Government

AMA leader on Medicaid panel stresses need to focus on physicians and patients

AMA Immediate Past President Dr. Nelson talks about why Medicaid is in disrepair and what he intends to do about it as a new federal adviser.

By David Glendinning — Posted Sept. 12, 2005

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Washington -- A federal commission tasked with reforming Medicaid has agreed on a set of recommendations aimed at cutting billions of dollars from the program over the coming five years. The next step for the 28-member group is to suggest a large-scale overhaul of the entire system. AMNews spoke with AMA Immediate Past President John C. Nelson, MD, MPH, one of 15 nonvoting members on the panel, in advance of the commission's September report.

Question: There are three other physicians on this panel. Carol Berkowitz, MD, is the president of the American Academy of Pediatrics, Howard Weitz, MD, is a cardiologist in Philadelphia and John Rugge, MD, runs a network of community health centers in New York State. Why is it important to have physicians on the commission?

Answer: It's important for physicians to be on this commission because physicians are in fact the ones who take care of Medicaid patients. Also, Medicaid constituents are not organized, so there isn't a constituency per se. Poor people often don't vote, they're not banded together, so someone needs to speak on behalf of the recipients as well as the physicians who care for them.

Q: Why does Medicaid need fixing?

A: There were some really good ideas when Medicaid began about how to cover those who are poor, but it's disintegrated because of differences between the states. What we have now is a hodgepodge where eligibility in one state is different from another, the benefits package in one state is different from another, and you just don't know what you're going to get. What has also happened is that Medicaid for the first time this year in aggregate has surpassed the amount of money being spent on education by the governors. It's the single biggest ticket item they're paying for. If you look at the bang for the buck, we can save so much money by getting people into care earlier, by using clinical preventive services, and maybe even be able to prevent the very kind of diseases we're putting them in the nursing homes for if we're wise in the ways we use the system. I'm looking for a very, very in-depth discussion and a total overhaul of the system.

Q: What do you intend to do in recommending solutions?

A: I'm going to do a lot of listening first. Remember, there are two parts to what we have to do. By Sept. 1, we are to recommend to Congress a mechanism for cuts of $10 billion over the next five years. A second, and I believe more important, task comes a year from December, when we are supposed to give to Congress a set of recommendations on how to fix the overall program. Now a trained chimpanzee can figure out the cuts. If one program is so many billion and another program is so many more billion, you add them together to get to $10 billion and you cut those programs and there's your money.

The challenge will be to do this in a way that's equitable and a way that's not going to disadvantage a particular group. I am especially concerned that the effect of these cuts may be disproportionate on minority populations. We start cutting specific programs or increasing the eligibility, then I'm concerned about what that's going to do to individual patients.

So, the questions I'm going to continue to ask will be the ones like, "OK, if we make this cut, what effect does that have on patients?" If we stop seeing patients in some of these programs, that doesn't mean the patients go away, it means our ability to pay for those problems goes away. They end up in the ER and can actually become more expensive. It seems to me that if we're serious about looking at ways to cut money from the program, one of the most significant will be to institute real clinical preventive services. Obesity, sexually transmitted diseases, teen pregnancy, violence, alcohol, suicide, tobacco and accidents account for almost half of what we spend on health care. If we can stop people from smoking, get their weights correct, etc., we can save big, big dollars. Perhaps we'll be able to find some administrative cuts. The fact is, everything is on the table.

Q: The commission's first charge of finding $10 billion in reductions has generated the most controversy. Do you think the cuts are necessary, or are you simply trying to make sure that Congress doesn't cause too much damage?

A: Congress has decided that they need to cut federal spending. The governors certainly agree that they need to cut the matching portion of their state budgets. So everybody agrees that the budget is too high. While I am all in favor of streamlining the program, I want to know what the real impact is on real people. We can find ways to provide the care more efficiently, more effectively, to get patients in earlier. Are you aware that there are probably tens of thousands of children who are available for the [State Children's Health Insurance Program] but simply haven't signed up? We need to be wiser. We can't sign a child up for health care through the Medicaid program and not care for the rest of the family, specifically the mother and the father. We've got to make sure we sign up families and not just individual kids. We've got to do it in an easier way. When you go to get your food stamps, why don't you also sign up for Medicaid and the other benefits. Why do we have to make it so difficult? We've got to be smarter about what we're doing. We've got to find all the efficiencies we can, but the bottom line is, we've got to make sure we take care of people the way we've planned to. And I think that we've put up so many barriers and such a hodgepodge of rules that it's actually hamstrung the process.

Q: Several congressional leaders who had the ability to appoint members to this commission declined. Families USA and several other groups are calling it a sham, saying that a panel can't make rational decisions about cuts in such a short time frame. As a nonvoting member, can you affect the outcome in a positive way, or will the commission only be able to rubber-stamp a conclusion that has already been found?

A: First of all, I'm convinced that there's no conclusion that's been drawn. The only pieces of paper we were given are those from the National Governors Assn. That group has made some recommendations, and we looked at that as a template because that was a good place to start. There was not time to do the in-depth study that needs to be done. We also looked at a similar document from the National Conference of State Legislatures. Finally, you need to understand what the process is here. These are only recommendations. They will go to Congress, which will make the ultimate decision.

Families USA and others who have taken potshots are doing a disservice. Rather than dissing us, why don't they get involved and help us come up with the answers? We don't need more division. We need more unity in what we're doing.

Q: You're a physician looking at a patient here, and that patient is Medicaid. What can we do to help get this patient better?

A: First we have to make the diagnosis. What I want to do is make sure we don't just slash at the offending shoots of the weed; we need to get down at the roots. That's why we need to take an opportunity to look at how this program works and how it's supposed to work.

The real value of this commission will be a year from December, when we come up with what I hope will be valid and evidence-based recommendations on how to make this patient better.

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