As the administrator at a large public hospital in South Carolina, I believe that Medicaid is critical to the health of our communities. This federal/state partnership pays the health care costs for many people, including low-income families, pregnant women and infants, and persons with chronic disabilities. One out of every five South Carolinians is a beneficiary of this program and half of all births in this state are covered by Medicaid.

As has been reported widely, Gov. Sanford and his administration have proposed to the federal government that some changes be made to the Medicaid program in South Carolina. I was asked by the Sanford administration to serve on an advisory group that reviewed these proposed changes.

This independent committee provided its input, and I write now, not on behalf of the advisory group or the Medical University of South Carolina, but simply to express my own personal opinion.

First, I believe that the current Medicaid system is badly in need of reform. This program now accounts for almost one-fifth of all state expenditures, and at its current rate of growth, it will approach a third of the state budget within a decade.

Clearly, as more state dollars flow to Medicaid, there is less money available for other essential state services, such as education and public safety. Every state in the nation is facing this same crisis and all are looking for solutions.

Above and beyond the financial imperative, I question whether the Medicaid investment is achieving the greatest possible return in terms of the health of the population served.

Too often, beneficiaries receive care from a variety of providers in isolated interactions with little or no coordination of treatment. Many Medicaid patients do not have a primary care practitioner, and therefore, are forced to use hospital emergency rooms as a source of care for routine problems. Not only is an emergency room an expensive place to deliver care, it is difficult to follow up on patients seen there to assure that the treatment achieved the intended results.

This is not the care that anyone would want for themselves or for their families. Those who have the best interests of Medicaid beneficiaries at heart should be seeking alternatives to the current system.

Whether or not one agrees with the particulars of the Sanford administration's plan, the governor deserves credit for taking on a difficult issue and for proposing creative solutions.

Some have criticized the administration's proposal as "out-of-the box" thinking. Rather than being a shortcoming of the proposal, I believe that its innovative approach is the most compelling reason to give it a try.

At the same time, I recognize that change is always frightening, even to those who acknowledge that change is necessary. In the present context, beneficiaries and their advocates may fear a loss of services and providers may fear a reduction in payments for services rendered.

Both sets of concerns are understandable, but to suggest that fundamental reform is not needed ignores the reality of the impending crisis.

Without getting into the details of Gov. Sanford's plan, several features are worth noting here. First, the plan allows more options for beneficiaries than does the current system. In general, Americans value choice when it comes to their health care and I believe that Medicaid beneficiaries should have choices as well.

Second, I applaud the effort to provide more Medicaid beneficiaries with a "medical home." Patients are best served when their care is delivered by providers who know them and follow them continuously. There is growing evidence that patients with chronic illnesses, such as heart failure or diabetes, can be managed more effectively in a coordinated program that prevents complications and unnecessary hospitalizations.

This type of disease management should be the norm rather than the exception for all patients with chronic conditions, including those enrolled in the Medicaid program.

I was grateful for the opportunity to review data and provide feedback to the administration on its proposed Medicaid plan. Many of the advisory committee's suggestions were incorporated into the revised plan.

There will be further opportunity for input from the General Assembly, and ultimately, the changes will require the consent of the federal government.

As the process moves forward, I hope that the principles of personal choice and coordination of care, so central to the reform plan, will be preserved. The nearly one million South Carolinians enrolled in Medicaid deserve high-quality health care and I applaud any effort to meet their needs more effectively.

Raymond S. Greenberg, MD, Ph.D, is president of the Medical University of South Carolina.