Paving the Road

A couple of hundred dump trucks filled with good intentions have arrived in Howard County. And County Executive Ken Ulman is setting about to pave the road to Hell with them.

Uninsured Howard County residents would get up to seven visits to a physician a year and help from health coaches as part of an ambitious low-cost plan that officials hope will enroll 2,000 people the first year and become a national model.

The Healthy Howard Plan, unveiled yesterday by County Executive Ken Ulman, is expected to cost $2.8 million the first year, $1.6 million of which is to come from participants who will pay fees of $50 to $115 a month. The program will launch July 1.

The goal is to gradually provide access to affordable and coordinated health care for about 12,000 uninsured adults and 5,000 children in one of the nation’s wealthiest counties by knitting together services from existing programs. To be eligible, participants must have household incomes of less than 300 percent of the federal poverty level, or $61,500 for a family of four.

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Ambitious, to be sure. Low cost? Well that remains to be seen.

The Howard County plan seems predicated upon several very shaky premises. The first is that the there is a ceiling on the number of persons involved. I think that this assumption alone will break the program. When I look at my pay stub (family of 5 using Kaiser Permanente) my employer and I jointly fork over about $800/month for health insurance. Don’t get me wrong, I’m glad to have it, but the fact is that I just don’t use that level of medical care and were I single I would opt out all together.

When one translates that to a small business, an employer who now provides health coverage can with good conscience pull the plug on their company plan because there is no way they can provide coverage that maxes out at $115/month. This, like the screwy SCHIP legislation that was vetoed, creates a perverse incentive for more companies to do what WAL-MART has been criticized for: laying off health care costs onto government insurance programs.

For the other weaknesses let’s read on a bit…

The Chase-Brexton Clinic in Columbia, which now treats about 1,000 mostly uninsured people, will be the focus of primary care services during the first year.


Instead, the program will provide primary health care at the Chase Brexton Clinic, plus free or heavily discounted medicines and access to participating specialists and mental health services.

The idea, Ulman said, is to guide people through the variety of programs and opportunities while working with them to improve general health.

That would reduce hospital visits by teaching better everyday habits and through improved management of chronic diseases such as cancer, diabetes and heart disease.

Under the county’s concept, each person enrolled would be evaluated by a physician and be paired with one of seven health coaches, six of them full-time and one part-time.

Thinking this through, the county intends to increase the patient load at this particular medical center by 19,000. It intends that each of these persons would be evaluated by a physician. Chase Brexton has 11 between its Baltimore and Howard County locations. And then it expects to gain some kind of measurable benefit from having seven persons, six of which are full-time, “coach” these 19,000.

So what are the benefits here, other than feeling good?

I think that anyone who can count can agree that 11 physicians can’t serve 19,000 additional patients and that the “coaches” are going to do little more than consume resources. But what service does this program provide:

As part of the program, participants who get emergency treatment at Howard County General Hospital would have any debts they incur there forgiven, which Beilenson said would help reduce reluctance to get treatment and prevent bankruptcies, ruined credit ratings and other stresses that produce health problems.

Victor Boccolino, president of Howard County General, said the hospital now accumulates up to $10 million a year in bad debts but eventually recoups up to 80 percent of that from Maryland’s reimbursement system.

The way it looks to me is that if a person without insurance goes to the emergency department and doesn’t pay, then their debt is essentially forgiven unless the hospital is able to attach assets which the person probably doesn’t have to begin with. (As an aside, the CDC reports that only 0.8% of emergency department visits are charged off). If some 80% of those costs are recovered via claims made against the state, then it seems to me that this program is an all around bad deal.

The county is out of $1.2 million. The clinic will be crushed under the weight of the increased case load (unless the county comes up with more money to pay for more doctors, and a larger facility, and more “coaches”). And the emergency departments probably will not see any substantial decrease in non-paying clientele.

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