Goal: Coverage that won’t soak taxpayers

Medicaid reform is necessary. People must be persuaded to better manage their own health so the state, in return, can offer viable options for the needy. Read opinions by the AJC Editorial Board; Joseph A Parker, president of the Georgia Hospital Association; and others. Then tell us what you think.

By the AJC Editorial Board

“I don’t want to see services that have been put into place deteriorated in any kind of way.”

— Blake Fulenwider, deputy commissioner, Georgia Department of Community Health.

Georgia has the right goals for Medicaid reform. Now it’s up to state officials to do the right things.

That’s a non-negotiable necessity when it comes to revamping the program that handles health services for 1.7 million Georgians, more than a third of whom are children or aged, blind or disabled.

It’s not hyperbole to characterize this group as a vulnerable population. As The Atlanta Journal-Constitution reported this month, Medicaid’s ranks include far more than the poor and their children. Participants include the elderly who’ve spent down savings gleaned during their working years, as well as the mentally ill.

Designing and providing a reasonably comprehensive care plan for these folks may well prove less costly than relying on a disjointed assemblage of clinics, hospital emergency rooms and even jails to fashion a patchwork of under-coordinated care.

That’s not to say Medicare is cheap. It is not, carrying a fiscal 2011 cost of $7.8 billion in Georgia. That makes it tempting for policymakers and politicians alike to fixate on bottom-line costs. Left lurking in the footnotes can be the human tally in pain and suffering induced by poorly designed or administered or just plain inadequate programs.

It’s likely the revised system expected to be announced this summer will expand use of for-profit companies to manage care, as is done now for children and pregnant women.

Care providers and patient advocates worry, with good reason, that expanded use of managed care could cause patient care and provider reimbursement rates to suffer. That should not happen.

It’s the decent and responsible thing for the state to adequately fund Medicaid and ensure that ends aren’t made to meet primarily through slashing benefits provided. Smarter care shouldn’t equal cut-rate care.

Last week’s announcement that Georgia’s Medicaid program is facing a $300 million shortfall in the coming fiscal year points out the tough job ahead — one we must do well.

That’s not to argue that effective cost controls aren’t necessary. They are. Getting the best value for taxpayer dollars is as essential as achieving significant improvements in the health of Medicare enrollees.

State health officials seem to be on board with that creed, which is good. A consultant’s summary for the Georgia Department of Community Health noted that, “Healthier individuals will have more productive lives and may lead to decreased program costs.”

The temptation to overpromise and under-deliver could prove strong because the challenges facing Medicaid are many. The report prepared for DCH, for example, outlines nine possible scenarios for redesigned Medicaid programs. We face a complex set of problems involving entrenched systems and entrenched human behaviors. This can’t continue.

In the end, the state must find ways to convince people to make better health care choices and become active participants in managing their own health or that of those they’re responsible for. A current and accurate bureaucratic phrase for achieving this result is managing the “whole person.”

In return for that acceptance of personal responsibility, the state must offer viable options to care for the needy in our midst.

Getting there will be easier said than done, but it must happen. We must continue to pare back growth in Medicaid costs. Smart, coordinated care must be offered. By doing both, we should save money and improve the health of at-risk Georgians.

Andre Jackson, for the Editorial Board.

Managing care will fix what ails Medicaid

By Joseph A. Parker

Gov. Nathan Deal and state health officials are calling for reform to Georgia’s Medicaid program. Georgia hospitals agree that change is needed. The challenge is how to do it.

The reform process began last year and we applaud the governor and Department of Community Health Commissioner David Cook for seeking input from all key stakeholders, including hospitals. We are committed to working together to find the right solutions for our patients and our communities.

As recently reported by the AJC, Georgia hospitals have major concerns with the current Medicaid managed care program implemented by the Perdue administration in 2006. Three for-profit, out-of-state insurance companies were charged with managing the care of low-income women and children in the Medicaid population by keeping them healthy and reducing the need for high-cost health care settings such as hospital emergency rooms.

However, the state’s own data shows that these companies haven’t effectively managed patient care. Instead, they’ve simply ratcheted down payments to health care providers, resulting in widespread dissatisfaction among doctors and hospitals frustrated by increased administrative burdens coupled with lower payments.

Despite these concerns, it is highly unlikely that these companies — known as care management organizations (CMOs) — will be leaving Georgia any time soon. The state simply doesn’t have the resources to abandon the current model and start over. We understand that and pledge to work with the state to reduce unnecessary costs and administrative burdens for providers, increase accountability for the CMOs and ensure that Georgia’s low-income women and children receive high-quality care.

