Critically important reforms to Medicaid that will save money and provide better care for Utah's Medicaid recipients are within our grasp, but they are slipping away due to early missteps in the state's Medicaid reform effort.
Let's back up a little bit: Two years ago, state Sen. Dan Liljenquist introduced Senate Bill 180, which sought to implement "Affordable Care Organizations" in Utah to cut Medicaid costs while improving care.
An ACO is a group of health care providers who agree to be held accountable for improving patient health, and they have financial incentives to work as a team to help their patients stay healthy.
A number of states are experimenting with ACOs, most notably New Jersey, which has experienced dramatic success with its own prototype, the Camden Coalition of Healthcare Providers. CCHP works with patients, especially those with chronic conditions, to help them become more prudent health care consumers.
No matter what kind of help patients need to manage their health, whether it's case management, enrollment assistance, or even transportation, CCHP helps them get it. Does it work? Yes. The CCHP model has cut in half the average per month hospital charge for the heaviest health care users, and has also halved the number of emergency room visits.
This is exactly what ACOs are designed to do: Improve care by eliminating waste and seeking the most efficient, effective routes to care. No wonder New Jersey Gov. Chris Christie recently signed legislation to take the CCHP model statewide.
What about Utah? We have a similar chance to set in motion dramatic increases in efficiency, quality and cost savings, but state leaders may have dropped the ball. After SB180, with the ACO provisions, passed unanimously, Utah legislators sought a waiver from the federal government. This is a process by which states seek to bend federal rules governing Medicaid, in order to experiment with new ways to improve care and cut costs. This is where the problems started.
Although the ACO content of SB180 was sufficient to get Utah on the road to effective Medicaid reform, our legislators decided to add a bunch of additional requests to the waiver that would actually undermine the goals of accountable care.
Specifically, they asked for "flexibility" on Medicaid cost-sharing limitations (although previous research shows that this would undermine access to cost-effective care) and they asked for authority to ration services if they ran low on money, without regard to any research-based guidelines to determine which recipients get which services.
This random, "slash and burn" approach flies in the face of the thoughtful reforms sought by the ACO approach, designed to replace arbitrary, inefficient decision-making with a coordinated and evidence-based approach to care.
Luckily, the Centers for Medicare and Medicaid Services rejected this approach, striking down these components of the waiver (while leaving intact the ACO provisions). But that's not enough: The state's ACO Contract Draft released last month is sorely lacking in outcome and quality measures, payment mechanisms, and other critical components of ACOs.
Where is the urgency coming from? There are worthwhile investments to be made in our Medicaid program, starting with the now optional Medicaid expansion. But if we don't find our footing on the ACO path, we may have difficulty sustaining such investments.
In our midst we have international models for integrated-care delivery (Intermountain Health Care and the University of Utah). Yet we have fallen off the path toward true accountable care. Utah can and must do better.
Judi Hilman is executive director of the nonprofit Utah Health Policy Project.