Magazine article Policy & Practice

Creating a 21st Century Medicaid Health Care Coverage System

Magazine article Policy & Practice

Creating a 21st Century Medicaid Health Care Coverage System

Article excerpt

In a nutshell, the U.S. health care system is broken. All you have to do is ask anyone who uses the health care system and you will get an earful about the dysfunctional way the system operates. At every level of the health care system there are systemic problems that are well documented. These systemic health care delivery system problems result in lower quality of care, higher-than-necessary medical costs, a loss of health system capacity, and a reduction in access to care. Medicaid is not immune to these problems; in fact, one could reasonably justify that Medicaid is both a victim as well as an enabler of the systemic dysfunction of the U.S. health care system.


Every problem has root causes. The root causes of our dysfunctional U.S. health care system include misaligned reimbursement policies and incentives, lack of integrated patient care processes, poorly coordinated patient care processes, poorly coordinated patient care treatment. A high percentage of the complaints expressed by Americans about the U.S. health care system can be attributed to these systemic root causes. So one might ask, if the root causes of the health system dysfunction are so well known, why have these problems been so difficult to overcome? Indeed, this is the very thing that has been at the center of the health reform debate. What makes a national initiative of health reform so difficult is that there is significant anti-reform inertia within the health care delivery system that must be addressed first. You cannot build sustainable health reform on a dysfunctional health care system. The U.S. health care system is not able to self-correct its systemic problems.

The U.S. health care system is not one system but many systems and subsystems of care. Each health care delivery system acts as it own agent in the poorly organized health care market. There is often very little incentive, and in some cases significant competitive disincentives, to align processes, integrate care management, or rationalize reimbursement schemes between health care delivery systems. One could make a reasonable argument that, in order to reform the U.S. health care system, you must first transform the health care system by addressing the underlying root causes and anti-reform factors causing the health system dysfunction.

Fundamental health system transformation must occur first at the point of care. The point of care is where the patient's and the provider's "moment of truth" occurs. The optimal result of this "moment of truth" is a productive health care encounter between the patient and the provider. Unfortunately, our current health care systems have an unacceptably high propensity to break down at the point of care and provide less than optimal care, at these "moments of truth."

Optimal care occurs when the patient's health care delivery system provides both the evidence-based quality health care and the most cost-effective level of care. Suboptimal care occurs when the health system provides neither quality of care and/or unnecessarily high cost care. Like the broader U.S. health care system, the Medicaid health care delivery system, more often than not, produces an alarming high percentage of sub-optimized health care encounters.

Viewing the health care process from the micro-level, there are two significant factors that contribute to sub-optimized health care encounters. The first contributing factor is patients who are ill-informed about health care needs and not engaged in their health care process. The second factor is clinical providers that are ill-prepared to provide optimal care, treating patients without the all relevant health information needed to provide consistent coordinated care and treatment. The level of health care system episode of care integration, care coordination, and patient and provider decision support that is consistently available during the episode of care is the greatest determinant of whether care will be optimized for each patient health care encounter. …

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