.
|
|
External review:
if Insurance Commissioner contracts with medical experts or IROs, reviewers must have qualifications similar to those
required for internal review; also hold unrestricted license, with no history
of sanctions or disciplinary action.
|
External
reviewer: DHMH
|
External
review: by independent organizations under contract with HCFA.
|
External
review by outside group under contract to insurer or state. Department of
Labor certifies and does oversight.
|
|
Insurance
Commissioner's decision may be appealed to the courts.
|
Further
appeal to Office of Hearings, Board of Review, Circuit Court.
|
Further
appeal to SSA Administrative Law Judge, Appeals Council, U.S. District Court.
|
External
review decision binding on insurer.
|
PAYMENTS
|
MARYLAND LAW
Effective 1/1/99
|
MEDICAID MANAGED CARE
ORGANIZATIONS
MCOs
|
MEDICARE
|
CONGRESSIONAL PROPOSALS
|
|
The
insured, through premiums, and health insurers assessed costs of the external
process.
|
State and
federal taxpayers.
|
Beneficiaries'
premiums and co-insurance, and health insurance trust funds.
|
Health
insurers and taxpayers.
|
Notes
*Republicans and Democrats have separate proposals. The Republican
proposals differ in three major ways:
- they would cover only those
individuals subject to Federal law.
- external reviewers would be
selected by health insurer.
- the law would not be changed
to allow consumers to sue HMOs.
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MEDICARE - FRAUD AND REWARD
By Dorothy Plummer
Health Study
The federal government has made the prosecution of Medicare fraud and abuse
a top law enforcement priority with the result that many health care
organizations are under investigation for problems related to complying with
Medicare regulations.
To help correct this costly situation, health care organizations, using the
guidelines of the Office of the Inspector General, are implementing formal
compliance programs. Our local Chester River Health System, comprised of Kent
and Queen Anne's Hospital and Chester River Home Care and Hospice is
establishing just such a program under the leadership of Robin Klinefelter, Vice President, Strategy Development, as
compliance officer. "Although we have always made every effort to comply
with laws and regulations, now we need to be able to demonstrate it." Ms. Klinefelter stated. "The compliance program will
involve every area of the hospital", she said.
The guidelines for compliance programs include seven required elements:
- written standards of conduct
and policies and procedures
- a chief compliance officer
- an education and training
program for employees
- a process to receive
complaints
- a system to respond to allegations
of improper or illegal activities and the enforcement of appropriate
disciplinary action
- audits and other evaluation
techniques to monitor compliance
- investigation and remediation
of identified system problems.
Areas of concern include:
- billing for items or services
not actually rendered
- providing medically
unnecessary services
- upcoding
- outpatient services rendered
in connection with inpatient stays
- duplicate billing
- hospital incentives that
violate the anti-kickback statue
- joint ventures
- financial arrangements
between hospitals and physicians
- Stark physician self-referral
law
- failure to provide covered
services or necessary care to members of an HMO
- patient dumping.
You as a Medicare recipient or financial guardian for an elderly relative
should be aware of these areas of potential fraud. To add incentive to your
vigilance, the Department of Health and Human Services announced that beginning
January 1, 1999 awards amounting to ten percent of recovered payments, not to
exceed $1,000 will be paid to Medicare beneficiaries who report fraud and abuse
of the Medicare system. To be eligible for the reward your information must
contribute to the recovery of Medicare funds not already under investigation by
law enforcement agencies, the Health and Human Services inspector general,
state agencies or Medicare contractors. The rewards will come from collected
over payments after all other fines and penalties have been recovered. You can
do your bit to fight fraud by calling your Medicare carrier or the Health and
Human Services inspector general hot line at 800-447-8477.
Information about the compliance program came through Robin Klinefelter.
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LOCAL HEALTH CARE STUDY (adopted
1996)
By Dorothy Plummer
TITLE
Study of health care in Kent County: A survey of existing
health facilities and providers; the impact of problem changes resulting from
both state and federal legislation as well as by economic pressures.
SCOPE
Study of how health care is administered in Kent Count
including medical providers (doctors, hospital, home health care, nursing
homes, hospice, etc.) and insurers. The study would also consider how
legislation will impact our existing system, e.g., imminent changes in Medicare
and Medicaid. Also to be reviewed would be market place development such as
managed care, the role of HMO's, local networking, how they operate, how the
consumer is impacted, effects of government regulations.
REPORT OF PROGRESS
Since its adoption of the Local Health Care Study item by
the Kent County League of Women Voters in 1996, the Health Care Committee has
acted as a conduit for information to the membership about changes on the local
health scene, emphasizing the impact of legislation, managed care and economic
forces on the structure and delivery of services. Studies resulted in reports
on the formation and growth of the Chester River Health system, modifications
in the Health Department, changes in Medicare and Medicaid, the delivery of
health services to young Kent Countians, increase of
health care costs and combatting fraud. In addition,
a public forum was held with representatives from Kent Count health care
providers on the impact of legislation and managed care on their delivery of
services. A study of the emergency medical system will be published in May.
RECOMMENDATIONS
In pursuing this study the Committee has not found an area
of local action that can be brought to the members' attention for consensus. We
feel little more can be added until some decisions are made at the state and
federal level.
The Board recomminds and the Committee agrees that
the local health item should remain, at least for a year, as a source of
information of local health changes. The committee would add a study of the
delivery of local mental health care be the main focus for this year's study.
The areas of health care often is not givent the
attention nor funding it deserves.
This report was submitted by Dorothy Plummer, Chair
Committee members are Elaine Naper and Carolyn Greene
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COUNTY GOVERNMENT
An ongoing study of the local form of county government and ways to make it
more responsive to the needs of county residents which includes publication of
openings on local boards and commissions continues.
The league will focus its efforts on local Zoning Boards as they consider
the recently passed Comprehensive Plan for the County and its implications for
land development.
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UNITED NATIONS
An ad-hoc committee of members from the Chicago, Washington
DC, and Montgomery County, MD leagues was formed to continue study and work on
the United Nations issue, which was one of the proposed items which failed to
be adopted for action or emphasis at the national LWV convention. If you are
interested in receiving their information write to:
League of Women Voters of Kent County
P.O. Box 374
Chestertown, MD 21620
And for more on the United Nations
at this site click here.
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