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Volume 27, Issue 469 |
June 12, 2006 |
MEDICAID UNDER THE DRA: WEST VIRGINIA TAKES A CRACK AT REFORM
Matthew Gever
The Deficit Reduction Act (DRA) could mean that legislators will have to find new ways to get involved in Medicaid reform.
Signed by President George W. Bush in February, the DRA allows states to change their Medicaid benefit packages without going through the often long and cumbersome process of getting waivers from the Centers for Medicare & Medicaid Services (CMS). Instead, states can reform Medicaid (within limits) by amending their state plans. The DRA also allows states to offer differing benefit packages to most children and parents, a change that had been prohibited under previous federal rules.
West Virginia and Kentucky are the first two states to take advantage of the new flexibility made possible by the DRA, having gotten the go-ahead from CMS to change their Medicaid programs through state plan amendments. (Kentucky’s reforms will be described in a future issue of SHN.)
The Mountain State’s reforms are intended to improve the health of Medicaid enrollees, tailor benefits to population needs, coordinate care (especially for members with chronic conditions), and eventually save the state money.
On July 1, the state will begin offering 160,000 healthy children and adults—about half the state’s Medicaid population—a choice between two benefit packages: a basic package based on the current Medicaid plan or one that will provide enhanced benefits to those who sign a “Medicaid Member Agreement” that they will comply with recommended medical treatment and wellness behaviors.
The program will be piloted in three West Virginia counties and gradually expanded throughout the state. Those who sign an agreement will be asked to choose a medical home such as a primary-care physician in a community health center (the three pilot counties have health centers that use electronic medical records). Enrollees in the enhanced plan will work with their provider to develop a plan of care and desired outcomes, navigation of the health-care system and support for achieving desired outcomes.
Providers will monitor and report on whether enrollees follow such healthy behaviors as showing up for appointments, undergoing recommended screenings, taking medication as directed and using emergency departments only for emergencies. Those who adhere (including both children and adults) will be issued “credits” on a quarterly basis that they can use to receive additional services such as tobacco cessation programs, nutrition education and chemical dependency/mental health services. Those who don’t follow their contracts may be moved back into the basic benefit package. They may reapply for enhanced benefits after 12 months or when their Medicaid coverage is renewed.
Before West Virginia’s plan was amended, legislators and administration officials had been developing a comprehensive 1115 waiver proposal (1115 waivers allow states to test new approaches to Medicaid by changing eligibility, benefits or cost-sharing). The administration drew the reforms that will be implemented in July from this not-yet-completed 1115 proposal and then changed the Medicaid program through a state plan amendment, as allowed under the DRA.
“The administration thought they could do it better than the Legislature,” commented Rep. Bob Ashley, minority chair of the Health and Human Resources Committee. However, he’s not opposed to the amendment. The administration “tried to keep the reforms so they hurt as few (people) as possible ... This is as good as it could be in West Virginia,” given the state’s budget constraints, Rep. Ashley added.
The DRA does not allow states to change the benefits given to seniors, adults and children with disabilities, children in foster care and most pregnant women. Additionally, children under the age of 19 must continue to receive all the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services required by federal law before the DRA was enacted.
Many advocacy groups are vehemently opposed to the reforms. The plan is unlikely to lower the amount that West Virginia spends on Medicaid largely because the affected groups account for less than one quarter of the state’s Medicaid costs, wrote Judith Solomon in an analysis of the program for the Center for Budget and Policy Priorities. She warned that the program could lead to litigation because the basic benefit package for parents and children will contain fewer benefits than the state’s Medicaid program now offers. “Under West Virginia’s definition of EPSDT, services such as diabetes care and mental health services would not be covered for children under the basic benefit package,” Solomon wrote. “This definition of EPSDT is contrary to federal law.”
CMS ruled that the plan was legal, responds John Law, a spokesperson for the West Virginia Department of Health and Human Resources. He added that children will continue to be screened and treated for diseases like diabetes regardless of benefit reductions.
“We don’t expect any immediate cost-containment,” said Shannon Riley, spokesperson for the state’s Medicaid program. “What we hope to see is dramatic improvements in the long-term health care outcomes of these healthy children whose parents are responsible and sign the member agreement.”
West Virginia’s Medicaid rolls have grown by 37,365 individuals or 12 percent since 2001. The state has not expanded eligibility, and cost-containment has generally been achieved by cutting reimbursement to providers.
Matthew Gever
States that would like to place more foreign medical graduates in their medically underserved areas may get some help, if Congress decides to overhaul the J-1 visa waiver program.
