Medicare

EVENT: Today - Making Medicare Sustainable

Joanne Kenen — Wed, 23 Jul 2008 11:50:00 -0400

The New America health team will be over at the Capitol Hilton today for our event, "Making Medicare Sustainable: Transforming Our Health Program for America's Seniors." The day-long session will launch our Medicare Reform Project. Rising health care costs and retiring baby boomers will make improving and sustaining Medicare a salient issue during the next president's first term. Medicare needs to become a smarter purchaser (and wiser utilizer) of health care. Join us and hear top academics, physicians, economists, legislators, and policy experts from across the ideological spectrum discuss how that can happen.

Not sure whether we'll be able to live blog it. If not, we'll try to post quickly, and we'll put up a link to a webcast (probably on Friday).

In the meantime, since your bloggers won't be around to attract your attention for at least part of the day check out this Colbert Report interview with Elizabeth Edwards (it's a week old, but we got a bit behind on our satire...)

REFORM: Project Medicare Reform Ready for Runway

Paul Testa — Fri, 18 Jul 2008 16:59:00 -0400

As our colleague Elizabeth Carpenter would say, it's like Fashion Week in Bryant Park for health wonks when a new MedPAC report comes out. We blogged extensively about the Commission's recent proposals for reforming the delivery system (here, here, here, and here).Today MedPAC released its June Data Book, filled with pages of glossy charts and helpful insights.

Our personal favorite: Chart 1-10 below. Medicare payment is organized in a way that focuses on the delivery of acute care services. However, as this chart and its description show, the great majority of spending is concentrated among a relatively few beneficiaries—many with multiple chronic conditions. Like a fierce outfit, treating these conditions requires coordination. Yet, Medicare currently provides little incentive towards the coordination of care, which is vital to improving beneficiary health and reducing cost to the taxpayers. Both are vital if Medicare is to be a worthwhile health insurance program and fiscally sustainable.

Of course, why read about Medicare reform in the magazines when you could see the real thing at next Wednesday's event "Making Medicare Sustainable: Transforming Our Health Program for America's Seniors," hosted by Len Nichols, Director of New America's Health Policy Program and Robert Berenson, MD, Senior Fellow at the Urban Institute.

The event will feature commissioned works and insightful commentary from some of the hottest names in Medicare reform. In fashion one day you're in, and the next you're out, but don't worry, you can guarantee a spot at the event by RSVPing here. You won't want to miss it, because when it comes to Medicare, there's only one thing to say: Make it work.

EVENT: Making Medicare Sustainable - July 23

Tom Emswiler — Wed, 16 Jul 2008 14:00:00 -0400

We want to encourage our readers to attend our big event next Wednesday, July 23, titled "Making Medicare Sustainable: Transforming Our Health Program for America's Seniors." It will be hosted by Len Nichols, Director of New America's Health Policy Program and Robert Berenson, MD, Senior Fellow at the Urban Institute. (Dr. Berenson has also guest blogged for us in the past.)

This day-long event will be the launching pad for our Medicare Reform Project. As you've probably heard us (and others) discuss, rising health care costs and retiring baby boomers will make improving and sustaining Medicare a salient issue during the next president's first term. To respond to these challenges, Medicare needs to become a smarter purchaser (and wiser utilizer) of health care. How can that happen?

The event will focus on recently commissioned policy papers that offer solutions for making Medicare more affordable and sustainable. Drs. Nichols and Berenson will be joined by top academics, including nationally recognized physicians, economists, legislators, as well as leading policy experts from across the ideological spectrum.

Please consider joining us for what we hope will be a thoughtful conversation. To view more details or to RSVP, click here.

REFORM: Fixing Medicare Could Help Us All

Joanne Kenen — Wed, 02 Jul 2008 20:32:00 -0400

We all know Medicare has problems. What you may not know is that we really do know a fair amount about how to fix it—and part of the solution has to do with changing the kind of medicine we use to take care of our over-65 population. Inside E Street, an AARP television production, (click here to watch—and you don't have to be 50 to learn something from it) invited several experts including New America's health policy program director Len Nichols to brainstorm.

