David A. Stein: Reforming Medicaid requires reform not rebranding

Regarding the April 17 Point of View “Why managed care is not the answer for N.C.”: I am a family practice physician with over 20 years in clinical medicine. I have practiced in the VA and been the clinic chief of several Army multi-specialty clinics. I have spent the past 15 years as co-owner of a private practice delivering care to the North Carolina Medicaid population.

The beauty of being my age is that I am old enough to have seen it all, but not too old to have forgotten the lessons of my experience. I was around when managed care was attempted and failed. If managed care were an effective method to deliver affordable, cost effective, quality health care, it would have been implemented in every state 20 years ago, and this discussion would not be occurring. Unfortunately, managed care has repeatedly failed in all measures each time it has been tried.

Accountable Care Organizations have not been proven to be cost effective in any long-term study. The new administrative costs are unknown, likely very high, and will not provide a benefit to our patients. Studies actually suggest that those clinics and hospitals that already deliver cost-effective, quality health care are unable to realize any further savings in the ACO model. More concerning is that the ACO model reproduces the financial incentive program that led to the problems within Veterans Affairs. VA administrators gamed the system to receive their bonuses while the most vulnerable patients suffered. We should not place the care of our most vulnerable patients in an unproven system that provides financial incentive to limit necessary care to our patients.

Both the managed care and ACO reform proposals have many of the same fundamental flaws. Neither actually reforms the North Carolina Medicaid system. They merely change the way a failing system is financially managed. Neither addresses the need for patients to responsibly use the Medicaid system in the same cost efficient manner that private insurance patients currently do. Finally, neither addresses structural difficulties in the Medicaid patient enrollment system that are inefficient and increase the cost of health care.

True reform requires that we dive into the Medicaid system and get rid of the wasteful way we spend money on health care. We can use the data that exist in the Community Care of North Carolina system to identify outlying, high-cost providers to bring them back in line with their peers. By eliminating the spending that is not providing benefit, and sometimes actually harming patients, North Carolina can reform and improve the health care safety net of Medicaid. This reform will require that the provider, the patient and the Medicaid system each be held responsible for keeping costs down.

This can be accomplished without decreasing the quality of the health care or limiting necessary care. It is time we get down to the hard work of actual reform of our Medicaid system.

The length limit was waived to permit a fuller response to the Point of View.

This story was originally published April 30, 2015 at 5:33 PM with the headline "David A. Stein: Reforming Medicaid requires reform not rebranding."