by Jaan Sidorov

First posted on Disease Management Care Blog 3/5/2014

Dr. Jaan Sidorov, host of Disease Management Care Blog

Dr. Jaan Sidorov, host of Disease Management Care Blog

Kudos to the New England Journal for providing a tidy summary of the latest Republican healthcare reform proposal. Up until now, the Population Health/Disease Management Care Blog was only vaguely aware of the GOP’s evolution from the political party of “no” to one of “go,” albeit with lots of caveats.

It seems the Senate Republicans no longer want to repeal Obamacare and are OK with keeping many of its more popular reforms.  Instead, they’re focusing on undoing selected provisions, such as repealing the minimum benefit, letting some returning some aspects of medical underwriting and resurrecting the “block grant” approach for Medicaid.

But one of the more interesting wrinkles in the proposal is “auto-enrollment.”

Those of us from the bygone days of “disease management” may recall the debates over the merits of “opt-in” versus “opt out” participation in our programs.  The former required persons to actively chose to be entered into nurse coaching, which had the advantage of committing resources to a highly motivated population.  The latter approach assumed all patients with a condition were enrolled and, only if they specifically requested it, would they allowed to stop the coaching phone calls.  Unfortunately, “opt-out” usually gathered many patients who never answered the phone and were “engaged” in name only.

Well, the Republicans are apparently proposing that states be allowed to “auto-enroll” persons eligible for premium payment support into an insurance plan or Medicaid without their up-front permission,just like the old “opt-out” disease management days.  The tax credit would cover the insurance costs, no bills would be issued to the consumer and voilà! the risk pools would expand.  Patient choice would be preserved, because persons could always just say no.

The DMCB was always of fan of opt-in disease management.  Not only were patients who wanted to be in the program more amenable to behavior change, it allowed the program to “flex” the nurses that we needed as the program grew in scope.  However, when it comes to insurance, the DMCB thinks the Republicans may be onto something with their opt-out insurance approach.