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

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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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The challenge of expanded Medicaid and the dearth of primary care physicians

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The shortage – current and future – of primary care physicians in the US has been a recurrent theme on both this blog and many other venues in journals and the blogosphere. In addition, several posts relating to the Affordable Care Act (ACA) have noted the difficulty Massachusetts has had since it implemented an individual mandate, with many more people covered and not enough primary care doctors to see them (Solving Medicare costs and the budget deficit: primary care, cost-effectiveness, and universal health coverage, Jan 5, 2011; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?, Apr 12, 2010). Apparently, there are a lot of states that will be in worse shape than Massachusetts, according to a study by Leighton Ku and colleagues in the New England Journal of Medicine.

In The States' Next Challenge — Securing Primary Care for Expanded Medicaid Populations (NEJM 10Feb2011;364(6):493-5) the authors look at the expansion of Medicaid mandated in ACA, to 133% of poverty for nonelderly adults by 2014, and note that this expansion will be far greater for states that currently have the most restrictive eligibility for Medicaid than those that have the most generous (e.g., Massachusetts). They note that this will require far more primary care doctors, and observe that many of these same states have the greatest deficit in primary care capacity. Using a creative approach, they create a “Medicaid expansion index” to identify how much a state’s Medicaid population will grow as well as a “primary care capacity index”. They standardized them so 100 was the average, and combined them to get a relative assessment of each state’s “challenge”; over 100 is worse than average, under is better. The scores ranged from 212.6 (Oklahoma) to 15.2 (Massachusetts, in fact!). Unsurprisingly, the states that face the greatest challenges are mostly in the South and Midwest, like Oklahoma, while the other states with low scores tend to be in the Northeast. Some of this is, as Ku notes, a primary care physician deficit in those states with high scores, while and much of it is a result of the fact that these high-score states have such limited current eligibility for their current Medicaid programs that they will have the largest number of newly-insured people.

The authors acknowledge that the “Access to care is determined in local service areas, not at the state level. Access problems could be more severe in rural or inner-city areas than in suburban communities, for example.” No doubt they will be; as many posts on this blog (e.g., Primary Care and Rural Areas, Apr 28, 2010) have noted, distribution of providers (not only physicians but nurse practitioners and other “midlevels”) is not even close to adequate, both for primary and subspecialty care. There are too few providers in the inner-city, but in rural areas the situation is worse -- 20% of Americans live in these areas, but well under 10% of doctors practice there. Only family physicians distribute in proportion to the population, but 20% of family physicians is not anywhere near 20% of doctors. Other primary care specialties, such as pediatrics, are very concentrated in urban areas (Primary Care, Pediatrics, and Physician Distribution, May 21, 2009).

Ku, et.al., express some guarded optimism, suggesting that expanded insurance coverage will support more primary care doctors – but note that the expansion also doesn’t begin until 2014. Given the long time frame to create physicians in any specialty, this will at best leave us with several years of shortages. And, at the current rate, “at best” is unlikely. The authors emphasize the need for training more primary care doctors, especially in the most “challenged” states, but really make no suggestions that are likely to have a significant impact, citing such things as expanded scope for “midlevels” (does not address distribution) and expectation that increased funding for Federally-Qualified Health Centers (FQHCs).

In the very next article in the same issue of the NEJM, Stephen R. Smith does make some suggestions for change that would likely produce more primary care doctors. In A Recipe for Medical Schools to Produce Primary Care Physicians[1], he starts with the admissions process, suggesting that admissions be MCAT (Medical College Admissions Test) “blind”, meaning that above a pre-defined minimum score, MCAT scores will not be considered (so that a student with a very high score is considered “more desirable” than one with just a high score). He emphasizes the need to select students “…who express a desire to serve underserved populations, who demonstrate altruism, and who are committed to social responsibility” because “they are more likely to go into primary care”. (However,expressing interest is not the same as actually having interest. See the experience of Pennsylvania’s Commonwealth Medical College. [2]) He suggests that the curriculum be based on a “patient-centered learning approach” with continuity follow-up of actual patients and teaching of “basic science” in the context of these actual patients. He urges that the entire curriculum be built around the competencies needed for a primary care physician, that students be taught in inter-professional teams, and that community-based settings be used for training.

