Medicaid's "cumbersome" policies often lead to patients not getting or filling their prescriptions, receiving important diagnostic tests, or managing their chronic disease, which will lead to more costs down the road, according to a new report released by the Association for Community Affiliated Plans.

The Medicaid system, which varies by state, requires beneficiaries to show proof more than once a year that they and their children are still eligible for the public program. This leads to many falling off the rolls, which is a cycle that interrupts their continuity of care and jeopardizes their health.

Additionally, with so many people "churning," which means dropping out and back in to the Medicaid rolls every few months, the federal goal of measuring the quality of the patient care has become extremely problematic if not impossible, according to the group, which represents 42 nonprofit safety-net health plans serving six million beneficiaries in 23 states.

The Association for Community Affiliated Plans proposes that Congress pass a "Medicaid Continuous Quality Act," which would establish 12-month continuous eligibility, similar to most private health plans throughout the country.

While such a policy change would be more expensive, it would have economies of scale, the report said. For example, an adult enrolled for just one month in 2006 had an estimated average expenditure of $625 that month; someone enrolled six months had expenditures per month at $469; and an individual enrolled for a year had a monthly cost of $333.

One reason for the reduction, the report said, is that with more continuous coverage, patients receive more preventive and primary medical care reducing the need for more expensive hospitalization. Another reason is that some uninsured people join Medicaid at their most needy time, because they are ill, but their need for care "becomes less acute after those initial needs are addressed," the report said.

The 30-page study, "Improving Medicaid's Continuity of Coverage and Quality of Care," was prepared by Leighton Ku and colleagues from the George Washington University Department of Health Policy. It was based on statistics from the 2006 Medical Expenditure Panel Survey conducted by the federal Agency for Healthcare Research and Quality.

Under current practice, the report estimated, Medicaid will cover 68 million people during the course of this year, but 13 million will not be enrolled in any given month mainly because their eligibility expired and they did not have a chance or the means to renew it. That results in lowered payments from the state and federal government to the providers and plans, whose officials say that administratively, getting those people eventually re-enrolled becomes an even bigger administrative and costly headache.

Officials from several health plans said creating policies that provoke churning is a common practice in states that are trying to reduce costs. "States use the redetermination process to save money in times of tight budgets," says Elaine Batchlor, MD, chief medical officer for LA Care, a Medicaid plan that has 750,000 members. "They tend to increase the frequency of redetermination; that's one way to decrease the number of people covered."

Even some states that have a 12-month continuous eligibility policy may throw roadblocks into the process by requiring periodic reporting of income, residency or other data, on a more frequent basis, "so the person may lose coverage after, say, three months if she fails to submit a periodic report in time," the report said.

The renewal process, originally designed to prevent welfare fraud, has become too complicated and difficult, the report said. For example, some states require in-person renewal rather than recertification online, by e-mail, regular mail, or over the phone.  Requirements may include documentation of income, assets, and residency. Often, low-income people have difficulties meeting these requirements additionally because they have unstable living situations and don't receive renewal notices on time, have unstable unemployment, or limited literacy or English comprehension, the report said.

Margaret Murray, chief executive officer for ACAP, notes that the process may cost providers and plans another $180 for each enrollee who temporarily falls off the rolls. The amount may seem small, but can add up quickly. "This is an issue that is integral to the health reform debate," she says.

"Because of the complex administrative processes, families often do not know when their Medicaid certification periods expire, maybe dropped without knowing it, and do not know why they lost coverage," the report says.

Georganne Chapin, president and CEO of Hudson Health Plan of New York, with 90,000 Medicaid enrollees, gave an example. "Even one month of missed eligibility can be devastating," she says. For example, a patient who is in Medicare for nine months, but doesn't renew and misses one month "doesn't take her blood pressure medication. She has a stroke, one she's never coming back from."

The report lists those with the best coverage continuity policies as Arkansas, Connecticut, the District of Columbia, Hawaii, and Louisiana, while the worst were Florida, Georgia, Kansas, Montana, and Nevada.

Continuity of coverage also depends on other factors. The average Medicaid enrollee was covered about 78% of the year, but those who are blind and disabled were covered at 90%, and those who were disabled were covered at 82%, presumably because they were on a fixed income. Children were covered at 80%. But non-elderly, non-disabled adults had the worst coverage period, about 68%, according to the report.

Serious health problems can result from even brief interruptions in care for people with diabetes, asthma, and chronic obstructive pulmonary disease, which require regular use of medications, such as steroid inhalers. Without those drugs, patients may need acute hospitalization.

According to an article in a 2005 edition of the journal Cancer, patients with breast and cervical cancer who were enrolled in Medicaid for longer periods of time had less severe cancers than those enrolled for shorter periods, perhaps because their disease was caught earlier in its progression.

