Tuesday, July 19, 2011

"Reforming" Medicaid, or Cutting Medicaid: No shortage of folks to cast the first stone


Jeff Colyer, MD, the Lieutenant-Governor of Kansas, has been leading an effort for Governor Sam Brownback to “reform” Medicaid for the state. This is of concern because the state faces the same budget crunches that are faced by most states and the relatively high cost of Medicaid as a percent of the state budget (about 22% in Kansas). Gov. Brownback wants to cut $200-400 M in Medicaid expenditures and is looking for ideas on how to do so. In the Fiscal Times, Blair Briody’s piece Medicaid’s Ticking Bomb Could Wipe Out State Budgets discusses the challenges states face with increased enrollment in Medicaid (6.5% in 2009) because of job losses resulting from the same economic crisis that has state revenues down. Of course, there is another solution, but (like most new Republican governors) Gov. Brownback and his legislature are firmly opposed to increasing revenues (ie, taxes)

Dave Ranney, reporting for the Kansas Health Institute, covered the second of two (so far) public forums, held in Wichita and led by Lt Gov. Colyer and attended by Secretary of the Department of Health and Environment Bob Moser, MD (Moser is a family physician; Colyer is a plastic surgeon). In Medicaid forum generates long list of reform ideas Ranney lists many of the ideas identified by working groups. They include:

• Enact policies that discourage non-emergency visits to emergency rooms.
• Remind families of their moral obligation to at least share in the costs of caring for frail elders.
• Reward behaviors that improve health. Discourage those that do not.
• Increase the numbers of nurse practitioners in the state’s rural areas.
• Let Medicaid beneficiaries know how much their services cost.
• Do more to promote “living wills” and hospice care, less to promote nursing home care.
• Limit families' ability to switch managed care providers more than once a year.
• Do more to encourage businesses to hire disabled people.
• Approach companies like Home Depot and Lowe’s about helping people with disabilities make their homes accessible; installing wheelchair ramps, for example.
• Foster home-like homes for frail seniors or disabled people who might otherwise move to a nursing home.
• Reduce the potential for fraud and abuse by not allowing family members to be paid for caring for elderly relatives.
• Close one or both of the state hospitals for people with severe developmental disabilities.
• Find ways to better coordinate patient care.

Something is missing from this list. That would be any suggestion that the state has a responsibility to provide quality health care to Medicaid recipients. Of course, that might cost a lot more, not less money. Some of these ideas are reasonable, like asking Home Depot and Lowe’s to help people, encouraging businesses to hire the disabled, and developing “home-like homes” (I love that; as opposed to ‘non-home-like homes’, or ‘home-like non-homes’?) for frail seniors and disabled people. They might even help some folks, but they are unlikely to save Medicaid much money.  Others, such as increasing the number of nurse practitioners in rural areas, are good ideas, but without a strategy that addresses how are of little use. Nurse practitioners do not locate in rural areas for the same reasons that physicians do not: because they are often from urban areas and can make more money in urban areas, particularly working in subspecialties rather than primary care. Paying them more to work in rural areas might be effective, but that also would cost more money.

Closing the state hospitals for people with severe developmental disabilities would probably save money, but only if adequate services can be provided for them in the community. Whoops, that will also cost more money. And that money will be vulnerable every year, especially when there is a budget shortfall. We have experience in this area. Several decades ago, across the country, we closed state mental hospitals because we could provide better mental health care in community mental health centers while giving the patients a better shot at a higher quality of life. Unfortunately, after “de-institutionalization” (as it was called), federal and state governments ratcheted down funding for community mental health services. The result? Lots of homeless, under-treated, mentally ill people. It is not clear to me that those with severe developmental disabilities will even do as well.

Doing more to promote “living wills” and hospice care might be good for many people, Medicaid or not, as would finding ways to better coordinate patient care. Of course, nursing homes are businesses, and state government wants to be business-friendly.

The most obvious characteristic of the list is that most of the suggestions fall squarely in the category of “blaming the victim”. They are mean-spirited and reflect a definite sense that the people who are receiving Medicaid are, by and large, irresponsible, manipulative, and wasteful. Certainly they are not anything like the people making the suggestions! Thus, we should limit their ability to change providers and we should emphasize the importance of families taking care of their elders (whether those families have any resources or not; whether they have families or not). In the cases where they do have families we need to reduce the potential for fraud and abuse by not allowing family members to be paid for caring for elderly relatives, enact policies that discourage non-emergency visits to emergency rooms, let beneficiaries know how much their services cost. How these would save money without hurting the health of beneficiaries is not made clear. What if the providers are not meeting the patients’ health needs? What if the frail elders (and here I assume that we are talking about people who receive both Medicare and Medicaid, known as “dual-eligibles”) do not have families, or if their families are without resources? What if they do have families and now those family members cannot go out and get a job because they are caring for frail elders but we won’t pay for it? And what is the point of reminding them what their benefits cost? It is presumably health care providers who order the tests and treatments, and these are based, presumably, on medical need.

It is actually, by and large, a pretty ugly list. Maybe we should remind the members of these citizens’ panels what their benefits cost. Are they paying out of their pockets for their health care, or do they have insurance? Is there anything more morally acceptable about receiving inappropriate, medically unjustified, non-evidence-based health care if one is insured by something other than Medicaid? Or is not receiving appropriate, medically justified, evidence-based health care more acceptable if one is on Medicaid? In my last post I cited the June 28, 2011 NY Times article, “New prostate cancer drugs extend lives but raise costs”, in which Andrew Pollack notes that Medicare is going to look into whether to pay for drugs that may extend life for a few months but cost upwards of $90,000 per course of treatment, but that “…some patient advocates and politicians portrayed the review as a step toward rationing.”  I hope that these are not the same people who are advocating rationing for those who are poor.

Because that is what Medicaid patients are. Poor. Not all poor people get on Medicaid, of course. In most states, including Kansas, only poor people who are children and their mothers, severely disabled people, or people in need of long-term care, are on Medicaid. Not undocumented people, not childless adults no matter how poor or in need of health care. But everyone on Medicaid is poor. If there were any poor people on these panels, whether or not they were Medicaid recipients, you can be sure that these suggestions did not come from them. There is not a single working-class, middle-class, professional or upper-class member of any of these panels who would want to change places with these poor people so that they can get Medicaid. It is so much easier to judge others.

The reality is that the most useful suggestions will not save much if any money, and most of the rest are mean. In an Op-Ed in the Wichita Eagle, state Rep. Jim Ward (D-Wichita) suggests that the cuts first “Do no harm”. He states it is from the Hippocratic Oath, which it is not really (see Physician Oaths and Social Responsibility, July 7, 2011), but it is a good idea. Another really good idea is close management of the sickest, highest-cost, highest-risk patients using health coaches or promotoras (such as those described by Dr. Atul Gawande in The hot spotters: can we lower medical costs by giving the neediest patients better care?” and discussed by me in Freedom abroad, health at home: experiments in preventive health care, February 13, 2011).

The necessary step to both maximizing health and minimizing cost is to have a single-payer system so that we are all in the same program, so that cutting your benefits cuts mine. Then we can make wise decisions on the most medically appropriate, as well as cost-effective, way to spend that money.

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