Tag Archive for: Priorities

The American health care system is the most expensive in the world. While delivering technically excellent care in many instances, it also has tremendous documented failures, including overuse of certain procedures, poor management of chronic conditions, excessive and duplicative use of diagnostic tests, avoidable errors that lead to harm and death, and expensive, wasteful administrative processes. In that context, it is imperative that all of the forces of health reform align to squeeze out waste so resources can go toward the unmet needs so many people have and back into the pockets of families and businesses that have far better uses for their limited funds.
Health reform provides states with a broad array of new tools for improving the quality and efficiency of the health care system. These tools include pilots for the establishment of pediatric accountable care organizations, the promotion of medical homes for people with chronic conditions, demonstrations on bundling payments for hospital, post-acute and physician services, and the broad authority embodied in the Center for Innovation.
Far beyond these specific demonstration programs, states have the ability to align the purchasing power they have within Medicaid, CHIP, public employees and retirees, and the new exchange. That leverage, used in conjunction with Medicare and private purchasers, can, through payment reform, benefit design, using data, and setting ambitious population health goals, yield changes in how health care is delivered. Leading states already have in place public and private partnerships that are using payment reform, transparency with respect to price and quality, and other tools to achieve targeted improvements in health system performance.
 

The ultimate goal of the health care system is to improve and maintain people’s health and functional status. Population health goals create a bridge between public health and personal health, because population health goals are only attainable through the coordinated efforts of both systems.

The prevention and public health components of the federal law represent a fundamental shift from public health as an afterthought, subject to annual appropriations in competition with the more visible personal health services, to a core, sustained investment. In addition to the creation of the National Prevention, Health Promotion, and Public Health Council, which will coordinate federal strategy, the law includes a large number of grants to address topics including surveillance, public health laboratories, childhood obesity, and racial and ethnic disparities. States will need to consider how closely the criteria for these grants match the priorities and programs in the state.

On the personal health side, the law expands coverage for preventive services, promotes employee wellness programs, and increases payment levels to primary care providers through Medicaid.

The combination of expanded insurance coverage, appropriate benefit design, improved data collection and monitoring, and the increased investment in public health make it realistic for a state to pursue targeted and substantial improvements in the health of the population.

People eligible for both Medicare and Medicaid account for 42 percent of total Medicaid spending. This group of frail elders and a subset of people with disabilities experiences poorly coordinated care and high costs. Improvements in care for those who are dually eligible has long been a priority for states.

The federal law creates new challenges and opportunities for states. On the challenge side, the changes to the Medicare Advantage program will have implications for existing Special Needs Plans, which, despite their limitations, have been one source for coordination between Medicaid and Medicare. It is not yet clear how this will play out. States will also need to figure out how to integrate the new CLASS Act—a voluntary long-term care insurance program—into their overall strategy for meeting the long-term care needs of their citizens.

On the opportunity side, the law extends and expands the "Money Follows the Person" demonstration program to provide enhanced matching funds to help residents of institutions move back into the community, and creates new options for supports for people with disabilities. The law also establishes a competitive rebalancing incentive program that provides enhanced Medicaid matching payments for home and community-based services if states adopt certain delivery system reforms. The federal law creates a new office within CMS that focuses exclusively on the dually eligible, and the dually eligible are a target population for reforms that can be implemented by the new Center for Medicare and Medicaid Innovation. These two offices have not yet taken shape, but they offer unique vehicles for states to pursue models of integration between Medicaid and Medicare that have never before been available.

On average, people without health insurance use about 60 percent of the health care services as people with coverage. Expanding coverage will increase demand for services, which will strain the capacity of those parts of the health care system that are already under pressure. Particular challenges will arise in the areas of primary care, culturally competent and linguistically accessible care, and highly specialized care. Coverage expansions will occur at the same time as some institutions—community clinics, health centers and public and other safety net hospitals—are experiencing significant changes in their financing.

Expanding capacity is a long-term endeavor, so states must start now. The federal law provides some important opportunities. There are grant funds to support community health workers. There are opportunities for innovative payment and delivery models associated with telehealth in the areas of behavioral health and treatment of people with chronic illnesses, in particular by non-medical providers. There are significant changes in the allocation of graduate medical education training slots to emphasize primary care and outpatient settings and increased requirements on nonprofit hospitals to identify and meet community needs.

There are a number of new funding streams designed to expand provider supply in underserved areas, promote a more diverse workforce, expand the number of oral health professionals and expand nursing capacity in federally qualified health centers. Federal grants to states to support alternatives to the current medical liability system may affect supply. And, while the new federal law does not make any changes in this area, now would be an excellent time to revisit state scope of practice laws and the state’s approach to training and credentialing medical professionals.

Health coverage expansions will not create a provider supply problem, but they will highlight the problems states already have. The goals of health reform will not be met if the newly insured find that their coverage is a hollow promise.