Utah’s Medicaid answer

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As Utah looked at ways to address Medicaid, we knew that we would need a comprehensive approach that fundamentally restructured the Medicaid payment system, looked at waste, fraud and abuse and worked towards returning Medicaid to the states.

Utah’s answer – and that of a growing number of states – is to move Medicaid to a managed care system. That will require a block grant waiver from the federal government, a change in how we manage patients in the system and in how we pay our providers. We want our providers operating in an evidence-based fashion, as we know that unnecessary procedures push costs up. We will restructure how we pay providers to treat and prescribe for their patients, so we have a system that rewards rather than punishes innovation and efficiency. Right now, the system drives people to the ER for even their most basic needs. Emergency room care is, of course, the most expensive option for medical treatment. As we change our payment model, moving to a bundled payment, or accountable care approach, we expect to see a decrease in the bottom line – something that is good for all concerned. In fact, Rep Paul Ryan is proposing the federal government move all states to a block-grant, managed care approach.

Another area that needs attention is the area of Medicaid fraud and abuse. A recent audit of both state-run and private clinics showed “upbilling” to be a problem in on overwhelming majority of cases. We will continue to tighten up our Medicaid eligibility requirements and implement appropriate follow-up to ensure the requirements have indeed be met. We plan to upgrade our claims tracking and will be prosecuting Medicaid fraud through our Attorney General’s office.

Finally, we believe that Medicaid needs to be re-focused as a state program that serves the neediest among us. Obamacare needs to be repealed. No state can afford its implementation. States need to be able to run their own Medicaid programs, including the determination of eligibility. There is not a one-size-fits-all policy that can adequately represent all citizens living in say, Tennessee, Alaska, Hawaii, Massachusetts, and Utah. Each state has unique circumstances and should be able to tailor their Medicaid program to fit their state. Utah should be able to administer the Medicaid program in the way that best meets the needs of all Utahns – and that could eventually mean we wean ourselves off of the federal program completely.

The bottom line is no state – including Utah – can afford to continue the status quo. There is an answer that balances the needs of those Medicaid was designed to help without bankrupting the state – and I think this year we found it. SB180, sponsored by Senator Dan Liljenquist (R-Bountiful) passed unanimously in both bodies and was signed by the Governor. Senator Liljenquist spent the entire interim working with all interested parties and came up with a balanced restructuring that is already being hailed as a model for the nation.

It is this type of innovative thinking that continues to place Utah out in front of the nation on fiscal issues – a really great place to be.

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16 Responses to “Utah’s Medicaid answer”

  1. rmwarnick Says:

    Why not advocate a single-payer, Medicare-for-all system? You could control costs, cut overhead and paperwork, and no money would have to be set aside for health care industry profits. The only thing wrong with this idea is that the special interests, and the politicians who depend on special interest campaign contributions, will never support it.

  2. markg91359 Says:

    RM,

    Great idea, but if the legislator takes the time to answer your question at all (which is unlikely) she’ll probably use a lot of adjectives like “socialist” to describe what you want. The critique that the right makes of a Canadian style single payor system is that its “government run”. This, in their minds, makes it inherently inferior to a system based on the “free market”.

    Never mind the fact that the free market has had decades to work through the current woes with medical care availability and costs. It ought to be obvious to anyone but a pure “woodenhead” at this point that its failed. In fact, the goal of care for all has become more and more elusive with about 48 million uninsured Americans currently.

    I had an old car once that I was really attached too. I kept pouring time and money into the thing hoping that someday it would run like a new car. After three years of spending too much money on parts and repair bills I gave up. I finally got a new car that ran well. The old car is just like our current medical system. Deep down everyone knows it needs to be replaced. Yet, they get hoodwinked into keeping what they have because people scream “socialist” or big government at them.

