Sunday, March 22, 2009

Reform Medicare. Appoint Guardians. Next?

The Disease Management Care Blog likes to check out what’s new over at the Health Affairs blog. It’s a good example of the emerging spread of traditional ink-based medical media into the blogsphere. While print publications still beat web posts in terms of prestige, the DMCB isn’t too sure that counts for much when timeliness is at stake. Apparently Bob Berenson and Len Nichols agree. With health care reform proceeding apace, they have a big incentive to let Health Affairs post a quickie cliff notes summary of their 199 page New America Foundation “Making Medicare Sustainable” report.

Knowing how busy readers are, the DMCB has created this even shorter cliff notes summary of the Health Affairs cliff notes. The DMCB also found and includes some other nuggets of interest:
  • It’s the costs of health care, not the lack of insurance coverage.

  • Change Medicare and everything else follows. Medicare leads the way.

  • Elimination of waste and inefficiency should take precedence over tax increases.

  • The path is clear: a) value-based purchasing in lieu of fee for service, b) physician accountability in lieu of routine payment, c) Congressional oversight and evidence-based coverage in lieu of micromanagement and wide physician leeway and finally d) driving a coherent policy in lieu of dealing with multiple agendas.

  • Value based purchasing is the use of multiple tools that lead to the right kind and mix of services, of desired quality, at a reasonable cost based on the total population’s needs instead of individual interventions aimed at individual diseases. Nugget: there is precious little in the original Medicare statute that prohibits value based purchasing. Rather, regulations that promote it have never been successfully promulgated.

  • In order for Medicare to take advantage of value based purchasing, it will need to be reformed.

  • One ingredient for reform: creation of a new “entity” that is insulated from day to day lobbying. It can free Medicare to strategically and tactically pursue value based purchasing with integrity and the public’s confidence.

  • Persons in the new entity are “Guardians” and they decide which coverage and pricing can be made by CMS and which can be made by Congress. Guardians are subject to Senate confirmation and have term limits. Nugget: Guardians” are selfless stewards of government modeled after Plato’s Republic.

  • And finally the original report points out that value based purchasing can include traditional disease management.


Get Off My Back said...

I agree with you that the biggest problem is Medicare itself. In fact, we have a Medicare-Medicaid crisis, not a health care crisis. Which means, in short, once the government gets involved in the overall health care service system, we're finished. That's when the real crisis begins.

Jaan Sidorov said...

While I'm sympathetic to Get Off's point of view, I recall that Medicare and Medicaid were created because the elderly and the economically disadvantaged pretty much shut out from accessing doctors and health care. When markets fail, government steps in. As a result, from the Big Picture point of view, government involvement has arguably been one of the crowning achievements of U.S. involvement in healthcare.

That being said, there are other problems. One approach is to harness markets, the other is to increase government involvement. The two aren't necessarily exclusive, and that's where the debate lies......