As Providers Weigh In, State Officials Continue Review of Medicaid and Peachcare

Atlanta, GA – In part to prepare for the new federal healthcare law, state officials are considering major changes to Peachcare and Medicaid, Georgia's health insurance plans for children and the poor.

In 2014, hundreds of thousands of Georgians will be newly eligible for the two insurance programs. A recently-released report commissioned by the state explores how to expand them amid tight budget times.

Health advocates and providers have already expressed concern over several recommendations in the report that call for more patient coverage under care management organizations, or CMOs, which are set up to control costs and coordinate patient care within provider networks.

While most Medicaid recipients are currently covered under one of Georgia's three CMOs, about a quarter still receive fee-for-service coverage, which allows patients more control over their own care but places less emphasis on preventative care.

Kevin Bloye of the Georgia Hospital Association says Georgia's current managed care system is broken. It underpays doctors and creates administrative hastles over what procedures are necessary.

"These care management organizations are very good at managing and ratcheting down costs and payments to healthcare providers but have not fulfilled their promise to actually manage the care of Georgia's Medicaid population, keeping them out of the hospital and keeping them healthier," said Bloye.

Bloye wants the state to cut down on bureaucratic red tape and model North Carolina, which has a single, physician-run CMO.

Georgia Department of Community Health commissioner David Cook agrees that Georgia's managed care system could be less burdensome. He says despite the negative connotation of managed care, it's still the best way for the state to control costs while driving quality measures.

"I don't think the provider community disagrees with well managed care," said Cook. "The question is what are the guidelines that you're using, are they appropriate guidelines, and are they being administered in a way that's not a 'gotcha' mentality or to just deny care because of costs."

Cook says he's open to looking at North Carolina's system, but cautions that Georgia - barring a federal waiver - is required to run at least two CMOs. He also says the North Carolina model has too many unknowns in terms of tracking quality of care and keeping costs down.

Still, Cook says all options are on the table. He says since the report was released last week, state officials have been in dialogue with GHA and other provider groups about redesign options.

"The challenge is going to be what kind of system can we design that's going to drive quality, that's going to help coordinate care and costs in what right now is a fractured system," said Cook.

State officials are reviewing options into the spring and will issue a final recommendation to the Governor in April.