    The free market will never fix the health care problem because it isn’t profitable to insure those people who are sick and need health insurance the most. On the other hand, healthy people will likely be offered incentives and health care they don’t really need to try and entice dollars out of their pockets. The idea that the average Joe Blow can evaluate things like whether Lipitor is a better medication than Zocor is unrealistic. Evaluating healthcare is much harder than picking a new tv or a new car and the consequences of a wrong choice are much greater.

    But have no fear, we’ll continue to hear crap like “private is always better than government” (even when its not).

  3. Pops Says:

    Kudos to Senator Liljenquist. Sometimes I wonder if he wears a cape and tights…

    We haven’t tried the free market in health care for a very, very long time. What we have now is the result of a power play by insurers to elbow private practice out of the picture, thus diverting the flow of health care dollars away from doctors and into their greedy clutches. It started decades ago with legislation to allow employers to offer tax-exempt health-care benefits to their employees, and has gotten progressively worse over the years as different groups jockey for position to tap into the gravy train that was created. It really isn’t “insurance” by any stretch of the imagination. But going from what we have now to a socialist approach would be going from the frying pan to the fire.

    Socialism is problematic because it destroys natural feedback mechanisms that align services with needs. It also pushes rationing decisions away from those who receive care to bureaucrats. I’m not comfortable with the idea of some bureaucrat telling me I can’t have the medical care I need because I’m too old or don’t have a favored profession or trade. Then there’s the specter of being denied service because of the color of one’s skin, one’s religious beliefs, or one’s political affiliations.

    All government-run programs are problematic because they invite fraud and waste. Perhaps you missed the part in Holly’s post about fraud and abuse being a major component of the Medicaid cost problem. Why would a single-payer system be any different?

    What we really need to do is return to a free market approach, not move further from it. Get employers out of the picture. Revert back to real insurance (catastrophic coverage).

    Perhaps we do need insurance reform to address the pre-existing conditions problem – but there’s an argument to be made that those who refuse to buy catastrophic coverage when they’re well should suffer the consequences of poor planning, relying of course on the voluntary assistance of family and friends who might choose to help them when it comes time to deal with the consequences of poor decision-making.

    Free markets improve the decision-making ability of citizens by requiring them to suffer the consequences of their choices. Shielding people from the consequences of their choices, or not allowing people to make choices at all, results in a dependent and incompetent citizenry – but then perhaps that’s the intent.

  4. rmwarnick Says:

    Pops, unless you’re younger than your name you will be enrolled in Medicare soon. I hope you are, because Republicans are trying to abolish Medicare for Americans under age 55.

  5. Dwight Says:

    Pops the free market approach with three players completely destroys the natural feedback loop. Patients don’t know how much things cost, some doctors don’t. Doctors or their employers often benefit from unnecessary tests. Insurance companies benefit when they pay the least. Egregious examples include stalling on transplant decisions until it’s too late, or not paying for time with a nutritionist for a newly diagnosed diabetic in hopes that when it comes time for the leg to come off the patient will be on another plan (often a government one). Then there is also a sometimes less direct conflict with the drug companies and drug reps.

    Pops do you think those with chronic conditions should just be allowed to be sickly and die? Cystic Fibrosis is an expensive chronic condition from birth that no individual or family could possibly hope to cope with paying for. The life expectancy has increased dramatically with proper care. It’s interesting that in countries with socialized medicine a child with cystic fibrosis can expect to live 10 years longer than in the US. CF patients in the US often skip medications too expensive, they often are unable to marry due to it jeopardizing their care, and they often are unable to get jobs cause they can’t wait 3 months for employer insurance to kick in, assuming there will be no hiccups even, and instead must remain eligible to be classified as disabled and rely on government programs. Whereas in socialized medicine countries they can marry, work full or part-time as they are capable and not have to worry about the detrimental changes that could cause to their healthcare.

