The $8 Billion Solution? NY's Big Medicaid Reform

New York State's $8 billion federally supported -- or imposed -- Medicaid reform plans are so well underway that the public comment period for this interesting, complex, somewhat promising and fundamentally disappointing plan ended in October without a single public meeting or seminar to explain to the public the "evaluation criteria" that were supposed to be the basis for public comment.

Indeed, few people who are not health administrators seem to know anything about where the $8 billion will go.

Although the "reform" plan will decide the fundamental tenor of New York Medicaid services for years after its official five-year implementation period, what the state has actually proposed under federal prodding has received almost no ordinary press or media coverage. I have not seen any serious analytic articles, screaming editorials, or the other scrutiny one might expect the general media to direct to an unprecedented reform of Medicaid, on which New York now spends $53 billion a year to serve 5 million recipients, with the $9,158 per recipient cost more than double the national average per patient!

So, let's boil down this complex plan, which the state has presented under the rather awkward acronym DSRIP (Delivery System Reform Incentive Payments) to two questions. Can DSRIP accomplish what the federal Center for Medicaid Services demanded in return for its billions -- specifically a 25 percent reduction in the state's flagrantly excessive hospitalizations over a period of five years?

Equally important can the state's DSRIP plan, self-advertised as innovative reform, seriously transform New York State Medicaid during those five years, moving the state toward a system that supports wellness, rather than just better managing sickness?

The answer to the first is almost certainly yes. The answer to the second is a sad no.

To start by giving credit where due, the New York State office of Medicaid management, headed by Jason Helgerson, has already prodded notable savings out of state Medicaid. Considering the sheer bulk of the New York system -- its huge competing interests of medical centers, medical clinics, many unions, medical schools and on and on -- this is no mean accomplishment. Moving the New York State Medicaid system is rather like trying to move 10 oil tankers attached by a string and it is a compliment to Mr. Helgerson's skills, and the overall efforts of the NY State Health Department, that it has moved at all.

The DSRIP plan would continue this by forming something known as PPS's (Performing Provider Systems) whose goal is to bring down unnecessary hospitalizations by 25 percent in their cachement area. PPS's are led by a major hospital, with dozens of other "providers" -- nursing homes, drug treatment centers, smaller clinics, home health care agencies, developmentally disabled programs, and so on -- attached to them. There will evidently be some 41 PPS's throughout the state. The PPS partners work together to coordinate services for patients who have the particular diseases the PPS has decided to target; the lead hospital, which gets most of the many, many millions of dollars involved, also works to better coordinate patient care within its own services.

And there you are. Hopefully, we now have a clinical system where, instead of being shuffled from appointment to appointment until they get so sick they are hospitalized -- the way hospitals traditionally make real money -- patients' illnesses are much better managed.

What we won't have, until the state fully includes community organizations in DSRIP, is a system that effectively moves from managing illness to promoting wellness. It is little recognized outside the field of community health -- because it was so decidedly not the mission of hospitals to create health -- that in the age of chronic disease, there are many, many proven ways to improve health by bringing inexpensive, short-term interventions to the community; it almost makes the heart weep to consider the degree to which these interventions, which are barely used now, still won't be used in the future unless DSRIP is changed to really include them.

For just a few examples: short, chronic disease self-care courses not only bring down hospitalizations but can reduce terrible complications, like diabetic foot ulcers and amputation. The use of community-based doulas (birth coaches), specifically not attached to a hospital, but trained to give one-on-one coaching to mothers during birth, slashes Cesarean section rates. AIDS Self-Care education, made accessible at community sites, even homeless shelters and soup kitchens, demonstrably improves medical outcomes.

Pretending to build health in communities absolutely paralyzed by chronic disease without making proven education and other interventions truly accessible is preposterous. In South Bronx public housing, 30 percent of residents my organization interviewed already know they have diabetes. Self-care courses brought right to public housing is the only -- and cheapest way -- that these hundreds of people will ever get the benefit of education proven to reduce complications and hospitalizations.

Meanwhile, without that key education, the Bronx now has 5000 hospitalizations a year for diabetes-related foot ulcers alone!

Equally important, people from the poorest, sickest communities, including those with chronic disease and other conditions, can be rapidly trained to deliver many of these interventions themselves; being a doula only requires a standard four-day training as does becoming a community peer educator able to teach some of the best proven self-care education courses.

For DSRIP to embrace real reform, a requirement that PPS's include community-based groups as full partners, and direct at least some funding to them to start providing well-evaluated wellness interventions right at community sites -- public housing, senior centers, schools, homeless shelters and so forth -- is basic. Beyond that, using local residents with chronic disease, disability and various other conditions as the educators will do something that can never be done by clinical medicine ever: it starts to make people now just seen as "patients" into real participants in promoting health in their communities. It starts to make health something seen as real and attainable.

Even without a directive from New York State, many PPS's have come to realize they need to include community groups to reach their goals. But only a directive from New York State can clearly say, "We are now determined to have wellness, not just better managed sickness." And, if the New York State Health Department doesn't properly include communities in DSRIP, the federal government can actually order it to do so. After all it's their $8 billion -- or really yours.

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