How I Think Medicaid Should Work

After dealing with Medicaid for years and seeing how misused and abused the system is. Here is my idea of how I would appropriate it. The goal of my plan is to reduce spending and abuse, while improving total care. Some of this does include using state run welfare as an incentive, but we'll get to that later on. At times this may sound like an oversimplification but I feel the loopholes need to be closed and simplifying Medicaid is a good thing. Here is the total cost of Medicaid by states

Here it is:

1. Start with the same qualifying guidelines based upon the current United States poverty thresholds. These would need to be adjusted on a per state basis as $10,000 in California doesn't spend the same way $10,000 does in Indiana. Link to chart 1. Link to calculator. Link to chart 2. Other guidelines in regards to disability, pregnancy and the elderly would remain unchanged.

2. Cut the age of children covered to only those under the age of 18. I am not sure if all, but I know that at least some states have set coverage to children up to age 19. This may only be a small savings but since childhood ends at 18 for everything else, why not Medicaid? Also at 18 someone can legally go get a job and can support themselves.

3. Limit the number of kids a family is allowed to have on Medicaid to 1. If a family has more than 1 child and is forced to go on Medicaid, the parents will not be covered and a max of 3 children will be covered. This may seem cold blooded at first but why should others be punished for the poor decisions of those who cannot support what they have created. If I were in this situation, I'd be sure to do what I could to keep ALL of my children covered first. This same theory could also be applied to food stamps and welfare benefits.

My own opinion is that Medicaid and related benefits should not be a benefit to having more kids. Unfortunately in my own experiences in retail pharmacy, many people are shown and told from a young age how to ensure the survival of themselves and their family by milking the government system for free entitlements. By the same token I do believe that every person should be given a fair chance against whatever circumstances they come into this world under. To steal a quote from Dietrich Bonhoeffer, "The test of morality of a society is what it does for it's children."

4. Limit the amount of time an adult can be on Medicaid. My personal suggestion would be 5 years consecutively and a maximum of 15 years between ages 18 and 65. This would help to eliminate people who are living on the system while providing coverage enough for them to get back on their feet through tough times. Thus it's a system set up to help people in case of catastrophe and great need, while cutting those who abuse.

5. Random and frequent drug tests as well as checks for misuse and abuse. Although the test itself would be an increase in expenditures, it would help to ensure that those who are on Medicaid are not dealing in illegal activities (whether it be illegal use or selling) and using the government as a free ride. This would also include tobacco as a substance of abuse. I think most people agree that if someone is found to have an illegal substance in their body (marijuana, heroin, not prescribed opiates, etc.) that they are misusing tax dollars and hence forth do not need the assistance they are receiving.

I have seen many patients who use their government provided healthcare to sell what prescriptions they are given to others. This doesn't only include drugs of abuse such as opiates and benzos, but also chronic disease medications (hypertension & dyslipidemia medications). If someone else can't afford a physician's visit or chooses not to have insurance but can treat their disease by buying medication secondhand from someone who gets them for free why not do that? The goal of this clause it to minimize drug abuse Here are a few decent reads: Abuse, Diversion, Fraud, The Costs of Tobacco.

6. Promote the use of contraception. This includes providing easy access to birth control, condoms, Plan B and any other methods a provider sees fit. This would also include allowing patients on Medicaid to bill condoms, contraceptive foams, etc. to their health care coverage without a prescription. The thought being that the increase in accessibility will help prevent the poor from having unwanted children and helps in aiding to reasoning for my #3 point in this article. Interesting article for those with PubMed. Another read everyone can access.

7. Patients with at least 2 chronic disease states must enroll in medication therapy management (MTM) programs and all patients make >75% of all regularly scheduled medical related visits. This is the MOST vital component in this article! This clause would ensure that patients are in contact with healthcare professionals in a manner that has been proven to decrease overall healthcare expenditures while improving the quality of their healthcare. For those of you who think this is unfair healthcare aimed at benefiting the poor you are right. It also benefits everyone else by spending less money and is thus good for everyone involved. Here are two viewpoints on a version of this: The Hot Spotters by the New Yorker and the actual study.

If you can improve care for those who are poor and those who are unhealthy while reducing costs, why wouldn't you do it? Therefore if a Medicaid patient who qualified did not participate their benefits would be cut. If over the course of 2 years they did not show efforts to help control their disease state while enrolled in this program, they would also be cut. Too cold blooded for you? Well, it's a way to help force patients to use these services with hopes that they will listen and improve their own health while saving money long term for everyone else. If they don't take advantage of what they are given, I, personally, do not feel sorry for them.

This is also a major area where pharmacists can intervene and really help further healthcare in the United States. I feel strongly about this as I see and deal with people on a daily basis and can get a good understanding about them with my own interactions with them. This can vary from MTMs to simple medication reconciliation at hospitals and exit counseling. Here are some examples: NACDS, Cost of medication adherence, A Critical Review of MTMs, Do's and Don't's, Cost Avoidance.

8. Charge copayments for every service. This may spark a little controversy but if you include what their expected copays are in a monthly check it will cover them. Why include it in a check then? Why not just waive the copays? This logic is simple; people only respect what they pay for. If they do not feel an out of pocket burden because something is free they will take it for granted. If they know a prescription costs $15 and an office visit costs $25, they will respect it more and will thus be more apt to listen and adhere to what is prescribed.

