AlignMap

From Nov. 3, 2008 American Medical News - By Doug Trapp

American Medical News Critiques West Virginia Medicaid Incentive Program

The graphic above is the heading for an American Medical News¹  story about the West Virginia Medicaid patient incentive plan.  The basics of the West Virginia plan and my perspective on it was discussed in this blog two years ago at West Virginia Medicaid Compliance Contracts – The Plan, The NEJM Perspective, & The Rest Of The Story.

See if you can guess AMA’s perspective from the clues in the headline:

When incentives lack appeal:
Medicaid reform meets confusion, skepticism

That’s right – in formal terms, this means  “Incentives used in the West Virginia Medicaid reform plan to encourage certain behaviors in patients lack appeal, thus causing confusion and skepticism.”

In less formal terms, it means “The West Virginia Medicaid reform plan stinks.”

Now, try the subheading:

West Virginia is one of the first states to offer inducements
for patients who pledge to follow physicians’ orders,
but most of those eligible aren’t taking the bait.

Let me suggest that the key words are “… most of those eligible aren’t taking the bait,” a figure of speech that leads me to suspect that it required the totality of the author’s self-discipline to forgo his impulse to add “Thank God” at the end. After all, I’ve never read a story in which good things happened to anyone who does “take the bait.”

At the risk of provoking the AMA to reconsider its position, I agree with their point that the bureaucratic implementation of the incentive plan is – hmmmm, let’s call it suboptimal. In fact, I am probably more critical of the plan’s structure than is the AMA. More about this a little later.

The Criticisms

The  article’s  basic argument is presented in the excerpts that follow:²

The program, which began almost a year ago in most parts of the state, is a novel attempt to use incentives to boost enrollees’ personal responsibility and ownership over their health care. Eligible enrollees who agree to a wellness plan, follow other physician directions, and show up on time for medical appointments can receive free additional benefits, such as help with quitting smoking and membership in Weight Watchers. Those who don’t take the option are relegated to a basic plan with somewhat fewer benefits than their existing plan.

Enrollment in the enhanced plan so far has been low. About one-third of West Virginia’s Medicaid beneficiaries — who numbered 392,000 in 2007 — are eligible for Mountain Health Choices based on their relative good health. But only about 15,500, or 12%, of those eligible had signed up as of Sept. 30, according to state counts. Another 3% had begun the enrollment process.

Why hasn’t the program been more popular?

Some patients simply might not know about or understand the program. Others might not read well enough to grasp the details. But even for those who want to pick the enhanced option, it’s not always simple.

For starters, Medicaid enrollees are instructed to call their primary care physician. “Many don’t have a primary care provider,” said Renate Pore, president of the patient advocacy group West Virginians for Affordable Health Care. “They don’t know who they’re supposed to call.”

Some eligible enrollees might not see a need for extra benefits, said Sarah Chouinard, MD, medical director of Primary Care Systems Inc., a health center in Clay, W.Va. For example, a 30-year-old woman with seasonal allergies might think she just needs her allergy prescription and annual Pap smear, not a wellness plan and extra hospital coverage.

The requirement that patients commit to regular office visits could pose a barrier for those with limited transportation options, said Rodney Fink, DO, director of clinical service for Access Health, a group of six health centers in southern West Virginia, including the Beckley facility where Dr. Bennett works.

Some observers say the state needs to do a better job of selling beneficiaries on the extra benefits. Dr. Fink said doctors also need to do a better job of focusing their patients’ attention on it.

… The Deficit Reduction Act of 2005 gives states authority to offer varying benefit levels to Medicaid enrollees. A few states, including Idaho and Kentucky, responded by offering incentives to beneficiaries who adopt healthier behaviors. Other states, such as Florida and Wisconsin, set up similar programs under waivers from the Centers for Medicare & Medicaid Services. The Deficit Reduction Act of 2005 lets states offer varying benefit levels to Medicaid enrollees.

But West Virginia took the concept one step further by limiting benefits for Medicaid recipients who do not promise to follow a wellness plan and listen to doctors’ orders. The state is now on the line to prove the tactic will work.

The ultimate goal of Mountain Health Choices is to forge relationships between patients and physicians that lead to healthier lifestyles and better preventive care, said Shannon Landrum, spokeswoman for the West Virginia Bureau for Medical Services in Charleston. …

Parents must agree to pick a medical home for their child, bring the child on time for a minimum number of office visits, and ensure that immunizations are up to date and prescriptions are followed. The agreement is similar for adults, with the addition of required screenings, such as colonoscopies, glucose levels and mammograms.

