Originally created 10/24/98

Alternative care system popular



Big hands usually aren't a bad thing, except when they keep getting bigger. As he watched his hands and feet swell from acromegaly, swelling due to an overactive pituitary gland, Dewayne Walden had to turn to his health maintenance organization.

And unlike the current horror stories about denied care hyped by politicians and others, it turned out well.

Mr. Walden, a chemical operator at The PQ Corp. plant in Augusta, went from a primary care physician to an endocrinologist and finally a neurosurgeon, who removed his pituitary gland and stopped the swelling.

"It's worked wonders for me," Mr. Walden said. "I've heard people say you get what you pay for, but for what we pay, I think we're getting good service."

More people in Augusta are about to follow Mr. Walden and find out exactly what managed care means.

As managed care continues to grow in Augusta, hospitals and doctors continually have to agree to lower prices in order to keep having access to large groups of patients now enrolled in the HMOS and preferred provider organizations, or PPOs. Those changes are forcing area hospitals to lower costs any way they can.

"Every time we sit down and negotiate with a managed care company, everybody wants to pay less than they paid you the day before," said Michael Kerner, chief executive officer of Columbia-Augusta Medical Center. "That's a tough thing for all the hospitals to do and continue to provide the best quality care."

In the past year, the number of people enrolled in HMOs in Augusta has increased from 37 percent to 42 percent, according to the Georgia Managed Care report by Harkey and Associates.

The amount of companies opting for the less restrictive PPOs is even outstripping that, said Allen Roberson, president of the Greater Augusta-Aiken Area Health Care Coalition.

That trend will increase dramatically when the Georgia Merit System of Personnel Administration accepts bids from PPOs to provide health coverage for state employees, which would amount to more than 400,000 people.

The contracts will be awarded by region and in the Augusta area that will mean about 27,000 people, said Neil Vannoy, executive vice president of commercial operations and government projects for Blue Cross Blue Shield of Georgia, one of two companies expected to bid for the Augusta contract. Bids are due Tuesday and a decision is expected by the end of the year.

"Clearly that's a large population," said Patricia Sodomka, executive director of Medical College of Georgia Hospital and Clinics. If a hospital or doctor group had not joined a managed care network so far, "certainly you would at this point," Mrs. Sodomka said.

That may be one reason University Hospital, which had not been a part of Blue Cross' managed care companies before, said it will be part of the network Blue Cross submits with its bid, said Lou Imbrogno, chief executive officer of University Health Link.

After months of negotiation, he stopped short of saying a deal had been reached but said that state employee group was important.

"That's a substantial number of folks and obviously you would want to have access to those people," Mr. Imbrogno said.

Blue Cross said it does not consider its PPO to really be managed care. In an HMO, patients are typically assigned to a primary care "gate-keeper" physician who must be seen or consulted before being referred to specialists. The patient typically pays nominal amounts for office visits and drugs. In a PPO, the employee gets a menu of doctors and hospitals to choose from where they get a better price and lower co-payment, though they can still go outside the network and pay more."It's Managed Care Lite," Mr. Vannoy said. The PPOs tend to provide a wider choice of providers and that is important to consumers, he said.

In fact, all the negative publicity surrounding HMOs is having an impact, said Mr. Roberson, whose business group bands together employers to negotiate better deals for health care.

"There's a backlash against HMOs," he said. More companies are choosing the less restrictive but generally more expensive PPO option to allow their employees more choice, Mr. Roberson said.

That choice is increasingly important to patients, Mr. Kerner said. And more and more doctors and those who had not wanted to join, such as University, are joining in.

And more providers are likely to join the less-restricted PPO than an HMO, which would bring up an interesting dilemma for local providers -- if everyone is in the plan, no one is guaranteed any new business for the lower price they agree to, Mr. Kerner said.

"You don't see anything for giving a bigger discount," Mr. Kerner said. By agreeing early on to work with managed care companies, over the last three years Columbia Augusta had gained new patients and new admissions, Mr. Kerner said.

Others like University seemed to lose a little, particularly this year, though Mr. Imbrogno said he didn't attribute that to not being in managed care companies, although it could clearly have an impact next year if the hospital stayed out.

Which is what employers, and now the state, had been hoping would happen all along -- they would get both a lower price and more choice. And it seems to be working, said John Cobb, Augusta site manager for PQ.

"The ones who had been holding out, they're coming around now," Mr. Cobb said.

Tom Corwin covers health issues for The Augusta Chronicle. He can be reached at (706) 823-3213 or newsroom@augustachronicle.com.