POOR HEALTH
Webb, Gary S.
POOR HEALTH For patients on welfare, there are no rules against lousy care BY GARY S. WEBB Any day now, tens of thousands of mothers in Dayton, Ohio, may lose the right to choose who will...
...Welfare HMOs have been tried before, with mixed and sometimes fatal results...
...Vision and hearing tests for children are almost never done...
...Cleveland's poor almost found out, before the city's hospitals skittered away from the plan last year...
...Only half of the black infants were tested for sickle-cell anemia...
...Sometimes you just have to jump in feet-first," explains Ohio welfare director Patricia K. Barry...
...The program is ripping poor folks off...
...One of the HMO's physician-owners was a convicted insurance swindler who was on probation at the time he bought his stock...
...That initial decision eventually helped undermine the entire concept [in California]," Senate investigator Jonathan Cottin testified in 1975...
...The rest of them were scams...
...The letters won't mention that the clinics probably aren't equipped to handle medical emergencies or that workers with murky backgrounds will x-ray them and test them with equipment that hasn't been regularly maintained or even checked for accuracy...
...If we gave them $800,000 and they only spent $600,000 [on patient care], we have no rules that specify what they can or cannot do with the remainder," says Offner...
...And the HMOs have computers to alert the owners to physicians who are costing too much...
...As California's governor in The administration has said the people have no say in the matter...
...The Dayton program got the Ohio legislature's blessing a few months after Senate Majority Whip David L. Hobson, a Springfield millionaire, was treated to a campaign fundraiser by the executives of the debt-ridden HMO which will run the Dayton program...
...But even if the mothers in Dayton were given the full story, it wouldn't matter...
...A decade later, long after California had abandoned the Reagan program, Ohio officials, ,with the help of the Federal Health Care Financing Administration, stepped into the same sinkholes...
...But when a Federal Medicaid-fraud investigator tried to look into the HMO, he ran into a wall...
...But what happened in California is happening again in Ohio...
...POOR HEALTH For patients on welfare, there are no rules against lousy care BY GARY S. WEBB Any day now, tens of thousands of mothers in Dayton, Ohio, may lose the right to choose who will provide medical care for themselves and their children...
...Governor Celeste recently announced on live statewide television that he is solidly behind the mandatory welfare HMO program for Dayton's poor, because, he said, the state has to do something to bring down Medicaid costs...
...The people they work for don't know for sure whether they're even licensed to practice medicine...
...Unlike Medicaid, under which private doctors treat patients and get paid after sending their bills to the state, a welfare HMO gets its money up front...
...The program was chaos, total unadulterated chaos," says Dr...
...But Foster testified that he didn't pursue the case because of "some political crutch" the company had...
...Most welfare HMO doctors—who must give permission before a welfare patient can see another doctor or check into a hospital—have an additional, personal incentive to cut corners...
...Bureaucrats at the Department of Health and Human Services push the idea every chance they get—to the point that more than a million poor people are now enrolled—an increase of 283 per cent between June 1981 and December 1986...
...At a Columbus HMO, the chart of a woman with large masses in both breasts showed "no documentation of further study or investigation...
...Each month, the state sends a huge check based upon the number of patients enrolled in the HMO...
...Percy Frazier, a Dayton obstetrician opposed to the HMO...
...Foster's embarrassed bosses quickly denounced his surprise testimony and shuffled him off to Florida...
...They've got one customer [the state welfare department] and that customer writes them an enormous check every month and then doesn't ask any questions...
...In fact, Ohio's first HMO contract went to a company run by former directors of the most tainted HMO in the California program...
...It is so irresponsible to spend public dollars on a system that encourages nonperformance, and in fact makes it more profitable not to provide services, without an adequate system of auditing and monitoring," says Thomas Moore, the health-care consultant brought in to clean up the mess Reagan's experiments left behind in California...
...Moore says that of the fifty-two HMOs California hired to treat welfare patients, no more than twelve to fifteen "had any business integrity...
...Reporters found a Columbus HMO— whose owner arrives at his clinics in the back of a chauffeur-driven Mercedes—rampant with self-dealing transactions...
