Thursday, August 4, 2011

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?

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