  6. reffaree Says:

    Pops: This site is overrun with D-bag Socialists like DBAGwarmick, D(UMB)wight and SUEahole Connors. Unfortunately Holly is too PC to run a site that can disseminate the truth without telling the conservatives who reply in a VERY FRANK MANNER to “PLAY WELL IN THE SAND BOX” So I suggest you save your time as I will and prepare yourself for the upcoming insurrection that these Liberals will soon launch on our Republic this summer. DO NOT DOUBT ME.

  7. reffaree Says:

    gOOD BYE HOLLY. HAVE FUN PANDERING TO YOUR SOCIALIST CONSTITUENTS. GOOD LUCK IN THE FUTURE.

  8. hollyonthehill Says:

    Oh for pete’s sake. It really is possible to have a conversation without calling someone a “D-bag”. Really, it is. Even when you disagree with them.

  9. Pops Says:

    …the free market approach with three players completely destroys the natural feedback loop…

    You seem to have missed a key point in my comment. That isn’t a free market approach. Part of the reason it doesn’t work is because it isn’t.

    Pops do you think those with chronic conditions should just be allowed to be sickly and die?

    Do you think those with chronic conditions and refused to buy catastrophic coverage while they were healthy deserve to steal the property of other people to receive medical care?

    I don’t think they should be allowed to die, but the means to provide the needed medical care should be provided voluntarily by family and friends.

  10. Ronald D. Hunt Says:

    “catastrophic coverage”

    You really don’t get it, The problem with your catastrophic coverage insurance idea is how costs are distributed. And I am not talking some ideological perspective on who pays for what or how they pay whatever, I am talking about the distribution of health problems and how the cost of treatment applies.

    That is to say 90% of the cost in health care is incurred by 10% of the population. That is to say high deductible insurance saves only a marginal amount over comprehensive, of course we have to ignore the adverse risk of additional costs from late treatment of disease due to increased cost in primary care under such a plan preventing people from going in when treatment is cheaper.

    Further the population group most likely to be stuck with high deductible insurance is the least likely to be able to afford it, If you have a chronic disease and basically have to eat the first 20K of medical expenses every year that is more then enough of a difference to bankrupt even upper middle class families.

    And remember the numbers don’t support your position that these medical bankruptcies are from people who went without, 78% of medical bankruptcies are from people who had insurance at the onset of their disease. or medical problem.

    And don’t forget their is a certain amount of emergency room care costs you can never libertarian your way out of without resolving to some truly disgusting changes to how the law treats hospital emergency care. Namely, as it stands now emergency rooms are required by law to stabilize patients without regard to their ability to pay, and it is often the case that said ability can not be confirmed due to inability of the patient to communicate. If you are out cold after a car accident with no ability to give the emergency room/ambulance your insurance info should they be allowed to let you die, they have no way of knowing if you can pay or not? And remember we are talken serious dollars here 20% of the system is emergency care.

  11. Pops Says:

    That is to say 90% of the cost in health care is incurred by 10% of the population.

    That’s the whole point of insurance. Insurance isn’t something you get “stuck with”. It’s a product you choose to buy to hedge against the possibility of events that would otherwise be catastrophic in nature.

    And remember the numbers don’t support your position that these medical bankruptcies are from people who went without, 78% of medical bankruptcies are from people who had insurance at the onset of their disease. or medical problem.

    Bear in mind that what you’re calling “insurance” isn’t really insurance.

    …without resolving to some truly disgusting changes…

    Like walk-in clinics that charge $40 for the stuff people are currently taking to the ER? Truly disgusting that.

  12. Dwight Says:

    Pops what are people with chronic conditions supposed to do? Many outlive the insurance company they had from before they were diagnosed. If they switch to another company, either that company will deny them, cause they will cost more than they put in, or that person will now be ‘stealing’ from the other people putting into that insurance plan.

  13. Ronald D. Hunt Says:

    “That is to say 90% of the cost in health care is incurred by 10% of the population.”