Among the suggestions: use technology not only to keep better medical records that help doctors coordinate care across several specialists, but also to take better care of people at home. We have the means—and we'll develop more in coming years—to monitor people at home, and know when and how to intervene before a crisis develops in a patient with conditions like diabetes or congestive heart failure.

Len reminds us that Medicare can be a catalyst because the program has so much influence over the whole health sector. So fixing Medicare is good for all of us—not just because of the economic implications but because by getting care right for the elderly we can probably improve health for us all.

REFORM: Good Grief! Seeking MedPAC's Advice on Primary Care

Paul Testa — Tue, 24 Jun 2008 12:43:00 -0400

Lucy van Pelt used to charge five cents for advice. That's peanuts compared to what some patients will pay today for the services of "health care advocates," according to the Boston Globe. And although the intent is to help people navigate the system, their very existence illustates some of that system's biggest problems.

These firms specialize in coordinating a patient's care and helping them navigate our complex and often overwhelming health care system. What doctors to see, what treatments to seek, where to go with an emergency at 3:00 a.m.—they'll answer all your questions—for a price that can range from $150 an hour to $100,000 a year.

Advice on treatment options, disease management and the coordination of care can take many shapes and forms, but, arguably many of the services provided by these health care advocates, in an ideal world, should be provided by a patient's primary care doctor. Yet, one of the people interviewed for the Globe article said he called his advocate because he didn't want to bother his primary care doctor with routine questions. Having someone to answer your routine questions, to know when there's something bigger at stake, is part of why we need a primary care doctor in the first place! But our current system is set up so that all too often it obstructs rather than encourages such relationships, which are the foundation of health care. These firms, in contrast, are adding another layer of care—and only for people who can afford the fees.

We get what we pay for in health care, and right now we're paying primary care doctors to squeeze in 15 minutes (or less) with as many patients as possible. In its June report to Congress on Reforming the Delivery System, MedPAC made extensive recommendations addressing payment reform, comparative effectiveness, and, yes, primary care.

The report stresses the importance of primary care to the delivery of efficient, high-quality care. The two main recommendations are simple but needed:

Pay primary care physicians smarter. Medicare's reimbursement schedules are more byzantine than Constantine the Great. The basics of evaluation and management—the bread and butter of primary care—are undervalued relative to more intensive procedures like heart surgery because the fee-for-service payment is based on the manual difficulty of completing a medical service. When a heart surgeon becomes more efficient, he or she can perform more operations with fewer complications and is paid more because the volume of cases increases. But this fee-for-service system produces perverse results in primary care. The emphasis should be on education, coordination and management of complex disease—but doctors just aren't paid for putting in the time required to do those tasks right. Instead, they're paid (not much) by the visit. MedPAC proposes adjusting payments in a budget-neutral manner to more accurately reflect the value of primary care. Done correctly, it could allow primary care doctors to spend more time with patients doing the things some are now having contracted out.
Demonstrate the value and viability of a medical home model of care. A medical home coordinates a patient's care, including prevention and chronic disease management. Generally built around primary care doctors, a medical home can also incorporate specialists (like endocrinologists for diabetes). MedPAC also lays out some of the conditions it sees as the foundations of medical home model, including: pay for performance, health IT, and 24/7 access. Framing the proposal in terms of a pilot project—which unlike a Medicare demonstration project does not have to be revenue neutral and can be used to set payment policy—shows how serious the report's authors are about the potential value of a medical home.

We aren't criticizing individuals who go out and purchase something they think their family needs. But it really isn't an answer to the problems in our health care systems; problems which can be addressed by more and better primary care, more integrated delivery systems, and a payment system that rewards coordination instead of fragmentation. More sustainable reform, components of which MedPAC has laid out for us, would change the incentives of our current system so that primary care doctors are paid more for managing their patients' health. And that's something even good ol' Charlie Brown—and maybe even Lucy—could be happy about.

