Medicaid As Savior or Betrayer of Access

The largest insurer in the nation is in a great position to lead the nation toward improvements. A major change in favor of primary care, mental health, and basic services could go a long way to restore basic health access - the foundation of an efficient and effective health care delivery system. Medicaid is the largest insurer in the nation. The problem with Medicaid may not be the amount of health care cost, but how the dollars are spent. 

Payment increases for Medicaid could boost basic services for 70 million people insured by Medicaid and another 50 - 70 million in places where Medicaid is most dominant. This is because access is about local workforce to deliver basic services, not insurance expansion. 

With more dollars invested in basic services through Medicaid, all of the people in places with lowest concentrations of access, workforce, and spending could benefit. 

With lowest payments and fewer dollars going to locations with higher Medicaid patient levels, 

  • The Medicaid patients suffer from access barriers and the lack of primary care and basic services 
  • Patients with insurance suffer as lowest Medicaid and low Medicare payments fail to support local workforce and access for patients with Medicare and other plans. 
  • Access is about overall support for local workforce, not necessarily expansions of lowest paying Medicaid and expansions of high deductible (catastrophic care) plans that are least supportive of local primary care and basic services. 
Sometime ask asthmatics with high deductible plans what happens when they have to pay full price for albuterol, inhaled steroids, an ER visit, or worse. And you thought EpiPen was bad?

Best Practices Should Be Applied for Basic Health Access Recovery

Accountability should be required of all involved in health care. This also includes the designers. Lack of accountability for a hospital or practice can impact hundreds or thousands. Designers should be held accountable for the adverse impacts upon tens of millions and other consequences such as demoralizing the team members who provide the care.  

Health policy experts talk down best practices or accountability to physicians and other providers. In fact, the accountable care legislation has vastly increased the micromanagement powers of those who design and pay. The lack of designer accountability is app  Best practices should also be applied to designers and their designs. There should be evidence rather than assumption.

The Basics of Basic Health Access - To recover basic health access requires more team members in more places with more support. Primary care, basic, office, and cognitive services are most specific to health access recovery and are even more important where access has most fallen behind. This is best seen in the counties lowest in physician workforce.

Generalists and general surgical specialties supply over 70% of the workforce in the 2621 lowest physician concentration counties where 40% of the population struggles due to only 21% of physicians. The five general surgical specialties most needed are declining most at 2 - 3 percentage points a year. The oldest are found in the lowest concentration counties as few remain general specialists and fewer distribute where needed. Recovery of General Surgery is Impossible Primary Care Must Rise from the Ashes of the Last 20 Years

There Is No Best Practices without 
Supporting the Team Members to Practice Best

This is the best practices route to facilitate integration, coordination, outreach, and other basic health access functions provided by team members. It is also the opposite of spending more for EHR, or for HIT maintenance, or for Primary Care Medical Home, or for practice consultants, or for administrative and other non-delivery costs. 

How do the designers get away from promising more for less
without investing in anything?

Movies such as Back to the Future made fun of politicians that made these promises, and yet we have health care designers that get away with this year after year and failed plan after failed plan. 

Talking about the functions without providing the means to the end is not best practices for any health care designer.

Better Payment for Basic Health Services is Specific to Recovery

Medicaid patients are concentrated in 2621 lowest physician concentration counties with 40% of the people most left behind. They are left behind because Medicaid and other lowest paying patients are concentrated in these counties. 

