Tag: Medicare

Myths and Facts About Health Reform Part III

May 1, 2010• 55

By MAGGIE MAHAR

MYTH #1: In negotiations over reform, hospitals were forced to accept sharp cuts in Medicare funding.

FACT: In those negotiations, hospitals come out winners. They “were inside the tent very early on, negotiated a decrease in their Medicare updates that they figured out was acceptable” the Urban Institute’s Bob Berenson explained in a recent Health Affairs roundtable. (Berenson is in good position to analyze the changes: he was in charge of Medicare payment policy and managed care contracting at the Health Care Financing Administration – now called the Centers for Medicare and Medicaid– from 1998 to 2000 )

“And now [hospitals] are off limits until 2020 from the new board that is supposed to [make sure] Medicare hits spending targets,” Berenson added referring to the Independent Payment Advisory Board (IPAB) that will recommend ways to trim Medicare spending if it continues to grow faster than the Consumer Price Index. IPAB begins its work in 2014, but hospitals and hospices are exempt from IPAB”s proposals until 2020.

Moreover, while annual increases in Medicare payments to hospitals will be trimmed slightly, these cuts will be offset by the fact that hospitals will be seeing an influx of paying patients. Beginning in 2014, millions of formerly uninsured patients will no longer need charity care. Granted, the “Disproportionate Share Funding” (DSH) that many hospitals now receive to help defray the expense of caring for a disproportionate share of poor patients will be sliced by 75%, but a portion of the 75% cut will then be distributed back to hospitals, based on how much uncompensated care a particular hospital is still providing.Continue reading…

To Know and Be Known

Apr 30, 2010• 7

By ROB LAMBERTS, MD

I was happy when I looked at today’s schedule.

Two husband and wife pairs were on my schedule, both of whom have been seeing me for over ten years. Their visits are comfortable for me; we talk about life and they are genuinely interested in how my family is doing. They remember that I have a son in college and want to know how my blog and podcast are doing. I can tell that they not only like me as a doctor; they see me, to some degree, as a friend.

Another patient on the schedule is a woman from South America. She has also been seeing me for over ten years. I helped her through her husband’s sudden death in an accident. She brings me gifts whenever she goes on her trips, and also brings very tasteful gifts for my wife. Today she brought me a Panama hat.

I know these people well. I know about their past illnesses and those of their children. I know about their grandchildren, having hospitalized one of them over the past year for an infection. I know about the trauma in their lives as well as what they take joy in. They tell me about their trips and tell me their opinions about the health care reform bill.

I spend a large part of their visits being social. I can do this because I know their medical situation so well. I am their doctor and have an immediate grasp of the context of any new problems in a way that nobody else can. This is not just in the context of their own medical ecosystem, it is in the larger family context. This means that I know how to read between the lines when they say something – knowing what I can ignore and what subtle things are out of character. This also means that I don’t have to practice defensive medicine – as I not only have a low risk of lawsuit, I also can rely on my intimate knowledge of them to keep excessive ordering of tests and referrals to a minimum.

That is the joy of primary care that doesn’t get talked about as often as it should: I have a genuine personal investment in my long-term patients. I know them and am known by them. It is also a much more efficient way to practice medicine. I don’t have to order tests to get information when my personal information is so great.

A 21% cut in Medicare may have put an end to it. When we were staring down the barrel of losing that much revenue, we seriously talked about our threshold for dropping Medicare. The political game of chicken was not only played at the expense of physicians, it put great fear into many of my long-term patients that they would lose me as their doctor. Yes, many of them would probably ante up and pay cash to maintain that relationship, but a new negative dynamic would definitely be thrown into the mix. Some just couldn’t afford to pay me out of pocket (even with a discount).

We need a system that encourages relational medicine rather than discouraging it as our system does now. Getting a bunch of mid-level providers in Walgreens is not the same as having an adequate primary care workforce. I cherish my relationships with these people and they are, to a very large extent, the reason why I haven’t seriously contemplated dropping Medicare until recently. I am a very important part of their lives – a stabilizing force that helps them deal with the difficulties of getting older and getting sick. But they are an important part of my life as well. I have a personal stake in their health because they bring me joy and connection.

After the visit, I gave the woman a big hug. I was wearing my Panama hat.

My nurse says it would look good with my Jimmy Buffett shirt.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

Medicare To Cover Preventative Care

Apr 22, 2010• 6

By ED PULLEN, MD

A nice surprise buried somewhere in the Health Care Reform Bill is that starting next year Medicare patients will be able to get annual preventative care exams that are paid for by their health insurance. It may come as a surprise to those of you with commercial insurance who think of coverage of an annual exam as a routine thing for insurance to cover, but up to now Medicare has only covered a “Welcome to Medicare” exam in the first year after turning 65. From then on no physical exams at all are covered, and many preventative services like colonoscopy and mammography were either not covered, or subject to fairly high copays and deductible costs. As a physician this has always seemed like this is backwards. I can make a pretty good argument that a physical exam for a 27 year old man is not needed annually, but it is essentially always a covered benefit in any plan the young insured patient has through an employer. Older adults are far more at risk for cancer, heart disease, diabetes, hypertension, depression, and safety at home issues than young adults. I am pleased that better preventative services coverage for our older and more vulnerable adults will be a paid service starting in 2011. This is discussed nicely in a recent NY Times article by Leslie Alderman in his Patient Money column.

