Profile of Baltimore HealthCare Access, Inc. (BHCA)November 2002
When Maryland implemented mandatory Medicaid managed care (called "HealthChoice") in 1997, it included more special needs populations in its managed care system than is typical among states: Children with special health care needs, children in foster care, pregnant women, adults with disabilities, people with HIV/AIDs, people with substance abuse problems, and homeless people were among those required to enroll in managed care. Maryland gave local health departments a strong role in protecting these vulnerable populations, giving the local health departments responsibilities for community outreach and education regarding managed care; finding people "lost" from the health care system or "noncompliant" with care and linking these people back to services; and providing ombudsman services to help HealthChoice enrollees resolve their complaints or problems with managed care.
The Baltimore City Health Department created the nonprofit 501(c)(3), Baltimore HealthCare Access, Inc. to take on these and other functions. This agency was able to quickly hire staff and configure new administrative structures and policies to adapt to changing needs―tasks that would take much longer in a large bureaucracy. BHCA's Board of Directors includes senior local health department officials and is chaired by the City's Commissioner of Health, giving the ombudsman program as well as other BHCA functions a direct reporting relationship with the city's highest health official. The Board also includes key community representatives. One advantage of having the ombudsman program in a quasi-public agency (as opposed to a governmental agency) is that it is often perceived by consumers, providers, and advocates as more "user-friendly" and somewhat "independent."
BHCA's Consumer Ombudsman Assistance Program (COAP) resolves complaints; educates and assists enrollees, providers, and advocates; and acts as a catalyst for systems change. It has a staff of ten, including a nurse coordinator, a special needs liaison coordinator, two community ombudsmen who are generalists, and five special needs liaison/ombudsmen for (1) children with special needs and children in foster care or kinship care, (2) adults with disabilities or chronic illness, (3) people with substance abuse/HIV or homelessness, (4) the Hispanic community, and (5) perinatal/family planning, and administrative support. The special needs liaison/ombudsmen provide individual and group help to special needs populations, educate providers, prepare written educational materials about managed care for use in the community, and work on systemic issues related to their respective populations. Additionally, each month, all COAP staff routinely follow up with hundreds of pregnant women who are newly eligible for coverage to assure they are connected with appropriate services.
The COAP program is part of a larger statewide HealthChoice complaint resolution system. Throughout Maryland, HealthChoice enrollees with concerns or problems are encouraged to call their health plan's customer service line. If they are not pleased with the outcome or if they do not want to contact the plan, they can call a toll-free statewide enrollee action telephone number. The Complaint Resolution Unit of the Maryland Department of Health and Hygiene works to resolve callers' complaints. For example, in January 2002, the state received about 2300 calls, 23 percent of which were designated as complaints (rather than queries or information/referral). Of these, 25 percent concerned authorization for or referrals to specialty care; 27 percent involved billing issues; 22 percent involved care management; and the others were a variety of concerns. Once the Complaint Resolution Unit closes a case, it refers it to the local health department (or in Baltimore, to BHCA) for more intensive follow-up. The local ombudsmen often make home visits. They ensure that any agreements made by the MCO, provider, or state regarding disposition of the complaint are actually followed and determine whether the consumer/family needs any additional education, advocacy, or referrals to meet comprehensive needs. The local ombudsmen also receive referrals of more complex complaints that have not been closed at the state level.
In fiscal year 2002, COAP received 872 referrals for education and assistance from the state Enrollee Action Line/Complaint Resolution Unit. Special Needs Liaisons provided training to 286 provider and consumer agencies or groups, and they provided ongoing technical assistance on managed care systems improvement initiatives.
To track complaints and identify systemic issues, BHCA's COAP program uses the data system "Respond CenterPoint." BHCA is very satisfied that the data system can be adapted to the ombudsman program's changing needs.
One systemic issue that BHCA has addressed is managed care case management. Maryland managed care plans are required to provide case management to special needs populations, but the ombudsmen had received many complaints since HealthChoice's inception from enrollees/families who were unaware they had a case manager. In large part, the managed care plans seemed to be providing only administrative (i.e., utilization review) case management. BCHA raised this issue in public forums and behind the scenes to make sure this problem was addressed in the state's recent comprehensive evaluation of HealthChoice. It was, and since the evaluation confirmed the existence of serious problems with case management, the state is planning to convene a task force to address the issue more systematically.
For more information about BCHA, see the Web site www.bhca.org, which contains many downloadable resources about managed care. An article about BCHA's ombudsman program appears in the Maternal and Child Health Journal, Vol. 4, No. 4, 2000.
