Super Committee To Physicians: Go Texan or Go Dishwasher

Room for one more!

Once again, the Disease Management Care Blog got it right: the prognosis for the Congressional 12-person Super Committee was only slightly better than the likelihood that the DMCB was a Justin Bieber love-child.  How could the Committee ever succeed with the 13th Man being elsewhere overseas, while Dr. Krugman on the left and the WSJ's editorialists on the right were both agreeing that any deal would be Satan's spawn?

But if budget cutting is a good thing, why are the equity markets down?   In addition to the lingering threat of an eventual Moody's downgrade, the DMCB suspects stock holders a) have calculated a $1.2 trillion budget cut was never really up to the task*, and b) fear that the 2012 Congress won't stick to its guns.

So, asks the DMCB, what's next? 

Automatic cuts will be applied to discretionary federal spending as well as the defense budget.  While Medicaid is spared (much to the relief of our nation's governors), Medicare is facing a 2% sequestration which, because premiums and cost sharing will go untouched, translates into payment cuts for hospitals, doctors and other providers.  An additionally toxic wild card is a looming additional "SGR" 27.4% Medicare physician fee schedule cut.

How will the DMCB's physician colleagues react to this dysfunction? 

Not well:

1) for those in physician owned practices, it may come down to deciding whether or not to go postal Texan.

2) for those in salaried positions, they can look forward to their Administrators turning to the "dishwasher" approach of maximizing patient throughput-dependent revenue: there's always room for a few more.  And if docs expect Uncle Sam to have any sympathy, they need to think again.

Let the games continue.

(HT to George Will)

How The Medicare Entitlements Could Be Reformed, Why That Is Unlikely And Why Medicare Needs Disease Management More Than Ever

Will the Committee Come to Order?

In a prior post on the coming Congressional "super committee" scorched-earth Battle of the Budget, the Disease Management Care Blog predicted that there will be no time, no technical knowledge and no tolerance for any fiddling with Medicare entitlements.  That leaves reducing payments to providers.  Former HCFA Administrator Gail Wilensky agrees.

Yet, for some insight on how Congress could reduce entitlements, check out this proposal from U.S. Senators Lieberman (I-CT) and Coburn M.D. (R-OK).  Four of the more interesting features are......

Phase in an age eligibility of 67 years (because our life expectancy is increasing)

Increase the premium for Medicare Part B (it will reduce its dependence on tax revenue) and require those with higher incomes to pay more (for the same coverage, by the way).

Consolidate the deductible at $550 for Medicare A and B, while sweetening things with an out-of-pocket maximum at $7500 (but increase it for persons with higher incomes, even though they won't be getting better coverage by the way).

Prohibit "first dollar" coverage by the private Medi-gap plans (which will presumably disincent beneficiaries from using unnecessary care services; critics could charge that that could have the same impact the use of necessary care services too, especially for the poor).

While the baby-boomer DMCB ponders the prospect of having to chose between higher premiums with elevated out-of-pocket costs versus having to shop around with a premium-supported voucher, Congress has a far more fundamental choice: it is going to have to chose between making voters pay more or paying providers less.  Given the outline above combined with the toxic partisan rancor, it's already pretty clear what the political choice is going to be.

Last but not least, the DMCB continues to be mystified by the unwillingness of CMS to reconsider its posture on covering remote coaching disease and population health management.  If CMS wants to save money, here are three good reasons to do so:

 1) the suite of services, sophistication and "reach" of modern disease management have grown considerably since the bad old days of Medicare Health Support,

2) there's some evidence that Medicare Health Support actually did some good, and

3) much of the cost-saving, patient-centered care management activities of the successful Group Practice Demonstration were modeled after old fashioned disease management including phone calls by nurses that were external to the primary care sites.

Here's a future question for the super committee to ponder as it tackles CMS' rising costs: if State Medicaid programs and commercial insurers currently rely on versions of disease management and if ACOs are likely to do so once they're up and running, why isn't it good enough for a supposedly innovative CMS?