    The point of that statement is to say that the difference in cost between good comprehensive insurance and the junk high deductible insurance is minor, $100-$200 dollars per month at most, And the price difference right now is quickly disappearing as inflation in high deductible plans is higher then comprehensive plans due to that adverse risk in disease detection thing I talked about.

    “Like walk-in clinics that charge $40 for the stuff people are currently taking to the ER?”

    Plus $120 for that blood test, plus $80 for the stints, plus $200 for month supply of cipro to keep infections away. Sorry no their are far to many people who would wait until their was a big infection and surgery requirements aka wait until it is bluntly unignorably obvious, stupid yes but in your world they will hit the deductible and go far beyond destroying any so call savings.

    And again, what does the ER do when you can’t communicate your ability to pay?, THAT IS A HUGE CHUNK OF THE COST.

  14. Pops Says:

    …good comprehensive insurance…

    There’s your problem. “Comprehensive” insurance is foolish. If you could buy car insurance that would pay for oil changes and other routine maintenance, would you go for it? Keep in mind that an oil change would probably run $500…

    And again, what does the ER do when you can’t communicate your ability to pay?, THAT IS A HUGE CHUNK OF THE COST.

    That’s pure conjecture on your part.

  15. Ronald D. Hunt Says:

    “That’s pure conjecture on your part.”

    No its not, My brother was life flighted off the side of a mountain after a motor cycle accident where he broke both of his femur bones, he ran up $180,000 dollars in hospital bills(this is amount the insurance didn’t pay not sure what full bill would have been), the hospital did not have any information about his insurance or ability to pay for that care until 3-4 days later.

    The hospital eventually wrote off the entire $180,000 that the insurance didn’t cover(aka the tax payer eats it), But either way they had no information on ability to pay until day 3-4, should they have let him bleed to death for lack of that information?

    “. If you could buy car insurance that would pay for oil changes”

    You can, and no it is not that expensive, almost every dealership out their will have some sort of extended warranty that covers oil changes. It is generally a bad deal all extended warranties are, but we are talking about two completely different concepts here. In one case their is the car which is an inanimate object of a relatively limited depreciating value an object that has no feelings, feels no pain, and is easy to replace, And in the other case we have a human being which has feelings, feels pain, and has a value that can not be defined by a function of money and is can not be replaced.

    To say nothing of the vast difference in cost of maintenance between the two entities, and the vast difference in how costs are distributed between the two different sets of entities. Car maintenance being fairly predictable across the number set and costs generally evenly distributed, where as human maintenance costs are fairly random across the dataset and tend tends to be very unevenly distributed.

    Even the insurance industry is pushing high deductible plans less because they don’t bloody work on the function of long term sustainability. high deductible insurance pushes the cost problem bankrupting the system out maybe 6-7 years or so, either way at current cost growth sometime between 2030 and 2040 your insurance policy will cost more then the median income of the united states.

  16. Pops Says:

    No its not, My brother was…

    That’s anecdotal evidence. I’m sorry for what happened to your brother, but go sit in the ER waiting room and compute the ratio of conscious to unconscious arrivals – that would get you a bit closer to reality.

    ..some sort of extended warranty…

    And you’ll never guess why they offer them. It’s because the profit margin on the extended warranty is ridiculously high. It does anything but drive costs down.

    And in the other case we have a human being which has feelings, feels pain…

    Get over it. There isn’t anything about economics that doesn’t ultimately involve people. Today it’s medical care, tomorrow it will be food, them comes housing and employment. That path leads nowhere good.

    …because they don’t bloody work…

    Real insurance worked fine until government started meddling in health care. So, you apparently don’t think homeowners’ insurance works, either, then, because the cost of replacing a house that burns down is ridiculously higher than providing no benefits to a homeowner who never makes a claim. That’s the point of insurance, which point has been muted by virtue of the fact that we’ve changed the definition of the word “insurance” because of government meddling. (What we had back in the day was real insurance, which can’t be achieved by simply tacking a high deductible onto the faux insurance we have today.)

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