These are all good ideas. They are consonant with recommendations I have made (of course, this makes them good :)!). While they do not look at “output variables” (mainly income/reimbursement), they do address the two areas over which medical schools have the greatest control – the students they admit (“input variables”) and the curriculum (the “process”). The suggestions that Smith makes have all been tried, and they all work to a significant degree to increase the number and percent of primary care doctors. At the University of Kansas, for example, we do have essentially “MCAT-blind” admissions, and look for the characteristics he suggests, among others, believing that such personal characteristics as caring, altruism, and communication skills are not only important for primary care, but for all physicians. The problem is absolutely not that we don’t know what works; we do. The problem is that we have, nationally, lacked the commitment to implement these strategies on a large enough scale to have a sufficient impact on the supply of physicians.

There are two big issues, though. Obviously, the first is that “output variables” – mainly the enormous differential in expected physician income – are not addressed. This is critical. As long as reimbursement policies by Medicare (see “Outing the RUC: Medicare reimbursement and Primary Care”, Feb 2, 2011) and other insurers dramatically favor subspecialists and especially proceduralists, there will not be enough primary care doctors. Indeed, the other “problem” medical students often identify with primary care – less than appealing “lifestyle” (read: “too much work”) is related to this; if you make a lot more per hour, you have to work fewer hours.

The other big issue is that Smith addresses his suggestions to the many new allopathic (“MD”) medical schools being currently created. He notes that these are (mostly, although not all) designed to increase production of primary care physicians (although, as noted in the footnote about the Commonwealth Medical College, even those may have trouble getting students who are actually interested in primary care), and he is correct that adopting his suggestions, among others, is more likely to keep them on that path. However, this is too simple; it forgives existing medical schools from fulfilling this responsibility, and they absolutely should not be so forgiven. This is particularly true for the most “elite” schools, many of them private and in the Northeast and very “selective” (indeed “selectivity” – the percent of applicants that you turn down – is a criterion for high rank by US News and World Report). Such schools are also the ones with the highest amounts of National Institutes of Health (NIH) research support, and pride themselves on producing researchers. Different schools, the refrain goes, have different mission; we produce “physician scientists”, somebody else should produce the primary care doctors (hey, like those “new schools!”).

The problem is twofold. First, these schools produce a lot of physicians, and they need to produce the kind of physicians that the community needs. Second, these schools set the standard for what most other schools want to be like – to be highly ranked by US News and get lots of NIH money. The last big expansion of medical schools, in the early 1970s, was also supposed to produce primary care doctors, but many or most of them immediately abandoned that mission and began trying to be like Harvard or Johns Hopkins. What needs to happen is that Harvard and Johns Hopkins need to look more like the University of Kansas, and produce a much higher percent of community-serving primary care doctors. In fact, so does the Warren Alpert School of Medicine at Brown University, where Dr. Smith works.

So, in case I haven’t been clear, two things need to happen:
1. Current physician reimbursement formulas need to be abandoned, and Medicare needs to adopt a reimbursement scheme that will result in primary care physicians having at least 70% of the income of subspecialists. Where Medicare leads, private insurers will follow.
2. All medical schools must adopt admissions policies that de-emphasize high exam scores and emphasize desirable personal characteristics, and lead to much greater diversity of students by socioeconomic status, geographic origins, and race/ethnicity. They need a curriculum that reinforces these skills, problem solving, independent learning, and communication. The elite private schools should take the lead; where they lead others will follow.

When? What should be the timeline? Immediately. Right now. No delays. Both should have been done yesterday.

[1] Smith SR, “A Recipe for Medical Schools to Produce Primary Care Physicians”, NEJM 10Feb2011;364(6):496-7 (online available only to subscribers)
[2] The Commonwealth Medical College in Scranton, Pennsylvania selected its students based on an expressed interest in primary care, but found that in their first class, on a pre-matriculation survey (before they even started school!) only 23% still said they wanted to be primary care doctors! (Tracy & Smego, “Discordance of Self-reported Career Goals of First-year Medical Students During Admission Interviews and Prematriculation Orientation”, Family Medicine, Jul-Aug 2010.
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