Is Rhode Island spending more than other states caring for the elderly? Or not enough?
(See update, below, plus a reminder: the final Reinvent Medicaid public town hall meeting is scheduled for tonight at 6 pm at the East Bay Family Health Center in Newport.)
That's a question that's come up for debate at the recent "Reinventing Medicaid" town hall meetings around the state, and in statements from groups with a stake in the outcome of Gov. Gina Raimondo's plans to trim nearly $180 million dollars in state (and federal) Medicaid spending.
Here's what's under magnifying glass: to make the case for why Medicaid must be "reinvented" and spending curbed, Raimondo's Reinvent Medicaid Working Group has presented data about how much is spent on particular groups of Medicaid enrollees. They cite data about the amount spent on the elderly, showing figures that put Rhode Island way ahead of other states. Groups like the nursing home industry association and a group of doctors promoting legislation that would create a single-payer health care system say the data is wrong.
Who's right? As with most health care spending questions, the answer is that it depends on whom you ask, and how they tally the data. But here's what I've learned about the discrepancy.
In a nutshell, the Working Group is using Rhode Island data. And it's counting fewer people. The fewer the people, the more money it looks like we're spending on each enrollee. It counts fewer people because it's counting "average eligibles," not unique individuals. Here's what that means: not every Medicaid enrollee stays enrolled all year long. People lose their eligibility and leave the program, or come back on. It's called "churn." Average the number of people on the program for a given year accounts for that churn. Some say this is more accurate, because you're not spending money on someone who's not enrolled.
Other groups are citing Kaiser Family Foundation data. The Kaiser data counts unique individuals, no matter how long they're enrolled, as if they were receiving services all year long. At least, this is how staffers at Rhode Island's Executive Office of Health and Human Services explained it to me. Also, they tell me, the Kaiser data includes a special education payment and money paid to hospitals to help compensate them for charity care. So the Kaiser data accounts for more Medicaid spending overall, but spreads that money among more enrollees. Hence the lower per-aged-enrollee spend. They contend this is the more accurate number, and that we're not spending enough caring for our elderly.
Still with me?
If not, not to worry. I think the larger issue is not exactly how much we're spending on each elderly Medicaid enrollee, but what we're spending that money on. Is it helping that patient live they way he or she wants? No one can argue that the most expensive forms of care are institutional ones: nursing homes, hospitals, long term stays in facilities. We can argue about whether those costs are justified. And we can argue about whether Medicaid enrollees are staying too long, or going too soon, into institutional care. We know that some older Medicaid enrollees are frail enough that nursing homes are the only option, and that many provide compassionate, competent care.
But tackling those kinds of questions is exactly what many prior efforts to "reform" Medicaid have been about. The Global Waiver, the Integrated Care Initiative, and other projects have been trying to crack this nut for a while: how do you keep people out of nursing homes and hospitals as long as possible? There are lots of attempts to do this right now in Rhode Island, but the state hasn't managed to scale it up and make it stick. Perhaps that will come.
Update: Virginia Burke, with the Rhode Island Health Care Association, an industry group for nursing homes, points out there's more to the debate than simply whether you count enrollees per year or full-year enrollees per year. In a statement to Rhode Island Public Radio, Burke wrote:
"There’s also whether or not you are including patient co-pays, and whether or not you are offsetting with intergovernmental transfers, whether or not you are including DSH payments [Disproportionate Share Hospital payments to hospitals that provide charity care], and if so, how they are allocated across enrollees. Are you counting just “full benefit” enrollees? Or are you including “full and partial benefit enrollees”? (Partial benefit enrollees don’t get health care that’s covered by Medicaid, but they get Medicaid payment of their co-pays.)"
Plus, Burke said, you can't compare Rhode Island's numbers to national numbers if you're using a different measuring stick.
And finally, Burke argues that looking at the average spending per aged Medicaid enrollee doesn't tell you very much about whether that money is well spent. Rhode Island's elderly, Burke contends, are sicker and older than elsewhere in the nation, and require higher levels of care.
No matter what we're spending per enrollee, and no matter what measuring stick we use, another question remains: can Rhode Island afford to continue spending that amount?