Would You Want To Do Business With Medicare Under These Two Scenarios?

The Disease Management Care Blog doesn't think so. It may be dating itself, but it recalls an original Star Trek episode that featured Harcourt Fenton Mudd. His shady promises proved to be part of a grand design concoted to serve Mudd's devious interests, and Mudd's interests alone.

So with that introduction, the DMCB found two other scenarios within the U.S. Senate Finance Committees' “policy options” that are under consideration as part of its healthcare reform efforts. Based on rosy interpretations of some existing science that are really tilted toward to the government’s advantage, they aren’t win-win, or even win-lose. They’re simply Mudd-like win.

‘Payment for Transitional Care Activities’ (page 10)

This would pay for ‘transitional care management’ for recently discharged beneficiaries with a chronic illness DRG, based on interventions that have ‘proven successful’ in the Medicare Coordinated Care Demonstration Program, the Medical Home and ‘other care management models.’ Physicians would be reimbursed for ‘in person’ activities performed by non-physician professionals within 30 days of discharge. Payment would be contingent on not being readmitted.

That may sound good except for one small problem: the Medicare Coordinated Care Demonstration hasn’t really proven to be successful. In addition, the reason the Medical Home has been slated for a demo is because we don’t know if that’s going to be successful either, especially when it comes to readmissions. Limiting payment to ‘in person’ activities is not only Neo-Luddite, it’s an example of there-you-go-again, here comes one-approach-fits-all Medicare. What, Medical Homes will not get credit for telephoning patients? Can they count on Medicare alerting them in a timely manner when a patient is discharged from the hospital? Since re-hospitalizations will never get to zero despite the best of care, the DMCB suspects the only winner in this payment methodology would be Harcourt Fenton Medicare.

‘Accountable Care Organizations (ACOs)’ (page 17)

Since the Physician Group Practice (PGP)Demo ‘showed promise,’ the option here would be to set up a mechanism in which groups of providers would aggregate into business units that would exist to a) meet quality thresholds and b) benefit from a 50% gainshare once savings get beyond a 2% baseline.

Recall, based this DMCB post about the PGP, that a grand total of two out of ten organizations received any money in the gainshare, though the Senate Finance policy paper says there were four. Hmmm, doing the math, that means the odds are against the average ACO provider group ever making any money on this. However, assuming that a 40% chance of payment from Medicare is an accepted business practice, keep in mind that the types of physician groups that participated in the PGP demo in the first place provide less than 1% of the entire healthcare in the U.S. But the lack of generalizability to the other 99% is not all: what is missing from this policy option is any mention of how the PGP groups relied on old-fashioned disease management. As the DMCB recalls, the groups in this demo were also stymied by the lack of data support from Medicare. Based on what the DMCB is reading, this is also very tilted toward Uncle Sam-Mudd.

(There's lots more on Accountable Care Organizations here)