Yale researcher leads successful effort to access HMO fees for Medicaid patients

In a study of access to specialty healthcare by the uninsured and publicly insured in New Haven, Yale researchers found that recent state budget cuts, out-of-date provider rates and other policy changes had caused a decline in care by private practice physicians.

"When we noticed that underinsured and publicly insured patients were having increasing difficulty obtaining timely referrals to a variety of specialty physicians, we grew concerned that HMOs were paying low rates for these patients," said lead author of the study Kari Hartwig, assistant clinical professor in the Department of Epidemiology and Public Health (EPH) at Yale School of Medicine.

Hartwig, co-author Marie Harris and the Greater New Haven Partnership for a Healthy Community (GNHPHC), worked with New Haven Legal Services to obtain disclosure of the rates Department of Social Services contractor HMOs pay specialists for treating Medicaid patients. The HMOs under state contract had argued that rates were proprietary and should not be disclosed.

The figures, released by order of Governor M. Jodi Rell on October 18, revealed that HMOs and the state are indeed paying doctors less for treating Medicaid patients than private insurers pay for comparable services.

The GNHPHC is a consortium of community health centers, area hospitals, the health department, EPH and other community health agencies. The group documented the experiences of New Haven area safety net providers referring uninsured, Medicaid and SAGA (State-Administered General Assistance) patients for specialty services in gastroenterology (GI) and cardiology since Connecticut state budget cuts in 2002.

Data collected included key interviews with six referral staff and five specialty physicians from each of the four participating agencies between January and April 2005. The team also statistically analyzed the two hospital databases, examining payer mix and percentage change in cardiology and GI visits from 2000 to 2005.

Hartwig and the team said state policymakers should consider a variety of remedies like tax breaks, increased reimbursement rates, uncapped SAGA funding, restoring SAGA non-emergency medical transportation and expansion of the Husky program to new populations struggling with health care. The team recommended building stronger relationships between private practice physicians, hospitals and federally qualified health centers (FQHCs), bringing specialists to FQHCs and building formal community volunteer initiatives to care for the uninsured.