The Governor’s Office recently released the Hawaii Healthcare Innovation Plan for transforming our health care system, with follow-up commentaries in the Star-Advertiser by Virginia Pressler and Beth Giesting.
There is no disagreement on the "Triple Aim" goals of better health, better health care and lower cost. Plus, reduced disparities and promotion of primary care and community care teams are good ideas.
However, there are serious problems with the implementation plan.
Access to health insurance does not equal access to care. In Hawaii, access and care coordination are not big problems for those insured through their employers under our Prepaid Health Care Act. However, for those with Medicaid, our managed care system relies heavily on policies that restrict and obstruct care, affecting roughly half the patient visits in the Medicaid clinic where I work. This is wasted administrative cost that contributes nothing to effective delivery of care.
These problems have led to a marked decline in doctors accepting new Medicaid patients. This is worst for psychiatry, and more than half the formerly participating psychiatrists have dropped out in the past five years, associated with a 30 percent rise in mental health emergency-room and hospital costs.
Almost all the care coordination problems seen in practice are due to problems with our Medicaid managed care system — a system left untouched by the Hawaii Healthcare Innovation Plan.
Patient-centered medical homes and community care networks cannot possibly be effective without robust physician participation. Training more doctors and other providers won’t help if they don’t accept Medicaid when they go into practice.
The health transformation planning process systematically ignored suggestions from physicians and other providers of care that would have made delivery of health care more cost-effective. Suggestions not being implemented include consolidat- ing and streamlining the structure of our Medicaid program, making community care networks accountable to patient care needs instead of to the administrative convenience of health plans, and standardizing formularies and prior authorization policies across all health plans.
The Hawaii Healthcare Innovation Plan hopes to reduce cost with "Account- able Care Organizations" and pay-for-performance initiatives, but pilot programs so far show these strategies don’t work and will cost more to administer than they can possibly save by reducing health care utilization.
Worse, we are attempting to implement them on top of systems designed to obstruct care, and that are effectively deterring physi- cian participation.
The most cost-effective Medicaid programs are administratively simple, physician-led initiatives organized around primary care, with no intervening layer of managed care insurance plans between funding and the care delivery system.
Leaving managed care plans in Hawaii’s plan adds to its complexity and cost and greatly reduces its effectiveness, with no offsetting advantages.
This extra administrative layer and the disruptions to care now imposed by the managed care plans guarantee that Hawaii’s health care transformation will fail to achieve its goals for access, quality, and cost.
Achieving the triple-aim goals will require administrative simplification and the participation of all our doctors.
A good start would be to consolidate Medicaid into a single program without managed care plans, but with support for primary care, community care networks, and physician-led quality improvement.
Then combine funding from Medicaid, employer-based health care, and Medicare (via Medicare Advantage plans), and pay physicians the same regardless of the source of funding for a given patient.
This would markedly improve physician participation and access to out- patient care for Medicaid and Medicare patients.
This system has also saved a bundle in acute care Medicaid costs for Mesa County, Colo.
