States Make Medicaid Patients Responsible for Care
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The newest front in the battle to hold down healthcare costs is patients' own behavior. Businesses and insurers are creating incentives to encourage Americans to eat better, exercise more and do what their doctors tell them. And take note, somebody is munching carrots outside our studio this morning.
States trying to save money on the Medicaid program for the poor are going beyond incentives. They're not only rewarding patients who work to improve their health, they're punishing those who don't.
NPR's Julie Rovner has this story of two states leading the way.
JULIE ROVNER reporting:
Medicaid is big business in Kentucky. The shared federal/state healthcare program covers more than 700,000 state residents, about 15 percent of the population.
Governor ERNIE FLETCHER (Republican, Kentucky): We have more Kentuckians enrolled on Medicaid than we do have students in K through 12.
ROVNER: That's Kentucky Republican Governor Ernie Fletcher. Needless to say, Medicaid is also a huge cost for the state - about $4.6 billion a year. And like many states, he says, Kentucky was having a hard time paying an ever-growing bill.
Gov. FLETCHER: Six hundred and seven five million dollar deficit was what we were facing at the beginning of the current fiscal year.
ROVNER: Fletcher knew he had three choices to fill that gap: cut benefits, raise taxes or - as he put it - fundamentally reform the state's Medicaid program. A doctor by training, Fletcher chose the latter. And he chose to reform the program by focusing not on doctors and hospitals and those who provide the care, but on patients - those who consume it.
Gov. FLETCHER: We want to encourage Medicaid members to be personally responsible and actively engaged in their healthcare. We wanted to follow the shift that we've seen in the private healthcare market for more consumer awareness education and decision-making.
ROVNER: Basically, the new Medicaid in Kentucky rewards members for healthy behaviors that holds down costs - like using generic rather than brand name drugs, or taking part in a disease management program to help control their asthma or diabetes or other chronic condition.
Gov. FLETCHER: For example, dental services, smoking cessation classes, more nutritional instructions. All of those things will be available as individuals cooperate with the disease management.
ROVNER: In other words, Medicaid patients who save money will get more health benefits in exchange. Benefits the state otherwise wouldn't provide. That's the idea in West Virginia too, according to Medicaid Director Nancy Atkins. But she says it's not just about saving money. It's about making patients more accountable for their own actions.
Ms. NANCY ATKINS (Medicaid Director, West Virginia): You know, we often talk to Medicaid recipients about their rights, but we don't always talk about the responsibilities or the expectations.
ROVNER: Starting this fall, most West Virginia Medicaid recipients will be required to sign a member agreement, promising not just to take their medicines and follow doctors orders but to show up for their appointments, which Atkins says is a big problem.
Ms. ATKINS: The no-show rate in the Medicaid population is about 40 percent, so we're trying to bring that down a little bit.
ROVNER: But unlike Kentucky, West Virginia is using a stick as well as a carrot. Patients who don't live up to their member agreements won't have access to what the state is calling its enhanced benefit package. That means, for example, they won't be eligible for mental healthcare or diabetes care or more than four prescriptions per month.
Cindy Mann, a Medicaid expert at Georgetown University, thinks West Virginia has gone too far in making patients promise to engage in healthy behaviors.
Ms. CINDY MANN (Medicaid Expert, Georgetown University): Those are important objectives for all of us, but sometimes difficult for all of us to do and sometimes particularly difficult for low-income families to do.
ROVNER: Take missed appointments, for example.
Ms. MANN: Low-income working parents often have the least flexible work schedule. Sometimes they do miss an appointment because of work schedules. And if they do, potentially, their child will lose very significant health benefits in the name of personal responsibility.
ROVNER: Then there's the little matter of making the doctor - who's supposed to be the patient advocate - in effect the compliance officer for the state. Joan Phillips is a pediatrician and president of the West Virginia chapter of the American Academy of Pediatrics. She says the prospect of having to report non-compliant patients puts doctors in a difficult situation.
Dr. JOAN PHILLIPS (Pediatrician; President, West Virginia Chapter, American Academy of Pediatrics): You know what the right thing is to do, and you need to report accurately. But on the other hand, if a family who may have a lot of other stressors or issues or for some reason is dysfunctional and can't carry their part of the agreement, their child will lose those benefits. That would be very hard as a physician not to just, you know, give the services.
ROVNER: And while the state will provide appeals processes for families who stand to lose benefits, Phillips says that will put even more strain on their doctors.
Ms. PHILLIPS: But that means paperwork. That means phone calls. You know, I just am afraid if the process is cumbersome, physicians are going to say, you know what, I'm not taking any more of these Medicaid headaches on, you know? And then we have an access issue all over again.
ROVNER: Advocates for the poor are worried that the personal responsibility mantra is really just another way for states to try to cut Medicaid benefits for people who need them. But backers say, if it works and patients really do get healthier, states will save money because less healthcare will get consumed.
Julie Rovner, NPR News.
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