People of different political persuasions generally agree that the health care system in the United States is in deep trouble, but there is no consensus on how to fix it. Hoping to reduce health care expenditures, the Bush administration passed the Deficit Reduction Act (DRA) in 2005, which provides greater flexibility to states to tailor Medicaid benefit packages to their populations. Before passage of the DRA, states had to provide comprehensive health insurance coverage for all low-income participants in their states. Now West Virginia and Kentucky are in the process of becoming the first states to make changes based on the new flexibility that will alter the way Medicaid is delivered. ENToday spoke with Medicaid officials in the two states and with physicians about how these changes could affect otolaryngologists-head and neck surgeons.
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September 2006Sharing Responsibility in West Virginia
West Virginia’s Medicaid redesign is based on the idea of shared responsibility for health care. Medicaid recipients will be asked to sign a member responsibility agreement stating that they will show up for their medical appointments or call and cancel in advance. Participants who sign the contract will be entitled to enhanced benefits, which can be used to obtain health benefits not included in the mandatory benefits plan. These changes will affect about 160,000 Medicaid beneficiaries, most of them parents of children served by Medicaid. Those who opt not to sign the contract or to honor it will receive only basic coverage that provides fewer benefits than in the past; however, the plan for basic coverage is still being developed.
Shannon Riley, spokesperson for the Bureau for Medicaid Services in West Virginia, believes that the membership responsibility agreement is a good change that will make members more responsible for their health care.
We want people to partner with us and we want all of our members to choose to sign the agreement, she said.
The theory behind the redesigned package is that it will result in long-term cost containment, rather than immediate cost-containment. People who are on Medicaid have obesity, heart disease, and diabetes, and we cannot approach this passively, she said. The newly designed Medicaid package should help members get the right screenings from the right clinic at the right time, Ms. Riley noted.
A new concept incorporated into West Virginia’s proposed redesign is a team approach that will provide overall health-care management for Medicaid participants and will prevent duplication of services.
Ms. Riley acknowledged that the Bureau of Medicaid Services needs to communicate with providers and let them know what to expect and how the new program will affect them. The Bureau is planning three pilot programs to educate providers and give them ample time to make changes to streamline efficiency, including switching to electronic health records.
Otolaryngologist’s Perspective
R. Arturo Roa, MD, who is President of the West Virginia Academy of Otolaryngology-Head and Neck Surgery, said that he has no philosophical or clinical quarrel with the idea of member responsibility agreements. Patients should be accountable for their appointments. No-shows are problematic, because they take up space in the day’s schedule that could be filled by another patient that would generate fees, he said. However, in his practice, he has not found that Medicaid recipients are more likely than other patients to fail to show up for appointments. He said most of his no-shows are hospitalized patients who fail to show up for follow-up appointments, but these are not necessarily Medicaid beneficiaries.
A lot of our Medicaid patients are very sick and will wait for hours to see us. We also see many children with ear infections, and mothers want to come to those appointments, he said.
Dr. Roa is concerned that the new redesign package not come with strings attached, particularly limits in what drugs will be reimbursed. My biggest complaint with Medicaid is that beneficiaries often do not get reimbursed for the drugs we prescribe; in particular, reflux medications. We see many Medicaid patients with laryngopharyngeal reflux disease who are not able to get their prescriptions filled and are given a different drug instead, Dr. Roa said.
Patients should be accountable for their appointments. No-shows are problematic, but I have not found that Medicaid recipients are more likely than other patients to fail to show up for appointments. – -R. Arturo Roa, MD
Kentucky’s Changes
Kentucky is taking a different approach. The plan is to provide four different benefit grids: one for the general Medicaid population, one for children, one for elderly people, and one for the developmentally disabled.
Instead of a ‘one size fits all’ Medicaid program, we plan to provide four different packages, more like the commercial world, said Thomas Badgett, MD, who is a pediatrician and Acting Commissioner and Chief Medical Director of the Kentucky Department for Medicaid Services.
The idea behind the redesign is to provide reasonable health benefits for the current eligible population, rather than unlimited benefits for a smaller population, he explained.
Kentucky has imposed limits on prescription drugs and on physical and speech therapy. Children are allowed 15 visits to the speech therapist each year. If more visits are necessary, then they can get authorization from the program, Dr. Badgett said. Adult patients are authorized for 10 visits to the speech therapist per year. Stroke victims and other elderly people are allowed 30 visits to the speech therapist each year. The prescription benefits entail modest co-pays, he continued, and most children and families will have no co-pays.
The redesign incorporates moderate restrictions. We tried not to make draconian changes. Before, there were no limits. Now we have 5-percent coinsurance on non-emergency ER use. We’ve had no outcry from physicians. They just want to know what the changes will be, Dr. Badgett said.
Criticism of Kentucky’s New Plan
Daniel Mongiardo, MD, who is an otolaryngologist and state senator in Kentucky, is not optimistic about the new plan. He said that neither the state nor the federal government can afford the huge health-care expenditures under the current system, so the state has resorted to a bag of tricks that shifts the costs onto patients who cannot afford it either.
Dr. Mongiardo predicted that patients will not get necessary services under the new plan, and he foresees serious problems. He said the new plan increases the co-pay for admission to the hospital to $50 and that many Medicaid beneficiaries cannot afford $50 and will not go to the hospital when necessary. We will see sicker and sicker patients and tragic outcomes, he said. When hospitals can no longer afford to take care of patients, quality of care suffers. We will also see more lawsuits.
Focusing on the limits for speech therapy, Dr. Mongiardo said that best practice is to have children see a speech therapist weekly until improvement is noted. In school, some children get speech therapy on a daily basis.
The bottom line is our system is broken. Health care is the only industry that has not undergone a major overhaul in recent years. There are multiple inefficiencies that need to be addressed. Information flow has to be computerized with a centralized access. To take money out of this broken system is only going to make things worse, he stated.
Dr. Mongiardo said that experience shows that managed care approaches do not fix the system. Things have only gotten worse under managed care. Politicians and bureaucrats think the same way, he commented. The approaches planned by West Virginia and Kentucky are tired approaches, he feels; he believes that a fresh perspective is necessary.
©2006 The Triological Society
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