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Monday, July 26, 2010

Providing Care in a MediCAID for Everyone World

For all who dream about a single payer US health care system, I continue to tell them the calories in that punch bowl by declaring that a US single payer system will look like Medicaid. I don't turn their dreams into a nightmares or urinate in that punch bowl. It's more like finding out that the girl of your dream has man hands.

In all likelihood, a national health care system will resemble Medicaid, the health plan that stretches dollars to the previously uninsured with tightly managed care and low provider reimbursement. According to Ingenix, in 2016, the number of Medicaid beneficiaries will grow by 30% while the numbers who have better paying commercial insurance will remain flat. Medicaid will be the fastest growing insurance market so providing care will become increasingly important. Here's how I think that it will play out:

1. Who are these new Medicaid beneficiaries? Some feel that the health care utilization of Medicaid beneficiaries is unique while some see the only difference between a Medicaid beneficiary and someone with a blue collar health insurance plan is union dues and 5% of the Federal Poverty Line. What we do know is that they will mostly be adults but what we don't know is how much pent up demand they have for health care services and what kind of services they want. What will probably happen is that their health care utilization will decrease over time as they can regularly access care as opposed to gorge on the newly opened health care buffet.

The significance is that for those who participate in the Medicaid world especially with dollars at risk in a capitated environment will have some rough early years. However, the health utilization will stabilize over time and there will be opportunities to be profitable in the future.

2. Nurse case management will be key: The type of care that current Medicaid beneficiaries receives is often related to their chronic disease state or difficult socioeconomic environment. Those types of problems don't require a doctor to tell a diabetic to eat more vegetables and not leave their guns on the kitchen table. Nurses or social workers are the best option. However, currently only doctors get paid for the visit while these types of providers do not. A change in the payment system can address the revenue side of the equation while greater use of mid-level providers (I think that's the right term for nurses or social workers. I wouldn't want to call them lower mid-level providers) instead of doctors will help the expense side.

3. The Medical Home will save the day! The Medical Home model is the idea that someone should get all of their medical services in one place and it should be coordinated. It is also a friendly place where a patient likes to go. Definitions vary wildly but it is the latest trend in health care delivery. The flip side of a medical home involving throwing random bits of health care in settings where no one knows your name isn't appealing so the Medical Home model should stick. Especially since there is more money for available in the form of Centers for Medicare and Medicaid demonstration projects or large employer groups who are so desperate to reduce health care costs that their alternative plan involves sacrificing a goat. Since there are so many organizations willing to pay for the research and development, the medical home model will be tested and ready for that influx of Medicaid beneficiaries.

4. Go Federal, Federally Qualified Health Center (FQHC), that is: There will be $11 billion available nationally to double the patients served by FQHC's or Community Health Centers. FQHC's receive federal grant funding are are reimbursed at their costs for Medicaid visits. They are well equipped and knowledgeable about providing care for the uninsured and Medicaid. They also get paid more than private providers due to the fact that they get reimbursed at cost for Medicaid patients. The application process for becoming an FQHC is not a simple one. However, with limited provider access and low Medicaid reimbursements for non-FQHC clinics, the benefits are well worth investigating the application process.

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