...Because they're on welfare, the state of Ohio has decided to force them to participate in its new cost-cutting program: health maintenance organizations (HMOs) for the poor...
...Ohio officials scoffed at such concerns as Moore's, saying that a doctor's medical ethics wouldn't allow such untoward behavior, but the medical audits the state has commissioned over the past few years aren't so reassuring...
...A welfare HMO in Columbus which got 99.7 per cent of its income from the Medicaid program hired two $ 150-an-hour lobbyists in 1986 to fend off a bill beefing up financial monitoring of HMOs, but that was okay with Ohio Medicaid Director Paul Offner...
...Ironically, Ronald Reagan knows better than most what kinds of havoc welfare HMOs can wreak on both the patients and the taxpayers...
...Darran Huggins, the medical director of the first audit team the state hired...
...And now Ohio's liberal Democratic Governor, Richard F. Celeste, is asking the Reagan Administration to waive the legal rights of 42,000 people—half of them children—so they can be made to sign up and stay in a welfare HMO for years...
...If the Reagan Administration has its way, welfare HMOs are the wave of the future...
...Senator Hobson, head of the Senate committee that "investigated" and okayed the contract, gave back the $2,400 he got from the HMO's directors, after news of the country-club soiree hit the papers...
...They'll get letters from some government official, telling them of their good fortune: They're slated to participate in a new state program designed to improve their health, help them have fatter babies, and raise apple-cheeked kids...
...With $3 million a year in management fees at stake, HMO owners can...
...Two-thirds of the patients with high blood pressure were not getting necessary tests, and lab testing was deficient for one out of four pregnant women...
...Evidence of substandard care and a failure to refer patients to specialists...
...But some HMO owners have found faster ways to do it: withholding medical care, making it too difficult to obtain, or kicking out sick patients...
...They are not required to spend it on medical care for their patients...
...Long before they had any regulations for them, Ohio welfare department officials handed out lucrative HMO contracts—in some cases to doctors then under investigation for Medicaid fraud—and permitted them to sign up 35,000 people, most of them children and young uneducated women...
...Theoretically, the HMO makes money by keeping its patients healthy...
...In that mess, you couldn't tell diddly squat...
...That's exactly what California's officials thought, Congressional hearing transcripts show...
...In Dayton, black activists and advocates for the poor have been fighting to keep the mandatory program out since 1984, but it's been a losing battle...
...Fifteen of seventeen HMOs inspected did not have Federally and state-required quality-assurance programs in place, which are supposed to monitor the quality of care the patients are getting...
...Mandatory welfare HMOs are experimental: States can't even start them without getting the Federal Government to bend existing laws and rules...
...Federal auditors found some HMO owners spending tax dollars earmarked for sick welfare patients on political contributions, corporate takeovers, pleasure boats, mountain cabins, luxury cars, and businesses on Guam...
...What the women won't be told is that some of those doctors are convicted criminals and Medicaid cheats...
...The Legal Aid Society of Dayton filed objections with every regulatory body its lawyers could think of, but didn't find out the legislature had given the program the go-ahead until a couple of weeks after the fact...
...Poor people in Milwaukee, Kansas City, and Minneapolis know them from the inside...
...When pressed, Foster testified that witnesses he interviewed told him the HMO "was somehow wired to the governor's office and that there had been some money transacted...
...That money has to cover every welfare patient's medical expenses for the month, or else the HMO covers the difference...
...Though welfare HMOs are supposed to improve medical care for the poor, critics say they are infinitely more dangerous...
...Adds former California program director Moore: "They [HMOs] don't give a shit about the patients...
...In Ohio, each of the 78,000 welfare patients is worth about $75 a month to the state's HMOs—for a total of $5,850,000 a month, or $69.2 million a year...
...Nor will the women be warned that the doctors' offices may be fire traps in which dozens of patients wait for hours without appointments, only to be examined by a physician's assistant or an exhausted osteopath who's seen eighty other patients that day...
...Another patient diagnosed as asthmatic had never gotten a chest x-ray, blood gas-analysis, or allergy test, and was being given "nerve pills" instead...
...Ohio's first major welfare HMO miserably failed its first medical audit but state officials were powerless since there were no rules against lousy care...
