Sciarillo W, Borenstein P E
Baltimore Healthcare Access Inc, Baltimore, Maryland 21202, USA.
Matern Child Health J. 2000 Dec;4(4):261-9. doi: 10.1023/a:1026699706365.
To present Baltimore City Health Department's (BCHD) experience in developing and operating an ombudsprogram for Maryland's Medicaid Managed Care HealthChoice Program as an innovative public health response to its MCH Title V assurance functions.
This paper presents a case study that 1) describes Baltimore City's Consumer Ombudsman and Assistance Program (COAP) in terms of development, function, structure, and resources; 2) provides a summary of its first 30 months' experiences, both quantitatively and qualitatively; and 3) describes COAP's successes, value, and limitations with respect to its three essential roles--a) conflict resolution for individuals, b) education for consumers, providers and advocates, and c) catalyst for quality improvement.
Over 1300 cases (involving enrollment, access, billing, and treatment issues) were referred to COAP by the State's Complaint Resolution Section during the first 2 1/2 years of HealthChoice. Ombudsman interventions resulted in conflict resolution for enrollees using a continuum of education, mediation and advocacy, and in generating systematic data for systems change through collaboration with state and community public health, managed care organization, provider, consumer, and advocacy officials and groups.
Public health ombudsprograms can effectively assist and educate enrollees; and provide concurrent, or real-time, information for consumer, provider, health plan, and advocacy groups, as well as public policymakers and legislators to better inform systems improvement and innovation. The community-based ombudsman role is an effective mechanism to ensure appropriate care for MCH populations and others with special needs. Such efforts can be funded by federal/state Medicaid administrative funds and are a sound investment in assuring access to comprehensive care for vulnerable populations.
介绍巴尔的摩市卫生部门（BCHD）在为马里兰州医疗补助管理式医疗健康选择计划开发和运营申诉专员项目方面的经验，该项目是对其妇幼保健第五条款保障职能的创新性公共卫生应对措施。
本文呈现了一个案例研究，1）从发展、职能、结构和资源方面描述巴尔的摩市消费者申诉专员与援助项目（COAP）；2）对其前30个月的经验进行定量和定性总结；3）描述COAP在其三个基本角色方面的成功之处、价值和局限性——a）为个人解决冲突，b）对消费者、提供者和倡导者进行教育，c）推动质量改进。
在健康选择计划的前两年半时间里，该州投诉解决部门向COAP转介了1300多起案件（涉及注册、就医、计费和治疗问题）。申诉专员的干预通过一系列教育、调解和宣传活动为参保人解决了冲突，并通过与州和社区公共卫生部门、管理式医疗组织、提供者、消费者以及倡导官员和团体合作，为系统变革生成了系统数据。
公共卫生申诉专员项目可以有效地协助和教育参保人；并为消费者、提供者、健康计划和倡导团体以及公共政策制定者和立法者提供同步或实时信息，以便更好地为系统改进和创新提供参考。基于社区的申诉专员角色是确保为妇幼保健人群和其他有特殊需求的人群提供适当护理的有效机制。此类努力可由联邦/州医疗补助管理资金资助，并且是确保弱势群体获得全面护理的明智投资。
