As Gov. Gina Raimondo's "Reinvent Medicaid" task force rockets toward the finish line, having recently spelled out more details about how the group recommends finding nearly $90 million dollars in savings from the program, they bring with them plenty of vocal feedback from health care stakeholders around the state. One hospital system, Care New England, has been a more dominant voice at the table, with the group's leader, Dennis Keefe, co-chairing the task force. The voice of the state's largest hospital system, Lifespan, has been less audible.
Why? And what are the implications? It's difficult to determine exactly why there seems to be a disconnect, but I am learning a bit more about Lifespan's positions through ongoing conversations with sources. Lifespan cares for many Medicaid recipients, which means they rely on millions in state dollars, so their participation in a major effort affecting Medicaid could touch a lot of patients and employees.
Apparently, the hospital system is ready to learn more about a proposal, floated by the Hospital Association of Rhode Island, to return some of the savings from a planned five percent rate cut to hospitals the following fiscal year, if they meet certain quality targets. But it's clear Lifespan has not been at the table when it comes to developing this proposal, and perhaps hasn't wanted to be. I'm told they have retained a consultant to help analyze ways in which the hospital system could lower Medicaid costs on their own.
Lifespan officials have said on the record that they need more time to review the proposal. The details have yet to be spelled out for how a hospital might go about earning back some of the money lost to rate cuts this year. And that's a good point: how can you agree to be measured if you don't know what the measuring stick looks like? If it's something you've never measured before, you might need to invest some time, money, and training to figure out how to do it better, or start doing it in the first place.
The incentive payments proposed by HARI would reward hospitals for preventing re-admissions and improving the coordination of patient care among different providers. These are things hospitals should already be doing, of course, and must do to avoid getting dinged by Medicare. But bear in mind that we are talking about a different patient population, Medicaid recipients, who tend to have more complex health issues than patients with other kinds of insurance. Coordinating their care with other providers and preventing re-admissions after a hospitalization might be more or less challenging for these patients depending on how high the bar is set. It's also important to remember that Lifespan owns a major trauma center, Rhode Island Hospital, which never turns anyone away.
Care New England head Dennis Keefe has been enthusiastic about an opportunity to earn back some of the money that would be cut (the Governor's budget proposes cutting hospital payment rates by five percent). A question was raised in the most recent task force meeting about how cutting the rates and then paying the money back the following year represented any kind of long-term savings. Keefe's response was that to earn the money back, hospitals would have to reduce utilization, which would reduce costs over the long term.
Keefe said he wasn't a fan of the rate cuts likely to be approved for this fiscal year. Nursing home owners also wonder how the state can expect better quality if it continues to cut rates, year after year. The response to these concerns is always: let's find a way to make some deeper, structural changes in Medicaid so that we don't have to keep coming back to the same old idea of cutting provider rates every year to make ends meet. How you do that, and how long it might take for those changes to yield real results, are the questions.
Neither this particular proposal (about an incentive payment for hospitals) nor any others contemplated now by the Medicaid task force are done deals. They must be fleshed out, presented to the governor, and ultimately reviewed by the General Assembly. To add a layer of complication, some of these proposals will require federal approval.
Will Lifespan and others get on board, regardless of the outcome, or are we in for some tough debates in the Statehouse? Not sure. I'll be watching, of course!