Berwick: `No` to Medicaid block grants, `Yes` to a larger role for behavioral health

In a Tuesday morning address at the 41st National Council Conference in San Diego, Donald Berwick, MD, Director of the Center for Medicare and Medicaid Services (CMS), took a firm stand against Congressional proposals to change the federal-state Medicaid partnership to a series of federal-to-state block grants.

While block grants are far simpler on the federal side, Berwick says that these are little more than a way for the federal government to “give it to the states and say ‘good luck.’ I think we’re in this together,” he says, noting that, “Medicaid is a partnership, and I love the ideal of that partnership.” Berwick believes that block grants weaken that partnership. And, following any change to a block-grant system he asks, “what happens if the partnership is further weakened, perhaps by a future recession?”

He also commented on the broad lack of knowledge about behavioral health among many medical professionals. “It’s not a new problem, that behavioral health isn’t well understood.” But he reassured conference participants saying, “Stick with it. I believe that behavioral health is one of the levers that the system much have to provide better care and lower costs. Your time will come,” he asserted, “maybe faster than you think.”

He cites an example: “If a diabetic with depression costs more to care for than one without depression, you’ll be noticed,” he says. As ACOs come into operation under a system of bundled payments, Berwick said they will be “quick to make you part of the equation.”

In other segments of his talk, Berwick envisioned two courses for the future of American healthcare. Though changes over the past 18 months, subsequent to passage of the Affordable Care Act, have been many, they are just phase one of the evolution of the healthcare system under the ACA, he says.

Phase one, expanding access to coverage, is just the first phase of the process. Phase two is where the action is, he explains, the steps needed to make phase one effective by actually improving care. He sees phase two evolving in several interconnected parts:

• Providing better care
• Delivering better overall health, and
• Providing that health at a lower cost·

While there are many proposals that involve reducing the cost of care, Berwick Is firmly against those would do so by “withholding care.” The ACA is a remarkable piece of legislation. It’s like discovering a huge tool set that can be used to shape the healthcare system in any way that we want.”

The use of those tools can pursue one of two paths. The country faces a choice between two strategies, he says. One way maintains that we would get costs under control by taking away, but cutting benefits, restricting access, or narrowing the focus of care. There are a lot of proposals that would deal with it in this way,” says Berwick. “While I think that approach is wrong, from a policy standpoint, you’ve got to have a counterproposal.”

Berwick favors a strategy that he says “would change the way that we do the work.” He maintains that “cutting costs by withholding care is bad, and, it’s unnecessary if we change the way that we do the work.”

Berwick asked the conference to “think for a moment about that change. It’s the kind of change that no one stakeholder—no single leader—can make. It’s something that we’ve got to do together.” He recognized behavioral health professionals as “critical to the process. You’re a pathway to care and CMS’ job is to make it feasible and attractive for you and other healthcare professionals to achieve the three goals.” CMS’ approach, he says, “is to ask of every policy, how will it support, or impede part of this effort—to provide better care, better health at a lower cost.”

Vital changes and innovations in care are now being pursued through many channels, says Berwick:

• The center for Medicare and Medicaid Innovation, funded with $10 billion over the next decade, is charged with fostering innovations in the organization and delivery of patient care. “This center has the authority to develop “all sorts of innovations in care coordination and community health.”
   
• “Dual eligible” beneficiaries—the 9.2 million Americans who suffer from combined mental health/medical diagnoses that account for some 40 percent of all state Medicaid spending. Of these, Berwick says that “maybe only 100,000 are in circumstances of properly coordinated care.” Expanding the prevalence of such care is critical to major cost savings and care improvements for this group.
   
• Development of medical homes, which are essential to shortening the length and complexity of the “journey through care” by reducing the handoffs between care providers.
   
• The new “partnerships for patients” program, which seeks to cut the relatively high rates of medical injuries and preventable errors by 40 percent by 2013. This program, he says, could result in $35 billion in savings in the near future. This would be just the down payment on the more than $100 billion in change-driven care savings that Berwick believes are possible.

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