D.C. officials are weighing several proposals that would overhaul the city’s estimated $100 million privatized program that provides health care for the poor.
The city-funded D.C. Healthcare Alliance, created in 2001 after the shutdown of D.C. General Hospital in Southeast, is near the end of its five-year contract to pay for prescription drugs, doctor visits and emergency-room treatment for low-income city residents not eligible for Medicaid.
The contract expires in May 2006, but city officials expect to issue within the next few months a request for proposals for a new contract. Officials for the city and the health care industry are discussing the structure of the alliance program, and changes are expected.
An internal Health Department review conducted by locally based Consortech Inc. of the alliance’s business operations concluded: “Maintaining the status quo is not a recommended alternative.”
One option calls for the District to buy alliance members health care coverage through Medicaid, a move D.C. Council member David Catania said would provide better specialized care and more comprehensive access to treatment.
Speaking at a recent council oversight hearing on the alliance, Mr. Catania, at-large independent, who is chairman of the council’s Committee on Health, said the program must spend its money more wisely.
Mr. Catania cited the case of an alliance member who went to the emergency room 48 times last year, and others who went dozens of times. “We can’t afford to pay for one person to go to the ER every week,” he said.
Instead, the alliance could hire a nurse who would consult with those members taking frequent trips to the emergency room, ensuring they receive proper preventive care rather than expensive hospital treatment, Mr. Catania said.
“You’d save money and provide a better quality of life,” he said.
Meanwhile, Council member Vincent C. Gray, Ward 7 Democrat, has called for the creation of a new Cabinet-level agency called the Department of Health Care Finance that would manage federal Medicaid dollars and take over contracting authority for the alliance.
Mr. Gray also said he wants to improve efforts to enroll city residents into the alliance plan, noting that Ward 7 — one of the city’s neediest wards — has the second-fewest alliance members in the District. “We should have one of the highest enrollments,” he said.
The alliance has received mixed reviews since its inception.
Last month, D.C. Mayor Anthony A. Williams credited the program with helping city residents live “longer and healthier” by reducing expensive emergency room visits while increasing visits to primary care clinics.
Mr. Williams cited statistics that showed 29 percent fewer emergency room visits and 38 percent more primary care visits among alliance members last year.
But, the alliance has been hampered by management turnover, contractor performance problems and complaints by providers about delays in getting paid. City auditors also have noted that the alliance failed to refer many eligible D.C. residents to the federal Medicaid program.
Mr. Catania said that mistake has cost the city tens of millions of dollars since 2001.
D.C. Chartered Health Plan Inc., a health maintenance organization, is the private health plan charged with administering and processing applications and payment claims for the alliance.
A recent internal Health Department review by Consortech, a copy of which was obtained through the Freedom of Information Act, showed D.C. Chartered Health has improved aspects of its claims processing, but major problems remain in ensuring that doctors, clinics, pharmacies and hospitals are paid on time and accurately.
“Review of the policies and procedures governing the claims receipt, validation and payment for the alliance program is lacking in organization, completeness and content,” the study by Consortech reads.
Despite the estimated $1.2 billion annual spending on Medicaid and about $100 million for the alliance, many city residents have trouble getting adequate health care, according to a recent study conducted by the nonprofit District of Columbia Primary Care Association.
The association found that nearly 300,000 residents live in areas with too few doctors’ offices or clinics, with the highest concentration of providers situated in higher-income sections of Northwest and too few located east of the Anacostia River.