The J-1 program is an important means of placing physicians from other countries in rural or urban health-care professional shortage areas. Ordinarily, foreign physicians who have completed their graduate medical education in the United States must return home. Under the J-1 visa waiver program, states and federal agencies may request visa waivers for these physicians as long as they practice in an underserved area for at least three years.
Since 2002, each state has been allotted 30 J-1 visa waivers per year. The program is popular: states and federal agencies requested more than 1,000 waivers in each of the past three years. However, the number of waivers requested by individual states varies widely, according to a May 18 report from the Government Accountability Office (GAO).
In FY 2005, about one-quarter of states requested the maximum of 30 waivers (see chart), while slightly more than a quarter asked for 10 or fewer.
The GAO queried the states on whether the annual limit of 30 was adequate for their needs, and on whether those that did not use their annual quotient would be willing to have their unused slots redistributed. The GAO report found:
- about 80 percent of the states—including many of those that requested the annual limit or close to it—reported the 30 waiver limit to be adequate;
- about 13 percent said the limit was less than adequate;
- of the 44 states that did not always request the limit, 25 said that they would be willing to have their unused waiver allotments redistributed (at least under certain circumstances); and
- another 14 states said they would not. “We feel that candidates may wait for a position in a more desirable location if slots were available rather than going to a very remote hard to fill location, which is the original intent of the J-1 wavier program,” said Tom Tucker, program manager of North Carolina’s J-1 Program.
The GAO estimates that the number of physicians practicing through the J-1 waiver is one and one half times greater than those who were placed through the National Health Service Corps. The fact that the House Judiciary Committee’s Subcommittee on Immigration, Border Security and Claims commissioned a GAO report indicates interest in reforming the program, but it’s too soon to tell whether or how the program would be changed.
States Use Additional Tools
While helpful, the J-1 waiver is not without its problems. In Wisconsin, for example, some officials worry that J-1 physicians are “just going to be here for three years and (then) will go somewhere else,” said Maureen Kartheiser, director of the Wisconsin Office of Rural Health (WORH). This has led the state to seek fewer J-1 waivers—12 last year compared with 29 in 2003—and to focus instead on state-designed programs.
Since 1979, WORH has operated a physician placement program that connects physicians to communities in need. Accessible on the Web, the program makes community profiles available and assists in spousal employment searches, among other services. To date, the program has helped to place 325 physicians in nearly 120 communities throughout the state.
In conjunction with the Wisconsin Department of Commerce, WORH also runs the Health Professions Loan Assistance Program, which provides up to $50,000 in loan repayments for health-care professionals who agree to practice in federally designated Health Professional Shortage Areas (HPSAs) for three years.
In North Carolina, many hospitals and physician groups are reluctant to seek out J-1 physicians, according to Judi Ashbaugh, medical placement specialist with the North Carolina Office of Research, Demonstrations and Rural Health Development. While the state office can process applications quickly, federal approval can take months, and many providers do not have that kind of time.
To attract physicians to underserved areas, the state operates a loan repayment program similar to Wisconsin’s. For a four-year commitment to a HPSA, a physician can earn $70,000 in loan repayments, plus an additional percentage to cover what is owed in federal and state income taxes on the $70,000. Through this program, the state averages 130 placements per year, the majority coming from outside of North Carolina. Retention rates are also quite high, Ashbaugh said. At least half of physicians stay in the same community after fulfilling their four-year commitment.
FEDS LEARN FROM STATES IN FIGHT AGAINST METHAMPHETAMINE
Christina Kent
A recently enacted federal law to combat methamphetamine production looks an awful lot like the laws passed in the last three years by at least 39 states.
That’s because the law, part of the U.S.A. Patriot Act signed by President George W. Bush last March, is based on laws pioneered by Iowa, Oklahoma, Oregon among others. Like the state laws, the federal one seeks to clamp down on “mom and pop” meth labs by making it more difficult to purchase large quantities of the common cold medicines that contain ingredients crucial to the manufacture of meth, such as ephedrine and pseudoephedrine.
In 2004, for example, Oklahoma passed a law (HB 2176) that limited sales of pseudoephedrine-containing products to nine grams per customer per 30-day period, and required pharmacists to keep a photocopy of IDs and a record of sales. State officials say the law has reduced the number of meth lab seizures from 1,200 in 2003, to single digits in 2005.
The federal Combat Methamphetamine Act (for summaries, click here) does not pre-empt tougher state laws, so state laws that are more restrictive will remain in effect. While state officials have mixed views on the imposition of a new federal law, supporters say it should help stamp out an unintended consequence of state laws: people who manufactured meth in a state that enacted limits on the sale of precursors sometimes moved their labs to a different state without such laws. The federal act limits retail sales to 3.6 grams per day per purchaser, and to no more than nine grams per person per 30-day period. All precursor-containing products must be placed behind counters, and retailers must maintain logbooks on transactions involving these products.
