MEDICAID REFORM Overview of Stakeholder Meetings

1. MEDICAID REFORM Overview of Stakeholder Meetings November 10, 2004 DCH Board Meeting

2. Stakeholder Meetings • Began with a legislative leadership meeting on August 23, 2004 • Met with statewide professional organizations and advocacy groups on August 24, 2004 at the Governor’s Mansion • A total of seventeen meetings were held from September through November, with over 275 healthcare leaders and advocates in attendance. • DCH has met with over 375 participants for the purpose of unveiling a plan to reform Medicaid and to collect input, suggestions and concerns. Georgia Department of Community Health

3. Legislative leadership Georgia Society for Managed Care VHA Managed Care Council Georgia Chapter of the American Academy of Pediatrics Georgia Academy of Family Practice Hometown Health North Georgia Dental Society Georgia Dental Association Georgia Dental Society Georgia Alliance of Community Hospitals Georgia Optometric Association Georgia Association of Community Services Board NAMI Georgia Metro Therapy Providers, Inc. March of Dimes Georgia Chapter National Kidney Foundation of Georgia Georgia Hospital Association Georgia OB/GYN Society Medical Association of Georgia American College of Physicians Georgia Pharmacy Association Grady Health System Georgia Children's Hospitals Covering Kids and Families Coalition Georgia Association for Primary Health Care Georgia Department of Human Resources Governor’s Advisory Council MH/MR/SA National Mental Health Association Georgia Mental Health Consumer Network Physical Therapy Association of Georgia Georgia Speech, Language and Hearing Association Other Behavioral Health Associations Who we met with… Georgia Department of Community Health

4. Here’s what we heard… Georgia Department of Community Health

5. Plan Governance • Require liquidated damages • Provide access for providers to come directly to the State with plan issues • Limit or cap plans’ profits • Re-invest program savings into healthcare infrastructure Georgia Department of Community Health

6. Carve-outs Most groups shared a desire to have the services they provide carved out by either: • Continue direct fee-for-service on a statewide basis • Regional approach • Pilot approach Georgia Department of Community Health

7. Member Issues • Access to healthcare services may be reduced • Member outreach and education is vitally important • Member responsibility for healthcare is a concern • Inappropriate ER utilization • Desire to see State create an ombudsman function for mental health • Concern that plans will deny needed healthcare services to members • DCH needs to more strictly enforce eligibility • Plans should require cost-sharing by members Georgia Department of Community Health

8. Provider Payment Issues • Provider reimbursement (FFS vs. Capitation) • Reimbursement levels for out-of-network providers • Concern that plans will overuse administrative denials and interfere with a provider’s cash flow • Desire for the use of standardization across the plans • Establish definition of a “clean claim” to comply with Georgia Prompt Payment Laws • Fear that plans will reduce reimbursement rates • Fear that plans will sub-capitate to providers • Desire to see State as a guarantor if a plan becomes financially insolvent • Loss of supplemental funding from UPL/IGT program • Need for Tort Reform Georgia Department of Community Health

9. Provider Network Issues • Concern that traditional community providers will be excluded from networks • Desire for DCH to mandate “Any Willing Provider” networks • Appropriate number and mix of specialists and sub-specialists • Assurance that, at least in rural areas, specialists can serve as primary care physicians • Plans should have a “real time” local physician advisory committee • Providers’ appeal process related to activities by CMOs • Consistent Utilization Management strategies across all plans • Concerns with administrative complexity • DCH should not allow members to seek healthcare outside the state Georgia Department of Community Health

10. Pharmacy • Fear of lowered dispensing fees • The potential State loss of pharmacy rebates associated with managed care • Fear that independent pharmacists may lose market share to larger chain pharmacies, under a plan • Interest expressed in the provision of case management and primary care services by pharmacists • DCH should not allow mail-order pharmacy services Georgia Department of Community Health

11. DHR Issues • Future role of county health departments • Future role of Community Service Boards • Managed care program impact on eligibility staff (DFCS) Georgia Department of Community Health

12. Questions & Comments Georgia Department of Community Health