Monday, September 9, 2013

The Nuclear Option.

State of California Beneficiary Identification Card

   California Governor Jerry Brown and President Barak Obama
Despite California’s challenge with debt Governor Jerry Brown has a very experienced hand on the rudder..He is no stranger to adversity, and seems to be quietly picking away at the trash left behind by several recent governor’s.
Brown seems intent on accelerating California’s Health Insurance Exchange and preparing Medi-Cal’s planned expansion for the newly ‘insured mandate.  There is serious concern about Medi-Cal’s readiness to accept more ‘insured’.  Financially it will be a challenge even with Federal matching funds.
Surrounding the increase in eligible will involve careful examination of an eligibility process that is seriously flawed. Depending on that for a foundation will doom the effort to failure and offer an empty promise to hopeful patients who may be rejoicing prematurely
As a former provider (physician), how I hate that new classification of my intellectual ability, and also as a recipient during hard times on disability, the process is not consumer friendly.  Want that our government would become patient centric and consumer friendly as well as accountable as in the PPACA.
Medi-Cal in it’s present form is not insurance !  It is not even a ‘safety net.  It is more like a trampoline with large holes that let patients fall through or if they are fortunate to hit something solid….they bounce around quite a bit before obtaining benefits.
If Medi-cal want to provide insurance coverage then they should pony up and act like a regulated insurer, not some special government agency that completely misses the point …
In it’s present rendition medi-cal rules are complex, much more than I could address in a short bl og.  The rules and regulations are nicely detailed here.   Eligibility requirements are a maximum asset value of 2,000-4,000 dollars depending on family size. Does this mean to obtain guaranteed insurance one must also be destitute in addition to being previously uninsured? In addition one’s income must meet a threshold below `125% of the poverty line, indexed according to family size.  None of this has a familiar sound in the world of ‘real insurance.’  Medi-Cal’s mantra is if you aren’t poor when you apply, wait, when you start getting <Medi-Cal benefits…you will be destitute or worse.
Furthermore medi-cal benefits have a unique term called “Share of Cost’  The accounting of how income and expense are determined is subject to a strange algorithm of which no one can explain, and neither can the clerks and administrators of the system. Plainly or not so plainly the numbers are crunched several time using differing indices to derive ‘real numbers’ from a byzantine matrix of adjustments,  factors indexed my more unknown guidelines. And finally all the regulations are set forth in llllll.

It is an outrageous system , designed to limit benefits, and somehow save the state.  The fee for service is antiquated and should be completely abandoned without a doubt.
The hope for Medi-cal/caid is the managed care option which truly is managed with case workers and some indication of attempts to be a consumer friendly system.  One serious flaw is that one must have no share of cost to qualify for the managed care option/ Losing one family member increases your share of cost by over 1200 dollars (per month), and terminates your physician arrangement since one is cast back to FFS Medicaid, whose providers are different than managed care Medicaid.
I very much doubt these facts have ever faced the scrutiny of voters….I doubt if legislators are even aware of how bureaucrats have usurped what they think is a ‘generous safety net’.
The Medicaid Expansion proposed under the PPACA is the subject of much discussion:
Most government systems need an injection of sound business practices, and I am not talking about venture capital or profits. Systemic errors seem to go on and on unchecked simply by the sheer size of government agencies. Mistakes are buried…few are terminated for incompetence, they are shuffled to other positions in the civil service system. Good management in health care goes far beyond short term financial savings. In fact Medi-cal often creates worse situations for patients.
Rather than list more of my observations in my next several blogs I will outline measures to correct Med-cal’s shortcomings before it’s dysfunction is spread by PPACA.
This is a system ruled by the “Lowest Common Denominator” invented by committee and administered by uncreative people unwilling or unable to step out of the box, blindly following rules, with the over-riding fear of “fraud and abuse’.  Abuse, yes…by the very system set up to protect and serve, fraud…maybe some but often due to the sheer volume and complexity of the system itself.
As an indicator of the coming melt-down:
President Barack Obama thinks his health care law makes states an offer they can't refuse.
Whether to expand Medicaid, the federal-state program for the poor and disabled, could be the most important decision facing governors and legislatures this year. The repercussions go beyond their budgets, directly affecting the well-being of residents and the finances of critical hospitals.
The health care law will go into full effect next Jan. 1, and states are scrambling to crunch the numbers and understand the Medicaid trade-offs. Louisiana's health secretary, Bruce D. Greenstein, is concerned that the Medicaid expansion could replace private insurance for many low-wage workers in his state, dragging down quality throughout the health care system because the program pays doctors and hospitals far less than private insurance. He says the Obama administration and Congress missed a chance to overhaul Medicaid and give states a bigger say in running the program.
"Decisions are made by fiat," he said. "There is not any sense of a federal-state partnership, what this program was founded on. I don't feel in any way that I am a partner." The Obama administration says it is doing its best to meet state demands for flexibility..
As an indicator of the coming melt-down:
President Barack Obama thinks his health care law makes states an offer they can't refuse.
Is Medicaid Expansion Good for the States?
Money fears vs. real benefits in Medicaid choice
Medicaid—the joint state-federal government health insurance program for lower-income Americans—would be expanded to cover those making 133 percent of the poverty level. States that refused to participate in this expansion would risk losing federal funding for their current Medicaid programs. However, the Supreme Court ruled the federal government could not withdraw existing Medicaid funding to punish states for not expanding their programs, thus giving states the choice to opt out of the expansion. More than a few states have expressed intentions of doing so.
Rather than fixing the underlying deficits (an not just financial) the Feds wanted to force states into their plan without relief. Fortunately the SCOTUS ruled otherwise.
Studies have shown that Medicaid patients fare worse in many cases than the uninsured. In many states, Medicaid pays doctors so little, recipients can't find a private physician to see them so they must wait, sometimes for hours, in hospital emergency rooms to get care. They deserve the dignity of private insurance, which states could provide if they were freed from Medicaid's mountains of red tape.
Empty Promise offered by PPACA
Further, the Medicaid expansion will harm the poorest and most vulnerable patients already on the program as they are forced to compete with millions of new patients seeking care from this limited pool of providers.
Many governors are rightly resisting adding another 16 million more people to Medicaid and are demanding that Washington give them more flexibility to improve the program.

Is this a system we want to expand to cover the uninsured?  Empty mandates again.

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