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Medicaid plan a big step forward for primary care

Gov. Andrew M. Cuomo's Medicaid Redesign Team came up with a plan that could not only save us billions of dollars now and in the future, but provide better care to Western New York's most vulnerable residents and build the foundation for a more integrated, sustainable health care delivery system.

The heart of the problem is that we have a very fragmented, uncoordinated, yet expensive health care system that serves none of us very well, but poor people with multiple health and social problems least of all. Fully 75 percent of Medicaid funding -- or $31 billion statewide -- is spent on 20 percent of patients with multiple chronic illnesses, HIV/AIDS, mental health and substance abuse problems -- and often all of the above.

Fewer than half of these high-cost patients have a dedicated primary care provider, and care for most patients is sporadic, reactive and uncoordinated. Indeed, a Medicaid patient with diabetes and mental illness may visit four different health providers, each prescribing medications, ordering tests, yet never communicating with each other. If the patient is hospitalized -- and they often are -- there is no easy way for the doctor and hospital to share information. This lack of coordination is costly -- both in dollars and the toll it takes on patients. In Western New York nearly 20 percent of all hospitalizations costing $47.3 million could have been avoided. New York State spends an estimated $1.4 billion per year on avoidable hospitalizations, and has the highest rates in the country.

The Medicaid Redesign Team plan calls for enrolling 1 million Medicaid patients in a "medical home," where a physician is part of a "care team" that takes active responsibility for the patient's health -- even when the patient isn't in the doctor's office. Information is shared among providers through electronic health records, and patients have access to clinical advice 24 hours a day. The payoff could be enormous. North Carolina's Medicaid program --less than one-quarter the size of New York's -- reduced asthma hospitalizations by 40 percent and saved the state almost $600 million over five years.

The medical home is an important first step toward an integrated health care system with new roles and responsibilities in the work force. Right now, workers who have the most contact with patients have the least responsibility for their health. Home care workers, for instance, have more patient contact than anyone else, yet little interaction with the patient's physician or care coordinator, the least amount of training and the lowest wages.

The Medicaid Redesign Team plan charts a course to more rational health care decisions, new models of care that emphasize prevention and coordination and a more accountable, affordable health care system that will benefit patients across the state.

Ronda Kotelchuck is executive director of the Primary Care Development Corp., a nonprofit group that expands primary care in underserved communities.

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