Managed Care, Medicaid to Pair? State Looks at Pluses of Preventive Health Care for Poor

Article excerpt

Byline: Dave Williams, Times-Union staff writer

ATLANTA -- Nearly four years ago, the last managed-care program serving Georgia's poor and disabled shut its doors.

The Medicaid HMO at Atlanta's Grady Memorial Hospital couldn't make a profit because it couldn't sign up enough people and couldn't get sufficient reimbursement rates.

But to William Sexson, a neonatologist at Grady, managed care's failure wasn't just economic.

It also was a failure to adequately care for patients -- for the infants he treats in the intensive-care unit -- on the part of an industry ill-suited for the low-income families enrolled in Medicaid.

He's worried now that state policymakers appear headed toward bringing back managed care in an attempt to rein in soaring costs that are driving the Georgia program's projected deficits into the hundreds of millions of dollars.

"[Medicaid recipients'] approach to health care is different," Sexson said. "They go in for health care when something bothers them. Preventive care is not part of the mindset. That's not something the industry can fix."

But defenders of managed care say health maintenance organizations and their ilk have made great strides in the years since Medicaid HMOs pulled out of Georgia.

They point to the 42 responses to last winter's formal request for ideas on how to reform Medicaid in Georgia as evidence that managed-care companies are convinced they can do the job this time.

"When we tried this before, managed care was in an earlier, less mature stage of development," said Tim Burgess, commissioner of the state Department of Community Health.

"They've become more adept at education and screenings . . . I don't accept the premise that this is such a unique population that can't be managed."

Nationwide, the numbers bear out the commissioner's arguments. Enrollment of Medicaid recipients in managed care took off during the 1990s to the point that it has become the dominant form of health-care delivery in the joint state-federal program.

In Georgia, Burgess is working on a number of short-term changes in the Medicaid program aimed at addressing shortfalls estimated at $432 million this year -- including state and federal funds -- and $940 million in the fiscal year that begins July 1.

He is expected to propose to the agency's board next month a series of cuts that could include lower reimbursement rates to health-care providers, reductions in benefits and/or tighter eligibility requirements.

Beyond such short-term measures, Burgess also is developing a long-term "new model" for Georgia Medicaid that likely would be based on managed care. He said some of the new system could be in place as early as fiscal 2005.

Burgess said the new program probably would involve mandatory enrollment in some form of managed care. The previous Medicaid HMO system was voluntary, which led to the low enrollments that helped doom those efforts.

"If we're going into this and make it work, we don't want to make the same mistakes," he said. …