healthcarejournalbr.com | September / October 2008 Issue |
Healthcare Journal of Baton Rouge
41
far we've had interest from hospitals, some physician
groups, and LSU. So I think what you'll have is a market-
place where everybody makes choices about which plan
is best for them and then we publish the outcomes of
those plans. Our role as a state then goes from just pay-
ing claims to regulating and monitoring those plans.
The other piece of this is fraud and abuse. Attorneys gen-
eral from all over the United States claim that about ten
percent of Medicaid spending is fraud and abuse. In
Louisiana that's about $700 million a year, assuming our
Medicaid budget is $7 billion. That's a lot of money. By
bringing in coordination of care, by having these net-
works, there are several requirements they are going to
have to meet. One of these is to have a fraud and abuse
detection system in place. We currently have a Medicaid
program integrity unit, that's literally made up of a dozen
or so people, which monitors tens of millions of claims. By
the time we figure out someone's stealing from the sys-
tem, they've already stolen the money and they're gone.
By having partners in that, we're casting a much wider net
and we're using some principles from the private market-
place to help.
We are also going to require that every plan be invested
in the medical home model so that every Medicaid con-
sumer has a primary care medical home. We also want to
have a robust utilization management program in place.
We need to make sure we identify someone who's been
using the ER for healthcare and make sure they know that
it's better to go to a primary care doctor's office. Those are
all things that we are going to be putting in place with this
concept. It's not just HMO's. In a lot of states, HMOs have
been the solution. In Florida, where I came from, 60 per-
cent of the Medicaid population was in HMOs. However,
just bringing HMOs into Medicaid the way other states
have done, I don't think is a solution for Louisiana. I think
it has to be something a lot more purposeful, that's more
outcomes driven. This isn't about saving money. In fact,
our proposal is not to say, okay this is where we stand
today and by putting people into coordinated care plans
we can save five percent. We are going to take what we
are spending today and we are going to convert it to risk-
adjusted based premiums. So the sicker you are the more
resources you have; the healthier you are, obviously it
doesn't cost as much for your care. Then we will make
sure the plans have the resources they need to provide
these services. Over time the savings will occur if we just
change our trajectory a little bit.
SWH: What should providers expect in terms of a
change in reimbursement or reporting?
Alan Levine:
I think with regard to reforming the Medicaid
system, what providers can expect is not unlike what they
experience with the commercial marketplace today. The
good thing about moving toward the model we're dis-
cussing is it is more like the marketplace. The way that
Medicaid is today, we set the rates and there's no negoti-