Compliance: What about a crackdown on patients?

The new policy, which will be initially applied in three rural counties, will reduce basic benefits for most people who are covered by Medicaid. To get "enhanced benefits," recipients must sign a "personal responsibility agreement" and abide by its rules. The agreement requires patients to keep their medical appointments, take their medications as directed, submit to screening tests, and participate in health improvement programs, among other things.

While the West Virginia State Medical Association agrees with the intent of the Medicaid experiment, an article in the New England Journal of Medicine blasted it, and some local physicians are also concerned about its potential consequences. "I think personal responsibility is important," says internist Greg Rosencrance, governor of the West Virginia chapter of the ACP. But he doesn't think it's fair to single out the Medi-caid population in this respect, and he also wonders whether it will result in worse care for some patients. "How this new structure impacts individuals' ability to obtain needed and adequate care is clearly going to have to be monitored."

The bottom line is that, as health costs soar, nothing is off the table. So you, too, might eventually have to deal with payers who tie patients' health benefits to their compliance.

Will better compliance cut costs?

The personal responsibility agreement is part of an overall Medicaid redesign that the state is implementing to cut administrative costs, improve the coordination of care, and "tailor services to meet the needs of enrolled populations." Medicaid officials hope that, in the long run, increasing patient compliance and improving health behavior will lead to slower growth in program costs.

Under the plan, approved by CMS last May, seniors, people with disabilities, children in foster care, and most pregnant women will continue to receive the benefits they got before the redesign. But others on Medicaid will receive less coverage than before. Both children and adults, for example, will be limited to four prescriptions a month. The basic benefit package will no longer cover things like diabetes care and mental health services, and it will offer reduced dental, vision and hearing services.

When Medicaid recipients sign a personal responsibility contract, they get "enhanced" benefits that include mental health counseling, long-term diabetes care, cardiac rehab, and unlimited prescription drugs and home health visits.

Judith Solomon, a health policy expert at the Center on Budget and Policy Priorities in Washington, DC, argues that Medicaid recipients who don't receive the full range of services-either because they don't sign the personal responsibility agreement or aren't able to comply with all of it-may actually end up in worse health and cost the state more in the long run.

Steven Artz agrees, noting that when Medicaid cut prescription drug coverage in the past, some patients landed in the hospital as a result. "The typical diabetic is on between four and six prescriptions," he says. "These patients are on one or two medications for their blood sugar, another drug for their lipids, and another for their high blood pressure. And if they have cardiac problems, they may be taking medications for arrhythmia or a platelet inhibitor. So, by limiting the number of prescriptions, this program could be a potential disaster."