...One Columbus HMO's medical files revealed 94 per cent of the patients had not been given a complete physical since they joined...
...Evidence that patients aren't getting needed diagnostic tests...
...If there is money left over, however, the HMO gets to keep it...
...Hence the incentive is to cut corners...
...It's like taxation without representation here," testified Dr...
...They show: ¶ Little evidence that children are getting vaccinated against diseases such as polio, whooping cough, diphtheria, typhoid, scarlet fever, and measles...
...They generate huge amounts of cash...
...These things are like casinos," he says...
...A patient in an HMO in Columbiana, Ohio, had a skin rash for seven years yet was never referred to a dermatologist...
...There was no quality assurance there that I could find...
...At one HMO nearly half the patient charts showed "medical treatment which was not consistent with the diagnosis...
...Ohio Senate investigators last year found an HMO in Warren which had spent $64,000 of its taxpayer-financed start-up grant on a fleet of new Oldsmobiles for the owners...
...The HMO owners were renting buildings to themselves, buying computer services and medical supplies from their own companies, and starting new businesses, all with Medicaid dollars...
...The first program-wide medical audits didn't occur for two years and now, four years into the program, the HMOs are still failing medical audits whose criteria they helped to develop...
...Easy as that...
...Moore says state officials are "kidding themselves" if they think welfare HMO owners will behave themselves while entrusted with millions of unmonitored tax dollars...
...Ohio officials have yet to do audits, even though they have plenty of reason to suspect their money is not in safe hands...
...If they want to hire another administrator, or invest it in Brazil, we have no control over that...
...The state issued a flurry of press releases disputing the agent's statements and defending the HMO...
...Their contracts give them big cash bonuses at the end of the year if they hold medical costs below a predetermined level...
...I got into it enough to where I felt comfortable there was a legitimate basis for criminal investigation," Federal inspector James Foster told an Ohio Senate subcommittee in 1985...
...The [Celeste] administration has said this program is going to go, and the people have no say in the matter...
...It's only lining somebody's pocket.' the early 1970s, Reagan presided over a disastrous welfare HMO experiment which led to widespread patient abuses, horrendous medical care, and outrageous profiteering by welfare HMO operators...
...The program is ripping poor folks off without adding anything to them...
...I didn't feel I was capable of taking on that issue...
...And they definitely won't be told that their new doctors will make more Gary S. Webb is a reporter in the Columbus bureau of the Cleveland Plain Dealer...
...The unwritten but de facto hands-off policy in the first years of the program tended to encourage unethical behavior and some very bad medicine...
...It was hit with a cease-and-desist order after a Columbus television reporter found the HMO's salesmen swarming into refugee communities, signing up Vietnamese and Cambodian families who had no idea what they were joining...
...Instead, the HMO owners were using their computers to watch their balance sheets, identify patients using expensive medicines, and cut down on referrals to specialists...
...The problem is that once the state's Once the state's Medicaid dollars disappear into a welfare HMO, the owners are not required to spend it on medical care for their patients.' Medicaid dollars disappear into a welfare HMO, where it goes from there is entirely up to the owners...
...Until we got independent audits, we couldn't believe anything they said," Moore says...
...money by not sending them to the hospital when they're sick, not referring them to a specialist, and not ordering diagnostic tests or expensive drugs...
...It's only lining somebody's pocket...
...All they'll have to do is pick a family doctor from a list the state will give them, or if they like, the state will do the picking...
...Though immunization rates of 80 per cent to 90 per cent are needed to prevent epidemics, children in Ohio's welfare HMOs average 45 per cent...
...Anemia testing is infrequent, though it is a disorder that commonly affects the poor...
...Welfare mothers can't afford to have lobbyists prowling the Statehouse halls in Columbus, plying lawmakers with campaign money...
...We saw plans out here doctor their books, lie about their financial condition, conceal assets...
...The state wouldn't buy paper clips that way, much less surgery, or the care of pregnant women and crippled children...
...Twenty-eight states use them in one form or another, with Wisconsin, Ohio, Arizona, and California leading the nation in the number of contracts...
Vol. 52 • May 1988 • No. 5