REFORM: How "Bundling" Can Save Us a Bundle

Guy Clifton M.D. — Fri, 20 Jun 2008 15:41:00 -0400

As promised, more on MedPAC. This post focuses on the Medicare Payment Advisory Commission's ideas on changing the way we pay doctors and hospitals.

As a physician, I'm impressed by the June 2008 MedPAC report because it's truly a comprehensive rethinking of how to reform health care finance and delivery in the United States. Prior MedPAC reports have recommended measures to improve quality such as paying doctors and hospitals for performance, usually with a few percent bonus for good results; correcting imbalances in the fee-for-service payment system; or reporting the rates at which doctors and hospitals use certain services. Those pay-for-performance programs have improved the quality of care in many hospitals. But they certainly have not reduced the cost of care, which as numerous researchers have shown varies wildly among individual hospitals, individual doctors, and U.S. regions.

This report recognizes the central fact of reforming the delivery of medical care: It can't be done as long as doctors and hospitals are paid through the traditional fee-for-service system. Because in that system, doctors and hospitals are basically paid by the piece. The higher the volume of services provided, the greater the revenues. If fees are cut, doctors increase their volume to make up for the lost revenues.

Medicare pays hospitals by Diagnostic Related Groups (DRGs). Hospitals are paid more for patients who have complications at discharge, even if those complications are hospital-acquired. In a significant change, Medicare is now refusing to pay for some preventable hospital-acquired complications or errors, known as "never events." But if a patient has multiple complications, as is common, the hospital is still paid more for them. (Incidentally, the Boston Globe reported this week that Massachusetts' state health programs aren't going to pay for certain preventable conditions identified by the National Quality Forum. According to the Globe, it's the first state to take such a step.)

The MedPAC report calls for something new. It recognizes that under the current system, hospitals have few financial incentives to reduce complications and shorten length of stay. MedPAC proposes "bundling" payments of doctors and hospitals for one episode of care. (The report acknowledges that the details of how to divvy up those payments are complex and will require some experimentation.) This arrangement will mean that efficient doctors will be worth more to a hospital than inefficient doctors; and it follows that efficient doctors, providing quality care, will be paid more. MedPAC recognizes the difficulty of pricing a bundled episode. For elective hospital admissions, such as non-emergency surgery, it will probably be straightforward because the patterns of response to surgery are usually predictable. For emergencies, however, the hospital course is less predictable. Quite a bit of work will be required to get the price points right, but all in all, this is a far-sighted report that gets straight to the issue of the perverse payment incentives in fee-for-service medicine and offers a pathway forward.

REFORM: MedPAC Says Sustainability and Quality Mean New Approaches

Joanne Kenen — Mon, 16 Jun 2008 17:26:00 -0400

MedPAC's big June report is out, and it's full of big June ideas. Really big ideas. The panel, which advises Congress on Medicare policy, outlines (not all for the first time, but more emphatically and comprehensively) a lot of ideas for changing a lot more than technical fixes to fee scales and payment rates. MedPAC is ready for the whole enchilada (or whatever the geriatric equivalent would be. Chicken dumplings?) in reshaping the system so that it is both higher quality and more cost-effective. The nonpartisan panel of experts wrote:

Fundamental changes are needed in health care delivery in the United States and in Medicare. ... Recent studies show that the U.S. health care system is not buying enough of the recommended care, is buying too much unnecessary care, and is paying prices that are very high, resulting in a system that costs significantly more per capita than in any other country.

Medicare does more than take care of the elderly and disabled. It sets patterns and models for much of the U.S. medical system, affecting how hospitals function and doctors practice. It also costs a lot. The commissioners stated further:

Without change, the Medicare program is fiscally unsustainable over the long term. Moderating projected spending trends requires fundamental reforms in payment and delivery systems to improve quality, coordinate care, and reduce cost growth.