In the area of prevention (as opposed to criminal justice), the act authorizes three-year grants to address the use of meth among pregnant and parenting women. Pregnant women entering treatment are increasingly reporting meth as their primary substance of abuse.
The “mom and pop” labs produce only about 20 percent of the meth consumed in the United States. To combat the “super labs” located in Mexico, Asia and California that produce and export the other 80 percent, the federal law requires that the U.S. State Department analyze worldwide production of meth, versus legitimate demand, and recommend steps to Congress.
Below is a sampling of other legislation that states are considering or have enacted.
Alaska – Taking a page from a program first established in Kansas and now in 11 other states, HCR 4 urges that a “meth watch” program be established in Alaska, using federal and private funds, with state matching funds being appropriated if necessary. Community organizations would apply for funds and implement the programs.
Arizona – SCR 1033 would deny probation to persons convicted of possession or use of methamphetamine.
Colorado – SB 002 (signed by the governor in May) requires that contracts for the purchase and sale of residential property disclose whether the property has ever been used as a meth lab.
Hawaii – HB 1874 requires persons convicted of manufacturing or trafficking in meth or other dangerous drugs to register with the state Attorney General. The registration information would be made available to the public.
For information on some of the myths that surround meth addiction, see “Graphically Speaking” in this issue of SHN.
Anna C. Spencer
Sometimes saying you’re sorry is the right thing to do. That is, unless you’re a physician who may have erred in a diagnosis or treatment. Physicians are often told to avoid apologizing to patients or their families for fear of getting sued for medical malpractice.
Apologizing, however, may be an effective strategy to reduce litigation. “An apology actually deflates a scenario people have built up in their mind when they think they have been wronged,” said Doug Wojcieszak, spokesperson for The SorryWorks! Coalition, a nonprofit organization trying to ease the medical malpractice crisis.
In addition to potentially easing anger and pain, the strategy appears to be effective in reducing the number of medical malpractice lawsuits. Since the implementation of an apology program in 2004 at the University of Michigan Hospital Systems, the number of pending lawsuits against the hospital network has been halved, and defense litigation costs have decreased from an average of $65,000 per case to an average of $35,000 per case, resulting in a total average annual savings of $2 million.
The effectiveness of an apology notwithstanding, some physicians still shy away from revealing remorse and concern. To encourage apologies—with the goal of reducing malpractice premiums by reducing cases—some states are passing laws to protect physicians from having their words used against them in future court proceedings.
On May 31, Iowa Gov. Tom Vilsak signed HF2716, which protects health-care professionals who express sympathy, sorrow, commiseration, condolence, compassion or a general sense of benevolence to families affected by a negative outcome from having that expression used against them in court. In addition, in March, Utah enacted SB41, which makes inadmissible as evidence of an admission of liability, any statement, gesture or conduct expressing apology, sympathy or describing events leading to a patient’s outcome. In 2005, 19 states considered legislation to protect providers from having their apologies being used against them in a malpractice suit; Louisiana, Maine, Montana, South Dakota and West Virginia enacted such laws.
Some argue, however, that apology laws are one of the weaker stabs at malpractice insurance reform. “While an apology is certainly a positive thing, apology laws don’t get at the underlying issues that are driving the malpractice crisis,” said Michelle Mello, researcher at the Harvard School of Public Health and author of a recent report on the medical malpractice crisis and the effectiveness of various state tort reforms. The measures that typically are thought of as malpractice reform are highly controversial, including caps on non-economic damages, statutes of limitations and joint-and-several liability reforms (which limit each defendant’s liability for judgment to that defendant’s percentage of fault).
Attempts to remedy the medical malpractice crisis must aim at addressing instability in the insurance market, encourage disclosure, increase participation in patient safety programs and “compensating patients in a more equitable way when they are harmed,” says Mello. In her report, she calls for implementing schedules of damages (or a series of dollar ranges that vary with injury severity), disclosure and “early offer” programs under which providers promptly and candidly disclose errors with an offer of reasonable compensation, establishment of special “health courts” and administrative compensation systems. These remedies address the two reasons patients generally file suits: anger over lack of candor and need for compensation.
Still, Wojcieszak avers that “an apology offers a good middle ground” for reducing litigation and medical errors. Encouraging doctors to apologize “increases transparency and allows physicians and hospitals to learn from their mistakes and fix processes,” he said. “Tort reform nibbles around the edges but the patient/doctor relationship is where the action is in the medical malpractice arena.”
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