June 13, 2011
Caring for the Underserved: The Holes in the Safety Net are Getting Bigger
While nephrologists are very familiar with the uniqueness of the Medicare entitlement for ESRD patients, the critical importance, structure, and challenges to the Medicaid program that directly impact ESRD patients are less well known. Medicaid came into being in 1965 part of the same legislation that created Medicare. It was designed to be complimentary to Medicare- to provide a safety net for the support of health care delivery to individuals who could not afford to pay for care. Medicaid is different from Medicare however, since it is financed through a Federal/State sharing of cost program. There are no limits on what a given state can spend on its Medicaid program, and the Federal spending match is determined by formula varying from 50% of state costs (in 18 states) up to 74.3% (in Mississippi). The matching formula is based on state per capita personal income compared to the national average.
The current economic recession has been a disaster for Medicaid programs and there is no light at the end of that tunnel. Falling state revenues and an incredible increase in the enrollment in Medicaid programs have driven states to draconian measures to stop the bleeding. By the end of 2009 nearly 49 million Americans, one in six, were covered by Medicaid. Although MIPPA increased the Federal share of costs temporarily, that is coming to an end, and after July 1st of this year the Federal contribution will return to pre-2009 levels.
How are states responding to this crisis? Not rocket science- cut reimbursement to providers, renew the push to move Medicaid patients into managed care, create more restrictive medication formularies, and eliminate some high cost procedures from the list of covered services. The result will be less access to care, increased use of emergency services and withholding of medically needed services- all leading to unacceptable health outcomes for some of our most vulnerable.
For patients with ESRD significant Medicaid cuts proposed in North and South Carolina, Louisiana, Texas, Minnesota, California, Illinois and many other states could be devastating. But in the face of these challenges, nephrologists and the renal community have an opportunity to step forward and help states understand that creative approaches to improving quality for Medicaid patients with ESRD can also drive lower costs. Removing barriers to permanent access placement and avoiding catheter placement; increasing the emphasis on starting home therapy as an initial dialytic modality; initiating care coordination/care management in Stage 4 CKD are just three of the ways states could save money by investing in better care.
As a renal community we need to get involved in our individual states, educate them about the ways better quality for ESRD patients can control costs in their Medicaid programs and then we need to partner within our states to make this ideas become reality. I had the privilege of spending 1994-95 working with Senator Paul Wellstone from Minnesota. He stated:
“ …how can we live in the richest, most privileged country in the world, at the peak of its economic performance, and still hear [from politicians] that we cannot afford to provide a good education for every child, that we cannot afford to provide health security for all our citizens?”
— Paul Wellstone (The Conscience of a Liberal: Reclaiming the Compassionate Agenda)
Like Senator Wellstone I know we can do better.
I look forward to your comments, until next time.
Striving to bring quality to life,
Allen R. Nissenson, MD
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