CURIE: Perils of one-size-fits-all Medicaid
States racing to managed care risk endangering most
vulnerable
By Charles G. Curie
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The Washington Times
Friday, March 2, 2012
As states rush headlong into managed care in the
name of "in- tegration" and cost savings, those most
vulnerable among us are standing on the sidelines
and are most likely to become victims of a
public-health-policy offensive.
In these challenging economic times, Kentucky, New
Hampshire, Kansas and Louisiana have moved
aggressively toward mandatory managed care within
the past six months as a way to address their
expanding state Medicaid budget burdens. Other
states, including Florida and Georgia, are poised to
move quickly in the same direction. Still others are
making incremental progress toward the same end.
These dramatic policy shifts have not been without
major controversy and provider and service
disruptions.
Some of our nation's most vulnerable (and largely
voiceless) people receive their health care through
state Medicaid and safety-net programs. Proposed
Medicaid reforms for managed care will thrust these
people - including ones with serious mental
illnesses, children in foster care, physically and
developmentally disabled (including those with
autism) and many in nursing homes - into managed
health care.
While state leaders endeavor to reform their
Medicaid systems, the choices to which they are
defaulting will place the consideration and
decisions for the care of vulnerable people with
special needs in the hands of impassive monolithic
health plans. Just as "teaching to the median"
leaves students neglected at either end of the
talent spectrum, managing health care to the median
in traditional managed care leaves these populations
at risk, lacking access to quality health care and
health outcomes.
Health care is not easy to manage, and certainly the
chronic care needs of at-risk populations are not. I
know about these complicated challenges after a
career of more than 30 years working in all levels
of government mental-health and substance-abuse
programs. I have seen firsthand how the specialized
health care needs of just one of those groups,
people with serious mental illness, have been
largely unmet by traditional managed care.
Sadly, statistics from the National Research
Institute tell this story best: People challenged
with a serious mental illness die 25 years younger
than their counterparts in the general population.
This shorter life span is because their behavioral
health issues usually are compounded by one or more
chronic physical conditions, such as heart disease,
respiratory problems, diabetes or stroke.
In my field, we recognize that there is a complex
interplay between serious mental illness and
physical health conditions. Imagine someone with
bipolar disorder and diabetes whose disorganized
thinking causes difficulty monitoring his blood
sugar levels. Symptoms such as disorganized thinking
(associated with complex behavioral health issues)
often interfere with the effectiveness of primary
care. Systems of care founded on primary care leave
many of these populations with complex chronic needs
powerless, without access to the real "primary" care
they need.
Models of integrated health care for people with
serious mental illnesses that bring together care
for both mental and physical health needs in order
to improve health outcomes, as an example, must be
different to be effective. For such people, the
first focus must be on their behavioral health needs
to ensure successful impact of any physical health
care therapies on their co-occurring medical
conditions. There are models of specialty care that
can transcend existing practices by giving Medicaid
beneficiaries access to the right comprehensive
care, all while stabilizing system costs.
The outcome of such models is undeniable.
Pennsylvania's Behavioral Health Choices program
averted $4 billion in projected expenditures through
a specialty plan that integrates behavioral and
physical health care. New York's Care Coordination
Project also has been successful with a similar
complex-care-management program that has reduced
Medicaid spending by 41 percent compared to costs in
other municipalities in the state. Specialty care
plans have a proven track record from Arizona to
Iowa, from Nebraska to Massachusetts. Aside from
improvements in the quality of care, such plans have
yielded an average savings of 20 percent during
their second year of operation, with up to 15
percent projected in future years.
States have a window of opportunity to contemplate
new models of care thoughtfully for their vulnerable
populations. "One size" of managed care does not fit
all. Governors should take this time to think about
all of their residents and to demonstrate their
great care.
Charles G. Curie was administrator of the U.S.
Substance Abuse and Mental Health Services
Administration in the George W. Bush administration.
© Copyright 2012 The Washington Times, LLC
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