The West Virginia Medicaid Plan
West Virginia plans to require that residents of that state who are eligible for Medicaid because of low income sign the “West Virginia Medicaid Member Agreement.”1
The agreement lists “member responsibilities and rights,” the former of which include, for example, taking medications as prescribed, appearing for appointments on time, and using the emergency room only for emergencies.
Failure to meet these terms would result in the decrease or elimination of some benefits.
According to the legislation, West Virginia will track four indicators:
- Participation in health care screenings
- Adherence to health improvement programs indicated b their health care providers
- Attendance at medical appointments
- Compliance with medication schedules
The NEJM Perspective
Source: Personal Responsibility and Physician Responsibility — West Virginia’s Medicaid Plan by Gene Bishop, M.D., and Amy C. Brodkey, M.D. NEJM Volume 355:756-758 August 24, 2006 Number 8
As Drs. Bishop and Brodkey point out, albeit in more measured terms, this scheme of contracting with patients has been justified and, I believe, pseudo-beatified, by its supporters invoking personal responsibility, an understandably popular concept.
The authors note that “[the policy’s] speedy approval by the Centers for Medicare and Medicaid Services (CMS) demonstrates the agency’s enthusiasm for such an approach” and that the head of the CMS, Mark McClellan declared that “Medicaid enrollees in West Virginia will now become part of an emerging trend in health care that empowers patients to make educated, consumer-driven decisions related to their own treatment.”
[Note: Shouldn't someone alert Dr. McClellan that the rest of us of figured out the code so we know that whenever a bureaucrat from the government or a healthcare organization says "empower the patient," that bureaucrat actually means "give the patient two poor choices instead of one mediocre one and tell him it's his responsibility to choose wisely."]
While personal responsibility is the mantra, it seems apparent, at least to me, that this program would change the dynamics of the doctor-patient relationship dramatically, shifting it from an autonomous patient negotiating his or her health care with a clinician to something that would more resemble an employee being instructed by a superior with his job on the line if the employee resists or fails to meet production goals.
Medicaid patients will assume obligations and be required to meet standards significantly beyond those demanded of other patient groups. Not only does this violate the basic principles of fairness but it also overlooks the fact that Medicaid patients are more likely at the mercies of public transportation, have fewer funds, less access to wholesome foods, less opportunity to participate in exercise programs, and, since 75% are children, have no authority to enforce their own wishes.
The authors use an all too realistic scenario of a 53 year old obese woman with diagnoses of diabetes and schizophrenia who is unable to lose weight as required and misses appointments, probably because of her psychosis. Under the new regulations, she stands to lose her health benefits, including those funding her mental health care.
While such patients are not unusual, the plan is fundamentally flawed regareless of the patient group(s) it would cover.2 The fact is that roughly half all patients with any diagnosis prescribed any medication will fail to comply. Complete compliance with complex treatment programs, such as diabetic treatment, is quite rare with rates in the single digits. Further, it’s not difficult to imagine, say, a surgeon who sincerely believes that an aggressive surgical approach to a problem is a given patient’s best hope for survival while the patient is less convinced and is frankly fearful of the risk of the operation. If this patient makes a reasoned, defensible decision to forgo or defer the surgery, should he or she lose health benefits? Or, as the authors rhetorically ask, “Is it irresponsible to refuse to take a medication if it makes you ill and you cannot reach your physician to ask for advice?”
The Rest Of The Story
It is not clear, however, from the NEJM Perspective that the West Virginia plan actually offers a Basic and an Enhanced plan and that only the extra benefits (i.e., those offered in the Enhanced plan but not in the Basic plan) are contingent on fulfilling the compliance contract. Failure to sign or successfully fulfill the contract does not eliminate the patient’s benefits entirely but rather shifts him or her from the Enhanced to the Basic plan. See thumbnails marked “West Virginia Plan,” “Benefits Package – Adults,” and “Benefits Package – Children” for details.
I agree with Bishop and Broadkey that, in toto, the problems of the West Virginia plan significantly outweigh its potential benefits. The specific details of the Basic Vs Enhanced plan are problematic. Mental health services, for example, are available only through the Enhanced plan; a psychotic patient would, according to my reading of these documents, lose his psychiatric benefits if, because of his psychosis, he were unable to keep his appointments and take his medications. Moreover, implementing this idea with the population with the fewest resources to follow through on their personal health plans seems a mistake. Most importantly, however, the current West Virginia plan demands the most primitive form of compliance – obedience.
I find it difficult, in fact, to reconcile the contractual demands with these excerpts from the “Members Rights” section in the second half of the same document:
I have a right to decide things about my health care and the health care of my children.
I will not be treated differently because I am in the Medicaid Program.
My objection to the NEJM Perspective stems from my convictions that (1) reinforcing cooperation between clinicians and patients is a worthwhile strategy and (2) providing an enhanced healthcare package is itself a valid and potentially useful methodology deserving of more consideration. Denouncing the program without at least considering its potential benefits seems a case of throwing the baby out with the bathwater.
Documentation From The West Virginia Medicaid Plan
The documents below are from the West Virginia Medicaid State Plan Amendment as approved by the Center for Medicaid and Medicare Services. (Accessed August 23, 2006, at http://www.wvdhhr.org/bms/oAdministration/bms_admin_WV_SPA06-02_20060503.pdf.) Click on thumbnails below to enlarge to full size for reading.
Members Agreement - Page 1
Members Agreement - Page 2
West Virginia Plan
Benefits Package – Children
Benefits Package – Adult
Footnotes
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