Starting Sept 23, 2010, 6 months after the signing of the bill, all new insurance plans, or current plans which make certain changes will be required to cover preventative services recommended by the United States Preventative Services Task Force as category A or B ratings (A = conclusive evidence and B = very strong evidence showing benefit of receiving the services) and beginning Jan. 1, 2011 Medicare will also cover these services with no copay or deductible applicable.

This is good news for our seniors and should make it much easier for their physicians to convince our seniors, some of whom now have to choose between shelter, food or medicine on their poverty level fixed incomes, to receive preventative care.

Ed Pullen, MD, is a board certified family physician practicing in Puyallup, WA. Dr. Pullen shares his viewpoints on medical news and policy from a primary care physician’s perspective at his blog, DrPullen.com.

Don Berwick: An Activist Takes the Reins at CMS

Apr 2, 2010• 30

By BOB WACHTER, MD

While the health reform bill will have many effects, one of its most profound will be to unshackle the Centers for Medicare & Medicaid Services (CMS). Under the legislation, CMS is now far freer to undertake a variety of pilot programs and demonstration projects designed to improve quality, safety and efficiency, and to convert the successful ones into policy. And, if that wasn’t enough for those who have long been praying for a more activist CMS, we now learn that President Obama will select Don Berwick, the world’s most prominent advocate for healthcare quality and safety, to be the next CMS administrator. Although I’ve sparred a bit with Don over the years on matters of philosophy, I think he is a superb choice.

Don’s story is well known – a Harvard pediatrician and policy expert who became passionate about improving healthcare well before it was fashionable, he ultimately left his full-time academic perch to pursue his calling. In 1991, he founded the Institute for Healthcare Improvement, which ran on a shoestring for its first decade, fueled largely by the considerable power of Don’s vision and personality.Continue reading…

Who Is Don Berwick (and Why Is He Following Me?)

Mar 30, 2010• 79

By MAGGIE MAHAR

The rumors that I w rote about Friday are, in fact, true. President Obama will name Dr. Donald Berwick, president of the Institute for Health Care Improvement (IHI), to run Medicare and Medicaid. Berwick, who is a professor of pediatrics and healthcare policy at the Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health, will have to be confirmed by the Senate Finance Committee.

Just how tough will the confirmation hearing be? I’m not worried. Berwick can handle himself.

Granted, yesterday the New York Times called Berwick “iconoclastic,” i.e., someone who “smashes sacred religious images” or “attacks cherished beliefs.” But most who know him describe him a “visionary” and a “healer,” a man able to survey the fragments of a broken health care system and imagine how they could be made whole. He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. healthcare.

Berwick stands at the center of a healthcare movement that would reform the system from within. In 2005, Modern Healthcare, a leading industry publication, named him the third most powerful person in American health care. In contrast to others on the list, Berwick is “not powerful because of the position he holds,” Boston surgeon Atul Gawande noted at the time. (Former Secretary of Health and Human Services ranked no. 1, while Thomas Scully, the head of Medicare and Medicaid services captured the second slot.) “Berwick is powerful,” Gawande explained, “because of how he thinks.”

Listen to some of the clips below, from the film Money-Driven Medicine, produced by Alex Gibney, and based on my book, and you’ll understand what Gawande means. Soft-spoken, and charismatic Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.

Berwick isn’t just another ivory-tower philosopher. He’s “an extraordinary leader when it comes to inspiring people and creating the will to move forward,” Dartmouth’s Dr. Elliot Fisher told me in a phone conversation Friday. “And he can teach people how to do it. He has demonstrated his ability to teach people how to implement change in a complex system.”Continue reading…

The Reinvention of Social Progress

Mar 23, 2010• 31

By MERRILL GOOZNER

I watched C-Span through the entire voting process on Sunday night. Socialism? Tyranny? The Republican hyperbole was unhinged from reality.

Democratic claims that the health care reform marked a major milestone in domestic policy were closer to the truth. But billing the legislation as comparable to the advent of Social Security in the 1930s or Medicare and Medicaid in the 1960s simply isn’t accurate.

Why do I say that?Continue reading…

“I Am Not Bound To Win. But I Am Bound To Be True.”

