NEW YORK CITY: Ready For Mandatory Medicaid Managed Care?

      As New York City prepares to enroll most of its 1.2 million Medicaid recipients in HMOs, the New York Times reports that "many health care policy experts, some government officials and advocates for the poor seriously doubt New York's readiness." The Times reports that New York's plan "is not just the nation's largest" Medicaid managed care plan -- 19% of the city's "nonelderly population is on Medicaid" -- but it "is also likely to be the toughest to put into effect because of the city's vastly multilingual population, the depth of its social problems and relative inexperience with managed care even among its most affluent residents." Of the city's ill-preparedness, Susan Dooha of the Gay Men's Health Crisis said, "The moving trucks are outside the house, and the people are painting the walls, but I am not confident that the medical home is ready."

Problems Galore
      The Times reports that problems forecasted "range from the mundane to the profound." Advocates for the poor say "there has been too little thought put into how beneficiaries, many of them illiterate, non-English speaking, transient or without phones, will be informed of this sea change." Many doctors' offices and HMOs "lack the proper technical systems to monitor care." A rash of commercial HMOs have dropped out of Medicaid managed care programs nationwide and in the state, leaving only five -- Oxford, HIP, Empire, Wellcare and United Health Care -- still participating in the city's program. This trend leads many to fear that in the future "there will be too few primary care physicians and specialists to give high-quality care," especially in poor neighborhoods where patients "tend to be far sicker" and underserved by doctors. And "if most of the Medicaid HMOs are run by the same hospitals and clinics that have been serving Medicaid recipients for years," the Times reports the city could "essentially end up with separate but unequal managed care systems, one for the poor and one for the middle class." But perhaps the "most vexing problem" is that the shift to managed care will force Medicaid recipients -- who are used to visiting low-income clinics and the ER only after they get sick -- to "wrap their minds around a totally different system of care," one that "has often confused and frustrated a relatively stable and well-educated middle class."

The Bottom Line
      City and state health officials say they are ready to roll out the plan when it receives federal approval, which is expected shortly. "We have exercised a great deal of caution and diligence," state Health Department spokesperson Robert Hinkley said. The Times reports that the city will make the shift gradually and slowly, "starting with lower Manhattan, parts of Brooklyn and Staten Island," and "branch[ing] out in stages around the five boroughs. Each stage will take 13 months, with starting dates staggered at five-month intervals." For now, the Times reports, it looks like "the supply of primary doctors will not be a huge problem." New York University's Health Research Program Director John Billings, "whose capacity study is considered the gold standard in the industry," said, "The bottom line is that capacity is not as bad as we expected going into it." But others say current capacity rates are already too low and that things are sure to get worse once the plan starts moving into regions like the South Bronx and Queens. Nevertheless, the Times reports that "[b]oth the city and the state ... have made their move into managed care a crucial goal, asserting that it will ease the historically huge fiscal burden while providing better care for the poor." Neal Cohen, health commissioner for the city, said, "From a public health perspective, we're very hopeful that managed care will create on opportunity to provide more preventive health to correct the fragmented fee-for-service programs for the poor" (Steinhauer, 10/7).