I’ve been reading the Republican Governors Public Policy Committee’s recently released report, A New Medicaid: A Flexible, Innovative and Accountable Future. I was prepared to bring the full snark, sure that this was just another partisan document, completely full of bluster with no actual ideas.
But I’m not feeling that. Sure, there are elements of crazy, like “Solution #5: Require the federal government to take full responsibility for the uncompensated care costs of treating illegal aliens.” It’s already against federal law for Medicaid to cover undocumented immigrants, so this does nothing to reduce Medicaid spending whatsoever. But I suppose it makes some people happy to say it again. Others already exist in some form, like “Solution #9: States should be encouraged to develop innovative programs to reduce chronic illnesses and the burden of associated health care costs to individuals and the taxpayers.” And some are just odd, like “Solution #7: Federal and state financial participation in the Medicaid program should be rational, predictable and reasonable.” I assume this is meant to be insulting to current law.
But it’s not all like that. There are some good ideas in there, too. Here are a few:
Solution #2: States can create a specific “dashboard” to measure accountability utilizing recognized measures of quality, cost, access and customer satisfaction that reflects the state’s priorities and permits an assessment of program performance over time. Where possible, states will utilize the expertise of state, local and national organizations that have developed appropriate measures. In many cases, states already have developed extensive measures of quality and accountability, including customer satisfaction. These dashboards should utilize those processes instead of recreating onerous administrative burdens for states.
That seems totally reasonable to me, especially since we’re likely headed somewhere like this for the exchanges in the PPACA. Or course, the devil’s in the details, but that doesn’t mean this couldn’t work.
Solution #8: If a state can demonstrate budget neutrality, provide states the ability to use state or local funding, now spent as match funding, for certain health services thatwould pay for Medicaid services or health system improvements that are currently not “matchable,” but are cost effective and improve the value of the Medicaid program.This could include Health Information Exchanges, increased benefits for some individuals, improved care management and local care coordination, and pilot programs to test innovations.
Again, this seems like it could work, with proper safeguards in place.
Solution #11: Provide states with the flexibility, without requesting waivers or initiating the state plan amendment process, to pay providers based on providers meeting quality care and value-based criteria rather than the current fee-for-service approach. Allow innovative payment methodologies to encourage care coordination for all Medicaid eligibles, without exception. Other options could be capitated payments, shared savings, and incentive arrangements when such payments encourage coordination,reduce cost shifting and improve care delivery.
I have a hard time fighting against provider payment reforms, especially when they might save money and improve quality. We should be attempting more stuff like this.
Solution #25: The territories should be treated consistently, fairly and rationally in funding, services and program design.
That seems like a no-brainer.
Solution #26: At a state’s discretion, permit states to redesign Medicaid into multiple parts. Medicaid Part A would focus on preventive, acute, chronic and palliative care services; and Part B would focus on long-term supports and services (LTSS). This would enable a state to better manage the different needs between populations who only need LTSS. Eligibility for Part B would be based on income and functional screening of an individual’s long-term services and LTSS needs.
I’d need someone to show me why this is a bad idea, especially since this is what we do with Medicare right now.
Solution #27: Engage in shared savings arrangements for dual eligible members when the state can demonstrate the Medicare program reduced costs as a result of an action by a state Medicaid program.
That seems only fair. In fact, many of the “Solutions” pitched for LTSS seem totally reasonable.
You would think I’d be happy. Sure, there are ideas in this document which I don’t agree with, like the notion that block-grants are proven answers to funding issues, or the magical thinking that somehow states could lower costs, increase eligibility, and increase quality if only they were just allowed to. Yes, there are vague areas we’d need specifics for. But, on the whole, I can’t expect that the Republican Governors Public Policy Committee and I are going to start out in the same place, because we have fundamentally different ideas about how the health care system should function and improve.
Instead, though, I find myself somewhat sad. I’m feeling that way, because I realize this will go absolutely nowhere. In a rational world, with a functioning government, we would be able to agree on some of these points and disagree on others. We would allow some ideas we don’t favor to be attempted, in exchange for some of our own that others wouldn’t pick first. We’d compromise.
But there’s no way this will be debated. Opponents of the RGA will pick the pieces they hate the most and focus on them. Supporters will attack those attacks, and this will turn this into a partisan snipe fest for political gain. And we will go absolutely nowhere.
Of course, I could be wrong. Nothing would please me more.
