A Vision for a 21st Century Medicaid System

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A Vision for a 21st Century Medicaid System

Forwarding FYI.L.L.S.S. (Love, Learn, Share, Serve)

Proposition

It is possible to apply the principles of a 21st Century Intelligent Health System to create a 21st Century Responsible Citizen Medicaid program that emphasizes wellness, prevention, early testing and the most modern, patient-centered management of chronic conditions. Healthy people are more capable of living independent, productive lives, and they cost less. The marketplace needs to be transformed into a system of value-based competition. A transformed, value-based system will provide better outcomes, save money, and dramatically reduce health

disparities for America’s minorities.

Key Points:

1. Federal Medicaid rules, regulations, and waivers hamstring governors in their

efforts to modernize their Medicaid programs.

􀂃 CMS provides a CD-ROM with the 39,000 pages of program manuals and regulations that govern the Medicaid and Medicare programs. This figure excludes the thousands of pages of individual state laws, regulations, and waivers. By contrast, the Federal Employees Health Benefits Program (FEHBP) has only 208 pages of laws and regulations to govern 9 million federal employees (including Members of Congress), their dependents, and retirees.

􀂃 What is needed is a paper-free, individually-centered health system that actively supports continuity of care for all beneficiaries. This is extremely important for Americans with multiple chronic conditions. Medicaid must blend seamlessly into privately-owned health insurance plans.

2. States must take advantage of the Deficit Reduction Act. The Deficit Reduction

Act of 2005 included many provisions that affect Medicaid. States were granted

new flexibilities to change their Medicaid programs without approval from Washington:

􀂃 As an alternative to providing all of the mandatory and optional benefits under standard Medicaid, states can enroll select groups into benchmark and benchmark-equivalent plans, which are similar to SCHIP. The benchmark options are:

o The Blue Cross/Blue Shield PPO plan in the FEHBP

o The plan offered to state employees

o The largest commercial HMO in the state

o Other Secretary-approved coverage appropriate for that select group

ô€‚ƒ Allows states to establish home- and community-based services (HCBS) for certain populations without undergoing the 1915© waiver process. Now states need only submit a Medicaid state plan amendment to the federal government.

􀂃 Under the DRA, states can now impose premiums and cost-sharing for certain higher-income groups of individuals for any type of service, subject to some restrictions.

􀂃 DRA made major changes to transfer of asset rules that affect individuals’ eligibility for Medicaid’s long-term care services. The so called “look-back†period of asset transfers was extended from 3 to 5 years.

􀂃 Health Opportunity Accounts, modeled on Health Savings Accounts, were established in order to allow beneficiaries to pay for state-specified services.

3. Medicaid should be transformed with 100% insurance coverage as a national

objective. Leaving 45 million Americans uncovered is immoral, it is unjust, and over the long run it is more expensive. The President’s refundable tax credit proposals are a major step in the right direction because they are well-targeted at the majority of the uninsured (or their dependents) who are workers, but for whatever reason are not on an employer’s health plan. These tax credits will help the uninsured gain access to a private health insurance plan of their choice, one that can be supplemented by Medicaid dollars where appropriate. The ultimate goal is to have all Americans in a health plan of their choosing, one that remains their health plan regardless of income, employer or employment status.

4. Medicaid must evolve into a system that is value-based and not process-based. If

states outline a clear agenda for the elimination of racial and socio-economic health disparities, for example, then the federal government should hold them accountable for achieving those metrics and not simply micromanage how they do it. Governors and state legislators are closer to and more familiar with the unique circumstances in their own states and are better placed to run their Medicaid programs. The federal role should be cooperative and not antagonistic. Governors and state Medicaid directors should not have to go to Washington on bended knee to ask permission to improve how they deliver care to their citizens who are most in need.

5. The federal government, state governments, and the private sector must combine

their purchasing power to drive change through value-based competition. This will be the single most effective solution to transforming health and healthcare. As purchasers of healthcare, the public and private sectors should radically redesign the way they pay for health services. Our current system pays doctors, hospitals, and other providers based on the volume of services and procedures performed, not on their outcomes. A new model must be based on the quality and efficiency of the care delivered. To truly build a value-based system, we must adopt a core set of common standards to measure performance and value; base healthcare purchasing decisions on quality outcomes; make quality information widely available to consumers and researchers; fundamentally reform the reimbursement structure; and reward those providers who deliver the best quality care.

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FYI

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