‘Increased Medicaid access does not equal quality care,’ Guam doctor says

 By Jayvee Vallejera

Simply giving tax incentives to medical providers to encourage them to accept more Medicaid patients is not enough. Rather, the program itself needs a complete revamp, according to Dr. Thomas Shieh, an OB-GYN doctor and

longtime physician on Guam.

Thomas Shieh

In the testimony he provided on Bill 118-38, which would give tax discounts to medical clinics that serve Medicaid patients in Guam, Shieh said a wide spectrum of strategies can be implemented to achieve the goal of expanding the number of people who benefit from Medicaid, but just giving tax discounts to medical providers just “feeds into the profit-making side of medicine.”

Bill 118-38, titled “Medicaid Access Enhancement Act,” seeks to make more health care providers accessible to Guam's Medicaid patients.

The bill’s author, Sen. Sabrina Salas Matanane, said clinics serving Medicaid patients would be entitled to tax discounts. This, she said, would address the root cause of provider hesitancy to take on Medicaid patients due to low Medicaid reimbursement rates.

About 30,000 Guamanians are enrolled in Medicaid, accounting for nearly 20 percent of Guam’s population—a majority of whom fall in the low-income bracket.

Unlike Medicare, which primarily helps cover the healthcare costs of those who are 65 years old or older or those with certain disabilities, Medicaid assists low-income individuals and families, regardless of age. Both are federally funded.

Shieh, who has been in Guam for over 28 years, said the bill’s finding and intent about the lack of availability and accessibility of Medicaid services in Guam is spot on.

“Medicaid consumes a large share of the government’s budget, but access to quality care remains stagnant, especially for pregnant women,” he said.

The bill blames many factors for this, including not having enough healthcare providers willing to accept Medicaid patients, limited healthcare providers servicing the Medicaid population, and limited locations for Medicaid services across Guam.

However, Shieh believes that simply addressing the Medicaid population won’t solve a bigger problem.

He pointed out that even people with private insurance struggle with access to quality care, he added.

Citing the bill’s own findings, he said about 20 percent of Guam’s population has been covered by Medicaid over the decades. That only means, Shieh said, that 80 percent of the island’s population either must pay for their private insurance or go without coverage.

“Although the federal government provides latitude to each state and territory to deviate from federal law in providing amendments to [Medicaid], one does not have that luxury for the 80 percent of the rest of Guam’s population. Be that as it may, [Medicaid] on Guam needs to be completely revamped,” he said.

This lack of access, Shieh said, is tied to the quality of care that Medicaid patients in Guam receive, which is why he believes expanding access is only one part of what needs to be put in place in order to provide better health outcomes for Guam patients.

This can be done if Guam adopts a variety of ways to increase access to quality care that is not just focused on access.

“One does not translate to the other,” he said.

A possible way to do this is through performance reimbursements linking quality and efficiency of care to incentives for good-quality outcomes, Shieh said.

That means good results will result in incentives. The incentives need not be just cash, he said, but possible help with the administrative side of providing quality care.

“To provide monetary incentives without a link to determine quality outcomes will just be [money] wasted, regardless of an increase in access,” he said.

Shieh said an increase in the quality of care and performance is key, because just expanding access to medical care but not ensuring quality of care will not help the people at all.

Ensuring the accuracy of data collected on patient care is a must, Shieh said, to know if a patient did receive the quality of care they deserve and demand transparency.

Without it, if you only look at access, you won’t improve the health of this population, he added.

He also suggests a private-public partnership that he said works in other states. “In fact, it worked so well that almost all healthcare providers accept Medicaid with this partnership,” he added.

He said a private–public partnership will save on costs and reduce the load on government employees because it will be the private sector that will be doing the quality assessments.

Now if Guam doesn’t want a private–public partnership, or that can’t be achieved, it could implement a pay-for-performance model, he said.

He pointed out that one of the worst costs to Guam is bad birth outcomes, not the lack of access. This is where a pay-for-performance model could work.

One can argue that getting care is better than no care at all, but if there is no medical accountability for that care, then having access is moot, he said.

“Having access does not mean you will receive quality care,” he added.

He also suggests pressing Guam’s Department of Public Health and Medicaid to improve efficiency and their access, increasing and leveraging technology innovations, allowing telehealth to expand and resolving disparities in healthcare.

“You want to increase access to quality care? Don’t be so narrow-sighted on Medicaid only, because the majority on Guam are without Medicaid and they are also struggling with a lack of access to quality medical care,” he added.

On the part of Medicaid beneficiaries, Shieh wants them to take responsibility for their actions.

For example, those who can work should show proof that they have applied for and are looking for jobs. Smokers and alcohol drinkers should enroll in substance use and abuse reduction programs.

“The patients must be held accountable for their personal responsibility—from qualification for coverage to bettering their personal health,” he said.