August 26, 2009

Messing with Medicare

Senior citizens have been coming out in droves to express concern that health care reform legislation will deprive them of what they now have. Although most of the provisions of the proposed bills deal with ensuring access to health care for the currently uninsured and with regulating private insurance companies, Medicare enrollees are worried that “the government” will “mess with Medicare,” a program which many seem not to realize is the paradigmatic “public option.” Just how would health insurance reform affect Medicare—in fact, not in fantasy?

Both the Senate’s “Affordable Health Choices Act” and the House of Representatives’ “America’s Affordable Health Choices Act of 2009” address access, quality, and cost-containment. The majority of the many sections of these bills deal with such areas as individual mandates, employer requirements, premium subsidies, insurance pooling mechanisms, and benefit design. Only a few have anything to do with Medicare. One provision, expansion of Medicaid, would increase the number of older people who are “dually eligible,” i.e. who would qualify for both Medicaid and Medicare. This would increase the coverage available to older individuals, not decrease it.

Under cost containment, the Senate bill would establish a “Health Care Program Integrity Coordinating Council” to prevent health care fraud, waste, and abuse, in both public and private coverage. Who could be against eliminating fraud and abuse? In fact, a recent article in the New England Journal of Medicine estimated that the annual price tag for fraud and abuse is $60 billion, with fully $36 billion of this related to Medicare and Medicaid, the current public programs--enough to pay for health care reform. The House bill has a few more provisions under the cost containment heading. These include reducing payments for potentially preventable hospital readmissions—that just means giving hospitals an incentive to solve your medical problem the first time you are hospitalized, instead of making you come back again and again to get it taken care of. In a similar vein, the House bill calls for hospitals to report hospital-acquired infections and suggests eliminating Medicaid payments for preventable infections (Medicare already does this), a strategy intended to encourage hospitals to keep you from getting such an infection in the first place.

In the arena of improving quality, both the Senate and the House version of the bills call for financial incentives to health care institutions to promote efficiency, for example by supporting a “medical home” that coordinates complex patient care. They also call for more research to study the effectiveness of health care services and procedures. This has nothing to do with taking away coverage for useful treatments. If physicians don’t know what works, they can’t treat patients in an optimal way. It’s that simple. And right now there is overwhelming evidence that doctors have routinely used ineffective therapy or have started with expensive and burdensome treatment when less expensive and often less invasive treatment would work just as well, simply because they did not know what would work best.

The bills also contain specific recommendations dealing with prevention that would increase coverage of preventive services under Medicare—for those preventive services that have been shown to improve outcomes. That means many beneficial screening tests that are not currently paid for would be covered in entirety and a few that other covered but that do not improve health would not be. So yes, a few things might be taken away from seniors—tests that are not helpful. But is this being deprived? Why would anyone want to undergo a screening test that doesn’t lead to better health? Knowing sooner that you have a disease just means suffering longer if it does not translate into more effective treatment of the disease.

The Senate and House bills actually include provisions for long term care insurance. Until now, no one in the legislature ever talked about long term care although it is critical to the health and well-being of millions of older people who need home care services or nursing home care. Medicare does not pay for nursing homes, so the 1.5 million people living in nursing homes either pay out of pocket or “spend down” and enroll in Medicaid.

Finally, there are a few miscellaneous provisions in both bills that would affect older people. The House version, for example, would eliminate the notorious “doughnut hole” in the Medicare Part D prescription drug plan, which requires older patients to pay in full for prescription drugs after they have spent $2510 and until they qualify for “catastrophic coverage,” once they have reached a whopping $4350 in out-of-pocket expenditures. The Senate version calls for educational reform to increase the supply, education, and training of doctors, nurses, and other health care workers in geriatrics and primary care.

What’s not to love?

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