Making Tough Choices: Adults with Disabilities Prioritize their Medi-Cal Options
By Marjorie Ginsburg and Kathy Glasmire
California HealthCare Foundation - December 2004
In January, 2004, Governor Arnold Schwarzenegger proposed a major overhaul of Medi-Cal to contain costs… …the state requested assistance from the California HealthCare Foundation and The California Endowment to solicit, receive, and organize public input…
…Sacramento Healthcare Decisions… developed a simulation project to ask adult disabled Medi-Cal beneficiaries to design their own health benefits package when there were more options than dollars.
The project used CHAT (Choosing Healthplans All Together), a computer-based program developed by the University of Michigan and the National Institutes of Health. CHAT is a tool that engages individuals in the challenges of choosing health care benefits when choices exceed available resources.
The basic CHAT board is a pie chart consisting of up to 16 categories (with two or three tiers in each category). Each category tier costs a specific number of markers based on the proportional cost of that service… Altogether there were a total of 123 marker spaces on the CHAT board. Choosing all services at the current (Medi-Cal) level required 114 markers, but participants had only 100 markers to use in picking their benefits.
>From the findings:
- Given the nature of their health status, adult disabled Medi-Cal beneficiaries are often highly dependent on medical and supportive services. The CHAT decisions they make are heavily influenced by this basic fact.
- Maintaining a full range of Medi-Cal services is the most important consideration when CHAT participants design coverage that affects all disabled Medi-Cal beneficiaries.
- Having sufficient choice and availability of providers is essential for beneficiaries to feel secure about their health care services and confident that quality care is attainable.
Comparing CHAT responses between Medi-Cal beneficiaries and the privately insured:
- While health care plays a major role in the lives of disabled Medi-Cal beneficiaries, it is usually not central to the lives of most privately insured employees.
- Compromising on a benefits package was easier for privately insured employees than it was for those on Medi-Cal.
- Moderate cost sharing was more acceptable to privately insured employees than it was to those on Medi-Cal.
- Both groups felt that having a full range of health care services was the most important criterion for their coverage.
- Both groups consider choice to be the cornerstone of a quality health care system.
>From the Conclusion:
Agreeing to make trade-offs during the CHAT process is not the same as accepting those cutbacks in real life.
>From the perspective of the participants, there is no low-hanging fruit in Medi-Cal. Every service category has its advocate; every higher level tier has its promoter. While many acknowledged that Medi-Cal may have to change in response to California’s budget problems, participants were concerned that the state will make life considerably harder for them than it is now.
http://www.chcf.org/documents/policy/MediCalCHAT.pdf
Comment: Today, more attention is being given to health care costs than to other concerns such as the growing numbers of uninsured. The CHAT tool was developed to assist in providing consumer input into the debate over the perceived need to reduce health care spending.
The problem with CHAT is that it begins with the presumption that health care spending must be reduced, and it can be done so only by decreasing benefits and increasing individual cost sharing. The obvious risk of this approach is that policymakers will use it to further reduce the financial protection afforded by health care coverage.
California ranks at the bottom of funding in it’s Medicaid (Medi-Cal) program, yet Gov. Schwarzenegger wants to use the CHAT process to slash Medi-Cal spending even more. But when there is no place to cut, distributing 100 markers for 123 spaces cannot ever result in rational health policy decisions.
It is very instructive to look at the CHAT game board in the original article (link above). Nowhere on the board can you find rational choices for cost containment. Reducing administrative waste, enhancing a higher quality and lower cost primary care base, reducing supply side technological excesses that fail to provide benefit, and establishing an integrated information technology system are only a few of the measures that would tackle health care costs while actually improving benefits and coverage.
When we approach the patient-consumer for input on addressing health care costs, shouldn’t we provide them with information on beneficial options, or should we merely continue to expose them to the CHAT game and use the results as an excuse to slash and burn what we do have?