Give patients with chronic diseases a healthcare team. Monitor a state database to spot abuse of prescription drugs. Reward pregnant teens who keep their doctor appointments.

Those were among the many suggestions that flowed last week to a Senate committee examining ways to improve the quality and efficiency of Medicaid, the joint state and federal healthcare program for the poor.

The Senate hearing was one of two held last week as Missouri legislators grapple with whether to expand Medicaid to cover an additional 260,000 people, as envisioned by the federal Affordable Care Act. A House committee, meeting in St. Louis, heard from a long list of witnesses who urged that the program be expanded.

Medicaid pays for doctor visits, prescription drugs, nursing home care and other services for about 875,000 Missourians — low-income seniors, people with disabilities, and some families with children. Missouri’s program costs state and federal taxpayers about $8.5 billion a year.

The expansion would have added working-age people who make up to 138 percent of the federal poverty level, or $32,500 a year for a family of four. The federal government would have paid the tab for the first three years, with the state gradually picking up a share.

Many speakers at the House hearing testified that a decision not to expand Medicaid would fall hardest on the mentally ill, who receive few services in Missouri’s safety net funding.

But legislators have emphasized that the system must be overhauled first. Finding ways to reduce costs and improve care was the thrust at the Senate hearing.

Overall, about 25 percent of health care services are used by 1 percent of the patients, said Dr. Larry Lewis, a professor of emergency medicine at Washington University. The “super-utilizers” include people with chronic conditions, mental health issues and substance abuse problems.

Coordinating their care can reduce duplicative tests and unnecessary use of emergency rooms while improving patients’ health, he said.

“We have the most expensive health care system in the world, with outcomes that have really fallen behind many industrialized countries,” Lewis said.

Dr. Heidi Miller, an internist who works at a community health center in St. Louis, said one way to improve care was to give patients a “medical home.” The approach, which is currently used for some high-need Medicaid patients, involves assigning the patient a social worker and a nurse, who handle follow-up care.

Miller said those relationships had produced results, for example, for diabetic patients who learned to manage their disease and overweight patients who stuck with a weight-loss plan.

One key, she said, is that the contact is made by a trusted medical staffer, “not a remote call center calling the patient.”

Others urged legislators to consider shifting elderly and disabled people on Medicaid out of fee-for-service plans, where health care providers are paid for each service, into a managed care system, where people get their services through an organization under contract with the state.

Parents and children on Medicaid who live along the Interstate 70 corridor already are enrolled in managed care plans.

The elderly and disabled “consume 60 to 70 percent of your health care dollars,” said Christian Jensrud, vice president for business development at WellPoint, which operates Anthem Blue Cross and Blue Shield. “That’s where you can get the largest bang for your buck, improve quality and save taxpayer dollars,” said Jensrud, who projected $750 million in savings annually.

Jensrud also said carrots work better than sticks. For example, he said, his plan gives pregnant teens debit cards to use at drug stores to buy health-related products if they show up for pre- and post-natal visits.

Money is saved if fewer babies need intensive care. Also, doctors’ time is not wasted with missed appointments, he said.

Requiring low-income patients to make a co-payment doesn’t work, several witnesses said, because if patients can’t pay it, they still get the service.

“Cost-sharing basically means providers eat the cost,” said Daniel Landon, representing the Missouri Hospital Association.

The lack of dental care for most adults on Medicaid causes higher costs for the state, said Dr. Jeffery Kerr, an osteopathic physician from Rolla.

Kerr said he sees patients with dental problems, such as abscesses, about four times a day in the emergency room at a Houston, Mo., hospital where he works. He said it would be much cheaper for the state to send the patient to a nearby dentist, who would remove the tooth for $138.

Kerr also said that some people abuse the system by stopping at several emergency rooms to get narcotics for the same tooth problem. While the state tracks patients’ drug usage in a database, no one monitors it to prevent abuse, Kerr said.

At the House hearing, several dozen people testified, with all but a few speaking in favor of Medicaid expansion.

Sitting around tables on a crowded stage in a small theater on the Forest Park campus of St. Louis Community College, committee members heard witnesses for about eight hours — asking questions and at times badgering those who dared to speak out against Medicaid expansion.

Several witnesses told evocative personal stories about how Medicaid helped sustain them in hard times and return them to productive lives.

“A few short years ago Medicaid helped save my life,” said Jim Shortall, an entrepreneur and board member of several local, state and national mental health associations.

“People like me can and do recover,” said Shortall, who has a bipolar disorder. “Treatment works — if you get it. Medicaid … bridged me to where I am today: employed and insured.”

Medicaid advocates also delivered boxes containing what they described as 1,750 official witness forms of Missouri residents testifying in support of Medicaid expansion.

Former Sen. Jim Lembke, who appeared on behalf of a nonprofit organization called United for Missouri, was among a handful of speakers who testified against Medicaid expansion.

Lembke, who noted that 27 states had decided so far not to expand Medicaid, said the program’s rising costs ran the risk of bankrupting Missouri and other states.

“I don’t believe that we can trust the federal government,” he said.

Sgt. Jeremy Romo, coordinator of St. Louis County Police Department’s crisis intervention team, said he believed a decision not to expand Medicaid would be “a disaster” for low-income people with a serious mental illness who need access to care and follow-up treatment.

“They end up losing their lives,” he said.


                                                                  ST. LOUIS POST-DISPATCH

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