Reforming Medicaid May Become Toughest Job Ever for Baker Administration

Anyone who follows politics or government in Massachusetts has seen these numbers. They bear repeating: 

• Over the past seven years, spending on Medicaid (MassHealth) has increased 65%.
• Next year, total Medicaid spending is projected at $15.3 billion. 
• At $15.3 billion, Medicaid will account for 40% of the entire state budget.

Medicaid insures 1.8 million income-qualified citizens.  That’s 26% of the total Massachusetts population of 6.7 million. Source: U.S. Census Bureau.

Medicaid is jointly funded by the state and federal governments.  Of the $15.3 billion due to be expended next year, $6.8 billion will be state money.

As anyone who has ever so much as touched the state budget has said, Medicaid spending is on an unsustainable course.  To keep MassHealth from imploding and plunging state finances into chaos , the Executive Office of Health and Human Services (EOHHS) proposes to transform it  via the creation of Accountable Care Organizations (ACOs).

In the words of EOHHS, ACOs “are provider-led organizations that coordinate care and have an enhanced role for primary care, and are rewarded for value – better cost and outcomes – not volume.”  To put it another way, costs should go down because:

One, all those medical professionals who care for Medicaid patients will work collaboratively to deliver truly needed care in the most effective ways and settings, and

Two, all those medical professionals, gathered under new ACO umbrellas, will not be compensated on the basis of how much care they provide but rather on how effective that care is -- by how they  make people measurably better and healthier.

That's the theory.  Making it the practice will be exceedingly difficult. Twenty-six percent of the population is linked to the status quo and naturally apprehensive of change.  The Gov. Baker administration is the change agent. 

It’s good that Massachusetts is progressive, good that we have a consensus that people who are sick, hurt, disabled, etc., should be cared for regardless of whether they can pay for care or afford medical coverage.  An emblem of civilization, Medicaid needs to be preserved and improved.

Every resident of Massachusetts has a stake in the success of the transition to ACOs, now scheduled to occur in the fall of 2017.

I was glad that, during the recent rollout of this comprehensive Medicaid reform proposal, EOHHS mentioned the importance of curtailing deception and fraud by scammer providers. Scammers comprise a small group, no doubt, but the product of a small cohort of determined crooks is invariably huge.  

EOHHS noted that Medicaid spending on home health care services increased 41% last year and that 80% of that growth was “driven by providers new to the Commonwealth since 2013.”  Definitely fishy.

Not long ago, MassHealth handed to Attorney General Maura Healey info on 12 home health providers it believes are fraudsters.  The most common forms of cheating are billing for services not actually provided or provided at levels below those at which they are invoiced.

What makes cheating in home health care especially repulsive is how little one group of front-line workers, the home health aides, are paid for the very hard work they do for the homebound and the infirm and/or the chronically ill. 

In cases of fraud, folks at the top of home health companies take their ill-gotten gains to the bank in recent vintage BMWs; folks at the bottom drive home exhausted in ancient Chevies, hoping the needle won't slide over to empty.