1) How did you come to be appointed the Medicaid Commissioner?
2) You know Gov. Bentley well, but what did he say to you to convince you to accept this job?
I have known the Governor for over 60 years and over the past three years or so we've talked about ways to develop affordable health insurance, either with an exchange or by other means, and a portable health record. I think we both understand each other on what we think about health care and health insurance. I still check with him every few weeks to be sure we're in agreement on issues but overall we continue to share the same opinions on health care. As a result of that personal history, he asked me before the Republican Primary if I would go to Montgomery with him and I said 'absolutely not'. He didn't mention it again until after the primary and again I told him 'no'. But after the second time, I couldn't sleep for three nights. I couldn't get it out of my mind. My wife and I discussed it and after we prayed about it for two to three days, I came to the conclusion that if he wanted me there, I couldn't refuse. There have only been a few times in my life when God's direction was unmistakable and this is one of them.
3) What are your priorities for Alabama Medicaid?
During my first month at Medicaid, I discovered that we were not where we should be with our information technology. Our enrollment system was 30 years old and we were hampered in our ability to share information both inside and with other agencies outside Medicaid. Due to the funding streams from CMS, Medicaid had become the default agency for the development of the IT infrastructure for both the Insurance Exchange and the Health Information Exchange since 2009. I made the decision early on that the development of our IT system had to be our primary initial goal in order for the agency to meet the demands of the fundamental changes going on in Medicaid and health care.
Since that first month, three additional priorities have come up as a result of some research done for us by Auburn University Montgomery and UAB.
First, we will consume about 35% of the FY12 General Fund Budget. If current trends continue, it is estimated that we will require about 92% of the General Fund Budget by FY 2020. That cannot happen.
Second, because of our economy and the Affordable Care Act, we anticipate an increase of around 500,000 new enrollees in Medicaid by 2014. Our average monthly enrollment will be in excess of 1 million Alabamians in 2014. As a result we estimate that we will need an additional 1,000 primary care providers to meet the need.
Third, due to the technological changes, the demands of a changing health care system and the limits of the state personnel budget, we are facing a critical need to redefine the agency work force.
Therefore, our three new emerging priorities are to: 1) Address our needs from the General Fund budget; 2) Recruit more physicians to participate in Medicaid; and 3) Redefine our work force essential to our agency mission.
Overall, my intention is to make Medicaid a meaningful service and not a demeaning experience for patients.
4) Are there any opportunities to outsource or privatize any aspects of Medicaid?
Commercial managed care has never been used in Alabama that I know of but we do recognize that they are very effective in reporting outcomes data that reflects their efficiency and the quality standards achieved. To that end, we have developed three pilot programs modeled after North Carolina's Patient Care Networks that will give us the features of a managed care program and at the same time keep all of our spending in Alabama. Based on North Carolina's experience and the experience of a similar program in South Carolina, we feel we can get the same savings with our programs that would be realized with a commercial managed care program.
We are, however, developing an RFP for outsourcing our Non Emergency Transportation network. It will free up some agency personnel to help me meet my third priority mentioned above.
5) Are there any other states with Medicaid programs that might be good models for Alabama?
Basically, if you have seen one state Medicaid Agency, you've seen one state Medicaid Agency. Due to economic, political and socio-cultural factors, every Medicaid Agency is unique. We do share ideas and programs that one state may copy from another but it always has to be modified for the circumstances of that particular state.
For example, in 2009, Alabama developed a unique method of reimbursement for pharmacies using average acquisition costs (AAC). This has enabled us to gain control of the rate of increase in pharmacy payments. We have been successful to the point that our system is now being adapted for use by Oregon and CMS. Also, our Patient Care Networks are modeled after North Carolina and we are one of about 30 states who are developing PACE programs for care of the over 65-year-old dual eligibles.
6) What is your projected budget shortfall for next year and how do you foresee funding it?
In FY2012, our original internal estimate was that we would need about $700 Million from the General Fund. The Governor has committed to protect Medicaid since it is essential to the existence of the entire health care system in Alabama. Under his leadership, the agency was able to find new efficiencies to reduce the general fund need to $643 Million. Working with a cooperative legislature, we were able to secure the necessary funding for Medicaid for FY 12. We feel that the new programs we are initiating will be adequate to effect the General Fund savings we need to have.
7) Are there opportunities for innovation and cost-savings in Medicaid?
Yes. I am anxious to see how the new programs will affect our bottom line. The pharmacy plan, the Patient Care Networks and the PACE program are new and their full effect on the budget is yet to be seen. We feel we can build, modify and expand those programs in the next two years to maximize our savings.
I believe that there are additional savings available but you know as well as I do that there is a political component as well as a financial component to budget cuts. We saw this all too well in the last legislative session. A lot of the decisions to cut benefits, especially to state employees and teachers, were painful and difficult to make. The same will be true with Medicaid.
8) How have you found CMS in your negotiations?
Without doubt, the most pleasant surprise I found when I took office was the depth of expertise and experience of the senior and executive staff at this agency. Their working knowledge of Medicaid and CMS along with their experience and contacts with CMS continues to impress me. We have a very effective working relationship with CMS when problems arise. I cannot take any credit for that, it is the professionalism of the agency staff.
9) What unique perspectives does your background as a physician give you for your current role?
As I have said in other interviews with my professional colleagues, the one most valuable asset I have brought with me to this job is the ability to do a history and physical. Dr. Tinsley Harrison was right; if you listen, the patient will tell you what's wrong. I have found that if you will listen with an open mind, understand where you want to go and ask the right questions, you can figure out pretty quickly what needs to be done at Alabama Medicaid.
10) As a physician, what advice would you give Alabama physicians and hospitals for their interactions with the Alabama Medicaid Agency?
My advice to Alabama physicians and hospitals is to pay very close attention to what happens with the federal budget and be prepared to change. Just as we have had to make extensive shifts in our technological thinking over the past 30 years, we need to be prepared to make paradigm shifts in our medical finance thinking over the next 20 years.