Accountable Care and the Implosion of Medicaid Programs Throughout the Country

This issue of the Journal continues our focus on the myriad of ways in which we can enhance accountable care. The last issue of the Journal focused on the many challenges of implementing the medical home. I commented in my introduction to the Medical Home issue on my opposition to prescriptive process-driven approaches to certification of the Medical Home. Similarly, I am opposed to a one-size-fits-all approach to health care delivery reform. That is, I am opposed to the belief that only accountable care organizations are capable of delivering improved quality at the best-possible price. I would simply like to see accountable care delivered by whatever entity can step up to the plate and deliver improved outcomes quality at a efficient price. As in the past, I define outcomes quality to include a continuously decreasing rate of "potentially preventable events": that is, decreased potentially preventable

* initial admissions (hospitals and nursing homes),

* readmissions,

* complications,

* emergency room visits, and

* ancillaries (broadly defined to include not just radiologic tests but more appropriate pharmaceutical prescribing)

This issue of the Journal focuses on the evolving role of case managers in our health care system. Case managers can function in any of the names that policymakers are throwing about these days: medical homes, accountable care organizations, and managed care organizations, that is, any organization that is taking on some form of financial risk. Each of these organizations is assuming a certain level of financial risk in their effort to improve outcomes quality. These organizations expect that when they hire case managers of the type described in this journal, that would both measurably improve outcome quality and decrease potentially preventable events.

These developments cannot happen soon enough. Medicaid programs throughout the country are in the process of imploding because of state budget deficits, while at the same time, it is our Medicaid programs that are supposed to be the "home" for millions of newly insured individuals as a consequence of the recently passed health reform law. In response to these twin challenges, we need to marshal all our outcomes improvement efforts that save money as rapidly as possible to forestall the natural tendency of Medicaid program directors to simply cut benefits rather than the harder task of improving quality at a better price. However, even if dramatic improvements in Medicaid programs are possible, they cannot do it alone. That is, and most importantly, Medicaid program directors need to consider joining forces with those parts of state government that are responsible for health insurance for state employees (active and retired). Together, Medicaid programs and state employee health insurance offices can have a greater impact on any of the organizational entities that are providing care and are assuming financial risk.

This issue, carefully edited by Roger Kathol from Cartesian Solutions and Cheryl Lattimer from the Case Management Society of America, highlight the importance that case managers will have if efforts at accountable care are to be successful.

The remainder of this issue provides our regular features: our ambulatory management column by Dr Ron Goodspeed and the latest news from the Republic of Texas.

-Norbert I. Goldfield, MD

Editor