Better payment from Medicaid for basic services
  • Sends dollars where services are most needed and are currently least supported
  • Shifts workforce back to primary care and basic surgical services - the opposite of the current directions to procedural, technical, highly specialized for MD DO NP and PA
  • Sends more dollars and jobs where dollars and jobs are most needed - factors that may be most important to actual health, education, and other outcomes improvements. The current design widens disparities.
  • Sends more dollars where child poverty levels are highest with 45% found in these counties with 40% of the US population. This is also another indicator of the need for Medicaid services and the importance of Medicaid services in recovery of more than just access.
  • Would increase the providers that accept Medicaid patients just as lowest payments shrink stated participation and shrink actual participation even lower. GAO investigations have indicated that what practices said about accepting Medicaid was not what actually happened.
  • Makes training interventions more effective - the opposite of training interventions that cannot work because payment support is too low to support more team members where care is needed
  • Decreases the need for recruitment and retention bonuses as well as locums temp workforce - the opposite of accelerating costs of recruitment, retention, and locums such as 1 million more dollars each year in a state like Alaska or about $2 more per person in the state just as an ante (not for actual primary care workforce).
  • Decreases turnover of physicians, a cost of $300,000 for each primary care physician lost due to lost productivity, time for orientation, recruitment costs, retention costs, and other adjustments needed for care delivery. As the complexity goes up, so does the time and cost.
Note the Irony of Medicaid Expansion Vs Basic Payment Increase

Higher basic payments from Medicaid allow practices to expand services to those without insurance. Lowest paying Medicaid prevents sufficient workforce in ways that damage access for patients with or without insurance.

Concentrations of Least Supportive Insurance Compromise Access

Expansion of lowest paying Medicaid does not have the ability to recover access as costs of delivery are higher than Medicaid revenue paid. Insured and uninsured in these lowest physician concentration counties suffer due to concentrations of
  • Lowest paid Medicaid
  • Lower paid Medicare
  • High deductible plans
  • Veterans and other populations that often seek care outside of local practices
Best Practices for Health Access Is Not About Shipping Dollars Outside

The 2621 counties lowest in physician workforce need more dollars paid in and fewer dollars paid out. The current designs are the opposite. Billions must be sent outside the county for EHR, HIT, and other regulatory costs.

The designs with or without insurance expansion prevent primary care workforce recovery.

No Substitute for Hard Work and Hard Working Team Members

Once we have true reforms boosting cognitive, office, basic, primary care, and mental health services it would take 15 - 20 years to rebuild access (at least a half generation of workforce). 
It is not best practices for ACA designers to increase Medicaid primary care payment for two years, force a costly administrative change to higher and then lower payment, leave primary care practices hanging, force a series of changes decreasing productivity, and then continue to demand more from team members despite less support.

The Clock Is Ticking

As it is, 2025 will come without a change in access because of the choice to reform other areas, rather than basic access to care. Internal medicine by 2025 will have minimal contribution to primary care after only 1000 - 1300 per class year for general internal medicine for an entire generation of workforce. Family medicine will remain with 80,000 active graduates but only 65 - 70% will be active in family practice positions as ER, urgent, and hospitalist increases continue following higher payment and more support by design. Physician assistant and nurse practitioner contributions will remain the same because payment design remains the same. Expansions of PA and NP will result in steadily lower proportions found in primary care positions, especially family practice positions. Only the family practice positions filled by MD DO NP and PA have population based distribution - essential because 36% are found in the 2621 lowest physician concentration counties with 40% of the population. All other specialties concentrate where workforce is most concentrated - the opposite of health access improvement.

Keeping the Eye on the Ball

Commonwealth continues to support technology, innovation, and insurance expansion. But these are not going to allow Commonwealth to move the 2025 health system to high performing, efficient, or high quality. Access will worsen as demand will increase and outstrip support. The elderly, the most complex patients, and population growth are all increasing faster in the counties with 21% of physicians already too stretched to cover 40% of the population and stretched even more by lowest payment by design.

Commonwealth will be unable to report progress across the vulnerable populations that they hope to address as the disparities in payments continue to widen the gaps. The top physician concentration counties will continue to do even better and the lowest concentration counties will do worse as 70% of the workforce (generalists and general types of specialties) will continue to be tied to lowest payments and lowest concentration county providers are paid less and penalties under MACRA will be highest.

What is True Value in Medicaid or in Primary Care or in Team Members?

The value of Medicaid or of primary care or of team members is primarily about what is invested in each. Value is not about expansions of lowest paying insurance, cost cutting dollars saved, narrow networks, rapid expansions of largely untested technology, or higher costs of delivery not specific to care delivery. 

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