My Care Ohio: A Triumph of the Stick over the Carrot

Warning:  This week’s post is a rant about Ohio Medicaid policies and policymakers.  (For my background description of the My Care Ohio program, see last week’s post “Managed care for Ohio Medicare/Medicaid ‘Dual Eligibles.’“)  Feel free to tell me that I’m wrong or to ignore me until next week.

Gov. Kasich has, from the beginning, targeted the long term care Medicaid costs in the state budget.  Any sane governor would look for ways to reduce that cost because it is often the largest single line item in the state budget.

When he first took office, Gov. Kasich proposed having more people receive their long term care at home (presumably through the PASSPORT program.)  Now, however, his administration has launched My Care Ohio, a managed care program for the state’s “dual eligible” population (i.e., people on both Medicare and Medicaid.)

My Care Ohio will provide care coordinators to all covered people.  The care coordinators’ job is to make sure that all involved caregivers and providers that stand under the managed care umbrella are on the same page.  That’s great!  Excuse me, though, if I have misgivings that the care coordinators unspoken instructions will conflict with this promising description.

The care coordinators work for the managed care organizations.  The managed care organizations are insurance companies.  These managed care companies will be paid a flat rate for each of their insureds in the program.  Insurance companies make money by paying out less in claims than they receive in premiums.  So, I cannot help but believe the care coordinators main job will be to cut costs.  Now, I’m not necessarily against cutting costs, but the managed care model tends to cut costs by squeezing (or squeezing out) the care providers.  This is the “stick,” and I fear a decline in the quality of care over time.  I resent the use of this stick when the governor talked up the carrot in the past.

The carrot would have been (and maybe still can be, but only after the My Care Ohio 3-year pilot program runs its course) changing Medicaid rules a little bit to create a greater incentive for people to choose to stay in their homes on Passport rather than move into nursing homes.

Currently, it’s tricky and unpredictable when applying for Passport, especially when there’s a married couple.  The standard on what the well spouse (the spouse not seeking Medicaid coverage) can keep while the spouse needing care can qualify for Passport should also be used for a spouse seeking nursing home Medicaid.  (These standards set how poor a married couple must be to qualify for Medicaid.)   Unfortunately, these standards are not the same between nursing home Medicaid and Passport (at least, they aren’t implemented in the same way during the application process.)  It is financially more advantageous to go into a nursing home, the highest cost place to receive long term care.

If the “how poor is poor enough” question were answered the same way for Passport as for nursing home coverage, more people would choose to stay at home.  The “carrot” would be the same financial eligibility standards.

Well, Gov. Kasich abandoned the carrot.  He’s picked up the stick, and I expect him to use the stick to force provider payments lower.

My Care Ohio is being touted as giving “dual eligible” people more choice.  Except for the choice between cost-cutting insurance company A and cost-cutting insurance company B, I don’t see many choices in the My Care Ohio program.  A real and valuable choice could have been whether to get long term care at home, in an assisted living facility, or in a nursing home.  That is a choice that would mean something to seniors and their families.

I wish the Ohio Department of Medicaid had chosen the carrot of evening the Medicaid eligibility playing field so that the choice to stay home (where Medicaid’s costs are much lower) would be as financially advantageous as moving into a nursing home.

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