State embarks on disease management for Medicaid patients

ATLANTA - Patient advocates are worried that the state's decision to introduce managed care to Georgia's Medicaid program will leave recipients at the mercy of HMOs more concerned with profits than health care.

They're afraid that ongoing negotiations with the federal government for more flexibility in how the state spends its Medicaid dollars will lead to higher co-payments for an array of services.

With those and other controversial cost-cutting changes in the offing, the only element in Georgia's multifaceted overhaul of Medicaid that is winning universal support is disease management, an effort to keep closer tabs on patients with chronic illnesses that is being rolled out this fall.

"That's kind of the no-brainer of the Medicaid initiatives,'' said Rep. Jeff Brown, chairman of the House budget subcommittee that oversees health spending.

Brown, R-LaGrange, took part in a task force two years ago that did an early examination of Georgia's options for bringing soaring Medicaid costs under control.

"We felt that was the No. 1 opportunity for savings,'' he said.

The state Department of Community Health kicked off its disease-management program, christened "Georgia Enhanced Care,'' in August by awarding one-year contracts to two vendors with four renewal options.

APS Health Care will receive $8.8 million to serve Medicaid patients in the northern half of the state, including metro Atlanta.

United Healthcare will get $18.7 million to handle central and south Georgia.

Despite the difference in payments, the two will serve roughly the same number of patients - about 50,000 aged, blind and disabled Medicaid enrollees - and each is expected to produce about half of the $42 million in savings the program is projected to achieve during its first year.

In fact, when they signed on the dotted line, the two companies promised to reach those targets.

"If they don't save us money, we don't pay them anything,'' said Community Health Commissioner Tim Burgess.

A simple concept

Disease management is designed to save money as well as improve the health of chronically ill patients by more closely monitoring their conditions.

People with diseases that can be kept under control with medication - including high-blood pressure, asthma, hemophilia and schizophrenia - are encouraged to take their medicines on time and in the proper amounts.

They also learn how to avoid acute episodes so they don't end up in an emergency room or being admitted to a hospital.

It may sound simple, but it's not happening today for Medicaid patients, said Joseph Parker, president of the Georgia Hospital Association.

"Most of them don't get care when they need it, and when they do, it's in the emergency room,'' he said. "Just keeping people out of the ERs saves a lot of money.''

Burgess said limiting the disease-management initiative to the aged, blind and disabled - a small percentage of the 1.5 million poor and disabled Georgians covered by Medicaid - was driven by the nature of managed care.

He said the state decided to keep that group out of the managed-care program that is being extended to most Medicaid recipients.

"That industry doesn't have a track record we were comfortable with in moving the aged, blind and disabled into managed care,'' he said.

Consumer advocate Linda Lowe said the jury also is out on the two companies chosen for the disease-management initiative, even though both have experience in other states.

"Everybody agrees that people with chronic illnesses are not necessarily receiving very good disease management,'' she said. "But we really don't know how these companies are going to do it. ... How much regular contact are patients going to have with human beings?''

David Hunsacker, president of APS Public Programs, said his company will go well beyond the 24-hour call centers disease-management programs typically offer patients.

While APS will have one of those, he said the company also will place nurses inside health clinics and emergency rooms for face-to-face contact with patients.

"We're the first in the country to co-locate nurses with high Medicaid-volume provider practices,'' he said. "We'll have all the advantages of a central office but also be present in these communities.''

Hunsacker said the reason disease management is so popular is that, unlike managed care, patients aren't being screened for coverage decisions.

"There is really no down side to this,'' he said. "It has no authorization or denial aspects at all. It's additional service.''