Monday, August 18, 2008

West Virginia's Medicaid Redesign and the Ethics of Personal Responsibility

Two years ago, West Virginia launched a Medicaid redesign based on the premise that beneficiaries should be expected to play an active role in managing their own health. As a condition of eligibility for an expanded portfolio of benefits, beneficiaries were asked to sign a document of "member responsibilities and rights," which included taking medications regularly, keeping appointments, and avoiding unnecessary emergency room visits.

If you were a Medicaid commissioner responsible for a budget-busting program or a hard-pressed taxpayer supporting it, these expectations would seem eminently reasonable. Adult patients aren't children. It is condescending for clinicians to expect too little from patients. A patient of mine with significant substance abuse problems brought this home to me some years ago:

Patient: "You remember the time a few months ago when you said I looked strung out and asked me if I was using? I told you I wasn't, but I had taken cocaine earlier that morning."

Me: "That's what gets called 'denial' in the substance abuse world."

Patient: "Not denial...LYING."

In my view, the impetus for West Virginia's redesign was understandable and inherently admirable. The question at the time of implementation was whether a blunt instrument like member responsibility agreement could really work.

This month a Georgetown University evaluation of the program gave the answer. It doesn't work.

So far 85% of those who are affected by the changes are children. Almost all children on Medicaid (93%) have had their benefits restricted. This isn't because their parents have failed to do their part in the care process - it's because the documents never got signed in the first place. It isn't that parents have been reading the documents, deliberating about whether to sign, and then saying "no." The process has been so confusing and poorly implemented that non-signing of the documents is virtually inevitable.

Children make up 50% of West Virginia's Medicaid enrollees but only 22% of the cost of the program. The elderly and disabled make up 36% of the enrollees but account for 70% of the cost. The program evaluation does not document any impact of the redesign on these populations.

I hope West Virginia's failure doesn't stifle efforts to bring patients and families into more active collaboration in the effort to improve health and control costs. We won't make progress on these fronts unless patients, providers, and payers work together. West Virginia's experience tells us that bureaucratic fiat won't do the job. If I were the Medicaid commissioner there I would bring Medicaid recipients and medical leaders together to learn from the first two years of experience and plan for next steps.

All around us we see efforts to get a grip on health care costs and quality. Unfortunately, most of these efforts are based on wishful thinking about magic bullets. In West Virginia the magic bullet was a written contract for care. In private insurance the magic bullet is high deductibles. But gimmicks like contracts and deductibles won't do the difficult job for us without a concomitant shift in the values by which we govern our health care non-system.
(The Georgetown evaluation can be found here. New England Journal of Medicine articles about West Virginia's Medicaid redesign are here and here.)