Some points of contention

The West Virginia program is more controversial than other states’ because it automatically bounces nonparticipating beneficiaries — possibly without their knowledge — into the basic plan. Once there they encounter more restrictions than in traditional Medicaid, such as caps on prescriptions and mental health services.

For example, children in the basic plan are limited to four prescriptions per month, even though a child with asthma and attention deficit disorder could easily hit that limit, said Fernando Indacochea, MD, president of the West Virginia Chapter of the American Academy of Pediatrics. Landrum, however, said a state review of data from three pilot counties prior to implementation showed that children on Medicaid average fewer than one prescription a month.

And while individual mental health therapy is covered under the basic plan, crisis intervention is not, said Bob Hansen, executive director of Prestera Center, a mental health and addictions treatment agency in Huntington.

Georgetown University’s Center for Children and Families on Aug. 9 issued a paper criticizing the state for automatically limiting kids’ benefits via the basic plan. If the program aims to encourage healthy behaviors among Medicaid enrollees, said Joan Alker, the deputy executive director of the center, “I don’t think there’s any evidence that they’re achieving that.”

West Virginia already has learned some lessons that could be applied by other states considering incentives for patient compliance.

Dr. Fink said programs such as Mountain Health Choices won’t work unless staff at clinics and health centers proactively advise patients about their health care options. He added that physicians should form a second line of support and also gauge their patients’ awareness.

Landrum said it can be difficult to engage Medicaid enrollees as they gain or lose program eligibility. About 40% of Medicaid beneficiaries in West Virginia don’t renew their benefits from one year to the next. States that want to change Medicaid from a program that simply pays claims into one that promotes health improvement and wellness need to be patient and look for ways to measure success in the long term, Landrum said.
Hope for the future

To improve physician awareness, the state could notify doctors of their Medicaid patients’ deadlines for choosing a new plan, said Violet Burdette, CEO of Northern Greenbriar Health Clinic in Williamsburg. Eligible beneficiaries receive a Mountain Health Choices enrollment packet 60 days before their Medicaid benefits are changed. They have 90 days to respond.

Burdette also said enrollees might be more engaged if they had to choose either the basic or enhanced plan instead of being channeled into the less generous plan by default. Landrum said only two Medicaid beneficiaries have actively declined the enhanced plan.

Work of enrolling can fall on physicians

Some physicians are excited about West Virginia’s pilot program that offers incentives for Medicaid patients to stick with a wellness plan, even though it does cause extra work for doctors.

Sarah Chouinard, MD, medical director of a health center in Clay, about an hour from Charleston, said her facility has convinced more than a few patients to take advantage of the enhanced benefits in Mountain Health Choices. The clinic, which is in one of the three pilot counties for the program, treats about 7,200 patients, a third of whom are enrolled in Medicaid.

Dr. Chouinard said explaining the initiative to patients requires additional staff time but coordinates well with the medical home model the center offers.

Terrence Reidy, MD, was less enthusiastic. He practices at a community health center in Martinsburg, in the eastern part of West Virginia.

A state Medicaid representative visited his facility about a year ago to explain the role the center would play in promoting the expanded plan. “It seemed like our office was then expected to be the ones to get the patients to sign up,” Dr. Reidy said. The internist hasn’t been contacted by state officials since then, he said in late September.

The center treats about 2,400 Medicaid patients, two-thirds of whom are children. Only about 2% of patients have opted for the enhanced benefits. “It really has not changed our practice a bit,” Dr. Reidy said. Still, consulting even a few patients about their choices of Medicaid benefits and crafting wellness plans adds another unpaid job to his already tight schedule.

One job West Virginia physicians will not have is that of enforcer. The state will review claims records to track patient compliance with the enhanced benefits agreement.

The West Virginia Medicaid Plan As An Example Of Misalignment

If I were a hot-shot psychiatrist – and, as it turns out, I am – I would diagnose a severe case of ambivalence on the part of the creators of the West Virginia Medicaid Incentive Plan.

On one hand there are significant rewards offered to reinforce those desired patient behaviors in the form of a greatly enhanced set of benefits.

