Center for Studying Health System Change

espondents did not view care for the indigent as a major problem in Indianapolis. Two factors underlie this perception. First, the local economy is strong and the statewide rate of uninsurance is reportedly below the national average. Second, respondents believe the local system of safety net providers is effective and provides adequate access to services for people without insurance.

MEDICAID

The Indiana Medicaid program covers approximately 140,000 Indianapolis residents, or about 10 percent of the MSA population. Medicaid coverage is relatively limited, with AFDC income eligibility set at 51 percent of the poverty level for a family of three. Only seven states have more stringent criteria.¹² Medicaid reimbursement rates for physicians and hospitals were reduced substantially in 1994. This reduction, along with delays in provider payments that occurred when Medicaid switched to a new computer system, reportedly led a number of participating providers to withdraw from the program.

Indiana’s first Medicaid managed care effort, Hoosier Healthwise, was a primary care case management (PCCM) program. In 1995, the state introduced a Medicaid HMO program in three geographic regions, including Indianapolis. AFDC recipients are automatically enrolled in either the PCCM program or an HMO option, depending on their choice of primary care physician.

Wishard Hospital, the Indiana University Medical Center and Methodist Hospital formed the Central Indiana Managed Care Organization (CIMCO), a not-for-profit managed care company, to engage in capitated Medicaid contracts in Marion County. St. Francis Hospital, five federally qualified health centers and a panel of 170 physicians also participate in CIMCO’s network. Until recently, CIMCO was the sole risk contractor in Marion County, while Maxicare served the rest of central Indiana. As of November 1996, about 17,000 Marion County Medicaid recipients were enrolled in CIMCO. In late 1996, the state added a second HMO option, Maxicare, to its contracting program in Marion County. This second option is expected to increase Medicaid managed care enrollment in central Indiana because of the larger number of participating doctors.

Several issues have arisen with respect to Medicaid HMO enrollment. For example, the auto-assignment process sometimes splits family members among providers in different neighborhoods. In addition, some enrollees have become confused about which providers they may use. As a result, community health centers continue to treat these patients without reimbursement from Medicaid, and some have experienced shortfalls that have affected their ability to cross-subsidize indigent care.

CARE OF THE INDIGENT

Several providers located in central Indianapolis serve the community’s indigent care needs. Wishard Memorial, the county’s public hospital, is the principal source of charity care, followed by Methodist Hospital, the Indiana University Medical Center and St. Francis Hospital. James Whitcomb Riley Hospital is a major Medicaid and indigent care provider for children.

Indianapolis has two safety net clinic systems. The Marion County Health and Hospital Corporation runs five community-based neighborhood health centers, each of which serves about 17,000 patients annually, and manages the Citizens Health Corporation, a federally qualified health center that serves approximately 8,500 patients annually. Methodist operates HealthNet, a system of five federally funded clinics that see approximately 19,000 patients annually. The People’s Health Center is the most recent addition to HealthNet, with a total user population of approximately 11,000. In addition to Marion County and HealthNet, the Gennesaret free clinic provides outpatient care to about 3,000 homeless persons. The St. Francis system also opened the St. Francis Neighborhood Clinic in February 1997 to provide primary care services for the uninsured.

Political support for Wishard Hospital is strongin part, some respondents speculated, because other providers do not want to inherit its Medicaid and indigent care burden. Several years ago, under new leadership, HHC initiated a major reengineering of Wishard Hospital, using federal Medicaid disproportionate share funds to renovate the physical plant and institute a major consumer service initiative. These changes have helped Wishard compete effectively for Medicaid patients. Wishard is now developing a "virtual HMO" model to manage indigent care more effectively. Uninsured patients who present at the hospital or affiliated clinics will be tracked by its information system, assigned to primary care providers and receive a membership card and handbook. This model is designed to improve the overall coordination of care for the uninsured population.