Medicare As We Know It Is Ending Under the Republican and Democratic Proposals

Good bye!

Pssst.  Guess what.  If either the a) the President and his Democratic allies or, b) the resurgent "Path-to-Prosperity" Republicans ultimately win Medicare deficit-funding debate, "Medicare as we know it" is going away.

That's the conclusion of the weary Disease Management Care Blog after reading the text of today's speech by President Obama on reducing the U.S. budget deficient.  More information can be had by checking out this White House fact sheet. 

A previous review of the sweeping Medicare changing Republican Ryan proposal can be found here.  Those are big changes. 

But so are the President's.

In tones that even the New York Times called "partisan," Mr. Obama extrapolated on Congressman Ryan's "voucher" proposal and asserted it will result in "$6,400" in additional out-of-pocket expenses for Medicare beneficiaries. Arguing that it's smarter to reduce the overall cost of health care, the President proposes to instead attack "wasteful subsidies and erroneous payments," leverage Medicare's purchasing power to command discounts and incent doctors and hospitals to prevent injuries and improve results.

Readers may recall that all those audibles are already in the Administration's CMS Playbook. What caught the DMCB's eye was the added proposal to "strengthen" an "independent commission of doctors, nurses, medical experts and consumers who will look at all the evidence and recommend the best ways to reduce unnecessary spending while protecting access to the services seniors need." Furthermore, if "Medicare costs rise faster than we expect, this approach will give the independent commission the authority to make additional savings by further improving Medicare."

That 15 expert member "commission" is a creation of the Affordable Care Act, otherwise known as Independent Payment Advisory Board (IPAB).  It is empowered to bypass Congress with cost-saving changes to Medicare, so long as it doesn't change coverage or quality. What's more, just as the President said, if the changes don't result in actuarially projected savings, IPAB is responsible for generating additional recommendations that must be carried by the Secretary of HHS.  What's new about the President's proposal is that the Board will be charged with striving for even tighter GDP-based global cost targets than previously anticipated.

So, why could Medicare-as-we-know-it end?  Up until now, it has been the style of Medicare to cover all reasonably medically necessary health care services.  In the "real world" of patient care, Medicare beneficiaries - with the exception of some preventive services - get sick and doctors treat and get paid.  Under the Democratic IPAB proposal, it is highly likely that U.S. docs' treatment options will be clinically or economically curtailed to what is officially "evidence-based."  

While that doesn't necessarily sound bad, much of the published science that will underlie the Commission's recommendations simply isn't up to the task.  While certain testing and treatment strategies are superior to others, comparative effectiveness research can be illusory, research results can be less than pristine, outcomes may not uniformly apply to all individuals and they often remain chronically (and thankfully) open to re-interpretation.  Highly trained U.S physicians will wonder - just as they do in their tussles with commercial managed care today - how remote experts use flawed and "succesionist" logic to decide what's best for their patients under their special and unique circumstances.

That's a lot of change.

Even though it's ironic that the solution to CMS' failures to date is even more CMS, the DMCB also wonders if either Congress (with its partisan hearings and tradition of service to constituents) or the Executive Branch (favoring the special interests of key political allies) can really resist the continued political temptation to meddle in a trillion dollar industry.  That won't change.

While this could rekindle the death panel controversy, this could ultimately turn out to be what the President doesn't want: re-run of the 2010 debate over the role of government in health care.  The blogging DMCB, on the other hand, looks forward to a bloggy-target rich debating environment: do we want the enlightened allocation of health care resources or... do we want to harness the wisdom of markets?  Which is worse: top-down central planning or... forcing vouchers on vulnerable seniors and forcing them to choose between eating, heating or healing?  And finally, which party can frame ("vouchers!" or "premium support!") the debate and deploy the best rhetoric (that $6400 is not a CBO number, is it?) to meet their policy and political ambitions?