By Frederic S. Goldstein
President U.S. Preventive Medicine
fgoldstein@uscaremanagement.com
Medicaid has been a thorn in the side of every state budget for the past few years due to increased enrollments, expanded eligibility and growing costs for products and services. States have been seeking solutions to this problem and looked to the standard rap sheet of health maintenance organizations, disease management programs, high cost case management programs, preferred drug lists, rate reductions, pre-authorizations, primary care case management and other “vanilla,” 20th century approaches.
Some of these have had some impact on cost and quality, but for the most part they have not been enough to offset Medicaid’s ever spiraling costs leading to tighter and tighter State budgets. In a few years if nothing is changed, Medicaid will swallow everything, and other important state services such as schools, roads, prisons will be left with nothing. This trend is now exacerbated by a slowing economy; in fact State’s such as Florida are already facing projected budget deficits for the next few years.
While everyone talks about reforming Medicaid in an effort to solve this problem, most of these efforts have been tinkering around the edges or proposed grander plans that end up stymied by entrenched health care industry lobbying. It is time for one State to take the grand step and conduct the ultimate reform: implement a Medicaid program that provides and pays for preventive services in a comprehensive and effectively managed way so that in a few years, the number of beneficiaries being newly diagnosed with chronic diseases, those that incur the vast majority of the dollars, actually slows down.
Is this an easy task? No, in fact it will very hard. As has been demonstrated, few disease management programs in Medicaid or Medicare have been able to demonstrate savings and other approaches have not shown great promise either. But these problems are not insurmountable; the vast majority of these programs lacked the intensity and had ineffective approaches to changing the behavior of both the patients and the providers and certainly the communities.
So what should we do? Why not take one state, perhaps one of the poorest states in the country, with some of the least healthy citizens of this nation. The levels of poverty, poor health access, poor health literacy, and State fiscal problems will create the perfect opportunity to test a new model. Sign every Medicaid beneficiary up for “The Prevention Plan PLUS”, a full continuum of care management that covers primary and secondary prevention. Revamp the Medicaid fee schedule to pay providers for preventive services and link the entire state in a data network to give up to the minute data to any provider that the patient walks into. Partner this program with the key University Medical Centers, Hospitals, Medical groups, physicians, Community Groups, Religious institutions, schools, nursing programs, supermarkets, restaurants, etc. and let’s create a revolution, a sea change in an entire state; prevention from top to bottom.
We have a major problem that will not be solved by attacking it with the same old solutions, market force this, authorize that, slice up the chronics, cut rates to providers, we need something new, something that impacts every facet of how we live, something that is easy for anyone and everyone to understand. Let’s try the Grand prevention approach; it certainly can’t be any worse than the current tinkering around the edges with little or no meaningful results.