POSTED ON AUGUST 21, 2013:
Getting serious about tracking health outcomes
Bright red letters spelled out the words "no significant improvements," while a voice intoned that Medicaid "doesn't even improve physical health."
The message came as part of an online advocacy campaign against Medicaid expansion, based on findings from a study of physical health for recently-enrolled Medicaid patients.
The Oregon study, as it's come to be known, has been held up by some as proof that efforts to expand Medicaid are misguided.
"It's going to be a really disappointing effort to try to expand Medicaid in Oklahoma, whether that be through premium assistance or through a traditional Medicaid expansion," said Jonathan Small, the fiscal policy director for the Oklahoma Council of Public Affairs.
But while the study results published in May failed to prove a link between Medicaid enrollment and improvements in certain markers of physical health, others have said no simplistic conclusions should be drawn.
"It's quite possible that there were positive effects, but you would have to have had a much larger sample of people with the diseases of interest to detect it," said Julia Paradise, an associate director at the Henry J. Kaiser Family Foundation's Commission on Medicaid and the Uninsured.
The ad using red letters was directed at Arizona lawmakers. It drew a comment from one of the Oregon study's authors, Jonathan Gruber, who responded to questions from the Annenberg Public Policy Center's FactCheck.org news outlet. Gruber reportedly wrote that the spot "represents the negative findings of the study without talking about the positive findings: the fact that we find enormous improvements in mental health and in financial security."
There's a larger question, however, about emphasizing health outcomes to decide public health policy -- and influential voices, like the authors of Oklahoma's Leavitt report, seem to suggest more attention be paid to health outcomes when crafting health care reforms.
Paradise, however, warned about the limits of such an approach.
"Health insurance is a very important key to accessing care, but it is one factor among many that contributes to our actual health," Paradise said. She added: "I don't think we can expect Medicaid by itself to make people healthy anymore than we can expect private insurance to make us healthy."
The Leavitt report suggested ways that SoonerCare, the state's name for Medicaid, might be improved -- indentifying "areas of continuing improvement," in the words of Buffy Heater, director of planning and development for the Oklahoma Health Care Authority, the state agency involved with overseeing SoonerCare.
Heater spoke to a group of Tulsa health care and business leaders at a July forum organized by the Tulsa Regional Chamber.
She explained that the authority keeps track of several measures, including the Healthcare Effectiveness Data and Information Set and the Consumer Assessment of Healthcare Providers and Systems. This lets the state keep tabs on how many SoonerCare members access preventive care, for example, or how many comply with treatment plans, Heater told the crowd.
However, the Leavitt report authors suggested even more measurements.
"The health care authority over the years and, due to limited resources, has only pursued about 25 percent of the 75 measures that could be evaluated," Heater said. The long list of HEDIS criteria alone includes both general and highly specific measurements, some relating to screening and some related to follow-up care, for example.
Heater emphasized health outcomes as an area to measure more closely.
"We're very good at being able to count the number of members and count the dollars that are spent, but we have some work to do in ways that we can attribute those dollars being spent, to tying those directly to meaningful change for the health outcomes of Oklahoma's population," Heater told the group.
Jan Figart, associate director for the Community Service Council in Tulsa, said the push to measure health care processes dates back to the origins of Medicaid.
"They've become more sophisticated as the years have passed," Figart said, adding that health care reform efforts in the 1990s included a greater focus on measurements. The demand is for "higher and higher levels of accountability," she said.
With more measurement could come more financial incentives -- or penalties. Hospitals have been singled out for high readmission rates, for example, with the price being a slight reduction in federal funds.
The Leavitt report, pointing to possible improvement in the existing SoonerCare program, noted that existing incentives tied to things like higher screening rates or higher use of generic medications "may not necessarily translate to improved overall health outcomes."
The group suggested the Oklahoma Health Care Authority consider more incentive-based payments tied to health outcomes.
"Leavitt Partners recommends that OHCA consider broadening the incentive program to provide financial incentives for identified improvements in health outcomes, such as tobacco cessation, reductions in obesity, and improved health indicators from diabetes care," the report states.
As the Leavitt report authors noted, Gov. Mary Fallin in her State of the State speech called for an "Oklahoma plan" that "focuses on improving the health of our citizens, lowering the frequency of preventable illnesses like diabetes and heart disease, and improving access to quality and affordable health care."
But the recent Oregon study seems to at least indicate that health improvements don't necessarily happen quickly. Small said simply that the experiment suggests that Medicaid is "broken and needs to be fixed and not expanded."
Paradise, on the other hand, emphasized that the measurements shouldn't obscure the benefits of having health care coverage. "The logic is, if you have access to care and to treatment, that you are likely to do better," she said.
She went on to note how genetics, nutrition and education all factor into our health, while issues relating to housing and transportation also play a role.
"There are many other public policy considerations that will have to be addressed before we see the full degree of improvement in health that everybody wants," she said.
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