Can’t Get Clean

The network is stepping up its game.

They have elected to participate in a pilot program with the state-funded (and federally subsidized) Medicaid insurer, whereby they will no longer charge the state on a fee-for-service basis. Instead, they will receive a single bundled payment for an episode of care that will last from the date of the patient’s hospitalization through the end of the third month of the patient’s care. Essentially the insurer is incentivizing the network to provide quality and cost-effective care; if they are successful, the network gets to keep a portion of the savings. The problem in implementing such a plan is this: the Medicaid population is (historically) the sickest and least “compliant” population with the greatest number of comorbidities. In short, the Medicaid population features the network’s most complex patients.

“All we are doing is spinning our wheels deeper into the mud,” I said. We all know that the strongest risk-factor for nearly each costly condition in that population is the exact reason (which we have no influence over) that Medicaid is their insurer to begin with: they are poor,” I said to a colleague.

“Yeah, but they keep making their own bad decisions…what are ya gonna do?” he asked.

“How can you expect an individual to make decisions that mirror your own values when they are raised in a hopeless environment built on a foundation of inherent inequality? This reminds me of a conversation (last year) that I had with my grandfather (an old “southern gentleman”) and my father. My dad is a right-leaning would-be Trump voter who is quick to complain about how folks won’t pick themselves up by their bootstraps, how communities don’t take their streets back from gangs, and fails to understand why many people in the urban community don’t value a high school education. My grandfather was sharing an experience that he had when walking downtown in the mid-nineties when he walked by the soup kitchen. The line was out the door and he vividly remembers a teenager standing in line with a small boy; he thought to himself, ‘With that boy as a father, this kid doesn’t have a chance.’ My father raised his hands in frustration, ‘See? Exactly!’ he said. ‘This is what I am always talking about…they are just takin’ my money without workin’ a lick, and then their kids don’t learn how to do shit, either.’ [my colleague nods his head in agreement]. To which, I turned to my father and said, ‘Yeah, but [assuming that the teenager was a father and not a sibling – which I took issue with] if your assumptions are correct, then when you walk by that same soup kitchen today, that boy who didn’t have a chance almost twenty years ago has now grown up and may be in the same line with a child of his own. If he didn’t have a chance back then, why do you look down on him today?'”

My colleague looked at me in the eye and grinned: “That’s why I’m all for population cleansing.” My eyes widened. “Hey – keep in mind – I said ‘population cleansing’, not ‘ethnic cleansing.'”

Perhaps it was just an unfunny joke, but I preferred my father’s response: “Jesus christ, Keith, you know it’s more complicated than that.”

My father wasn’t funny, but he was right. It’s way more complicated than that.


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