When incentives lack appeal: Medicaid reform meets confusion, skepticism

West Virginia is one of the first states to offer inducements for patients who pledge to follow physicians' orders, but most of those eligible aren't taking the bait.

By — Posted Nov. 3, 2008

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"Do you have any monkeys in your ears?" Kim Bennett, DO, asked 4-year-old Chase during a mid-September checkup at a health center in Beckley, W.Va.

The pediatrician's exam found no monkeys, but he held up four fingers, signaling to Chase's mother, Amanda Muellins, that the boy would need four immunizations that day. Chase, catching on quickly, proposed an alternative: "I'll never be sick now. Ever."

Muellins didn't realize it, but because she had brought her son to the office visit and kept current with his shots, West Virginia's Medicaid program was willing to give him more generous coverage. But only if she acted to take advantage of it.

A thin packet mailed to Muellins several weeks earlier -- labeled "Urgent: open immediately" -- informed her that Chase soon would be enrolled automatically in a new Medicaid plan with basic benefits. It also said Chase could receive enhanced benefits if Muellins signed an agreement with his doctor that she would keep the boy's necessary checkups and immunizations up to date. But the enhanced option didn't make an impression on her, so she didn't sign up for it.

"I didn't know that they were doing any additional benefits," Muellins said. "I didn't really see anything different."

Her response to the Mountain Health Choices enhanced program appears typical for Medicaid beneficiaries and parents of Medicaid kids in West Virginia.

The program, which began almost a year ago in most parts of the state, is a novel attempt to use incentives to boost enrollees' personal responsibility and ownership over their health care. Eligible enrollees who agree to a wellness plan, follow other physician directions, and show up on time for medical appointments can receive free additional benefits, such as help with quitting smoking and membership in Weight Watchers. Those who don't take the option are relegated to a basic plan with somewhat fewer benefits than their existing plan.

Enrollment in the enhanced plan so far has been low. About one-third of West Virginia's Medicaid beneficiaries -- who numbered 392,000 in 2007 -- are eligible for Mountain Health Choices based on their relative good health. But only about 15,500, or 12%, of those eligible had signed up as of Sept. 30, according to state counts. Another 3% had begun the enrollment process.

Why hasn't the program been more popular?

Some patients simply might not know about or understand the program. Others might not read well enough to grasp the details. But even for those who want to pick the enhanced option, it's not always simple.

For starters, Medicaid enrollees are instructed to call their primary care physician. "Many don't have a primary care provider," said Renate Pore, president of the patient advocacy group West Virginians for Affordable Health Care. "They don't know who they're supposed to call."

Some eligible enrollees might not see a need for extra benefits, said Sarah Chouinard, MD, medical director of Primary Care Systems Inc., a health center in Clay, W.Va. For example, a 30-year-old woman with seasonal allergies might think she just needs her allergy prescription and annual Pap smear, not a wellness plan and extra hospital coverage.

The requirement that patients commit to regular office visits could pose a barrier for those with limited transportation options, said Rodney Fink, DO, director of clinical service for Access Health, a group of six health centers in southern West Virginia, including the Beckley facility where Dr. Bennett works.

Some observers say the state needs to do a better job of selling beneficiaries on the extra benefits. Dr. Fink said doctors also need to do a better job of focusing their patients' attention on it.

Looking for proof of concept

If West Virginia improves Mountain Health Choices, other states could be convinced that incentives can work to increase patient compliance with physician orders.

The Deficit Reduction Act of 2005 gives states authority to offer varying benefit levels to Medicaid enrollees. A few states, including Idaho and Kentucky, responded by offering incentives to beneficiaries who adopt healthier behaviors. Other states, such as Florida and Wisconsin, set up similar programs under waivers from the Centers for Medicare & Medicaid Services.

But West Virginia took the concept one step further by limiting benefits for Medicaid recipients who do not promise to follow a wellness plan and listen to doctors' orders. The state is now on the line to prove the tactic will work.

The ultimate goal of Mountain Health Choices is to forge relationships between patients and physicians that lead to healthier lifestyles and better preventive care, said Shannon Landrum, spokeswoman for the West Virginia Bureau for Medical Services in Charleston. The average age of those eligible for the enhanced plan is 14. "We really want those kids to have a long-term, trusting relationship with a health care provider."

Parents must agree to pick a medical home for their child, bring the child on time for a minimum number of office visits, and ensure that immunizations are up to date and prescriptions are followed. The agreement is similar for adults, with the addition of required screenings, such as colonoscopies, glucose levels and mammograms.

Some points of contention

The West Virginia program is more controversial than other states' because it automatically bounces nonparticipating beneficiaries -- possibly without their knowledge -- into the basic plan. Once there they encounter more restrictions than in traditional Medicaid, such as caps on prescriptions and mental health services.

For example, children in the basic plan are limited to four prescriptions per month, even though a child with asthma and attention deficit disorder could easily hit that limit, said Fernando Indacochea, MD, president of the West Virginia Chapter of the American Academy of Pediatrics. Landrum, however, said a state review of data from three pilot counties prior to implementation showed that children on Medicaid average fewer than one prescription a month.

