New York state is the New York Yankees of Medicaid programs, in John Rodat's view.

Like the Yankees, it's the biggest, most expensive organization in its league. And by some measures, like the number of people served and the pay it provides its employees, it is the best program.

But Rodat, a former state Budget Division analyst and health-care consultant, says the Oakland Athletics — as cited in the best-selling book "Moneyball" by Michael Lewis — would be a better model for New York to emulate: excellent results at a modest cost.

"The Oakland A's are a small-market team, but they win as much as the Yanks,'' he said. "If we get into the playoffs for one-third the price, we'll be doing fine.''

Of course, there are no playoffs in Medicaid's league.

"In baseball, but not government, there is a clear sense of wins and losses,'' he said. Still, he said, there are ways to measure success — and ways not to measure success — in delivering health care.

"The goal of Medicaid was to allow the poor and elderly to access mainstream medicine. We succeeded," he said. "So we say, the more services we pay for, the more successful we are. That's silly. Money is not a uniform indicator of the quality of care.''

To support that point, Rodat points to a study done by a Dartmouth College medical professor, Elliott Fisher, which showed that despite a large per-capita difference in Medicaid spending between Manhattan ($10,550) and Portland, Ore. ($4,823), there was no difference in either the quality of care or patient satisfaction.

The study suggested that as much as a third of medical spending is wasted on services that don't improve the quality of care, and that some people would be better off if they saw their doctors less frequently.

Using fewer health-care services — and spending fewer Medicaid dollars — does improve the quality of life for clients of the Resource Center for Independent Living in Utica, the center's director said.

"From where I sit, people are getting many more services than they either need or want," said the director, Bert Danovitz. "The system captures people and the state keeps churning out Medicaid payments. It makes people very dependent, segregating them and costing everyone a fortune.''

He said the average cost of caring for clients in the community is about $14,000 a year, compared with between $70,000 and $111,000 for nursing homes.

Dealing with the system

One of the center's clients is Kirk Marshall, 44, who has been in a wheelchair since he fell off a porch 10 years ago and injured his spine.

After he was injured, he lived in a nursing home for two years. But with the help of a new machine that helped chronic bedsores to heal, he was able to move into an apartment.

But then he was told that the extra nursing care he needed to use the machine would be discontinued because it violated state regulations. He fought that ruling through a series of hearings and administrative procedures and eventually prevailed.

"They wanted me to go back to a nursing home, which would have been a lot more expensive and is where I didn't want to go," Marshall said.

Danovitz, Rodat and other experts say the state can save money, and improve care, by becoming more aggressive about trying to keep disabled people like Marshall out of nursing homes.

Members of a task force set up by Gov. George Pataki agree.

A key finding of a report it presented to Pataki in January calls for people who need long-term care to get information and counseling that will steer them toward options other than nursing homes.

"The system will support self-determination, promote personal responsibility, provide services that meet consumer demands, provide quality care and affordability," according to the report. A Senate task force issued a similar proposal a few weeks earlier.

Looking for savings

Danovitz said the reports are on the right track.

"I was pleased there's an acknowledgement that we're institutionalizing too many people,'' he said.

The recommendations also conform to a 1999 U.S. Supreme Court decision that requires states to care for the disabled outside of institutions whenever possible.

So far, the state has lagged on complying with that ruling, the chairman of the Assembly Task Force on People With Disabilities said.

The state did virtually nothing between 1999 and 2002, when the Legislature passed a bill requiring compliance, to figure out how to implement the ruling, said Assemblyman Kevin Cahill, D-Ulster County. Meanwhile, 40 other states were drawing up plans.

"While New York state was denying there was a problem, other states were developing a solution," he said.

But Deborah Rausch, a Pataki administration spokeswoman, said state agencies were working on implementation plans during that period.

An estimated 10 percent to 15 percent of nursing home residents could live in the community if there were adequate services for them, said Carl Young, president of the New York Association of Homes and Services for the Aging, a trade group. He said savings could be in the billions.

Even beyond nursing homes, Rodat said, the state could save money just by looking more closely at patterns of illness and treatment.

For example, in a study he did in 1992, he noticed that children in the southwest corner of Niagara County were five times as likely to be admitted to hospitals with ear infections than children elsewhere in the state.

He found out that the area didn't have enough primary-care doctors, so that a problem treated as a routine doctor visit elsewhere required an expensive trip to the hospital.

"There are huge differences in how health-care services are used around the state — differences that generally go unnoticed by the state Health Department," Rodat said. "We tend to work off aggregate numbers and averages.''

He added that the state could save money if it adopted the successful strategies used in some areas, like Niagara, where the county expanded managed care to provide better primary care for children. These strategies are known as "best practices.''

Pataki's top health adviser, Robert Hinckley, acknowledged that Rodat's analysis was valuable, and was being looked at in the changes that Pataki's task force wants to implement.

"Part of the goal is to adopt best practices," he said.