However, hospitals’ biggest concern in this reform process is a proposal by the state’s consultant to shift the rest of the state’s Medicaid population — the aged, blind and disabled — into this same managed care arrangement. Simply put, this would be disastrous for everyone involved.

Before the first patient is seen under this new system, Medicaid CMOs would carve out anywhere from 10 to 15 percent of the funds currently used to pay hospitals, doctors and nurses for their own administrative costs and profits. We estimate this would amount to $450 million to $675 million a year.

To make matters worse, placing Georgia’s aged, blind and disabled into the CMO program would trigger a federal regulation resulting in an immediate annual reduction of $250 million in state and federal funds that go to Georgia hospitals and nursing homes.

Of this $250 million, about $100 million goes directly to Georgia’s teaching hospitals, such as Grady Memorial Hospital, that have physician residency programs. These programs are integral to ensuring an adequate physician supply in the state. In addition, cuts of this magnitude will hurt Georgia’s economy. Fifty percent of every dollar hospitals receive for providing care goes to salaries and job creation.

The loss of hundreds of millions of dollars annually will hurt not only our patients, but our employees and communities.

Finally, the aged, blind and disabled population has multiple chronic conditions that require true care management, and we believe that medical providers — not out-of-state insurance companies — have the experience, expertise and compassion to improve health outcomes for patients and achieve long-term savings through improved care management. Furthermore, the infrastructure is already in place to make it happen.

Thanks to Gov. Deal’s leadership and commitment to improving Georgia Medicaid, we have the opportunity to serve as a national model in creating an efficient, effective Medicaid program. But to do that, we must truly focus on managing care and keeping people healthy — not merely cutting payments to health care providers.

Joseph A. Parker is president, Georgia Hospital Association.

On the record: ‘Consider the options for redesign’

From the Georgia Department of Community Health’s “Medicaid and PeachCare for Kids Design Strategy Report”:

“States are increasingly looking towards new and innovative ways to decrease costs, focusing on providing benefits more effectively with greater administrative efficiencies rather than focusing solely on traditional cost containment strategies.”

“Factors outside the control of DCH, including health care reform, will also shape the future of Medicaid and PeachCare for Kids. For example, Georgia potentially faces major growth in Medicaid enrollment. These factors may create significant change in the Georgia health care marketplace and in Georgia Medicaid.”

“DCH is now ready to ‘take stock’ and consider options for redesign. There are opportunities to improve quality of care for members, contain costs, and make budgets more predictable. When designing the new Medicaid programs and services, there are opportunities for Georgia to address some of the current provider and member frustrations.”

“For Georgia to progress to the next stage of evolution, it will need to employ more rigor around contract monitoring, oversight and accountability to achieve successful outcomes and assure value. Monitoring contracts under a value-based purchasing model shifts the focus from monitoring structures and processes to monitoring outcomes — or measuring the value of the services that Georgia has purchased.

“The physician shortage must also be considered in any redesign effort. This includes both how the redesign itself can help to assure access for members despite the shortage and how the redesign might help to reduce physician workloads and incent physicians to participate in Medicaid and PeachCare for Kids.”

“Medicaid is one of the most expensive public programs in Georgia. Given limited budgets in a challenging economy, the State must have a Design Solution that is cost-efficient and has budget predictability.”

14 comments Add your comment


June 15th, 2012
8:46 pm

More clinics, opened 24-7, staffed heavily with doctor’s assistants, would save a fortune in money, and lives.


June 16th, 2012
6:32 am

Let’s face it, hospitals have made their money for years by performing unnecessary tests and treating non-emergency ailments in the ER at emergency prices. They hate any kind of coordinated care because people go to their doctor instead of to the ER, which cuts into their bottom line. Hospitals needs to figure out a way to change with the times instead of moaning and complaining about their pipeline of patients being cut. When people are getting care at doctor’s offices instead of ERs, thats good for everyone (except for the fat cat hospital CEOs making seven figures).


June 16th, 2012
3:09 pm

If more emphasis is placed on Fraud enforcement and expansion of its use into Medical provider of services versus the lip service of concentration of fraud by some legislators on recipients where fraud is small in size of dollars versus huge amounts of dollars paid incorrectly through fraud by the providers of service. A sizable chunk of these misused funds could be recouped and placed back into the general fund for better use. However campaign donations are far more important and whats a little fraud anyway?