One of my pet peeves is when people who are on Medicaid complain that their medication is free. Nothing is free. NOTHING! Someone somewhere is paying for it, hence it should be valued at least partially.


9. A stricter formulary.  Every pharmacist and prescriber hates dealing with prior authorizations of insurance companies.  However, in government run systems, as well as privately, they are a great cost savings measure.  Medicaid does have this in place however, a more stringent guideline system could further cost savings.  For example, if every patient was who needed a statin for dyslipidemia where to first try pravastatin for 6 months over atorvastatin, there could be a great savings.  This savings could be even higher if patients were found to be successful on pravastatin, thus eliminating the need to have ever prescribed atorvastatin.  The same rings true for many drug classes and disease states.  This could also apply to even specific OTC versus prescription products such as fish oil (compared to Lovaza) and niacin (compared to Niaspan) as long as they had proper regulations.  This is relatively in place already but an even further belt tightening could save millions.  Just please make a relevant list available to providers with an easy to use interface.

That's about all I can think to modify most current Medicaid systems. Personally, I think any time government expenditures can be reduced and care can be improved it should be done. Since I have now put my views out there, what do you think? I am sure there is plenty to debate here and I look forward to any and all comments.

-The Pharmer

Medcaid Fraud May Be Legal, As Long As You Get Their Permission

Medicaid fraud totaled around 12.9 million dollars in 2007 according to the U.S. Office of Department and Management. Medicare fraud was slightly less at $10.8 billion. Though this number may sounds shocking a fair amount of this may actually be due to the Medicaid and Medicare itself.

Near the close of business today I had a phone call come in from a patient's parent asking us to refill her son's necessary medication. I obliged and went about my regular duties while my technician filled prescriptions and did other small tasks. Withing 30 minutes of calling a woman showed up to pick up the prescription that was phoned in for a refill. I looked up the desired prescription and saw it was in troubleshoot due to an insurance problem. This is where it the government based programs ALWAYS get something wrong.

I opened the prescription on and saw that the problem was that Medicaid claimed the prescription was not properly billed to the child's correct primary insurance. To clarify his parent were divorced and his mother had custody BUT his father had insurance that still covered him and therefore must, by law, be billed previously before billing Medicaid. I double check with the patient and I had all of the correct information in the system. I fiddled with some rejection issues for billing 2 different insurances that I have picked up along the way. Still to no avail.

This means I have to face every pharmacists nightmare. The dreaded insurance call...

I got through amazingly quick (probably because who the hell is filling prescriptions on a Friday nigtht that isn't a pain med or possibly birth control). When I get through I am connected with Gino who was surprisingly pleasant throughout the call, unlike most people who I reach when calling Medicaid. I explain to him the problem, that the insurance is being billed correctly yet I can not get Medicaid to cover the rest. Gino gives me several more options that I did not previously try but all are futile.

Then it dawns on me.

I can go back and see how the prescription was billed previously. As I pull up how this prescription was previously billed I mention it aloud to Gino. Gino says, "Well that makes sense since that was the billing number that kept coming up on my screen." There is one major problem though. With the way I am billing this rather expensive prescription I am telling medicaid that I am actually billing a different insurance company than I am and I am also saying that I did not collect payment from the primary insurance. Basically I am telling Medicaid that I am not getting paid for this and they need to pay it in full.

This is Medicaid fraud by the book!

"Wow, you're right! My system is saying that's the only way we can cover this prescription but they are literally telling me to falsely file this claim!" I ask Gino to leave a detailed message for his supervisor and he gladly obliges. I can actually he him scuttering around papers and pens to start writing. I stated to him the only reason I am doing this is because 1. it's in the best interest of the patient and 2. he told me to. He agrees and says he will send the tapes on to his superiors as well. We exchange goodbyes and hang up.

The woman who was sent to pick up the child's prescription is staring at me now with her mouth agape. "Wait, so Medicaid told you to committ fraud? What the hell?" "My sentiments exactly," I replied. The woman then went on a tirade and starting laughing about how she couldn't believe it but was not about to complain since the child definitely needs the medication. I agreed with her but what was I to do since I was instructed by Medicaid?

As I go to ring the woman out I ask for the patient's date of birth. "I think it's... I don't know we all have too many kids," states the man she is with. Seriously, now Medicaid patients are admitting they have too many kids!?!?! I can't believe my ears! After hearing this I half expected some hell spawn to appear from behind the pharmacy counter but thankfully it did not. The woman gave me the correct info and was glad I could help and planned on contacting her social worker.

This child had several prescription, all costing in the hundreds of dollars, that had been filled for over 6 months like this! The only way this could have happened is if somebody called Medicaid to get the override and repeatedly billed it that way. I can only imagine how many times Medicaid has told other pharmacies to fraudulently bill them in similar situations. With that being said it is now wonder why so many government programs are in the red or that Medicaid fraud is around $12.9 million. When an average guy from a small town with a little common sense can prove how there is a major loophole in a system designed by "well educated" politicians who make careers out of setting up these programs it is no wonder our medical system is "broken". Maybe if somebody high up in the Medicaid or government reads this I can get a consulting job in which they will pay me millions once I prove I can save them billions.

Mr. President Obama, I think I just got you a few more bailouts so how about...