And while individual mental health therapy is covered under the basic plan, crisis intervention is not, said Bob Hansen, executive director of Prestera Center, a mental health and addictions treatment agency in Huntington.

Georgetown University's Center for Children and Families on Aug. 9 issued a paper criticizing the state for automatically limiting kids' benefits via the basic plan. If the program aims to encourage healthy behaviors among Medicaid enrollees, said Joan Alker, the deputy executive director of the center, "I don't think there's any evidence that they're achieving that."

West Virginia already has learned some lessons that could be applied by other states considering incentives for patient compliance.

Dr. Fink said programs such as Mountain Health Choices won't work unless staff at clinics and health centers proactively advise patients about their health care options. He added that physicians should form a second line of support and also gauge their patients' awareness.

Landrum said it can be difficult to engage Medicaid enrollees as they gain or lose program eligibility. About 40% of Medicaid beneficiaries in West Virginia don't renew their benefits from one year to the next. States that want to change Medicaid from a program that simply pays claims into one that promotes health improvement and wellness need to be patient and look for ways to measure success in the long term, Landrum said.

Hope for the future

Mountain Health Choices has shown some promise. Enrollment in the three pilot counties, which began 20 months ago, is slightly higher than in the rest of the state, Landrum said. Enrollment across most of the state began about a year ago, but eligible beneficiaries in some counties will not receive packets until early 2009.

Some experts predict that enrollees will come around to the major reform. "The startup is not surprising. It'll change over time as people become more familiar with it and as the state refines its approach to it," said Dennis Smith, a senior fellow at the Heritage Foundation in Washington, D.C. He formerly directed the CMS Center for Medicaid and State Operations.

The West Virginia State Medical Assn. supports linking greater patient responsibility to more generous benefits, said President Stephen Sebert, MD, a family physician in Huntington. "It's premature to call the program a failure."

To improve physician awareness, the state could notify doctors of their Medicaid patients' deadlines for choosing a new plan, said Violet Burdette, CEO of Northern Greenbriar Health Clinic in Williamsburg. Eligible beneficiaries receive a Mountain Health Choices enrollment packet 60 days before their Medicaid benefits are changed. They have 90 days to respond.

Burdette also said enrollees might be more engaged if they had to choose either the basic or enhanced plan instead of being channeled into the less generous plan by default. Landrum said only two Medicaid beneficiaries have actively declined the enhanced plan.

The state is working with West Virginia University researchers to analyze Medicaid enrollees' responses to the Mountain Health Choices program to gauge how well it's working.

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W. Va. among nation's highest Medicaid users

There were nearly 375,000 Medicaid recipients in West Virginia in 2005, the most recent year for which statistics are available. That accounts for 20.1% of the state's population, almost double the rate for neighboring Virginia, and higher than all but 13 other states. While several states are offering incentives to beneficiaries who adopt healthier lifestyles, West Virginia is taking it a step further and limiting benefits to those who don't. Residents enrolled in Medicaid in 2005:

9.2%: New Hampshire

10.0%-14.9%: Colorado, Connecticut, Idaho, Iowa, Kansas, Maryland, Minnesota, Montana, Nebraska, Nevada, New Jersey, North Dakota, Utah, Virginia, Wyoming

15.0-19.9%: Alabama, Alaska, Delaware, Florida, Hawaii, Illinois, Indiana, Massachusetts, Michigan, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Texas, Washington, Wisconsin

20.0%-24.9%: Arizona, Georgia, Kentucky, Mississippi, Missouri, South Carolina, Vermont, West Virginia

25.0%-29.9%: California, District of Columbia, Louisiana, New Mexico, New York, Tennessee

35.2% Arkansas

Note: Maine did not provide data to the Centers for Medicare & Medicaid Services.

Sources: U.S. Census Bureau, CMS

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Work of enrolling can fall on physicians

Some physicians are excited about West Virginia's pilot program that offers incentives for Medicaid patients to stick with a wellness plan, even though it does cause extra work for doctors.

Sarah Chouinard, MD, medical director of a health center in Clay, about an hour from Charleston, said her facility has convinced more than a few patients to take advantage of the enhanced benefits in Mountain Health Choices. The clinic, which is in one of the three pilot counties for the program, treats about 7,200 patients, a third of whom are enrolled in Medicaid.

Dr. Chouinard said explaining the initiative to patients requires additional staff time but coordinates well with the medical home model the center offers.

Terrence Reidy, MD, was less enthusiastic. He practices at a community health center in Martinsburg, in the eastern part of West Virginia.

A state Medicaid representative visited his facility about a year ago to explain the role the center would play in promoting the expanded plan. "It seemed like our office was then expected to be the ones to get the patients to sign up," Dr. Reidy said. The internist hasn't been contacted by state officials since then, he said in late September.

The center treats about 2,400 Medicaid patients, two-thirds of whom are children. Only about 2% of patients have opted for the enhanced benefits. "It really has not changed our practice a bit," Dr. Reidy said. Still, consulting even a few patients about their choices of Medicaid benefits and crafting wellness plans adds another unpaid job to his already tight schedule.

One job West Virginia physicians will not have is that of enforcer. The state will review claims records to track patient compliance with the enhanced benefits agreement.

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External links

West Virginia's Mountain Health Choices (link)

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