Group Agrees On Final Plan For Health Coverage Project

Associated Press, September 23, 2005

CHARLESTON  - West Virginia's Affordable Insurance Workgroup reached a consensus Thursday on the framework of a final plan for a pilot project to offer uninsured residents prepaid, primary care coverage through community-based health centers and private physicians' offices.

The group also continued looking toward ways to better control rising costs in the health care system.

"There are too many patients that I see in my office that can't afford health care," said Dr. Vic Wood, who developed a clinic-based health care program in Wheeling that has served as a model for the pilot.

About 80 to 90 percent of the average patient's needs are covered through primary and urgent care, Wood said.

"This will give access to primary care and urgent care at a fixed cost," he said. "Families can budget ... They know how much they're spending."

Up to eight sites would participate in the pilot and would determine patients' prepaid fees. The project would be regulated by the state insurance commissioner and the state Health Care Authority.

Workgroup members chose to include a "lookback" that limits businesses participating in the pilot plan to those that have not provided group coverage during the preceding 12 months. That restriction could be waived if employers provide a high deductible or catastrophic policy similar to the state's Small Business Plan.

The lookback or "crowd-out" would not apply to people seeking individual coverage for themselves or family members. It is meant to ensure that businesses do not abandon existing and more comprehensive plans, workgroup officials have said.

The pilot would offer prepaid coverage for primary care including diagnostic testing, emergency services and urgent care, immunizations, chronic disease management, routine gynecological care, dental care and preventive services.

Some group members have said additional services such as mammograms should be included. But not all clinics have the necessary equipment, others said.

Participating sites must be able to describe their referral relationships for more specialized care, the group decided.

"We don't want to have just Lone Rangers out there," said attorney Tom Heywood, the workgroup's chairman.

The workgroup is expected to deliver a proposal to Gov. Joe Manchin by Dec. 15.

Meanwhile, the group will continue looking at cost containment options for the state's health care system.

If the state focuses only on expanding coverage without addressing escalating costs, "It's going to ultimately be affordable by nobody," Heywood said.

Health care infrastructure is a major cost concern, said Health Care Authority Chairwoman Sonia Chambers, whose agency saw about $1 billion worth of certificate of need requests last year from hospitals to build, renovate or add services.

"That's a pretty staggering amount," she said.

Workgroup member Gail Bellamy raised concerns about the high cost of technology, as well as potential effects of a pent-up demand from patients who are part of newly expanded health coverage.

"They are going to start using services they have been postponing," Bellamy said.