Reformed Medicaid program must put coordinated care at forefront of efforts

(Press-News.org) SAN DIEGO, April 8, 2011 -- A reformed Medicaid program must put coordinated primary care at the forefront of its efforts, the American College of Physicians (ACP) said in a new position paper released today at Internal Medicine 2011, ACP's annual scientific meeting. Medicaid and Health Care Reform highlights how primary care physicians will assume a major role in providing care to Medicaid beneficiaries.

"The Medicaid program faces significant changes in the next few years as millions of current and newly eligible people will receive Medicaid coverage," said J. Fred Ralston Jr., MD, FACP, president of ACP. "With this challenge comes the opportunity to reform Medicaid to ensure its future sustainability and solvency."

ACP's paper contends that the program must do more to ensure that physicians can afford to provide care, that information can be shared across the health care infrastructure, and that administrative burdens are mitigated to allow physicians more time to care for patients. It emphasizes quality care over volume-based care and says the programs will need to provide beneficiaries with more options to meet their long-term care needs.

The 38-page paper provides brief updates on changes to the program over the last three to four years and makes a dozen recommendations on how the Medicaid program can be improved to ensure access and sustainability in the future:

The Medicaid program should serve as the coverage foundation for low-income children, adults, and families regardless of categorical eligibility. Medicaid minimum eligibility standards should be uniform on a national basis, and federally mandated Medicaid coverage expansions should be fully subsidized by the federal government. Further, policymakers should refrain from enacting policy changes that would result in vulnerable persons being dropped from Medicaid coverage.

Medicaid payment rates must be adequate to reimburse physicians and health care facilities for the cost of providing services, to enhance physician and other provider participation, and to ensure access to Medicaid covered services. Policymakers must permanently increase payment for Medicaid primary care and other specialists' services to at least the level of Medicare reimbursement.

Medicaid resources must be allocated in a prudent manner that emphasizes evidence-based care and mitigates inefficiencies, waste, and fraud. Efforts to reduce fraud, abuse, and waste under the Medicaid program should not create unnecessary burdens for physicians who do not engage in illegal activities.

In the case of long-term care, Medicaid beneficiaries should be offered more flexibility to choose among alternatives to nursing home care, such as community or home health care, since these services could be less costly and more suitable to the individual's needs. States and the federal government should collaborate to ensure access to home and community-based, long-term care services. Individuals with long-term care needs should be able to supplement their Medicaid coverage with long-term care insurance products.

States' efforts to reform their Medicaid programs should not result in reduced access to care for patients. Consumer-driven health care reforms established in Medicaid should be implemented with caution and consider the vulnerable nature of the patients typically served by Medicaid. A core set of comprehensive, evidence-based benefits must be provided to enrollees.

Federal and state stakeholders must work together to streamline and improve the Medicaid waiver process, ensuring timely approval or rejection of waiver requests and sufficient transparency to allow for public consideration and comment.

Medicaid should be held accountable for adopting policies and projects that improve quality of care and health status, including reducing racial and ethnic disparities and effectively managing chronic disease and mental health.

Congress should establish a counter-cyclical funding mechanism for Medicaid, similar to the funding mechanism for unemployment insurance, to increase the amount of federal dollars to the program during economic downturns. Substantial structural changes to Medicaid are necessary if states are to meet the needs of the nation's most vulnerable populations.

States and the federal government should reduce barriers to enrollment for Medicaid coverage. Efforts should be made to ease enrollment for all eligible persons, including automatic enrollment based on income. Implementation of citizenship documentation requirements should not impede access to Medicaid and Children's Health Insurance Programs (CHIP) for those who are lawfully eligible. States and the federal government should provide culturally and linguistically competent outreach and education to ensure understanding and enrollment of Medicaid-eligible individuals.

States should work to improve the physician and patient experience in dealing with the Medicaid program. Solutions should include reducing administrative barriers and facilitating better communication and prompt pay standards between payers and physicians. Financial assistance should be provided to Medicaid-participating physicians to purchase and implement health information technology.

Medicaid programs should ensure access for Medicaid enrollees to innovative delivery system reforms, such as the patient-centered medical home, a team-based care model that emphasizes care coordination, a strong physician-patient relationship, and preventive services.

Medicaid program stakeholders should consider alternative financing structures to ensure solvency, high quality of care, and uninterrupted access for beneficiaries, while alleviating the program's financial pressure on states. Particularly, financing and delivery of care for dual-eligible beneficiaries must be reformed. A physician—particularly a primary care physician—should be included among the membership of the Medicaid and CHIP Access Commission.

"The Medicaid system provides vital health services to vulnerable populations, such as the poor and disabled," Dr. Ralston concluded. "But like the health care system as a whole, Medicaid needs to be improved to emphasize preventive and primary care. The need for the program is even more elevated as we've seen during the recent recession when more people have been forced to rely on the Medicaid system for coverage."

### About the American College of Physicians The American College of Physicians (www.acponline.org) is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 130,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection, and treatment of illness in adults. Follow ACP on Twitter (www.twitter.com/acpinternists) and Facebook (www.facebook.com/acpinternists).