Friday, March 28, 2008

The Medicare Trust Fund: Problems and Non-Solutions

The Disease Management Care Blog has been reading about the Federal Government’s indolent cherry blossom-induced somnambulism over the downward spiral of the Medicare trust fund. But do not fret, present and future beneficiaries, because the same folks that brought you the Medicare Health Support imbroglio have ridden to the rescue with a press release outlining their recommendations for meaningful reform:
  • ‘Basing payment levels on provider reports on quality and their ability to prevent costly and life-threatening hospital acquired infections’

Hospital acquired infections include but are not limited to line sepsis, ventilator associated pneumonia, pseudomembranous colitis and surgical incisions. The latter probably get the most attention. One good study found the rate of these could be reduced from just under 4% to 0.6% with the administration of properly timed antibiotics. Don’t get me wrong, any avoidable infection is one too many, but I’m not sure the economics of making 99.5% vs. 96 % is all that compelling in the big picture.

  • ‘Providing transparent quality and cost information to beneficiaries and providers;’

With all this attention on evidence-based medicine, where is the evidence that this really works? Here's a report that casts doubt on the notion that patients use publicly available quality information in choosing one hospital versus another. As for the providers, skepticism abounds. I once presented a hospital’s Medicare data at a Grand Rounds at an academic medical center and was met with incredulity. I was also not invited back.

  • ‘Developing and testing strategies to pay more for better results rather than more services;’

The hospital P4P data is still young, but what information exists in the peer review literature suggests that the gains are modest at best.

  • ‘Implementing competitive bidding approaches to the delivery of care;’

The DMCB heard of this at a policy conference years ago and it makes sense. Note that the latest example of competitive programmatic bidding in the Medicare program was Medicare Health Support. If it’s good enough for Healthways, the DMCB figures it must be good enough for the nation’s hospitals.

  • ‘Promoting the adoption of interoperable health information technology;’

The DMCB doubts this is as big a money saver as many seem to think. It is not alone.

  • ‘Implementing reductions in market basket rates of growth, as proposed in the President’s 2009 Budget, including a proposed 0.4 percent reduction in the growth rate of Medicare payments if Congress does not pass a specific alternative proposal to achieve needed improvements in sustainability; ‘

Do not worry my fellow physicians. Pending the eventual discovery of MedPAC that there is a problem, other revenue opportunities include concierge medicine, botox parties, tattoo removal, depiliation, internet medication prescribing, personal wellness coaching, IT based virtual care, circuit riding around the country to testify in malpractice cases, and taxi driving.

  • ‘Increasing the share of program costs paid by the highest-income beneficiaries, as proposed in the 2009 Budget.’

So in other words, we each pay different amounts for the same health insurance benefit. In the opinion of the DMCB, that’s not a problem if the lowest income beneficiaries get their money’s worth, let alone mine.

But the DMCB won’t stop there. Notably absent was any mention of increasing the role of primary care physicians, determining how the chronic care model may address the health care needs of the costliest Medicare beneficiaries and – of course – capitalizing on the latest generation disease management programs that are being relied on by the majority of nation’s commercial insurers. Last but not least, how about using the Medicare Health Support program to find what works - and what doesn't

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