In the coming days, we'll delve more deeply into aspects of the report. But here are five points that struck us as particularly integral to getting away from a system that has evolved so that it too often rewards the quantity of care, rather than the quality.

1) Comparative effectiveness. MedPAC last year urged Congress to create an independent entity to figure out which drugs, procedures, devices, surgeries, etc. work best, and which don't work so well—or at all. MedPAC goes into more detail this year on the pros and cons of various models, but it stresses that that oversight should be independent and funding should be broad-based, "from federal and private sources because the research findings will benefit all users—patients, providers, private health plans, and federal health programs."

2) Medical home pilot project. A medical home coordinates a patient's care, including prevention and chronic disease management. It is centered around primary care doctors, but specialists can be part of it— notably, endocrinologists for diabetes. It's accessible when the patient needs it (not just 9:00 to 5:00, or else head to the nearest emergency room). Payments would be based on how well overall care is managed, not just how many services or procedures a patient gets. Requirements for the pilot program include using health information technology for clinical decision making, as well as up-to-date records of advanced directives.

3) Bundling and readmissions. We hear a lot of talk about shocking medical errors, but we pay less attention to all the things that can go wrong when patients transition from one setting to another, ie. a frail elderly person who has been severely ill in the hospital returning home, or transitioning between a nursing home and a hospital. One step MedPAC recommends (and it would be phased in during several years after hospitals are given the necessary data and feedback) is reducing what Medicare pays to hospitals with high readmission rates for certain conditions. Another is to "bundle" payments. That is going to require a lot of experimentation to get right, but the idea is instead of paying the hospital one chunk of money for inpatient care, and then paying for a lot of other doctors and tests and procedures in and out of the hospital related to the same illness, there would be one comprehensive payment (pilot projects and experimentation will be necessary to determine exactly how that will be divvied up).

4) More primary care. As MedPAC notes, raising payments for primary care won't address all the reasons (including lifestyle and status) that young docs choose high-paying, high-volume specialties instead of internal medicine, family medicine, geriatrics, and the like. But money can help. MedPAC also looks at how to draw on the cost-effective primary care expertise of advanced practice nurses and physicians assistants.

5 ) Disclosure. Hardly a day goes by (see this recent Boston Globe story about a Harvard psychiatrist) when we don't hear of another doctor or research team that was getting more money than we realized from a drug or device manufacturer. MedPAC wants more disclosure and public reporting. (Hmm. Do you think they can figure out a way of getting them to donate those payments to finance comparative effectiveness??? ) MedPAC outlines several mechanisms for greater transparency but notes, "payers, plans, patients, and the general public are often not aware of these potential conflicts of interest." They should be—sunlight is the best disinfectant.

POLITICS: Sometimes Health Reform Bills Do Pass...

Joanne Kenen — Tue, 13 May 2008 13:51:00 -0400

We've all done a lot of looking back to the lessons of 1993-94, and the long list of reasons the highly complex, ill-timed and politically-polarizing Clinton health care plan failed. But today the journal Health Affairs published an essay looking back not just at the failures of the Clinton plan but at the successful passage of two major health reform initiatives--the truly bipartisan State Children's Health Insurance Program (SCHIP) and the Medicare Modernization Act, which added prescription drug coverage for seniors.

The article, written by New America's Len Nichols, and Hill veterans Elizabeth Fowler and Christine Ferguson, acknowledges that the drug law remains controversial--a lot of Democrats don't like the basic structure of the drug benefit, and parties are still fighting about payments and changes the law makes to the overall Medicare program. But enough Democrats did back the legislation to see it enacted (barely), and some of them today acknowledge that even if it isn't the bill they would have written, even if they want to change some of it, it is helping seniors get their medication. The authors cite several reasons for its passage. Among them: President Bush took a hands-off approach to the details, letting Congress do its job of legislating. Republican Congressional leaders enforced party discipline so they held together to pass legislation that would help them politically. And, in the several years that lawmakers worked on the issue the two parties' models for delivering the drug benefit evolved to have at least some common ground.

