By Christopher Guadagnino, Ph.D.

Published October 1998

• React to this article in the Discussion Forum.

PND: What is the purpose of the HealthChoices Coalition?

OM: It is a coalition of 14 medical and lay advocacy groups that came together to address problems of Medicaid managed care in the five-county southeast Pennsylvania region. The state plans to implement HealthChoices in other parts of the state without, we believe, rectifying some of the problems that existed in its initial implementation. Wanda Filer, M.D., who at the time was the physician general of Pennsylvania, challenged me as chairman of Pennsylvania ACOG organization to lead a group of physician and non-physician advocates to bring the issue to the Governor’s attention because she felt we had a leadership position in women’s health care. This was exactly the kind of activity for which our office in Harrisburg and our advisory council exist.

In Spring of 1998 we invited organizations who provide care for or protect the rights of women and children in southeastern, western and central Pennsylvania, and also the insurance industry. We created a document outlining our seven key issues, which went to the governor in the middle of October. We’re hoping for his response. The coalition members have all volunteered to act in an advisory capacity to provide expertise to the state.

PND: Who are the coalition members?

OM: The 14 medical and lay advocacy groups are as follows: Region II Chapter IV of the American College of Nurse Midwives, Family Health Council Inc., Family Health Council of Central Pennsylvania, Family Planning Council Inc., Maternal and Family Health Services, Maternity Care Coalition, Obstetrical Society of Philadelphia, Pennsylvania Academy of Family Physicians, Pennsylvania Chapter of the American Academy of Pediatrics, Pennsylvania Perinatal Association, Pennsylvania Public Health Association, Pennsylvania Section of the American College of Obstetricians and Gynecologists, Planned Parenthood Pennsylvania Advocates, and Wanda Filer, M.D.

PND: What sort of response does the coalition hope to get from Gov. Ridge?

OM: What we would like is for the governor to direct the departments of Health and Public Welfare to make sure the state does not make the same mistakes in implementation of the HealthChoices program in the Pittsburgh region as were made in the Philadelphia region, and then to retroactively correct some of those mistakes in the Philadelphia area. There have been positive health benefits from the HealthChoices program for women and children. But there have also been administrative issues, barriers to care and access problems.

PND: Can you outline what the coalition views as the mistakes made in the HealthChoices program?

OM: Women have not been able to see physicians they have been seeing for ten years. A woman would come in for care but had been assigned to an entirely different primary care provider and was no longer able to come to the neighborhood center that she had been seeing for years, at which she had her maternity care, because the state had hired an out-of-state benefits company to do assignments. There were lots of misassignments of patients and physicians that interrupted continuity of care. One of the insurance companies required approval for every test ordered for pregnant women, including every routine ultrasound and every laboratory test. Care coordinators at small clinics would spend 45 minutes on the telephone trying to get a routine test approved rather than spending it with their patients to make sure that they have transportation to the clinic, that they call and come for the visits, that their laboratory tests were done, that their WIC papers are filled out so that their children get enhanced nutrition. Those barriers were never intended to be there.

One of the insurance companies chose to not allow women to self-refer even though it’s clearly in the HealthChoices program. That meant women would sometimes have a delay in seeking out prenatal care, which we know as medical professionals that delayed prenatal care is frequently worse prenatal care. Women were being denied access to the family planning centers, defined by the state to include pap smears, pelvic examinations, sexually disease screening, mammography. The state requires women to have access to that without referrals. Women have been denied care because of administrative snafus. The program is not meeting obligations that are required by the state law in terms of eligibility for children under the age of eighteen. There are also opportunities for enhancing the number of children who can be accessed by this program.

Each of us in the coalition has our area of expertise where we have gathered the information regarding the problems that existed. The Maternity Care Coalition has a significant list of issues. American Academy of Pediatrics has provided lots of data. The Family Planning Council has a significant amount of information regarding barriers to care. We’ve compiled documents from coalition members that substantiate the concerns that they’ve brought to the table about barriers to various services.

PND: What are the Coalition’s proposals?

OM: I sat in on a meeting of the Maternity Care Coalition where, although a representative of the Department of Health came and listened to the concerns, there was no action taken even though there were notes made. The group identified as one of its primary concerns that the state needed to have ongoing quality assurance and quality assessment. If a plan was not living up to HealthChoices’ intent, there would be an ombudsman or an office under the Physician General or the Secretary of Health that both providers and patients could call and have a redress of their concerns. We also feel that the state needs to have a relatively rapid and effective response to correct the problem.

We wanted to make sure that, by implementing HealthChoices in the western part of the state, we didn’t interrupt the already excellent continuity of care. When you see a patient for ten years, you know them well enough that if they tell you they have the worst pain of their life somewhere and you know they’ve had three children, that’s a significant pain and you take their concern very seriously. If you don’t know somebody, you don’t know whether or not to admit them to the hospital or send them home with some Tylenol.

Assessment of care continuity is important because you get to see how well you’re doing over time. That leads into the issue of data collection. We now have multiple forms from multiple insurance companies and the data is poorly collected or not collected at all. Some of the data that is collected in voluminous amounts is never looked at. What we’ve begun to realize is that, if you don’t have a way of looking at your data, you have no ability to assess what you’ve done and to make changes. Participants of the coalition felt we have an opportunity now with a new program beginning to institute a uniform data collection process which would allow us in the future to get information in a scientific fashion and make changes that would benefit the women based on data rather than based on hunches. The group suggested that the state have an advisory committee formed of health experts and data collecting experts to look at how best to collect data. Members could include provider, patient, government and insurance industry representation so we make sure that everyone’s confidentiality is ensured and that all interests are ensured.

PND: Did the coalition have any other concrete proposals?

OM: Neither providers nor patients, we felt, were adequately prepared for the HealthChoices program, so when women were switched sometimes they simply got a message that they had a new provider and a new card or they went to their old providers and their card didn’t work. They didn’t understand that they couldn’t access Family Planning services without going through their primary care provider, or were told by their primary care provider that they couldn’t access Family Planning services. An educational program for providers about how to work within and navigate the system would enhance compliance and lower those episodes of care not given or care delayed.

We want to have HealthChoices services available to children and increase the number to include all children up to age eighteen. We want continuity of care for children’s services.

PND: What is the coalition’s timetable, given that these proposals have gone to the governor?

OM: We wanted to make use of the fact that it’s election year to heighten the interest of government in improving services for women with children. But implementing HealthChoices is a multi-year, multi-step process. We will send copies of our proposals, after we’ve given the governor an adequate amount of time to digest and to respond to them, to all the members of Pennsylvania House and Senate and to other governmental and advocacy groups across the state. We continue to encourage more groups to join the coalition and to sign onto the document. The document is not perfect but it represents a real effort by many people who represent many thousands of providers and also many thousands of women to put down in a concise way their concerns. The implementation of HealthChoices is supposed to take place in the western part of the state in 1999. The implementation in the central Lehigh Valley, Harrisburg area is supposed to take place a year later. We want to be a resource for the Department of Public Welfare and for the governor in an ongoing fashion because this is a five-year program. We’ll still be there. We’re still going to be the groups that are providing the care to the women long after the current administration is gone.

PND: What’s the rationale for sending the document to the legislature?

OM: Greater visibility for the issues that pertain to the health of women and children certainly is one issue. The House and Senate propose and approve the budget of the state. We’re not unaware that there is competition for resources. We think that if more government representatives are aware of this level of concern from this many people, then someone will stand up and champion this issue.