American College of Physicians: Internal Medicine — Doctors for Adults ®

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Lessons in improving care for Medicaid HMO patients

One internist's efforts led to better care and access for the city's poor—and an award from ACP

From the March 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Jennifer Fisher Wilson

When Richard J. Baron, FACP, became the first medical director at Health Partners, one of Philadelphia's first Medicaid HMOs, he had his work cut out for him. It was the late 1980s, and the HMO faced a host of problems that included embarrassingly low immunization rates, lost and scattered patient records and little to no follow-up care.

One of Dr. Baron's first jobs was to fix the immunization problem. While some offices in the system had impressive immunization rates—as high as 98%—others were immunizing only 20% of their patients. His solution was to visit the successful offices, examine what they were doing right and help other practices incorporate their techniques. He personally visited offices to introduce new techniques like mandatory flow sheets to track all immunization records on a page in the front of patients' charts. The HMO also began requiring all offices to keep appointment books and helped them recall or follow-up on missed appointments.

Dr. Baron's efforts paid off. A recent in-house audit of the system's sites showed that more than 60% of children under the age of six had been immunized. At Health Partners' 12 largest sites, which account for almost half of all the HMO's pediatric membership, the immunization rate reached 86%.

"The flow sheets clearly helped people organize care and improve their delivery of services," said Dr. Baron, who at Annual Session will receive the Richard and Hinda Rosenthal Foundation Award given to a physician-scientist, clinician or scientific group whose recent innovative work is making a notable contribution to improve clinical care in the field of internal medicine.

Dr. Baron said that he accepted the job with Health Partners because he saw it as a way for Medicaid beneficiaries to receive better medical care—and better access to care—than traditional fee-for-service Medicaid programs provided. He is constantly reminded of the challenge by problems he sees with Medicaid patients in his own practice—which he continued even after he was promoted to senior vice president of the HMO.

As Dr. Baron explains it, Medicaid beneficiaries are notoriously hard to care for. Many lack permanent addresses, phone numbers and reliable transportation; many also regularly miss appointments. Making matters worse, many physicians refuse to accept Medicaid patients for reasons that include practical considerations like reimbursement and other reasons like racism.

In order to improve care that Medicaid beneficiaries were receiving in the Health Partners program, Dr. Baron first looked at the problems in fee-for-service Medicaid programs and found ways that the HMO could do better. For example, Health Partners remedied high emergency room costs by requiring the nearly 800 participating doctors to keep some evening and weekend hours. "If you cut a lot of ICU days, you save a lot of money," he said.

The extended office hours saved money for Health Partners and so helped Dr. Baron solve another problem: physicians' reluctance to take on Medicaid patients. Health Partners decided to pay private-level fees—as much as double traditional fee-for-service Medicaid fees—for Medicaid patients so that patients could get the same service as patients in private health plans.

And to reduce the high number of missed appointments, Health Partners developed Little Partners, a program in which representatives from the HMO actually go into the community and try to find patients who chronically miss appointments. If they can't reach a patient by telephone, the agents try to track the patient down by visiting the residence listed in the patient's chart. "In the hospitals, patients have a social worker," Dr. Baron said, "but you don't typically have that for patients who aren't in the hospital. The follow-up allows physicians to be more successful with providing care."

The Little Partners program can also provide transportation for patients who are having problems making their appointments. As Dr. Baron explained, avoiding a trip to the emergency room more than justifies the cost of paying for some patients' transportation to visit their physician.

One indication of the success of Dr. Baron's efforts is Health Partners' membership numbers. The HMO's enrollment went from 10,000 in 1988 to 90,000 by the end of 1996, even though enrollment in HMOs during that time was voluntary for Medicaid patients. "People choose Health Partners," Dr. Baron said. "We are clearly offering better choices for patients."

With changes in state legislation, membership is expected to grow even more this year. Health Partners is one of four HMOs in the Philadelphia area participating in HealthChoices, Pennsylvania's plan requiring all Medicaid beneficiaries be enrolled in managed care. The program officially began in February.

Ironically, however, Dr. Baron's devotion to clinical medicine may preclude him from sharing in some of that success. Because of its rapid growth, Health Partners could no longer afford to offer him the flexibility to work part time. As a result, Dr. Baron recently stepped down from his roles as senior vice president for medical affairs and medical director and has taken a more limited role in provider education.

"For the past 10 years, I have had the incredible opportunity to work in two spheres that are complementary for me," he said. "But I didn't go to medical school to be a corporate executive."

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