On the other hand, it’s as though the administrators fear that the incentives will prove too popular so bureaucratic hurdles (e.g., the requirement that the patient designate a primary provider and take the initiative to sign up for the program)  were created to minimize the number of patients taking advantage of the more extensive, more expensive plan.

I do not believe, however, that the increased expectations placed on the physicians as an uncompensated, de facto administrative assistant and compliance monitor is part of that ambivalence. Nope, I believe that assigning uncompensated tasks, necessary for the functioning of the plan, to physicians and ther offices is merely one more instance of habitual legislative laziness.

Otherwise, one is face with explaining why a the plan’s administrators, who apparently believe in the power of incentives, would create a program that rewards patients but not only fails to reward the clinicians for reaching the same end-points but penalizes them by requiring them to perform work without pay.

Enough of the preliminaries – my contention is that the problems in the design of the West Virginia Medicaid Incentive Plan can best be characterized as a lack of alignment.³

There are so-called pay-for-performance schemes that reward or penalize clinicians, for example, based on the extent to which they follow treatment protocols or on the percentage of their  patients that follow specific pateint protocols, such as designated disease screenings (e.g., mammography or colonoscopy) or participation in disease management programs. There are programs like the West Virginia Medicaid plan that reward or penalize patients for specified healthcare behaviors.  I know of no programs that coordinate both clinician and patient reinforcement systems.⁴

In fact, many programs seem to follow the West Virginia model by offering to reward one group (patients in West Virginia’s case) and simultaneously punishing the other (assigning time-consuming administrative tasks to clinicians without compensation). In these situations, the issue is not a lack of alignment but misalignment.

Further, we’ve only addressed aligning two healthcare stakeholders, the clinician and the patient. In many cases, for example, a patient’s outcome depends primarily on the dedication and efforts of a non-professional caregiver such as a spouse, family member, or friend.  Yet, I find no programs that provide even token rewards for this group beyond generic support groups. Other stakeholders, such as community organizations with healthcare programs, likewise must be taken into account.

And third party payers, bless their hearts, have to be in alignment with other stakeholders if ongoing healthcare efforts are to be have a chance.

And – steel yourselves – on a macro level, pharmaceutical companies and medical equipment manufacturers have to be transformed from miracle workers/sources of all evil (choose one) into participants who gain and lose in unison with other stakeholders.

OK, I only said it was easy to understand the benefits of alignment, not that it was easy to design or implement a well aligned program .

1. American Medical News is a newspaper produced by the AMA for physicians.↩
2. While I have included a large portion of the text and have tried to keep the sense of the original article intact, there is always a risk of distorting the author’s intent. Consequently, I urge viewers to read the entire piece available here: American Medical News↩
3. I use “alignment,” In the context of healthcare, to indicate the condition of the patient, the clinician, and other stakeholders sharing mutual aspirations and grasping the complementary nature of their roles such that each individual or entity involved can support the treatment decision made, even if is not the first choice of a each stakeholder.↩
4. I have purposively chosen the “I know of no programs that … ” sentence format because I continue to believe that healthcare providers and patients benefiting in concert is such an obviously beneficial idea that someone somewhere must have tried it; I just haven’t run across it yet. ↩

This excerpt from the New York Times article, Los Angeles Stages a Fast Food Intervention,¹ not only describes the latest example of a government taking action to nudge its citizens toward better nutrition but also succinctly summarizes analogous efforts in the recent past:²

I especially admire that wording of the fundamental issue,

I don’t have an answer, but I am convinced that the preceding question, adjusted for other healthcare issues, deserves far more attention on a national scale.

Until a consensus is reached, the determining factor in such decisions defaults, it seems, all too often to the individual or group who has become invested in a cause to the point of promoting – or coercing – that program. For example, consider Arkansas Governor Mike Huckabee’s interest in passing regulations to halt obesity that was triggered by his personal 100 pound weight loss.³ His efforts may be well intentioned and the resulting laws and resolutions may even be good policy, but depending on the enthusiasms, prejudices, and political motivations of powerful leaders hardly makes for an organized approach to the underlying problems.

And, until a means of distinguishing between personal choice and public health concern is reached, dietary regulations, restrictions on tobacco and alcohol use, mandated mental health treatment, directly observed TB therapy, … will continue to be passed and enforced erratically. And, it will continue to be difficult to provide a scientific explanation why, for example, banning trans-fats is viewed as an acceptable exercise of government while no one appears to be pushing obligatory exercise.

