Thursday, June 16, 2011

Medicaid's Travails

The Disease Management Care Blog has generally steers clear of the painful topic of Medicaid, but two recent publications in prominent journals caught its eyes.  Both are reminders of Medicaid's continuing provider payment travails.

Taxpayers Get What They Pay For:  The first article is from the New England Journal, describing the success rate of research assistants' paired calls requesting new patient appointments for fake patients to 273 Cook County Illinois private practice pediatric specialty outpatient clinics.  The only difference between the two calls was one that was that one involved a child with Medicaid insurance status, while the other was for a child with Blue Cross Blue Shield (BCBS).  179 or 66% of the "Medicaid" children couldn't get an appointment, while that was true for only 29 or 11% of the "BCBS" children  - a difference that was both ethically and statistically significant.  For the children who got an appointment, the average wait time was 42 and 20 days for Medicaid and BCBS, respectively.

The authors point out that in Illinois, a moderately complex office visit is paid at $99 for Medicaid and $160 for BCBS.  While that should hint at the underlying problem, the DMCB predicts that the authors' "mystery caller" methodology will be adopted by State Medicaid programs, and that clinics that routinely turn Medicaid patients away will be somehow sanctioned.

Taxpayers Don't Get What Can't Be Measured:  The second article is from Health Affairs.  The DMCB didn't know this, but a part of Massachusetts' 2006 health reform included the state's Medicaid program ("MassHealth").  A pay-for-performance program was specifically aimed at reducing racial and ethnic health care disparities.  The clinical performance measures were based on an aggregate score based on a complex formula that used combination of observed versus optimum rates of surgical infections, pneumonia care, pediatric asthma care and maternal and neonatal health for minorities versus whites.  Hospital "structural" measures focused on governance, administration, management, service delivery and customer relations.

Despite widespread support among hospital administrators, the program was limited by low white vs. persons of color baseline differences, as well as small sample sizes that limited statistically valid comparisons.  In addition, hospital administrators reported that the program operationally burdensome, because if was layer on top of the other mandated reporting programs required by other state agencies.  The authors also point out that the legislature simply didn't anticipate that patients with varying ethnicity would be unevenly distributed across the Commonwealth's hospitals, or that the chosen measures didn't demonstrate that there were disparates.

While the program may have benefited from better planning, the DMCB thinks this was a nice try. It's also an example of  the benefit of limiting health reforms to the State level. Imagine the colossal waste of money would have occurred if this had been mandated by Congress at the federal level.


The Notwithstanding Blog said...

How do you sanction a Medicaid-participating clinic for not taking enough Medicaid patients? Bar them from Medicaid?

Jaan Sidorov said...

The most obvious would be to make licensure conditional on Medicaid participation AND timely access. I've not heard of this, but the State could also require participating hospitals to somehow have adequate numbers of participating providers with adequate access.....?

The Notwithstanding Blog said...

I would imagine the former would cause an exceptional physician revolt....