For-profit companies paid billions of taxpayer dollars to coordinate medical care for poor children and pregnant women on Medicaid excel at paperwork but fall short when it comes to improving the health of patients, a recent report concludes.
The findings come as the state prepares to expand the so-called “managed care” approach to 430,000 elderly, disabled and mentally ill Georgians who need much more complex and expensive care.
“They’re not doing a very good job at what we expect them to be good at — health care,” said Eric Jacobson, executive director of the Georgia Council on Developmental Disabilities. “Now we’re asking them to take on a whole different kind of service and expect them to have better outcomes.”
State health officials — who commissioned the report — and executives of the companies involved say that while the report reveals the need for improvements, the program has enhanced the quality of care and saved Georgia’s financially ailing Medicaid program hundreds of thousands of dollars.
“WellCare does what is necessary to help our members access the right care, at the right time, in the most appropriate setting,” said Julie Pulliam, a spokeswoman for WellCare, one of three care management organizations, or CMOs, hired by the state to oversee the care of 1.2 million Medicaid members.
In 2011, the CMOs successfully met state and federal documentation and compliance standards, according to the quality review report. As a whole, however, the CMOs met only a few of the more than three dozen performance targets set by the state, including dental visits for children and immunizations for adolescents, the report shows.
The CMOs improved from the previous year in several areas, such as chlamydia screenings and physical activity counseling. But reviewers found the companies’ performance significantly lacking in many others.
Fragmented care and inadequate treatment plans led to delays in care, according to the report by Health Services Advisory Group, which reviews Medicare and Medicaid programs across the country. Disease management programs lacked goals tied to clinical guidelines. Patients struggled to get access to medical specialists, especially in rural areas.
Most notably, the report found, the CMOs as a whole failed to meet any of the 10 performance targets related to comprehensive diabetes care. They all also fell short of cervical and breast cancer screening goals.
Despite the mixed results, the Department of Community Health will begin early next year to shift Medicaid’s so-called “aged, blind and disabled” population into a more limited form of managed care that will be optional.
Families and advocates for families fear outside organizations may cut services to be able to make a profit on such expensive patients. They also question whether medically-based companies will be able to provide help with housing, job training and other social services people with physical and mental disabilities need to live productive lives in their communities.
If they’re already having problems, Jacobson said, “what does it mean for folks with disabilities who are going to be more difficult to serve.”
Savings cited
Georgia turned to the managed care approach in 2006, hiring WellCare, Amerigroup and Peach State Health Plan to coordinate the overall care of mostly low-income children and pregnant women on Medicaid. The goal: keep people healthier and save the ailing government health program money by emphasizing prevention and other methods.
Other states have used the same strategy to deal with ballooning Medicaid costs.
Making sure patients have regular preventive screenings helps avoid expensive emergency room visits and hospital stays. Coordination among primary care doctors, specialists and other providers can cut down on duplicated services and medication mix-ups.
The state pays the CMOs a lump sum for each patient, thereby limiting Medicaid spending. It’s then up to the companies to figure out how to pay for patients’ care and still make a profit. The CMOs received roughly $2.7 billion in fiscal year 2010, state data shows.
The CMOs saved Georgia at least $400 million between 2007 and 2011, according to the community health department. The state spends roughly $2.5 billion on Medicaid each year with the federal government chipping in billions more.
An outside organization reviews CMO performance each year measuring access to care, children and women’s health, management of chronic conditions, behavioral health services and medication management.
Amerigroup performed best in the most recent review, though the CMOs outperformed each other in certain areas.
WellCare is working to improve in a variety of ways, including focusing more on outreach to members, using telemedicine and a new incentive program for primary care doctors, Pulliam said.
Pam Keene, a spokeswoman for the state community health department, noted that the CMOs have outperformed the more traditional Medicaid model used for other members not in managed care. In that model, Medicaid patients go to the emergency room or doctor when necessary without any one provider taking a big-picture view of their care.
‘Right direction’
Both WellCare and Amerigroup have expressed interest in the state’s plan to move elderly and disabled Medicaid members into managed care. Other companies can also compete for the business.
Amerigroup’s parent company, WellPoint, coordinates care for people with disabilities in other areas of the country, spokeswoman Maureen McDonnell said.
The state is expected to ask for proposals from companies this summer. Keene emphasized that the new program will be optional and the state will pay for each service a patient receives, not a lump sum as it does with the current CMOs.
Meantime, advocates say they will continue to keep a close eye on the state’s efforts.
The focus needs to be on improving people’s health in the long run, not short-term savings, said Cindy Zeldin, head of advocacy group Georgians for a Healthy Future.
The question is, she said, “what can the Department of Community Health and policy makers do to actually address that?”
The old health care system wasn’t working but the state needs to be cautious, Jacobson said.
“We’re probably moving in the right direction,” he said. “But we’ve got a lot of bumps along the way.”
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