Finally, how about this scenario: The newly elected Governor of Illinois, desperate to keep his campaign promises to hold down state healthcare costs stumbles across the AlignMap web page outlining the costs of medication noncompliance. The Governor checks with the Director of Public Health who explains that the state has long passed laws and regulations regarding, for example, treatment of communicable diseases, including mandated, observed treatment for some disorders. The Governor extends this principle in a bill that mandates total treatment compliance for all patients covered by state run or managed programs under penalty of permanent disbarment from the program. By tying the compliance regulation to anticipated improved health for those covered, the Governor cowes the legislature into passing the bill.

Scary, eh?

On the other hand, as long as we continue the hodge-podge sysemn (or lack of system) now in place, we certainly don’t have to worry about those nasty hobgoblins of consistency (whether foolish or not)

Credit Due Department: The hobgoblin pictured above, I find belatedly, is employed, when not illustrating Emersonian expressions, as mascot for The Wychwood Brewery, producers of Hobgoblin Ale.


Footnotes

1. Los Angeles Stages a Fast Food Intervention by Kim Severson, New York Times August 13, 2008↩
2. OK, I’m disappointed that the list didn’t include Chicago’s recently overturned foie gras ban, but otherwise it’s a representative listing↩
3. See Schools, Healthcare, & Dietary Regulations↩

Source: ‘Tough Love’ Lessons From a Deadly Epidemic Barron H. Lerner, M.D. New York Times June 27, 2006
____________________

This article focuses on directly observed therapy (DOT), in which healthcare workers monitor the administration of medications, its role in quelling the increase in tuberculosis cases in New York in the 1990s, and its proposed use in the treatment of HIV. It also deals with the conundrum of determining the proper course of action when the rights of the individual clash with the public good, all in all an appropriate topic as we approach this country’s Independence Day.

Public Health & The Treatment Of Tuberculosis in the 1990s

While there were other causative factors, noncompliance was a significant problem in the rise in tuberculosis in the 1990s, especially among patients who used injection drugs or had psychiatric problems. The author notes, “In one often-cited study, 89 percent of tuberculosis patients at Harlem Hospital were lost before completing treatment.”

Not only did those patients fare poorly and possibly infect others, but their incomplete compliance led to the drug-resistant forms of tuberculosis.

With federal financing, New York aggressively expanded the use of DOT, with outreach workers administering anti-tuberculosis medications special clinics, the patients’ homes, or wherever patients could be found.

Further, those who didn’t fare well on DOT were placed under forcible detention, either at Bellevue Hospital or at Goldwater Hospital. According to Dr. Lerner, “More than 250 patients were detained between 1993 and 1998, some for as long as two years.”

From 1992 to 2001, new cases of tuberculosis dropped from 3,811 to 1,261.

HIV Treatment Monitoring

The New York health department has now proposed a similarly aggressive program for treating HIV. Specifically, these regulatory changes would include

• Simplifying consent for H.I.V. testing to encourage clinicians to screen more patients
• Tracking H.I.V. in a manner similar to tuberculosis
• Monitoring patients to ensure that they take their medications properly

Commentary

Dr. Lerner has done a laudable job of illustrating and summarizing the strengths of DOT and its effectiveness in managing tuberculosis within the confines of newspaper column. And, he points out the clinical issue that differentiates tuberculosis from HIV as a public health issue – the tuberculosis, unlike HIV, can be spread through casual contact.

Dr. Lerner’s primary argument is, indeed, primarily clinical in scope: Given that DOT is effective in reducing morbidity and mortality caused by noncompliance, thereby saving lives and decreasing the risk of epidemics to the public, public health officials should be legislatively allowed to use this tool.

If this perspective becomes the exclusive approach, of course, it begs the ethical question of how one determines at what point the danger to the public at large outweighs the rights of the individual to the extent that treatment can be legitimately coerced to the point of imprisonment, whatever nomenclature is used to designate forced detention and however humane the conditions.

It seems intuitively clear to me that at some point, public safety demands, even in a democracy, the restriction of the rights of those who endanger it – even if the individual is innocent of wrong doing and the danger is unintentional. It seems equally clear, however, that government cannot rationalize draconian measures simply because they work.