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The Enemy of My Enemy: Medicaid

As a physician, I treat Medicaid patients in New York City. Perhaps to your surprise, I can say with assurance that my patients receive good care. Those looking for a bottom-line may read no further. For those interested in the details, I will add that their good care is not without extraordinary efforts on both their and my parts, and there is no relief in sight.

Medicaid has become one of the most hotly debated issues in health reform. Almost all agree that reform is badly needed. In Congress, it has become a numbers game about millions of people and billions of dollars. One side decries the poor health outcomes that will derive from people losing coverage; the other argues that Medicaid desperately needs reform, not only to serve today’s recipients but also to effect solvency for future generations. Many are being told that empowering the federal government further is the way forward; conversely states, both red and blue, feel they can better serve their citizens if they were given more flexibility in managing Medicaid. How Medicaid is reformed is critical to the future of health care reform because it will form the template for the design of Medicare and private insurance going forward.

Indeed, Medicaid today represents one of the weakest forms of health insurance in the United States. The problems of managed care are in full force for Medicaid on a daily basis: Academic journals and lay publications have documented Medicaid waste, its loopholes and gaming, its fragmentation and inherent inefficiencies. Often patients are rebuffed and unable to see their usual provider because he or she has suddenly gone “out of network.”

Doctors often must obtain prior authorization (permission) from the patient’s health plan to prescribe one generic drug over another or to schedule a necessary study. I serve a panel of about 500 patients and can attest to spending at least one half day per week completing Medicaid-related forms and another half day on calls to obtain prior authorizations for both drugs and studies — sometimes speaking with judicators using a template of questions, who are unfamiliar with the diagnoses under consideration.

I often find that a generic drug covered last week has fallen out of favor and that the patient’s plan no longer covers it. But we doctors haven’t been informed of the switch so the prescription goes unfilled, and the patient never gets the needed medication. Once a request for a study has been approved and the test scheduled, the patient often fails to receive notice of the appointment because after the several days’ delay in obtaining authorization for the study, notification of the appointment falls through the cracks. I often receive lists from the health plan administrators for patients for whom the plan believes I am the primary doctor. Invariably I only recognize a few names because many are not my patients. Inaccuracies abound. And yes, it is getting worse.

I fear that Medicaid’s care delivery is what we all can expect to receive with continued government intrusion into medical care. Unless Medicaid’s problems are recognized and repaired, the dumbing down of health care delivery, aka one-size-fits-all-(or-none)-medicine, will become pervasive. Any state that adopts a single payer health care system would be the first to discover this.

The truth is that thus far, most attempts at “bending” the rising cost curve for Medicaid are cutting costs at the edges in ways that can harm the patient. They simply pick a hypothetical number for cost and hope the square peg of cost will twist into that round hole. This willy-nilly type of cost-cutting will not bend the curve, but it will surely lead to plummeting quality of care.

Those who favor competition as the first step of the solution want to give states the option to experiment with tailored reforms. Competition can and must be the sine qua non for reform. But today, there is a significant impediment to competition-based reform. Making costs, benefits, and provider lists transparent must be the first step for competition to work.

Medicaid for my patients is administered through one of several different plans. Unlike Medicare Part D, where information on the cost of drug coverage and co-pays are readily accessible to consumers, billing administrators for Medicaid rarely know how much tests and drugs are reimbursed, and how much of the cost may devolve to the patient, depending upon her Medicaid managed care plan. Why? Because, that information is difficult to ascertain and it’s often a moving target.

According to the Catalyst for Payment Reform and the Health Care Incentives Improvement Institute Report Card for 2016, where states are rated based upon pricing information available, only 3 of the 50 states received an “A,” one a “B,” two a “C,” one a “D,” and 43 an “F.” The year prior, 45 earned an “F,” and only four states improved their rating from 2015 to 2016. This deficiency has not been corrected by the ACA (Obamacare).

Not only would cost transparency enable competition among plans, knowledge of cost can be a powerful tool for those ordering studies. I deliver several lectures on health reform to our medical residents. These resident physicians are recent medical school graduates who provide care for both inpatients and outpatients at several major hospitals in the New York City area. At the outset, I administer a questionnaire, asking if they know or have been taught the cost of the tests that they are ordering day in and out. They do not and most haven’t even had a lecture on the topic. Once those numbers have been obtained, their test and medicine ordering is reduced substantially.

Why haven’t they been taught? Well, in some cases, practical health policy hasn’t been incorporated into medical school curricula. But, more to the point, in most cases, it’s very hard to obtain that information, for both patients and practitioners.

In a prior piece, I identified the failing infrastructure and the fragmentation it spawns as a fatal flaw in cost control — how the lack of interoperable health records causes duplication and reduplication of testing, causing costs to spiral, both within and without Medicaid.

But you say other geographies have accomplished single payer and some (really very few) have a citizenry that is supportive of it. The difference is that our multi-fragmented and non-transparent system cannot simply be morphed into theirs without repair and revelation of the information required for it to operate.

This repair could and should begin with turning loose the forces of competition on Medicaid. We are Americans, shown to excel in problem-solving, and if we can agree on one thing, it is that our health system is in dire need of repair. Let’s begin by reforming Medicaid.

Dr. Slater is a practicing physician in New York City and served as U. S. Assistant Secretary for Health from 2001-2003.

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