Local Help For Medicare Recipients
A lower-cost supplemental insurance plan for local Medicare recipients is a first step towards community-based health care.
Thursday, April 15, 1999
It''s no secret that our nation''s health care system is in crisis. HMOs are pulling out of communities, physicians'' groups are going bankrupt and government-funded programs continue to cut back on services offered. While insurance companies rake in the bucks, consumers reel under ever-skyrocketing insurance premiums--millions of Americans are uninsured, while millions more are dangerously under-insured.
In the face of this mounting crisis, health-care professionals across the country are looking inwards, towards their own local resources, to try and develop innovative methods of ensuring that all their residents receive the health care they need, at prices they can afford. It''s a quiet revolution, and it involves creative thinking that goes beyond the traditional split between public vs. private funding for health care. And Monterey County is, experts say, on the cutting edge.
"What''s emerging is neither corporate, nor government-managed, but a community-based health care delivery system," says Dr. Eliot Light, a primary care physician in Pacific Grove.
"We''re not going to be turning to the federal government or the state for health care anymore, because the help isn''t there," says John O''Brien, owner and director of Central Coast Senior Services in Pacific Grove. "All the dollars that can be squeezed out have been ''squoze''. We need to empower ourselves locally."
This Friday, a consortium of local hospitals, physicians, politicians, consumers, advocacy groups and senior living organizations will unveil a plan for providing lower-cost supplemental insurance for the county''s estimated 45,000 Medicare recipients. It''s a plan that was a year in the making, it demanded unusual cooperation from groups that formerly operated at odds with one another, and it''s being hailed as the first step towards the ultimate goal of a community-based health care delivery system for all county residents.
The group spearheading this new Medicare product is the Monterey Regional Health Development Group (MoReHealth), which emerged out of a blue-ribbon committee set up five years ago by President Clinton''s former Chief of Staff, Leon Panetta, to examine the ramifications that Fort Ord''s closure would have on the health care services provided to our area''s more than 30,000 military retirees. About half the members of that original committee stayed together to form the nonprofit MoReHealth, which decided two years ago to focus its efforts on health care for local seniors.
At a meeting last May 14, MoReHealth empowered a volunteer Medicare Options Working Group to concentrate on easing the financial worries of local Medicare recipients. Their job became even more pressing this Jan. 1, when the county''s only Medicare HMO pulled out of the area, leaving thousands of elderly residents in the lurch. For $30 per month, the HMO used to "cover the Medicare gap," making sure that all health care services outside Medicare coverage were provided. Since January, Medicare recipients have had to either purchase expensive supplemental insurance policies, or go uninsured, risking financial ruin if unexpected medical bills arise.
MoReHealth Chair Maj. Gen. (Ret.) William Gourley, who also heads the Medicare Options group, estimates that half the county''s 45,000 Medicare clients either have no supplemental insurance, or are paying more than they can afford in order to have it. His group interviewed several insurance companies, and settled on the Glacier Insurance Co., agent for the East Coast-based Monumental insurance company, which will offer Monterey County Medicare recipients a supplemental insurance policy that will be, Gourley estimates, "15 to 20 percent lower" than what they would normally pay. The policy will be available after May 7, and will be overseen by a new nonprofit, Senior Health Access Group (SHAG), created last week out of the ashes of the Medicare Options Working Group.
This lower-cost Medicare insurance policy was possible because of two reasons. First, says O''Brien, "because it''s community-based, there''s no profit motive, and that makes it more affordable."
Second, the power of numbers: MoReHealth was negotiating with insurance agents in the name of 45,000 potential clients, and brought every major health care player in the county to the negotiating table on its side, including the CEOs of our four major hospitals: Community Hospital, Natividad, Salinas Valley Memorial and Mee, in King City. That, says Gourley, was unprecedented. "There are big moats around CHOMP, Natividad and Salinas Valley," he says. "Whenever there was trouble, they''d pull up the drawbridges and go to war. We''ve brought people who otherwise wouldn''t talk to each other together to the same table."
Managed-care experts outside our area say Monterey County''s fledgling efforts at a creating a community-wide health care collaboration are unique, perhaps in the country. "Other communities have tried this, on a similiar scale, without success, but Monterey seems to have all the elements for success," says Mike Dwyer, a Los Angeles-based managed-care expert who has been consulting MoReHealth. "It''s just getting underway, but the spirit of cooperation you see among the group is unique."
That cooperation may break down when the stakes are raised. Right now, says Light, it''s easy enough for, say, the local hospitals to back MoReHealth''s proposed Medicare supplemental insurance policy. That''s not taking money from their pockets. But as more and more steps are taken towards creating a comprehensive community-based health care funding and delivery system--something Light very much favors--old alliances will change, and some may find that threatening.
Really, says Light, why shouldn''t the health care industry take a cue from local banking initiatives? "What credit unions are to the banking system, this is to the health care system," he suggests. "Local control, regional funding mechanisms, and a network of distributors."
"This is one step in hopefully many more, bringing together formerly disparate groups to create a community-wide response," says O''Brien.
Those providing health care, and those demanding health care, can no longer afford the luxury of promoting their own individual cause at the expense of the other''s. Assuring greater access to health care at affordable prices demands greater cooperation than in the past.
"You can''t have a continuum of care without a continuum of payer," O''Brien notes. "Medical services are not given for free." cw