Possible Changes to Georgia Medicaid and their Affect on People who have Bleeding Disorders

Horizons in Hemophilia, May 2012

By Michelle Putnam, MPH, Associate Director of Research and Advocacy

If I were to ask you, who is the largest payer of health care services in the United States, what would you say? Blue Cross Blue Shield? United? Maybe Cigna?

Nope.

The answer would be the United States Government. The combined Medicare and Medicaid programs, which pay for health care services for the elderly, disabled, and low income people, cover about 90 million people in the United States. Medicare covers health care costs like doctor's visits, hospitalizations, and prescriptions for people 65 and older. Medicaid covers health care costs for low-income people, mostly pregnant women and children and the aged, blind, and disabled. It covers 1 in 3 births in the country, and is one of the largest safety net systems for low-income working families.

Because Medicaid is based on income, it makes sense that as a recession occurs and people lose their jobs, many more will sign up for the program. This, of course, requires that both the state and the federal government spend more money to cover more people. Some states, like Georgia, which have experienced very high unemployment over the past few years, are experiencing declining revenue and increasing expenses, and are looking for ways to cut state budgets. Unfortunately, the Medicaid program is frequently on that list of cuts.

Georgia is once again looking at overhauling its Medicaid system, with the main goals being to save money and to transition all of its enrollees into managed care.

In 2006, Georgia decided that the best way to save money on its Medicaid program was to institute “managed care.” The state began paying a fee to companies (many of them are subsidiaries of large national companies) to manage the care of its Medicaid enrollees. Each company gets a set amount for each person and controls when the person sees a physician or specialist, which doctors are in network, and which medications the person can take. The state transitioned only pregnant women, children, and low-income people into managed care.

Over the past five years we have learned first-hand how managed care can negatively affect people with bleeding disorders. We have seen clients who were denied access to factor, or were visited by nurses not skilled in infusion.

This past year, the state consulted with an outside agent to determine if it should move its entire Medicaid population into managed care, including the elderly and people with disabilities. These are the people who need health care services the most, and require the best comprehensive care to manage their conditions. It can be somewhat easy to manage care for those who are young and healthy, but transitioning those with behavioral issues and chronic disease requires much more forethought and planning, and many managed care companies do not have the experience in caring for people with rare, complex conditions.

Care management is not a new concept in health care, as people with bleeding disorders know. Hemophilia treatment centers have long been an example of the quality of care that can be provided when a comprehensive team of physicians, nurses, and social workers help people take charge of their own care. Managed care companies, however, have historically lacked the experience and nursing staff to adequately assist their members who have bleeding disorders.

It is of concern that if everyone on Medicaid is transitioned to managed care, large national companies will dictate which specialty pharmacy you use, and may limit your network of providers. We encourage you to reach out to the state and tell them how the comprehensive care within the HTC has benefitted you and that preserving access to a wide, diverse network that includes specialists, nurses, social workers, and the pharmacy of your choice helps you stay healthy and productive.

Advocates and consumers from across the state have contacted the Department of Community Health to ensure that the Medicaid redesign does not negatively affect those with complex or rare conditions, like bleeding disorders. But, the more voices, the more impact, especially when it comes to a rare condition like hemophilia.

You can share your thoughts about the redesign on the Department of Community Health's website: https://dch.georgia.gov/00/channel_title/0,2094,31446711_180745696,00.html

If you would like to share your story or have questions about Medicaid policy or Georgia's redesign, please email Michelle Putnam at mputnam@hog.org.