Mar 21, 2010• 40

By MAGGIE MAHAR

So many said it would never happen. But now, on Sunday, March 21, 2010, it appears that reformers have the votes. Rep. Bart Stupak, the leader of the anti-abortion hold-outs, has announced that he will vote “yes.” – under the agreement, President Barack Obama will sign an executive order ensuring that no federal funding will go to pay for abortion under the health reform plan. This really doesn’t change anything. Stupak got nothing except face-time on television.

At last, Congress is about to take the first step toward transforming what we euphemistically call our health care “system.” In the years ahead, the laissez-faire chaos that puts profits ahead of people will be regulated, with an eye to providing affordable, evidence-based, patient-centered care for all.

Over the last three years, I have predicted that Medicare reform would pave the way for health care reform, and this bill makes that possible. Under the legislation, Congress will no longer be in a position to thwart Medicare’s efforts to rein in spending by eliminating waste. Not everyone is happy about this. Over at Politico.com former Republican Senator Bill Frist and former Democratic Senator John Breaux register their protest in a column titled “Keep Medicare in Congress’ Hands.”Continue reading…

Dear Mr President, Medicare Stinks

Mar 17, 2010• 39

By ROB LAMBERTS

Dear Mr. President:

The physicians and management in our office had a discussion this morning about the upcoming audits physicians are facing from CMS. I had to wait for my blood pressure to get out of dangerous range to write this letter. The frustration, fear, and powerlessness I felt made me really question whether it is worth continuing to see my Medicare patients.

I am a primary care physician and about 20% of my patients are covered by Medicare. As a whole, they are wonderful people, but difficult patients. The elderly are truly a delight to talk to, learn from, and care for; I consider it an honor to be their doctor. But the complexity of a person’s medical problems goes up exponentially as they near the end of their life. This means that I spend more time per patient for my Medicare population – which is OK if I can be paid for my extra time and effort.

But here is the message we physicians are being given:

Medicare auditors will be knocking at our doors, and if there are “problems” with our charting we will be told to send money back to CMS for our whole Medicare population. We are obligated to prove that we did not defraud Medicare to reclaim the money for the work we did. This is, obviously, consistent with the cornerstone of the American legal system, “A person is presumed guilty unless they can prove that they are innocent.”

The “problems” they are looking for are inconsistencies in the charting and the billing we do. These “inconsistencies” are not just egregious attempts at stealing money from Medicare, they are little things like this:

McAllen, TX As Outlier? Why Not Houston?

Feb 19, 2010• 27

By MERRILL GOOZNER

Or Lubbock? Or Oklahoma City? Or New Orleans? Or any of a dozen major and minor metro areas throughout the South? According to the Medicare Payments Advisory Commission, all of them have significantly higher usage rates and costs per Medicare enrollee than McAllen, which was high-cost locale ground zero for Atul Gawande’s famous New Yorker article, “The Cost Conundrum,” which has become, to use the New York Times‘ formulation, “must reading in the White House.”

Gawande grounded his analysis on per-patient Medicare claims data compiled annually by researchers at Dartmouth Medical School. “The explosive trend in medical costs seems to have occurred here in an especially intense form,” Gawande wrote after the Dartmouth Atlas of Health showed McAllen as the highest spending region in the country outside Miami, where Medicare fraud is an especially virulent problem. Not so, MedPAC said. Adjust for prices and McAllen’s outlier status compared to the rest of Texas and large parts of the South all but disappears.Continue reading…

The Reagan-Era Health Reform That Scares Both Parties

Feb 18, 2010• 31

By MICHAEL MILLENSON

Twenty-seven years ago, President Ronald Reagan and a Congress split between Republican and Democratic control agreed to a radical new payment scheme for Medicare. The resulting legislation trimmed billions of dollars from the federal budget and caused medical inflation to plummet, yet still maintained quality of care.

Although this stunning achievement led to a permanent change in how both the public and private sector pay for health care, it has gone curiously unmentioned during more than a year of rancorous health reform debate. Nor is it likely to arise at the much-ballyhooed bipartisan summit. The topic simply raises too many squirm-inducing questions. In this instance, conservatives and liberals alike can agree that political discretion is the better part of valor.

For Democrats, the changes in Medicare hospital payments enshrined by the Social Security Amendments of 1983 constitute an unpleasant reminder that reforms targeting cost can be, and have been, successfully decoupled from those aimed at improving access. Given the public enthusiasm for cost control over access expansion, acknowledging that reality might well deal a fatal blow to decades of liberal efforts to achieve the dream of universal coverage.

For Republicans, however, the reverberations of the Reagan-era Medicare revamp are even more unsettling. The most-revered figure in modern American conservatism agreed to an administered price system that the current guardians of conservative orthodoxy would undoubtedly denounce as socialist, Bolshevik or worse. Even more painfully, the scheme worked. Perhaps most painful of all, Reagan’s reasoning showed a pragmatic view of government much closer to today’s political center than it is to hard-right GOP ideologues.