The children's health program has been widely perceived as a bipartisan success from the outset. Clinton backed it, but Congress led the initiatve from the start. "The episode illustrates exemplary congressional leadership, a lack of partisanship, and a president leaving details to Congress while championing the basic goal and message of expanding coverage for low-income children."

Not so, however, for the second chapter of SCHIP, last year's reauthorization battle and Bush's veto. In that case, Bush rejected a bipartisan Congressional initiative and Republicans split among themselves, with the more conservative ones winning the day.

The authors conclude with three lessons (or wishes?) for next year.

Make health reform the top priority.
Be leaders, not partisans.
Develop a broad consensus, but leave the details to Congress.

Hope the folks on both ends of Pennsylvania Avenue next year, whoever they may be, are listening.

A Quick Thanks for Mother's Day

David Gray — Fri, 09 May 2008 17:21:00 -0400

This Sunday we honor the 83 million moms in America on Mother’s Day. We owe our Moms our lives and our thanks. Mother’s Day also turns our attention to our children and the need for more focus on them. Unfortunately, families with children receive a dwindling share for federal expenditures. Scholars Eugene Steuerle and Adam Carasso have found that between 1960 and 2005, federal spending on children declined from 20.1 percent of the domestic budget to just 15.4 percent, while non-child Social Security, Medicare, and Medicaid spending soared from 22.1 percent to 45.9 percent. This is not good for the development of our future generation.

It is within families that many Americans find the support and love to live their lives with joy. Many Americans work increasingly hard and it is within families that they experience unconditional love and support in times of trouble. For couples that do not have children, nuclear and extended families provide critical emotional support. In a variety of emotional and psychological ways, families enhance the lives of millions of Americans. And through children, mothers help ensure our future.

Let’s thank our mothers for all they do to make our families what they are.

Let’s let Mother’s Day be a wake-up call for us to invest more in our children.

Rev. Gray directs the New America Foundation’s Workforce and Family Program.

QUALITY: Medicare Seeks to Add to "Never Event" List

Joanne Kenen — Tue, 15 Apr 2008 15:16:00 -0400

You know those signs in gift shops, "You break, You pay?" Medicare has adopted that philosophy in refusing to pay hospitals for "never events"—things that just shouldn't happen to patients. Now the agency has proposed adding to its list.

Last year Medicare announced it would not pay for certain medical errors and conditions acquired in hospitals. Starting October 1, several private insurers followed suit. Now Medicare wants to add nine more avoidable conditions and complications, if acquired in the hospital. The goal, which we like, is to put some financial teeth in efforts to improve care of patients, including infection control. Hospitals should not be dangerous to our health.

According to the AP, the new list includes deep vein thrombosis, or a blood clot within the vascular system, which occurred in 140,010 cases for the fiscal year ending September 30, ventilator-associated pneumonia, which occurred in 30,867 cases, bloodstream infections with the staph aureus bacteria, 27,737 cases, and Legionnaire's disease, which occurred in 351 cases.

The focus on hospital-acquired infection has been slowly building since the Institute of Medicine in 1999 concluded that medical errors, including hospital-acquired conditions, caused up to 98,000 deaths annually. Congress in 2006 gave the Centers for Medicare and Medicaid Services the ability to deny payment for extra treatment costs arising from preventable conditions during a hospital stay.

Hospitals now have to report on 30 measures designed to assess quality of care. Medicare is proposing to add 43 new measures to the list. Payment increases are linked to quality reports, and the information is also shared with consumers on the Medicare web site. So maybe the slogan should be updated— "You Break, You Pay. We Tell."