June 16th, 2012
5:22 pm

No doubt the poor will be screwed. Most doctors already refuse to take Medicaid patients; even doctors associated with theoretically liberal institutions like Emory game the system by doing things like taking only 1 new Medicaid patient a month. The fact is most doctors are overpaid but they are essentially on strike against handling low revenue patients. Never-mind that the practice of medicine changed from a calling to a way to become a millionaire only after the advent of Medicare in the 1960’s. The medical profession is fully vested in this philosophy now and will not change without the retirement of the financial predators and their replacement by a new generation who again find medicine a calling. This will come about only when all the docs are put on payroll (a generous one to recognize their skill and training) and the education of those who want to become medical professionals and who are competitively competent is paid for by govt. scholarships. This plus the continued expansion of fields such as Physicians Assistants and Registered Nurse Practitioners under the same plan should put “health” back into healthcare. Medical associations, which operate like unions, and restrict the training of potential competitors should be stripped of these powers. Other industrialized countries do this and have much better health records than we do while their medical professionals still live quite well. Predators can use their genius to become stock brokers or hedge fund managers instead.


June 17th, 2012
1:24 am

yuzeyurbrane @ 5:22 pm – Unfortunately your statement about physicians and medicaid patients is not completely true. Your statement maybe true for some physicians that practice within the I-285 and metro Atlanta area. The only reason that is so, is there are far more commercially insured patients that live and work inside of I-285.

The majority of the physicians in Georgia that practice medicine outside of I -285 and Metro Atlanta, their operations Live and die on the number of Medicaid patients they treat. The majority of those practices would not survive without regular payments from this particular State Program, period. Your comment About Emory is incorrect as well. Am not sure you exactly where you are finding all of your information. However my friend, you are being misled and lied to GREATLY.

As far as your comments on the other providers of service, I agree. that is where the savings and future of healthcare is headed in order to reduce the overall healthcare costs.

Most Physician Medical Associations in Georgia and across the nation oppose this expansion and its use, unfortunately for all of US! Just inquire with good ole Dr. Phil Gingrey and Dr. Tom Price Republican Congressman from Georgia they will explain why its not a good idea! :)

How fast can you say………. Well Heeled Campaign Donors Oppose! So goes the Congressmen.

Money cannot buy you love, but it sure can buy you a more favorable decision of support.


June 17th, 2012
9:45 am

Why is it wrong to insist that taxpayer dollars are spent in a cost-effective manner? Even the Andre Jackson writing on behalf of the liberal AJC Editorial Board recognizes that effective cost controls are necessary. Oh, and (heaven forbid) personal responsibility in terms of managing our own health is suggested? My how far the AJC Editorial Board has come in understanding that there are limits on the amount of taxpayer money available to be spent on entitlements.


June 17th, 2012
12:04 pm

Here is something to consider for the physician shortage..also some things to consider to help defray to cost of medicaid to the tax payer.

1) Make provider’s student loans forgivable depending on the number or % of medicaid patients they see. If providers borrow money from the government to go to school, then they agree to accept a certain number of medicaid patients. If they agree to this condition, then their student loans are forgiven over a certain period of time.

2) Start a sliding scale copay for patients on Medicaid. Some of these people can pay and should. They have Droids and I-phones in their pockets. It is time of medicaid patients to start putting skin in the game. The tax payer can no longer fully subsidize the cost of health care for orthers. The tax payer who has private insurance is paying more and more. The insured tax payer pays an increased premium (a hidden tax) because you have too many indigent care patients not paying…so hospitals cost shift and insurance companies respond by making the premium go up in addition to the taxes they already pay for the program.

3) Limit the number of visits for Medicaid on children. I know that sounds harsh, but patients on this do abuse the ER for runny noses and very minor issues. If a patient presents to the ER there should be a mandantory co-pay if the physicain or healthcare provider deems there is no emergency. If there is not emergency, then the patient need to pay the copay to help defray the cost and the patient/parents should be penalized or have substracted the number of visits per year.

This sounds harsh, but the system is not sustainable. Just because someone has medicaid does not mean or translate into access or even quality of care.


June 17th, 2012
12:47 pm

Jay, Unfortunately, Your solution of number #2 is already a tried and tested process and it failed miserably. In theory it seems workable, however in the real world it has proven to be a complete failure and totally unenforceable. You must remember the majority of these recipients are receiving these much needed benefits due to the lack of money. Most are struggling from day to day to keep food on the table and a roof over their heads. Its so easy to make cavalier proclamations when like you have never face such dire needs. NO, this suggestion does not work! period.

