Disagreement raged in the Republican party over a new Medicaid bill.

Intro: A Cape Girardeau Republican emerged as the leading critic on the opening day of Missouri Senate debate on the administration's plan to restructure the state's Medicaid program that provides health care coverage for nearly one million Missourians.

Amy Becker takes us into the Missouri Senate.

The attack came from Cape Girardeau Republican Jason Crowell.

Senator Crowell started by questioning the bill's sponsor, Republican leader Charlie Shields about the bill's provision for a statewide committee that would reward higher Medicaid payments to health care providers that had good outcomes for their patients.

Crowell argued that Medicaid patients themselves should be allowed to pick what their doctors and hospitals:

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CROWELL:In other programs like the food stamp program for instance, we as government chose not to, we gave dollars to teh individual. Those are redeemable not at the government warehouse, but at other places and other freedoms that are out there. Now we can control what happens with those, you can't get liquor with it, you can't get tobacco with it and things like that. But we don't create a whole new bureaucracy.

SHIELDS: You know, I'm open to new ideas. Maybe you do let the consumer pick, as far as I'm concerned when I'm paying for it, I want to reward the nursing home that has fewer pressure sores and fewer infection rates that drive cost up because they end up sending their people to the hospital. That's who I want to reward. If you want to say we should pay them all the same, I guess we could do that but that doesn't make any sense to me.

The debate between the two Republicans emerged a bit later over a provision in Shield's bill that would require a recipeient to go through a health coordinator or as the bill calls them "a health care advocate," who would be paid a flat fee per patient to control access to medical care.

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Description: SHIELDS: When we talk about coordinating care plans, they will get paid per member per month and they have to improve the health of the person and they have to keep the person happy.

CROWELL: That is so vague. That is so vague.

SHIELDS: It's a lot better than the Fees for Service, where they don't have to do either one right now.

CROWELL: In the end, the great thing that works for Fee for Service is that if I have choice and I have options, then I don't go back. I think thats a direction that is more philosophically in line. I mean you and I may disagree. I happen to support choice in education, I pretty much support choice in everything except abortion. I think that the more choice in the options you have you can basically, achieve that in a direction and get the same desired result not by the way you define happiness or the way I define happiness, but how that individual patient defines his happiness.

SHIELD: You say the presentation I saw last week, Let's talk about fever service and choice. We had somebody that choice to go to the physician office 124 times in two years and when they weren't choosing to go to the physician office, they chose to got to the emergency room 117 times in that two years. Basically in that two year time period it equates to every fourth day they are in the ER or physicians office. and that's their choice, you paid for it. But that was their choice. The bad part was we didn't give them the choice of someone helping to manage their care to learn why they were in the ER every fourth day or why they're in the doctor's office every fourth day. We only pay for them to go see the doctor. Of course we only pay the doctor to treat the illness, we don't treatthem to counsel them or teach them. We don't pay for a health care advocate who would help them make better decisions. But they do have choice, they choose to go to the office once every four days or they choose to go to the ER once every four days.

Shield's bill is designed to focus on paying for prevention of an illness and management of health care rather than focusing on paying only the illness itself.

Reporting from Jefferson City, I'm Amy Becker, KMOX News.

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The administration's Medicaid plan came under immediate attack from memebers of both political parties.

Amy Becker has more from Jefferson City.

A part from Democrat oppostion, Senate Bill 577 that introduces Medicaid reform had oppostion from the other side of the aisle.

Southeast Republican Jason Crowell questioned the idea of setting reimbursement rates for doctors based on the quality of patient outcomes.

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Description: I would say you want to invest that in the individual patient and give as much choice and as much freedom to that individual patient and then they can vote with their own dollars. Rather than have a government system come out and pick winners and losers on a vast playing field.

But the bill's sponsor Republican leader Senator Charlie Shields said the difference was that Medicaid-- it's the state that is paying the bill, not the patient.

What's called the pay-for-performance provision is one of several designed to hold down the rising costs of Medicaid health care coverage.

From the state Capitol, I'm Amy Becker.