Ka Wai Ola - Office of Hawaiian Affairs, Volume 11, Number 6, 1 June 1994 — Health Quest switches into high gear [ARTICLE+ILLUSTRATION]

Health Quest switches into high gear

SHIP and Medicaid recipients should know about the system and make sure they're signed up

by Patrick Johnston Some important changes are taking plaee for low-ineome families and welfare recipients of state and federal health care programs and it is important for eligible Hawaiians to be aware of these changes if they want to take advantage of all the benefits available to them. The Legislature has approved appropriations for Heahh Quest, a managed heakh care program aimed at Medicaid (AFDC) and and State Health Insurance Plan (SHIP) recipients. The Department of Human Services began sending out applications for the new program on May 9 with instructions to have them returned by May

27. The applieaUon allowed recipients to choose from a number of different health care plans, the ehoiee varying according to the island where the applicant lives. (See map at bottom of page.)

For information about Health Quest eall 586-5396

lf an individual did not send the application off by the 27th he or she will have a plan chosen for them. State officials plan to switch over to the new system August 1 . All plans offer an identical set of basic benefits although there is some difference in the structure of eaeh organization and the extra benefits they offer. Health Quest is Hawai'i's attempt to anticipate reforms in Washington by making a heahh care system that is cost-effective, reaches most lowineome and welfare patients, and provides them better overall health-care. lt represents a major shift in heakh care delivery for Hawai'i Medicaid and SHIP recipients.

In the past doctors received payment on a fee-for-service basis - if they treated a patient, they were paid for that service. The system was flawed in a number of ways. lndividuals wouId use a variety of different doctors for their medical needs. making it diffīcult to determine the patient's complete medical history. Also, physicians all had different rates, making payment difficult for Medicaid and SHIP staff to administer. And, because doctors were getting paid for eaeh visit, it made more eeonomie sense for the doctor if patients stayed sick and continued receiving treatment. In the Heahh Quest managed heakh care system, individuals choose a doctor - mostly likely a general physician - from their health plan and use the same doctor for all medical problems. This allows the doctor to have a better understanding of the person they are treating. As Doug Murata, President of Queen's Hawai'i Care, points out, "When you coordinate a managed care system, you have a doctor who knows the entire medical history of the patient." If the patient requires speciahzed treatment, the eonhnueā on page 6

AlohaCare bills itself as a community-based heahh plan. Members will be able to choose from a wide variety of hospitals and clinics on the Big Island, Kaua'i, and O'ahu. Queen's Hawai'i Care is part of the Queen's Medical System begun by Queen Emma and King Kamehameha IV 145 years ago. Like AlohaCare and HMSA, members ean choose from a wide range of clinics and hospitals. Queen's is offered on all islands except Lāna'i.

HMSA is the largest heakh plan in Quest and is offered on all islands. It has an extensive network of private physicians and members will have access to a wide range of hospitals and clinics. It is the only plan to offer dental services. Kaiser Permanente is 0'ahu-based and members have access to the nine clinics on the island. Kaiser Permanente is a medical group program and enrollees must agree to receive all their care from Kaiser clinics. In case of emergencies members will be able to use other hospitals. StraubCare Quantum is one of the oldest private group medical practices in Hawai'i. Its main elinie and hospital is in downtown Honolulu. Like Kaiser, it is a medical group program.

Health Quest from page 5

physician refers them to a specialist. For his services the patient's personal doctor is paid a monthly fee, not a fee for visits and treatment. "In the past there was no incentive to keep a person healthy," Murata explains. "For the doctor, economically it made more sense to have the patient keep on receiving treatment." Physicians ean join one or more of the heahh care plans. Patients then choose out of that pool the doctor they want to use as their personal physician. If individuals choose a heahh care plan that their present doctor is not a part of they will be allowed to change plans even if it is after the May 27 cut-off date.

I For the state and federal governments, Heahh Quest hopefully will V represent a way of controlling the spiraling cost of heahh care. By havI ing the heahh plans bid for and effectively take over the administration | of SHIP and Medicaid patients, the burden of keeping costs down has l been transferred to the heahh plans. The government will pay them a set amount - determined in their contract negotiations - and the plans must work with that money to pay for the costs of plan members. "The burden of keeping costs under control has now switched to the plans," says Dr. Larry Miike, Quest's medical director. When negotiating with the heahh plans, the state, for its part, could only work with the last year's Medicaid bill, factoring in inflation. For more information on Heahh Quest eall 586-5396.