States taking advantage of new flexible options provided by the Deficit Reduction Act to redesign their Medicaid programs are asking beneficiaries to take on a potentially much bigger role in managing their health as a condition of getting benefits.
Last week, HHS Secretary Mike Leavitt joined Idaho Gov. Dirk Kempthorne in announcing a series of tailored benefit packages that will be offered to children and families, people with disabilities and those eligible for both Medicaid and Medicare. All of the packages will feature benefits new to Medicaid, such as preventive and nutrition services, and preventive health assistance for smokers and the obese.
Instead of just asking whether a patient is poor, the state will instead be doing a health-risk assessment as part of the eligibility process for these programs, said David Rogers, administrator with Idaho's Medicaid division, during the news briefing to announce the plan.
This is to make sure that individuals entering one of the three tailored programs are getting the healthcare they need, said David Lehman, Kempthorne's policy director. By placing patients in these customized programs, "We want them more involved in managing their healthcare." Kentucky is another state that has recently customized its benefits, and will offer various packages based on age and health status.
West Virginia takes this concept of patient responsibility a step further, however. Beginning July 1, the state will transition eligible enrollees out of the state's traditional Medicaid plan, giving them an option to join either an enhanced plan or a more standard Medicaid benefit package. The enhanced plan offers additional perks, such as nutrition and tobacco-cessation counseling, diabetes care and a more generous prescription drug plan, said Shannon Riley, spokeswoman for the Medicaid program in West Virginia.
But there's a caveat: To enroll in the enhanced plan, beneficiaries must sign an agreement indicating that they will comply with all recommended treatment and wellness behaviors, such as visiting their physician when they are sick, bringing children to appointments on time and going to health improvement programs as directed by their physician.
In the past, states providing Medicaid benefits had to equally guarantee comprehensive health insurance coverage to all beneficiaries, a term known as "comparability."
The problem with this one-size-fits-all approach, however, is it's not tailored to the specific needs of various Medicaid populations, Riley said.
About 160,000 Medicaid beneficiaries will be eligible for the enhanced services in the state, Riley said. The new benefit does not apply to pregnant women, the elderly, or special needs populations within Medicaid.
The program has not yet been implemented statewide, and is still a work in progress. "Members will be enrolled in the counties in which this benefit is offered, and phased into the exchange (of benefits) at the time of their eligibility redetermination," which takes place each year, she said.
Riley insisted that the new benefits are an educational tool to show that good health is not a passive activity. No one will lose out on medical care, she said, but in not signing or complying with the medical agreement, beneficiaries will lose out on special rewards. The program is in the process of marketing such rewards, but an example might be to receive restorative dentistry for meeting certain health goals, she said.
What's missing is research showing that signing agreements will result in healthier patients, said Judith Solomon, a senior fellow at the Center on Budget and Policy Priorities. Conditioning key benefits like diabetes care on the compliance of these agreements means "you're taking something away from someone if they get to an exam late."
West Virginia's plan also prohibits using the emergency room for nonemergency care, Solomon said, which eliminates a resource people could use on evenings and weekends. "There's never been any data to show that families overuse the ER or not follow their provider's advice."
Riley insisted that the new benefit was not about short-term cost containment. "A lot of people are afraid that we're just trying to get beneficiaries into the basic program, and that's not the case." With the high rates of diabetes, childhood obesity and heart disease, the program's goal is to allow children and families to develop better relationships with healthcare professionals, and lead healthier lives, she said.