New goals for Medicaid

A very diverse group of folks have been discussing Medicaid's future in New York under the banner of the Schuyler Center for Analysis and Advocacy (SCAA). The group has patient and consumer advocates, providers and provider associations, insurers, counties and the Association of Counties, business, researchers and others. This self-described group of "strange bedfellows" pretty much agrees that New York's Medicaid program sorely needs reform and has started to explore whether they can find some common ground for reform. Regrettably hey are also pretty much agreed that no one should expect much of State policymakers.

At our last meeting, we agreed that each participant should propose revamped goals for Medicaid.

New York’s Medicaid program needs a dramatic re-alignment. This re-alignment should include improved client health outcomes, re-definition of financial responsibilities, aligning managerial and financial responsibilities, taking advantage of new technologies, and a new framework for overall program effectiveness and cost control.

Here are my proposed goals for a fundamentally different Medicaid program:

1. Explicitly change the goals of the Medicaid program from paying for service to health outcomes. Medicaid was established to enable the poor to receive mainstream medical services. Service has been the goal rather than the means to an end. Medicaid's goal should become to improve health and functioning; where that is not possible, to maintain it; where that is not possible, to slow deterioration. Where slowing deterioration is not possible or not the patient's choice, it should be to make the passing comfortable. Intrinsic to health and  functioning of Medicaid clients as the primary primary goal, health and functioning of should be measured. Then the contributions of service to health can also be measured and services and processes of care that contribute the most can be reinforced and those that contribute nothing can be abandoned.
2. Distribute and use the damn data.  Whether for quality improvement or for accountability, neither legislators, legislative staff, providers, most county officials, outside analysts nor interested others have the ability to examine what is and is not going on in Medicaid. Is there another enterprise anywhere that spends $40 billion per year without key constituents understanding how it's being spent? We've talked repeatedly about variations in service use (and expense) but there's been little or no effort to learn why the variations in care of New York's Medicaid clients exist and what difference they make in clinical outcomes, patient satisfaction, and patient health. Arguments that distributing the data risks compromising client/patient confidentiality are bogus. Today's technology readily enables the creation and web-based deployment of analytical database systems that display only summary data. Such systems are created from, but both conceptually and physically separate from systems that include individually identifiable information.
3. Align management and financial responsibilities for Medicaid by having the State assume full financial responsibility for all clients whose total costs of care exceed pre-set financial thresholds. For example, the State could assume responsibility for costs of care in excess of a given amount (say $30,000) during a given year; a higher amount for a given multi-year period (say $100,000 for a three-year period); and a still higher amount for the client’s life (say $250,000). In addition, the State should assume financial responsibility for those who have been discharged from a State institution or any other program for which the State has assumed full non-federal financial responsibility. This concept is similar to reinsurance. It not only provides financial relief for counties and New York City, it centers attention on the most expensive clients and ultimately on the processes of their care.
   
4. Focus attention on clients, particularly those whose health is most compromised and whose care is most expensive, the chronically ill and those at risk of becoming chronically ill. Rather than provider focused this concept is client focused. It cuts across all types of providers. New York's Medicaid Managed Care program excluded the elderly and disabled and the care of clients with psychiatric, substance abuse problems and HIV/AIDS. By and large, we excluded the sick clients. This leaves them ill-served and ignores the clients who account for a disproportionate share of spending.
5. Provide for a system electronic health records for participants in Medicaid and other State and locally supported programs. This is not merely providing electronic records, but a system behind the records of protocols and pathways to improve and make more reliable processes of care.
6. Integrate Medicaid with other programs that provide health coverage for low income populations. As the family, medical and financial circumstances of low income New Yorkers change, so does their coverage. When this happens, their medical care changes too and the State spends an immense amount on administrative functions moving clients on and off coverage and between different programs.

These are all sweeping goals and none among them could be accomplished or have an effect quickly. But we've now had 40 years of short-term proposals that have accomplished little or nothing.