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Trying to provide care that's different, not second class

A conversation with Helen Smits, MACP, about the challenges of heading up a Medicaid HMO

From the April 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Deborah Gesensway

After a long and distinguished career in internal medicine, Helen L. Smits, MACP, has set her sights on a new role: leading a Medicaid HMO. In her latest job, she has had to do some serious brushing up on her long-neglected obstetric skills and to renew contacts in social services fields such as housing and domestic violence. But the real challenge has been devising ways to provide care that's different, not second class.

Dr. Smits took the job as president and medical director of HealthRight Inc., a for-profit Medicaid HMO started by two Connecticut community health centers a year and a half ago. HealthRight, based in Meriden, Conn., has about 30,000 members, nearly all of whom are on Medicaid.

HealthRight patients get their care at community health centers and through a network of community physicians and hospitals. There are currently about 6,000 doctors throughout the state participating with HealthRight, including about 600 primary care physicians. The plan has not had particular trouble recruiting providers, Dr. Smits said, although pay has been dropping as the state cuts the premiums paid to the health plans as part of budget-cutting.

Dr. Smits, 61, earned her medical degree from Yale University School of Medicine in 1967 and did her internship and residency at the Hospital of the University of Pennsylvania, where she was the program's first woman chief resident. She has served as a professor at Yale University School of Medicine and the University of Connecticut's medical school, a hospital director, ACP Regent and HCFA's deputy administrator from 1993 to 1996. Last fall, she was elected to the Institute of Medicine.

Dr. Smits recently talked to ACP Observer about the intricacies of Medicaid managed care.

ACP Observer: In the time you have been at HealthRight, what have you learned about running a Medicaid HMO?

Dr. Smits: Medicaid managed care is very different from managed care that serves commercial populations. What you are really doing is using information systems to try to get care to people. A lot of your focus is on getting people in, not filtering people out.

Q: Why is it so difficult to get care to Medicaid patients?

A: There is no simple explanation. But one place where we now do a great deal of case-finding and outreach is in obstetrics. We began evaluating risk factors proactively about nine months ago, so we are just beginning to evaluate the effects. It appears to me that our number of very early babies and our use of the neonatal intensive care unit is dropping, but I can't prove that yet. It will be another three to six months before we're clear about what's happened. That's one of the programs that we feel is working well.

For example, we had a member who had gestational diabetes but didn't believe it. We had to spend a fair amount of time through repeated home visits convincing her of the importance of paying attention to medical advice and seeing that she got the care.

Q: What kinds of social problems do you find you have to address?

A: Up to now, we dealt with the obvious risks—providing home care, connecting with community agencies when people don't have adequate housing, counseling women who need to get out of a violent situation. Those are clear needs. We need to move on now to things like addressing smoking during pregnancy, giving dietary advice suitable for people's basic tastes. We have a very heavily Hispanic population. You need to be told about how to modify your diet in terms that work for you and recipes that work for you.

Also, the conventional childbirth classes can be very uncomfortable [in terms of their content] for some, particularly for the younger, single girls. We need to start looking at special classes for our members, or classes in Spanish, which not very many of the hospitals offer.

Q: Most of your patients are pregnant women and children. What is the role for internists in Medicaid managed care plans?

A: I've been at it about 18 months, and I've learned a lot of obstetrics and I've learned a lot about "bottle rot" and other dental problems, which are severe in this population. The implications for overall health are really tremendous.

Also, I think internists are often particularly well-trained in pharmacy and therapeutics, the substitution process in drugs. We're in the process of beginning to close our formulary because we're trying to control drug costs, and it gets right back to my infectious disease training.

Q: You have made a commitment to hire customer service representatives who are bilingual in Spanish and English. Does that lead to better compliance or better health-related outcomes?

A: I hope so, but we're not established enough to be able to study that. I think it relates to patients feeling better about calling us up with problems and questions. We've done a member-satisfaction survey, and the Hispanic members, particularly, are impressed by the bilingual service. They don't get that from service agencies anywhere else. It's not something they are going to get from any of the commercial plans in the state.

Something like 30% of our members are more comfortable conducting a phone call in Spanish. And we're now big enough that we cover Polish as well as Spanish. Polish-speakers are a small, but important, pocket. You have care-giving grandparents who speak Polish. And if we ever expand into Medicare, we'll get a lot more.

Q: HealthRight has made a decision that it will only deal with special populations, such as those on Medicaid. Isn't there an argument for having Medicaid patients in health plans alongside privately insured patients to keep the Medicaid patients from being given second-class care?

A: It sounds good to say that you want one standard of care, but it is a complicated issue. When we started, we had a commercial utilization management company handling our maternity cases and it didn't understand this population. It didn't have things like housing and domestic violence on its list of risk factors.

I've learned that one of the precipitating events for premature labor is dehydration. You literally have to spend time during a hot summer calling up people and reminding them to drink extra fluid. If you are dealing with an upper middle class population, they spend time in buildings that are air conditioned, and they don't need this service. There is a lot of that kind of difference. You have to be honest with yourself about the fact that this is different care. It's not second class.

Q: One of the issues nationally has been difficulty enrolling many of the otherwise uninsured children now eligible for Medicaid under many of the eligibility expansions of the last few years. What has been your experience?

A: This state is the same as any other. It is getting ready to start additional outreach. We're going to be watching how effective that is.

The problem is that families in general tend to try to avoid the stigma of being on Medicaid as long as the child is healthy. A family at 150% to 160% of the poverty line will dig into its pockets and often go to a clinic with a sliding scale and pay for the routine care. These kids only come into the program when they get sick. I'm not convinced that getting out there on the streets any more, doing more outreach, is going to get more kids in.

Another issue that our social workers say is problematic is families with anxieties about immigration status. The way the rules are, it is possible to have a family where all the children are American citizens and eligible for Medicaid and the parents are deportable illegal aliens. That family is not going to come in.

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