More than 81,000 Oregonians covered under Medicaid-almost double the expected number-have been enrolled into managed care through the Oregon Health Plan begun in February.
The new enrollees are being served by the state's seven HMOs as well as by 13 other capitated plans, including physician-hospital organizations.
More people are signing up for managed-care plans than forecasted, with applications flowing in at a rate of 225 to 275 a day at one OHP branch alone, state officials said.
"Besides having all these people come in, one of our biggest successes has been the interest shown by prepaid plans forming to serve this population," said Jean Thorne, director of the state Office of Medical Assistance Programs.
The OHP has encouraged HMOs that hadn't participated in the Medicaid program before-such as Qual-Med Oregon Health Plan-to begin serving the Medicaid population. Qual-Med merged with Health Net last January.
Expanding managed care. "A lot of Qual-Med's attention in the last 18 months has been to expand to relatively unpopulated areas, to get managed care out to those areas, and participating in the Medicaid program was a good way to gain membership. We've picked up about 3,000 members since February," said Fred Roberts, the company's director of sales and marketing.
The Oregon Health Plan, created by legislation first passed in 1989, is designed to expand Medicaid access to 120,000 Oregonians who are under the federal poverty limit and-through an employer mandate scheduled to kick in March 31, 1997-to cover the state's working uninsured. About 450,000 Oregonians are targeted by the plan.
The OHP includes a standard benefit package that surpasses Medicaid by providing extras such as dental services, routine physicals and mammograms. The standard package, which stresses prevention, is based on a list of prioritized healthcare treatments ranked according to effectiveness.
The money saved by not covering services below a certain cutoff point allowed the state to extend Medicaid coverage to more of Oregon's poor. The state is funding its share of the Medicaid expansion through a cigarette tax and money from the general fund.
Dealing with the list.Meanwhile, the infamous list of prioritized services, which critics have assailed as unconscionable rationing of healthcare, seems to be playing a relatively minor role in the actual delivery of care.
"The practice now is to be aware of the list, but we are making services available even if they are not compensated," based on physicians' professional judgments, said Bruce Bishop, government relations manager at Kaiser Permanente Northwest Region, Portland, Ore. "The list may be a useful tool for physicians to both appreciate some expression of social values from a broad community perspective and to understand what other practitioners think of certain procedures," he added.
Although Qual-Med's physicians by no means ignore the list, "we deliver the care that's necessary and that makes sense," agreed Mr. Roberts.
As thousands of people gain access to primary-care physicians, hospitals are beginning to see a reduction in the use of their emergency rooms for basic care.
In addition, "we're seeing a real decline in the number of people applying for (the state's welfare program). Apparently, the only reason they were on welfare was to get healthcare for their children," said Ken Rutledge, president of the Oregon Association of Hospitals and Health Systems. "We're trying to get these people mainstreamed into medical care, to get them to primary physicians, so they aren't using the emergency room as their waiting room," he said.
So, while the expansion of Medicaid has been more rapid than anticipated, the costs essentially have been offset by lower-than-expected welfare enrollment, Mr. Rutledge said.
Questionable future. Despite its successes, the OHP is threatened.
The plan was passed in 1989 by the efforts of "a broad-based coalition" that is now divided on the issue of how to reach universal coverage, Mr. Rutledge said. At the same time, most of the legislators who supported the measure are gone, and most of the current lawmakers "have no real attachment to it," he said. Part of the reason also is a budget crisis facing the state as a result of legislation limiting property taxes.
"And a lot of the same debate we've seen at the national level with respect to mandates has become a preoccupation here," Mr. Rutledge said.
It is by no means certain that the employer mandate will stand. A law on the books would automatically repeal the mandate in January 1996 if the state hasn't received an ERISA waiver by that date. If the mandate falls, the Medicaid expansion is threatened, sources said.
"You can't have one without the other. The plan is a public/private partnership that leads to universal coverage. If it's just a Medicaid expansion, there's no justification for it," Mr. Rutledge said.
That's why the state hospital association "has taken the lead in a statewide effort to inject fresh life" into the OHP, according to its campaign literature. The association already has garnered editorial support and plans an educational campaign.
"We plan to make it a big enough issue so that legislators will have to come up to speed on it," Mr. Rutledge said.
Meanwhile, the state is considering what cuts could be made to the OHP to meet budget constraints. "We're looking at establishing some (patient) cost-sharing" and providing incentives for providers to operate more efficiently, Ms. Thorne said. Phasing in the mental-health benefit, now scheduled for Jan. 1, 1995, also might be delayed, she said.
"There is some possibility of making some reductions under the list (of prioritized services)," Ms. Thorne added. "We think we can make some cuts there without much adverse impact...and still have a good benefit package."