13 INVESTIGATES: Medicaid in Alabama - Alabamas13.com WVTM-TV Birmingham, AL

13 INVESTIGATES: Medicaid in Alabama

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These little guys and gals are some of Alabama's sickest patients. Some of their families use Medicaid to pay for the high cost of months long stays in neo-natal intensive care units here at Northport Medical Center. 

Neonatologist, Guillermo Godoy said, "They have significant problems, bleeding in the brain, dependent on breathing machines, require very expensive intravenous nutrition."

One of those patients is Samuel Rowland. Born 14 weeks early, he's now seven weeks old.

Yamerys Rowland is his mom.

Samuel's Mom, Yamerys Rowland said, "Yesterday, I hold my baby for first time. It was like so amazing.  It was, I don't know how to describe the feeling (wipes tears) and I was so glad to hold Samuel."

Care for babies like Samuel can cost up to $5000 a day. That's according to the National Institutes of Health.

By 2016, how Alabama doctors and hospitals are paid to treat those who qualify for Medicaid like children, their moms, the very sick and others who meet eligibility requirements, will change.

Today reimbursement is fee based. That's where hospitals and doctors are reimbursed based on which services are performed on a patient like MRI's, various surgical procedures, mammograms, and more.

The new method will send an as of yet undetermined flat payment, per patient, per month, to care for a patient's needs to Regional Care Organizations or RCO's, which will then pay for services.

RCO's will coordinate the care and will manage patients by directing them to the most appropriate level of care, encouraging follow-up appointments, and look at issues that may be contributing to chronic health problems in five different regions of the state.

Cullman County and counties to the north are in Region A. Jefferson County and counties to the east are in Region B. Tuscaloosa County is in Region C, with counties to the west. Montgomery County and counties in the southeast of the state make up Region D, and the seven counties in the southwest, including Mobile are Region E.

Brian Massey is the administrative director of business development at St. Vincent's Hospital. Massey and his hospital were some of the players at the table making decisions on what Medicaid in Alabama will look like by 2016.

He has several concerns, this being a main one.

St Vincent's Hospital, Brian Massey said, "If a patient's care exceeds the amount, they're pulling from the state, you enter into a loss situation. The intent is to have enough people in your risk pool that maybe another patient won't have as much care need that year."

Massy's fear, hospitals will eat those costs, at least in the short run, when a patient's needs exceed what the state Medicaid office will pay.

Back in Northport, Samuel's neonatologist has a different concern – RCO's will be for-profit.

Dr. Godoy said, "That they don't put profit before care giving patients, that I hope they are morally and ethically inclined to do the right thing."

That's because, according to Dr. Godoy, so many Alabamians use Medicaid.

More than half of Dr. Godoy's NICU patients utilize Medicaid. And here at Northport Medical Center it's more like 60-80% of all patients use Medicaid to cover their health insurance.

Before the Great Recession in 2007, Alabamians who used Medicaid averaged just above 730,000 people.

Today, the average is more than 950,000 people.

Dr. Godoy said, "This area of the state of Alabama, we have a very high population that depends on the help of the Medicaid insurance."

With more than 20% of the state using Medicaid, there are certain expectations once the changes begin.

Massey said, "We want this to be implemented smoothly, and well, and without glitches."

Massey also believes as the state changes the way Medicaid is used, there will be winners and losers.

Massey said, "I do think physicians are in a good spot, because the exposure that they have in treating a Medicaid patient, we're talking primary care physicians, is not as great as hospital."

And Medicaid patients, according to the Alabama Hospital Association shouldn't worry about change in care although it will be different. The question remains how different, since there are still issues to be worked out, like how much the state will pay for each patient, which medical procedures will be included at the RCO level and changing anti-trust rules to allow a doctor, hospital and/or other health care entity to join together and set a fixed price for a health procedure or service.

But it will be the patients who will likely need the most guidance.

Alabama Hospital Association, Mike Horsley said, "And you're right, it does take sometimes education, some nudging for compliance. By nudging you mean making your appointments when you need them, getting checkups when you need them, getting prescriptions filled, all of the types of things that's going to contribute to your overall health."

And that's another reason for Medicaid changes - cutting costs in the long run by helping patients find primary care docs instead of using emergency rooms and looking more at preventative care, to keep Alabamians who are on Medicaid, healthier.

As for little Samuel, today he's healthier, and his mother believes he'll be alright.

Rowland said, "Yes, that's the most important thing, I got faith and I know the Lord's going to go miracles, he is already a miracle."

The next step in the Regional Care Organization timeline is for governing boards to be in place for each region. By law, they are supposed to be in place this time next year. The boards will be made up of providers, the public and investors.

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