Ore­gon study a wake-up call

Med­i­caid needs to change as it ex­pands to im­prove out­comes

Modern Healthcare - - OPINION COMMENTARY - Dr. Glenn Steele is pres­i­dent and CEO of Geisinger Health Sys­tem in Danville, Pa.

Re­cent find­ings from the Ore­gon Health Study have re­sulted in head­lines in­tended as a warn­ing for next Jan­uary’s planned ex­pan­sion of the Med­i­caid pro­gram (as part of the Pa­tient Pro­tec­tion and Af­ford­able Care Act):

“Bad news for Oba­macare: A new study sug­gests univer­sal health­care makes peo­ple hap­pier but not health­ier”

“Ore­gon study throws a stop sign in front of Oba­macare’s Med­i­caid ex­pan­sion”

“Giv­ing peo­ple govern­ment health in­sur­ance may not make them any health­ier”

Over­all, the theme of th­ese ar­ti­cles and much other com­men­tary has been that, given the study’s lack­lus­ter re­sults, the Med­i­caid ex­pan­sion, which will cost bil­lions of dollars, should not go for­ward. The head­lines have missed the point.

The Ore­gon Health Study refers to a 2008 ini­tia­tive that ex­panded Ore­gon’s Med­i­caid pro­gram to 10,000 low-in­come in­di­vid­u­als who were cho­sen through a lot­tery. The find­ings, at best, were mixed, with a de­crease in rates of de­pres­sion and re­duced out-of-pocket ex­penses, but no sig­nif­i­cant ef­fect of Med­i­caid cov­er­age on the preva­lence or di­ag­no­sis of hy­per­ten­sion or high choles­terol lev­els or on the use of med­i­ca­tion for th­ese con­di­tions; no im­prove­ment in in­di­vid­u­als’ di­a­betes; and an in­creased use of many preven­tive ser­vices and doc­tors’ ser­vices.

Let’s re­frame the dis­cus­sion. First, the Af­ford­able Care Act, like the Ore­gon lot­tery ex­pan­sion, is pri­mar­ily in­tended to in­crease ac­cess to health­care ser­vices by elim­i­nat­ing fi­nan­cial bar­ri­ers. The Ore­gon pro­ject ac­com­plished this. And this is one of the key goals of the pend­ing Med­i­caid ex­pan­sion.

Sec­ond, the im­pli­ca­tions of the find­ings are sub­ject to sig­nif­i­cant de­bate. Some have seen the re­sults as a warn­ing that the ACA ex­pan­sion may not lead to health im­prove­ment, while oth­ers ques­tion the method­ol­ogy but ac­knowl­edge that it was dis­ap­point­ing that the find­ings in some cases did not sig­nif­i­cantly im­prove health out­comes.

Here is what is key: Re­gard­less of how the

If the Med­i­caid pro­gram just ex­pands but does not change, we will not achieve sig­nif­i­cant im­prove­ment in par­tic­i­pants’ health sta­tuses.

re­sults are in­ter­preted, the study does pro­vide a wake-up call. Next Jan­uary, the Med­i­caid pro­gram will ex­pand. If the pro­gram just ex­pands but does not change, we will not achieve sig­nif­i­cant im­prove­ments in par­tic­i­pants’ health sta­tuses.

The rea­sons for this have been well-doc­u­mented. Our cur­rent health­care sys­tem does not work: It is frag­mented; health­care is not co­or­di­nated; ser­vices are pro­vided and, most of­ten, paid for in an old-fash­ioned piece­meal way with no ac­count­abil­ity for out­comes; and in many cases, poor care is rewarded with ad­di­tional re­im­burse­ment.

We should not be will­ing to ac­cept this. Health sys­tems across the coun­try, in­clud­ing Kaiser Per­ma­nente, In­ter­moun­tain, Den­ver Health, Vir­ginia Ma­son and many oth­ers, have shown that through re­design­ing how they pro­vide care in the acute-hos­pi­tal and am­bu­la­tory set­tings, pa­tients’ health out­comes have im­proved sig­nif­i­cantly.

At Geisinger Health Sys­tem, this has been our mis­sion as well. We have seen sig­nif­i­cant out­come dif­fer­ences for our pa­tients both ini­tially as well as long term af­ter re-en­gi­neer­ing hos­pi­tal-based and pri­mary care. One ex­am­ple is in Type 2 di­a­betes, where we fun­da­men­tally changed how we pro­vide and pay for care and con­se­quently achieved ma­jor re­duc­tions in heart at­tacks, stroke and retinopa­thy in our pa­tients. We are now work­ing with sys­tems in sev­eral states to help them adopt the in­no­va­tions we have im­ple­mented at Geisinger.

We know from our work and that of lead­ing health sys­tems around the coun­try that if we want the health out­comes for the ex­panded Med­i­caid pop­u­la­tion to be dif­fer­ent from the re­sults now be­ing re­ported for the Ore­gon study, pa­tients will need to be cared for in a rad­i­cally re­designed sys­tem. One push for this re­design could come from new ef­forts from the Cen­ter for Med­i­caid and Medi­care In­no­va­tion, which was given, un­der the Af­ford­able Care Act, the flex­i­bil­ity, fi­nanc­ing and au­thor­ity to func­tion as a national change agent.

The real force for change, how­ever, will have to come from the health­care sys­tem it­self—from health lead­ers across the coun­try who will need to com­mit to re-en­gi­neer how they pro­vide care and be will­ing to be ac­count­able for pa­tient out­comes. Scal­ing and gen­er­al­iz­ing the in­no­va­tions that have al­ready proven suc­cess­ful could pro­vide a jump-start on fix­ing our health sys­tem in time to care for this new pa­tient pop­u­la­tion.


Shirley Krueger of Salem, Ore., par­tic­i­pated in the lot­tery for the 2008 Ore­gon Health Study, an ini­tia­tive that ex­panded Ore­gon’s Med­i­caid pro­gram to 10,000 low-in­come in­di­vid­u­als.

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