New Medicaid program off to a rough start in Georgia
By Rep. Jay Shaw and Sen. Tim Golden
August 28, 2006 -- Atlanta, GA -- On June 1, North and Middle Georgians covered by Medicaid and Peach Care for Kids – half of 1.2 million statewide – were herded into care management organizations (CMOs) with three private insurance carriers. On September 1, another 600,000 Medicaid recipients from South Georgia are will be moved into CMO coverage.

Known as Georgia Healthy Families (GHF), this initiative of the Perdue administration is the single biggest change in Medicaid since the health plan’s inception, reassigning primary care physicians for working poor families (mostly women and children). Prior to implementation, the state’s Medicaid program operated under a fee-for-service system in which healthcare providers were reimbursed for services they rendered to patients.
Less than two weeks before the program is implemented in our region, the new program is the subject of much discord among medical providers in other areas of the state who awaiting reimbursement for services.

At a meeting of the state Board of Community Health on August 10, dissenting officials expressed outrage over late payments and other administrative flaws that have riddled this new system. Medical practices were said to be going bankrupt. On August 15, a group of Georgia physicians filed suit against the CMOs, claiming the companies owe millions of dollars in outstanding claims to doctors, hospitals and other health care providers. The suit alleges the companies knew that they were incapable of paying for services on time when they bid for, and won, state contracts totaling $3 billion. Because of the companies’ delinquency, the plaintiffs in the suit said they have had to lay off employees and scale back on providing services to low-income residents on Medicaid. A day later, more than 100 health care professionals had a rally at the State Capitol to bring attention to these problems.

We also know that families are being warned that Medicaid services to their children may be reduced in areas such as physical and speech therapy. The Department of Community Health has decreased access to each therapy from 20 to eight units per month (from five hours to two hours) without a prior authorization. This represents a 60 percent decrease in therapy services prior to requesting a prior authorization. Since March 2004, this represents an 80 percent decrease in services.

Therapists in our area have been told that the CMOs will not have a list of their patients available until at least August 28, only a few days before the implementation date of September 1. It is unclear if these patients will be able to receive any services after September 1 until the prior authorization process is completed.

The combined effects of long-term reductions in federal funding, no additional state funding for the program for 4 years, a federally required, increased target caseload of children served by the program coupled with decreased Medicaid support and increased costs has placed the Babies Can't Wait program in Georgia in serious financial jeopardy.
“This (CMO system) is probably going to implode in about two years,” predicted one administrator whose hospital has been receiving late payments for the services it provides to Medicaid patients.

When GHF was first introduced it was embraced with cautious optimism. It was billed as a consistent alternative for patients, who were typically treated by numerous doctors. DCH officials asserted that Medicaid and Peach Care for Kids members would be provided the same services they previously received without seeing a spike in co-payments.
Additionally, DCH officials maintained that the program would mean an $80 million windfall, which would accompany the reduction of patients that make costly trips to emergency rooms because they would have a regular doctor to assist them at the first signs of illness.
In other words, this program administered by CMOs was supposed to reimburse primary care physicians in a way that rewards them for keeping a firm handle on the health of their indigent patients. That could include everything from reminding patients to keep follow-up appointments to more closely monitoring glucose levels in diabetic patients and the blood pressure and cholesterol levels of heart patients.

However, this impasse over reimbursements has raised some initial concerns. What the governor fails to grasp is that sound healthcare, like education, are wise investments in human-capital resources. By ignoring the well being of so many children, the state in effect sabotages our economic future. We need a healthy and educated workforce if we’re to be competitive in the international market, and according to recent reports Georgia ranks among the bottom in attracting new industry.

Most Medicaid recipients work very hard for low-paying jobs that don’t offer any benefits. In most cases, these families have nowhere else to turn for healthcare.

Between now and September 1, South Georgia Medicaid/ Peach Care for Kids patients can get information about the plan by calling 1-888-GA-ENROLL (888-423-6765) or by visiting www.gahealthyfamilies.com. We call on the governor and his staff at DCH to get these problems as soon as possible, so patients can be treated and doctors, hospitals and other health care providers can be reimbursed.

• Rep. Jay Shaw represents the 176th District (Berrien, Clinch, Lanier and Lowndes counties) in the Georgia House of Representatives. Contact him at P.O. Box 245, Lakeland, Ga.; by phone at 229-482-3505; or by e-mail at jay.shaw@house.ga.gov.
• Sen. Tim Golden is Chairman of the Senate Democratic Caucus, and represents the 8th District (Brooks, Cook, Lowndes and Thomas counties) in the State Senate. Contact him at 110 Beacon Hill, Valdosta, Ga.; by phone at 229-293-0202; or by e-mail at tim.golden@senate.ga.gov.