As far as your number #3, not only is it harsh, but it is downright MEAN,NASTY, HEARTLESS, and CRUEL and certainly not Christian at ALL!
why is that people like you and others who think this way want to punish the most
DEFENSELESS, INNOCENT and HELPLESS victims of this entire situation.

I would be willing to say you are probably a Republican and an ardent PRO-LIFE supporter too!

Why do you want to punish the children for being sick? Most physicians know and understand that if they are presented with a sick child, The majority of them are going to treat that child that is before them. How could one take a look into a childs eyes and can see the obvious discomfort and say NO! I am so glad that it is not you in that emergency room providing care. I am certain if you took a look at your own child and see that he or she is not feeling well. You as parent will do any thing to get help to make that child better. It really saddened me to come to the computer on a SUNDAY morning of all mornings to see such a outlandish comment to be applied for any child in this great NATION! You should be on your knees begging for God’s forgiveness for such selfishness and cruelty. if I were your spouse or child, I would certainly be concerned about your level of caring for sure.

Why not take a more realistic approach by pursuing those who cheat the Medicaid system first. the biggest dollars in this area can easily be found in those who provide the most volume of services. That is the area where the most biggest dollars are lost and the areas where money is taken from those who truly deserve most assistance.

The physician shortage is not something NEW! it has been that way for years and no one at the DOME is willing or able to do anything about it due to the amount of money that is being spent fighting any real changes.

Like you they are just as selfish and uncaring for a growing sizable population of Georgia’s citizens. there are workable solutions to all of these issues but they are never easy. but to put the blame and all of the responsibility on those who are already desperately in need is not the answer either.


June 17th, 2012
12:55 pm

Skeptical @ 9:45 am – I am not sure anyone on this faceless Editorial board is Liberal about anything. They too are just as complacent and agreeable to our decision makers just so they can have access and what is actually received is something altogether different from what is reported. Fair and objective reporting is something that has been missing from the very soul of this organization and many others like it for some time. like everything else its about profit!


June 17th, 2012
2:06 pm

I, too, have been horrified when at the ER seeing nonemergency children and elders getting treatment on my dime. I say “my dime” because medicaid/peachcare/medicare all get supplements from our taxes, and many of us pay our health insurance premiums and copays and deductibles in addition.

I remember one time an older couple was there. The wife had a sore throat, and didn’t want to wait until morning to go to the dr.s office. Another time, a woman and her child were waiting. The child felt bad and had all day, but mom didn’t want to wait at the drs. office so she came to the ER for “quicker” treatment.

The rest of us, unless very wealthy, cannot afford unlimited trips to the dr, hospital, specialists, therapists, yet this is provided for Peachcare patients, at no cost at all (no premiums) until they are 6.

One thing I think will help is to attach a price to each instance of excessive care used. The rest of us have to make health decisions based on cost–we ALL should.


June 17th, 2012
2:35 pm

catlady @ 2:06 pm – Yes I agree Patient abuse does happen as with anything else. A similar example can be sighted by any Insurance Payor around the Nation even those who have coverage. Despite the occurrence we cannot truly justify abolishing a process based on a few bad apples. Whats worst than that and pretty much goes unnoticed and unpunished is Providers of services billing and getting paid for services that the billing provider never performed. There is far more offenses of Fraud and money spent on that offense in the Millions of dollars, than the example you just espoused upon.


June 17th, 2012
4:07 pm

Bernie, I defer to your differentiation of health care providers outside the Perimeter. It sounds logical. However, I have excellent sources of info re my Emory Healthcare example. I do acknowledge that Emory pushes up its Medicaid treatment numbers by having its residents and some other doctors largely staff Grady which is certainly better than many other health care providers. However, I stand by my statement re games by which it claims to be seeing more Medicaid patients at its own facilities than it really does. It is not as bad for Medicare patients but similar games are starting with them as well. It is like some colleges that like to say that 99% of their students are on scholarship but don’t tell you that some of the scholarships are just a few hundred dollars a year. Show me the numbers of how many Medicaid patients are accepted and rejected and if rejection is only a rare occurrence, I will be pleased to render a mea culpa.


June 17th, 2012
4:31 pm

yuzeyurbrane @ 4:07 pm – I am no position to take a stance on either side, but what I do know is that Georgia DHS has gotten better oversight over such programs and your issues may not be as bad as YOU claim. However, the issue of Provider Fraud enforcement and oversight does need further expansion and strengthening for sure!

Can't afford it

June 17th, 2012
6:01 pm

i am one of many without insurance who will now be served by Medicaid starting in 2014 following Heath care reform. hope you guys are ready!