Thanks to Carolyn Ingram from the Center for Health Care Strategies for serving as the keynote speaker for Georgians for a Healthy Future’s 4th annual Health Care Unscrambled policy breakfast event! Carolyn’s presentation described opportunities for flexibility with respect to the Medicaid program and provided illuminating examples from a handful of states taking innovative approaches. Carolyn’s presentation is available here.

CARE-M is a coalition of organizations who advocate on behalf of vulnerable populations, patients, and health care consumers in Georgia (Georgians for a Healthy Future is a member of the coalition). The coalition was formed shortly after the Georgia Department of Community Health (DCH) announced plans to explore redesigning Georgia’s Medicaid and PeachCare for Kids (CHIP) programs to ensure that the voices of these patients and consumers were heard in the process. Many CARE-M partners have been appointed to and serve on task forces and work groups convened by DCH to gain stakeholder input.

In May 2013, CARE-M released an updated version of its principles and concerns around Medicaid redesign, described below (you may also download this document in pdf format here).

CARE-M Principles and Concerns: Updated May 2013

CARE-M Principle: Improved healthcare outcomes for members should be the primary goal that drives changes to Medicaid. Improvement in the Medicaid system of services and supports will result in improved healthcare outcomes for the members.

Background — DCH’s Expressed Goals
o Enhance appropriate use of services by members
o Achieve long term sustainable savings in services
o Improve health care outcomes for members

CARE-M – Cross-cutting Concerns:

Concern 1: State Oversight and Accountability: Regardless of the details of any change or redesign, DCH must build and maintain adequate staff capacity and expertise at the state level to implement the plan, oversee operations, and diligently enforce contract requirements.

Concern 2: Medicaid Vehicle: As of Spring 2013 plans include using an 1115 waiver for foster children but a decision has not been made about whether or not an 1115 or a 1932(a) will be used for the Aged, Blind and Disabled populations. It is important that this decision be made soon and be communicated to stakeholders immediately. Regardless of the vehicle chosen it is critical to maintain the elements of care management that are working now and to consistently implement best practices.

Concern 3: Stakeholder Participation: Each population included in managed care must be fully engaged in designing, implementing, and monitoring the outcomes and effectiveness of the managed care program and be empowered to bring issues occurring in care delivery forward to the attention of the managed care entities and the Department of Community Health. This involvement should not end with the awarding of contracts, but should continue with providing feedback on system performance and recommendations for plan improvement. In order to perform this role effectively, stakeholders need access to performance data and progress on established benchmarks. After integration has been implemented, consumer involvement should extend into ongoing monitoring through representation in standing advisory groups at both a state and local plan level.

Concern 4: Definition of Medical Necessity: The definition of medical necessity for persons under age 21 is statutory and requires that determinations be based on the needs of the individual child. Medical necessity standards for persons age 21 and over should be modified to include those home and community-based services that are necessary to support individuals in a stable way in their homes, whether in the community or in a long-term care facility, despite having been excluded under a prior narrowly construed definition of medical necessity.

Concern 5: Appeals and Independent Problem Resolution: Stakeholders must be certain that any managed care system implemented in Georgia includes an easily navigable appeal system that ensures full Medicaid rights. The managed care system must include an independent ombudsman who has expertise in the delivery of Medicare and Medicaid benefits to seniors and persons with disabilities, including Long-Term Services and Supports and Behavioral Health services. This ombudsman will assist beneficiaries with appeals and will identify systemic problems in the CMO and be able to bring those concerns to the agency authority.

For more information about CARE-M, click here.

On Friday, July 13 the Georgia Department of Community Health (DCH) announced plans for next steps in the “Medicaid Redesign.”  Over the past several months, DCH has convened task forces comprised of stakeholders and advocates to formally provide input into this process. At the same time, advocates have come together as the CARE-M coalition to develop recommendations based on best practices for vulnerable populations. This redesign process is separate from but parallel to the conversations currently taking place regarding whether or not to move forward with implementation of the Medicaid expansion authorized by the Affordable Care Act. Ultimately, both processes will have a big impact on coverage and access to care for health care consumers throughout Georgia.  In a press release, DCH said:

“Today, the Georgia Department of Community Health (DCH) announced that it will move forward with implementing key recommendations from its Medicaid and CHIP (Children’s Health Insurance Program) Redesign task forces and workgroups. It will not, however, pursue wholesale restructuring of Georgia’s Medicaid program at this time because of increasing uncertainty at the federal level.”

According to DCH, the changes that the state will move forward with include: 

• Proceeding with at-risk managed care to serve Georgia Families members

• Transitioning children in foster care to one designated vendor statewide within the new Georgia Families program

• Maintaining Georgia’s current Fee-For-Service structure for ABD populations and services

• Moving forward with Home and Community-based Services Rebalancing. This rebalancing will help move patients from skilled nursing facilities to home and community based services.

• Begin utilizing a value-based purchasing model. Value-based purchasing will allow DCH to continuously improve the quality of care for our members while better engaging our providers and ultimately containing costs.

• Creating a one-stop portal will improve accountability and efficiency. Specifically the portal will give health care providers better information about their members and their medical history, streamline their credentialing process, and present providers with a measurement of key performance metrics and allow them to monitor quality and outcomes compared to their peers.

• Creating a Common Pharmacy Preferred Drug List that will simplify the program and reduce administrative burden on providers

The Department has committed to continuing its work with the task forces and work group through the RFP process and past the go-live date.  As members of the Children and Families Task Force and Substance Use and Mental Health Working Group, Georgians for a Healthy Future staff will continue to provide a consumer voice in these discussions and will continue to advocate for greater access to care for Georgia’s most vulnerable citizens.  For more information about the redesign process, visit https://healthyfutprod.wpengine.com/issues/medicaid-and-peachcare-redesign.

Report spotlights ways to enhance health care for GA children

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New study sponsored by Voices for Georgia’s Children, Georgians for a Healthy Future

ATLANTA, Ga. – Two of Georgia’s leading health care advocacy organizations issued a report saying the state could significantly expand medical care to more than 200,000 uninsured children with administrative practices, coverage policies and technologies already being used in other states. (more…)