Medicaid policy (and indeed most health policy in New York) is formed on the basis of provider type. Major components of the State Health Department are organized by provider type. Medicaid expenditures and operational measures are reported by provider type. Most reform proposals are focused on particular provider types.
This perspective has caused us to ignore a major opportunity to work with clients improve their health and to control expenditures. To do so, we need to ignore provider silos of care and shift toward tracking patient movement through systems of care – with emphasis on the patients and clients.
In effect, we should change the focus of policymaking and reporting from providers to clients – less client eligibility than managing client health.
To the degree that we focus on client eligibility, we should also take into account the effects of client turnover and the resulting discontinuities in care and client health management.
This leads us to focus new attention on Medicaid’s fee-for-service population (those not in the Medicaid Managed Care program) and even gives us an expanded view of long term care. Consider that the major initiative of the past decade has been Medicaid managed care which excluded the SSI population. They comprise about one-third of the population but they account for over three-quarters of the expenditures.
Much of the expenditures spent on the SSI population is spent in long term care, but assuming that therefore it is sufficient to base policy on nursing homes and home health care takes us down what has become a path that leads nowhere. In contrast, consider the striking variation in hospitalization of nursing home patients that is found nationally for manageable conditions. We need to consider not “stocks” of patients in categories of care, but flows of patients between them.
When we have thought about Medicaid populations in the past, we’ve grouped them by their aid categories, aged, blind, disabled, dependent children, etc. When doing so we should consider that these categories are direct descendents of cultural notions of the “deserving poor” from at least as far back as the Great Depression of the 1930s. We categorize those who we’re attempting to help based on concepts that are 75 years old.
With the exception of those with HIV/AIDS and psychiatric conditions, what we rarely do is categorize clients by the nature of their medical conditions and never based on their health status. Most of us have seen pie dual pie charts which show the relative proportions of Medicaid clients and expenditures by aid categories. What we never see is comparable charts sliced by type of chronic conditions or number of chronic conditions.
Thus, we can tell how much is spent on hospital care and on nursing home care. What we can’t tell is how many often clients with diabetes are hospitalized, what other services they use and what is the full range of other conditions they have. Nor can we evaluate the timing of the services they receive.
It’s time to turn the prism and begin doing analyses that cut across multiple types of care and setting policy based on it.