By Fanny Seiler, The Charleston Gazette, W.Va. Knight Ridder/Tribune Business News
May 1--The director of the state Public Employees Insurance Agency said Tuesday managed care doesn't work in rural areas, so starting July 1, PEIA will not offer managed care in 19 counties.
Tom Susman said Carelink has only 468 current policyholders out of a total of 22,816 in the 19 counties.
Healthy people enrolled in Carelink and less healthy policyholders opted for PEIA's indemnity insurance plan. 'They [Carelink] weren't assuming enough of the risk,' Susman said.
That meant PEIA was paying more of the cost. For HMOs to work, Susman said, 'they have to pick up a greater share of the risk.'
The director said managed care works better in urban areas, and in the Northern Panhandle, where the Health Plan of the Upper Ohio Valley as been in operation for many years.
'Managed care is a tough sale in rural West Virginia,' he said.
From the enrollee's side, if someone in the managed care plan lost his primary or family doctor and wanted back in the indemnity plan, Susman said, PEIA couldn't let him back until the year's enrollment was up. Only the primary doctor could refer a patient in managed care to another physician or a specialist.
'I'm sure there are some folks upset with us,' Susman said. The decision wasn't something that PEIA made 'nilly-willy,' he added.
In Logan County, for example, Susman said Carelink policyholders could go to Logan General Hospital in an emergency situation, but they couldn't make a follow-up visit to the hospital since it is not a Carelink provider.
Logan County had only 75 managed-care policyholders this year out of 1,841 residing in the county.
Additionally, Susman said, Carelink has jerked PEIA employees around with the benefits coverage.
Public employees in the 19 counties will have to join the PEIA indemnity plan, Susman said, but noted that appeals can be made to the director.
'It's not PEIA's fault that managed care doesn't work in rural areas,' he said.
In the PEIA 2004 plan year, Susman said, PEIA plans to offer an HMO look-alike as an option within PEIA.
'We've done that for non-state agencies,' he said, adding the agency is 'trying to build diversity.'
The PEIA look-alike will be an alternative to the PEIA indemnity plan.
Susman said North Carolina's state health agency did away with managed care options.
While Logan County has the highest number with managed care of the 19 counties, Grant County doesn't currently have anyone in Carelink out of 567 policyholders.
Nicholas County had the second highest number enrolled with Carelink, with 67 out of 1,332 policyholders in the county.
Pendleton County has only two Carelink policyholders out of 453 in the county, Hardy County has three in Carelink out of 589, and Hampshire County has four in managed care out of 1,050 policyholders in the county.
Other counties affected and the number of policyholders were:
--Braxton, 49 in managed care, 839 in the indemnity plan;
--Greenbrier, 48 in managed care, 1,951 in the indemnity plan;
--McDowell, 18 in managed care, 1,394 in the indemnity plan;
--Mercer, 12 in managed care, 3,568 in the indemnity plan;
--Mingo, 7 in managed care, 1,394 in the indemnity plan;
--Mineral, 11 in managed care, 1,302 in the indemnity plan;
--Monroe, 18 in managed care, 624 in the indemnity plan;
--Pocahontas, 13 in managed care, 751 in the indemnity plan;
--Randolph, 36 in managed care, 1,911 in the indemnity plan;
--Summers, 33 in managed care, 938 in the indemnity plan;
--Tucker, 18 in managed care, 613 in the indemnity plan;
--Webster, 33 in managed care, 545 in the indemnity plan; and
--Wyoming, 21 in managed care, 1,154 in the indemnity plan.
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(c) 2002, The Charleston Gazette, W.Va. Distributed by Knight Ridder/Tribune Business News.
