Obama's Choice to Lead Medicare Spells Reform

An exciting appointment to head the federal Medicaid & Medicare agency
The Lund Report

March 30, 2010 -- Daniel Patrick Moynihan once said: “If you’ve been in government a long time, as I have been, then the most exciting thing you encounter in government is competence. Why is this exciting? Because it’s rare.”
When I read the quote, even today, I can hear the late New York senator’s voice booming, his last word full with extra punctuation.
Today I’m excited for the government. Health care reform should bring nutrition to a starving Indian health system. And, if the next test for health care reform is execution, then the government might be on the right course. The New York Times reported Sunday that Dr. Donald Berwick is the president’s choice to head the Centers for Medicaid and Medicare Services.
This is a choice that exceeds Moynihan’s rareness of competency. Berwick represents the ideal, the one person you think could help the government, the people and the medical profession come together and a coalesce around the idea of excellent health care. Last December at the Institute for Healthcare Improvement conference I watched hundreds of professionals cheer on Berwick as they would a rock star. This is a doctor who’s willing to talk about what’s really important to people. “Health care has no intrinsic value at all. None, Health does. Joy does. Peace does,” he said in December. “The best hospital bed is empty. The best CT scan is the one we don’t need. The best doctor’s visit is the one we don’t need.”
Imagine that. Doctors we don’t need.
Berwick’s appointment is not official yet – and then the Senate would have to confirm him before he takes office. But I wanted to write about this now because Medicaid, Medicare and Children’s Health Insurance Program all play a key (and growing) role in funding the Indian health system.
The most important thing to know about CMS funding is that it’s an entitlement: If a person is eligible, the money is supposed to be there. That’s not true for Indian health because the system is based on annual appropriations. Every time IHS, a tribal program or an urban clinic can bill CMS for patient care, it adds money to the system.
This is also the way to improve the idea of “don’t get sick after June.” If a patient is eligible for Medicaid, the money is supposed to be there. It doesn’t require passing the life or limb test.
Berwick already has a working knowledge of the Indian health system. The Harvard professor wrote a book, Escaping Fire: Designs for the Future of Health Care, that cites the work of Southcentral Foundation and the Alaska Native Medical Center as a model of a quality, locally managed facility. Southcentral, the nonprofit affiliate of Cook Inlet Region, Inc., operates the outpatient facility with self-determination funding from the IHS, other grants, and money from Medicaid and Medicare.
Medicaid is especially complicated. The program is officially a partnership with between the federal and state governments. That means there are fifty different regimes, policies and procedures. Eligibility varies state by state. There’s often a split in the state mechanism for behavioral health and other services.
And then there’s the money. According to the Kaiser Family Foundation:  The funding shortfall for state budgets could top $350 billion by next year.
Indian Country isn’t supposed to be hit by these shortages; there’s a 100 percent federal reimbursement for eligible patients in the Indian health system (a process that’s supposed to be improved by the new health care reform law).
But nothing is simple when it comes to Medicaid and the Children’s Health Insurance Program. States aren’t keen to see these rolls expand even when there’s a federal guarantee. It’s even more complicated when you factor in those reservations that cross state lines. Utah would set the rules for Navajos living on that portion of the reservation, New Mexico another set, and Arizona with still another situation. I would love to see CMS rules that supersede state versions, treating Indian Country as a 51st state. Someday.
But there are other, more practical innovations that could happen at CMS immediately. There could be more experiments (requiring waivers) from providers about how health care is delivered. There could be less complicated paperwork to enroll in Medicaid as part of the implementation of health care reform.
Berwick is not a manager who will make the system we have work better. No, he’s the kind of leader who will help us invent something better – and the Indian health system will be a beneficiary.
Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at www.marktrahant.com
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There is near universal agreement that Berwick is a high quality player. However, no matter how good, the speculation does not recognize the inherent conflict of interest embedded in maximizing the interests of Medicare and Medicaid as contrasted to those of the rest of the population. This conflict is very apparent when it comes to provider reimbursement and the history of managing public sector expenses by reducing fees paid, knowing that such sub-par compensation yields higher fees for the rest of us. As CEO of CMS, does Berwick land on the side of seeking the most favorable financial terms with providers it can achieve? Or do we assume his position is one of more universal representation? Medicare and Medicaid are vested interests at the table. What Providence, Legacy, Kaiser fails to acquire in Medicare / Medicaid reimbursement is a shortfall that must be made up by others. Should providers expect improved or diminished public sector fees under health reform and Berwick's leadership?