Political Punt or Prudent Planning?

by Jeremy Alford

Wednesday, December 1, 2010

When it comes to the state's Medicaid case management program, four weeks - and a lot of noise - made all the difference. By Jeremy Alford

[Editor's Note: This story had been modified from its original version.]

The 14th of September was Bruce Greenstein's second day on the job as Louisiana's new secretary of health and hospitals. From the first part of the day to the last, he quickly transitioned from the trivial - a "new media" initiative involving Twitter, YouTube and the like that he promised would "transform the way" his department interacts with residents, despite this being a state where 57 percent of homes have no Internet access - to the political, inserting himself into a legal proceeding that allowed a Shreveport abortion clinic to continue operating.

While Greenstein said the new media initiative was a "directive" from Gov. Bobby Jindal, it's also likely that his official statement on the 19th Judicial District ruling was in line with what the top brass wanted as well. Jindal, a Republican with unquestionable national ambitions, ushered in a law in June making it easier for the state to shut down abortion clinics - and the governor has been bragging about this legislative accomplishment at every conservative fundraiser between Los Angeles and New York recently.

But it wasn't until Oct. 22 when Greenstein popped his political cherry. That's when he was forced to announce a $50 million funding deficit in Medicaid that was caused by unfunded increases in utilization. As a way to partly address this shortfall, Greenstein said DHH would be shuttering the state's Primary Care Case Management Program, known as CommunityCARE, which was originally created to provide a "medical home" for Medicaid recipients.

Greenstein made no bones about his distaste for the program. Looking back, one could even argue that Greenstein was hellbent on trashing it, hated it even. "This program has failed to show the results promised and is a perfect example of why this model of managed care in Medicaid doesn't work," Greenstein said. "For our $6 million per year investment in state general funds, CommunityCARE has done nothing to make people healthier. In fact, we've actually seen reductions in some key health measures under the program. We can't continue to invest in programs that do not deliver value by improving the health of the people they serve."

Four weeks later, however, Greenstein was singing a different tune. The same program that had "failed" and "done nothing" would be revamped, not scrapped, he announced. In fact, when Greenstein addressed the House Health and Welfare Committee late last month, he offered up an explanation of bureaucratic proportions. "We are no longer eliminating the program," he said. "We are eliminating the program as we know it."

So, what happened? In short, DHH's stakeholders flipped out. Health care providers, in particular, banded together to form the Coalition to Protect Louisiana's Healthcare, which counts as its members the State Medical Society, Louisiana Ambulance Alliance, Louisiana Hospital Association, MedicineLouisiana and the Metropolitan Hospital Council of New Orleans. Specifically, the coalition is urging lawmakers and the administration to investigate solutions that "may be politically inconvenient, but necessary to protect access to health care."

Dr. Andy Blalock of Lafayette, vice president of the Louisiana State Medical Society, says he was ready to hoot and holler about DHH's proposed elimination of the Medicaid program - and by no means was he alone. "We already have an access to care issue," he says. "If these cuts go forward, it will only get worse." Blalock adds that physicians are already running away from the Medicaid program, and any significant changes that pull money away from physicians would only serve as a stronger repellent.

Blalock's sentiment was mirrored all over the state this fall and winter, and may have caused Jindal's health leaders to fold like a cheap suit when it comes to the matter of shuttering CommunityCare.

Tyron Picard, executive vice president of Acadian Ambulance, argues the original plan to scrap CommunityCare as a means to developing a new coordinated care network, or CCN - a network that would be run by private insurance companies - was actually created by Greenstein's predecessor, Alan Levine.

But since Greenstein was hired, Picard says, health care providers have been given more of a voice. "To his credit, Secretary Greenstein not only heard the provider concerns about the original version, but acted upon those concerns by starting a statewide dialogue on how to tweak the CCN model to alleviate the concerns providers had about the ambiguities in the original version," Picard says. "My experience has been that he has been attentive to the concerns raised, engaged in learning as much as possible about those concerns aired, and willing to dialogue about possible solutions. I have found him accessible and responsive."

Greenstein now wants the revamped CommunityCare program, which takes effect Jan. 1, to serve as a "bridge" to the proposed coordinated care network that would be run by insurance companies. In case you haven't heard, the Jindal administration has also pushed the implementation date of the proposed CCN to late 2011, at which time the governor and lawmakers will be done with the approaching election cycle - a period that is traditionally bereft of political courage.

The Coalition to Protect Louisiana's Healthcare, meanwhile, is working on its own CCN proposal that will likely place the state's existing providers at the helm. Once it's introduced into the mix, it's highly likely that everything will change again. But that'll be par for the course. It will also serve as yet another reminder of how difficult it is to make tough decisions in state government - and how easy it can be to change them.

Jeremy Alford can be reached at [email protected].