Interruptions in Medicaid coverage are also associated with the greater use of expensive, inpatient psychiatric services and higher psychiatric costs, while those with more continuous coverage required shorter and less expensive behavioral health treatment.

LA Care's Bachelor said that not having continuity policies defeat the federal government's goal to keep track of people's chronic conditions. "When they're churning, it takes them time to get reconnected when they do come back to the system, and by then, they may even get a different (patient) number, don't live at the same address, and have a different phone number."

"For a commercial health plan, it costs money to build a disease management plan. And you might have some commercial plans saying it's not worth creating these plans because, they realize, [because of churning] 'we won't have a large enough cohort two years from now.'"

In addition to establishing a Medicaid Continuous Quality Act that would require states to provide 12-month continuous eligibility to child, adult, aged, blind, and disabled enrollees, the report recommends these other actions to improve Medicaid care:

• Establish a performance-based bonus payment system for states that enhance retention


• Provide matching funds for electronic data sharing


• Expand the scope of Medicaid Quality reporting comparisons

Massachusetts-based doctors, professors, entrepreneurs, and hospital IT experts are using $20 billion of stimulus money to help shape the electronic medical record landscape for the country as a whole. According to John Halamka, chief information officer at CareGroup Healthcare System, "The average use of EMRs in the U.S. is between 2 and 20%. In Massachusetts, we're somewhere between 30 and 50%, so we've had a fair degree of experience with what works and what doesn't work."

A survey of nurses from all over the globe has found that nurses believe heavy workloads, coupled with insufficient staff, are impacting patient care and outcomes.

The International Council of Nurses and Pfizer Inc. External Medical Affairs collaborated on the survey of 2,203 nurses in 11 countries, including Brazil, Canada, Colombia, Japan, Kenya, Portugal, South Africa, Taiwan, Uganda, the UK, and the United States.

Most significantly, the survey found that 92% of respondents face time constraints that prevent them spending necessary time with individual patients. In addition, 96% said that spending more time with individual patients would have a significant impact on patient health.

"Nurses are key patient advocates and have always been patient-focused," said Paula DeCola, RN, from the office of the Chief Medical Officer at Pfizer, Inc. External Medical Affairs, in a statement. "The research shows that for nurses, the most favorable aspect of their profession is indeed patient contact."

Other key findings of the survey include:

• Nearly half of nurses (46%) say their workload is worse today compared to five years ago
• The nurses surveyed were most concerned with heavy workloads (42%), insufficient pay and benefits (22%), a lack of recognition for their work (15%), and too much bureaucracy (13%).
• Nursing as a career is viewed as worse today than it was five years ago in Canada (52%), the U.S. (46%), Taiwan (45%), and the UK (39%). But nurses in Kenya (71%), Brazil (64%), and South Africa (63%) were more likely to see their roles improving over this time.
• When asked to rate the likelihood they will still practice nursing in five years, 53% say it is "very likely." However, the commitment varies by country: Nurses in Portugal (77%), Brazil (75%), Canada (71%), and the U.S. (68%) say they are very likely to stay in nursing for the next five years, while nurses in Kenya (38%), South Africa (33%), Taiwan (33%), and Uganda (32%), say they are less likely to do so.

The survey also found that nurses would like to expand their healthcare responsibilities, including the authority to prescribe medicines to patients. Eight in ten (83%) nurses surveyed say they currently do not have the authority to prescribe medicines to patients, but seven in ten (70%) say they want nurses to have this authority. Nurses in Colombia (61%), the U.S. (59%) and Taiwan (57%) are most likely to oppose nurses having this authority, while those in Kenya (94%), the UK (87%), Canada (87%), Uganda (84%), and South Africa (83%) are most in favor of it.

The research shows that having greater independence and control over their practice area, sufficient staff, greater involvement in decisions impacting their work and patient care, and improved work-life balance have a significant impact on the likelihood that nurses from across the globe will remain in nursing, according to the survey authors.

And, they added, that is important as countries all over the world struggle to provide quality care to all patients. Displeased nurses fleeing the system could have disastrous effects on a country's healthcare. Nurses represent the largest group of healthcare providers in the world, which is why ICN Chief Executive Officer David Benton said that it is urgent to respond to their needs with adequate staffing, greater independence, and greater involvement in decision-making.

"Nurses globally are thinking about leaving the profession, which will further impact already burdened healthcare systems, including in countries such as Kenya, Uganda and South Africa," Benton said in a statement.

How does healthcare create more engaged nurses? Benton has this idea: "Nurses must be involved in crucial policy conversations as healthcare systems are growing, developing and changing."