Years of budget cuts and soaring health care costs are spurring big changes to the state’s ailing Medicaid program, and they could affect how hundreds of thousands of Georgia’s most vulnerable citizens get medical care.
Starting next year, state health officials plan to dramatically expand the use of outside companies to coordinate overall care for elderly, disabled and mentally ill Georgians who are some of Medicaid's most complex and expensive patients.
The goal: curb rising health care costs and improve care by shifting to a “managed care” approach in which the companies take a big picture look at peoples’ medical needs — from ensuring they are taking medicines for chronic conditions to arranging rides to regular check-ups.
Advocates worry that private companies out to make a profit could end up limiting patients’ access to critical services as they look to hold down costs. State health officials say the managed care program will be voluntary and focused foremost on meeting patients’ individual needs, not just on saving money.
“We’re going to do it right versus fast,” Georgia Medicaid chief Jerry Dubberly said in an interview with The Atlanta Journal-Constitution.
Officials say the move stands to save the taxpayer-funded program money by emphasizing preventive care that helps keep people healthier and out of the hospital.
Better tracking patients can also lead to better sharing of information among doctors, which cuts down on duplicate testing, and fewer unnecessary trips to the emergency room. One Medicaid patient ended up in an ER 250 times in one year, Dubberly said.
“There are people who don’t know where to turn,” he said.
Expanding managed care could affect roughly 430,000 people with physical disabilities, the mentally ill, nursing home patients, and individuals with developmental disabilities, such as cerebral palsy, on Medicaid.
Some family members who have struggled for years to form fragile networks of health care providers for such loved ones are anxious that care could get disrupted.
The state’s decision on a voluntary managed care approach comes after a more than year-long process to revamp the $7.8 billion Medicaid program using managed care companies. That effort was largely put on hold last summer amid uncertainties about the federal health care law and concerns among some that the state was moving too fast.
The state already uses for-profit companies to oversee care of 1.2 million mostly pregnant women and children on Medicaid. But care for people with disabling physical or mental conditions that keep them in bed or wheelchairs is often far more complex and expensive — requiring not just medical care but help with housing, job training and other social supports.
This population represents one-quarter of all Medicaid members but accounts for more than half of spending. Average per-person costs for this group are nearly $10,000 a year, compared with $3,000 for mothers and children.
The managed care plan currently in the works is more modest than proposals debated last year.
For one, while Medicaid beneficiaries will automatically be placed into managed care, they will be able to opt out.
The state will also continue to process individual claims rather than paying managed care companies a lump sum for each Medicaid member. Some states take the latter approach, but critics say companies could cut services to save money.
While advocates are relieved people won’t be forced to participate in the program, concerns remain.
They worry medically-based managed care companies may not be able to provide the social services that are critical to helping the mentally ill and disabled live successfully in their communities instead of institutions. There’s also concern about how companies plan to make a profit on patients whose care is so costly.
“Anyone who goes into this thinking there’s money to be made with mental health, that’s going to be a real disappointment for them if they do it right,” said Ellyn Jeager, head of public policy and advocacy for Mental Health America of Georgia.
Similar concerns have been raised across the nation as a growing number of states faced with severe budget constraints have begun shifting high-cost Medicaid members into managed care.
Many advocates fear forprofit companies hired to manage care will try to cut or deny services. That can be avoided if state contracts have standards and penalties that hold companies accountable, said Matt Salo, executive director of the National Association of Medicaid Directors.
“If what you’re doing is skimping (or denying services) … you’re going to get hammered,” Salo said, adding that states must have enough money and staff to oversee those contracts and hold companies accountable.
In Georgia, companies that want to manage Medicaid care will submit proposals to the state this summer. They will have to be able to provide both medical and social services, Dubberly said. The goal is to have the program in place by early 2014, he said.
Meantime, advocates are anxious to hear more details of how the program will work. Allowing members to opt out is a good feature, but there are still lots of questions, said Linda Lowe, a consumer health advocate.
“The plan could improve care,” she said. “But we’re not letting our guard down.”
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