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Sunday, April 29, 2012

Why We Don't Want To Get Rid of Medicare-Our Best Tool for Health Care Reform

Why We Don’t Want To Get Rid of Medicare-Our Best Tool for Health Care Reform
The pressure is on for federal budget slashing and of course social programs (not defense) are top-of-the-list for cost reductions, including the malignant call for block granting the Medicare program. Having previously analyzed the Bush Administration’s Deficit Reduction Act of 2005, including the odious federal government, “claw back provision” for reducing federal contributions for state Medicaid programs, this article reviews some potential impacts of a block grant or per capita allowance for Medicare participants. Parallels are drawn between the Medicaid changes and what may happen to Medicare if it is schlepped to the states. Finally, Medicare’s impact on overall health care policy making in the United States is analyzed.

Would Block Granting Medicare Look like the Medicaid 1115 Waiver Plans?
As of 2005, half the states already had approved Medicaid 1115 plans including: Alabama, Arizona, Arkansas, California, Colorado, The District of Columbia, Florida, Georgia, Idaho, Illinois, Maine, Massachusetts, Michigan, Missouri, New Jersey, New Mexico, New York, Oregon, Puerto Rico, South Carolina, Tennessee, Texas, Utah, and Washington. Oregon is famous for its health care plan which assesses a clinical and cost/benefit value for treatments covered by its subsidized public health care program. Most of the other states with Medicare 1115 Plans have eliminated benefits under the programs or drastically cut enrollment for poor residents. By example, Missouri eliminated 500,000 people from its Medicaid program. Many of the states with Section 1115 waivers used the provision to charge co-payments and premiums to certain Medicaid eligible constituents.

Impact on Drug Costs-Zip
In addition to cutting back on benefits, one of the trends for state implementation of Medicaid 1115 Waiver Programs is to pass more of the prescription drug costs to their plan participants. This does nothing to contain costs and merely makes low-income people pay more for their medicines. Medicare is also doing this with its drug program, by allowing pharmaceutical companies to charge retail market prices (the highest-in-the-world) for drugs while offering “discounts” to Medicare participants. It doesn’t take a rocket scientist to figure out that the pharmaceutical companies just raise their prices to include the “discounts” to the Medicare set.

Side effects of Medicaid 1115 Waiver Programs
Deferring Health Care
One of the provisions that Medicaid 1115 Opt-Out Plans can make, is to transfer more plan costs to the poor who are enrolled on these plans, however, that may mean people avoid medical care. This is a conundrum, though Medicaid enrollees have health insurance, they may not have enough money to contribute to the co-payment requirement. The Journal of Health Affairs published an analysis of the Utah State Medicaid program which showed that cost sharing up to 10% did have a negative impact on the indigent patient’s ability to obtain health care (AKA they deferred treatment).[1]

Clinician Access
Patients enrolled on Medicaid plans have insurance, but may not have a primary care clinician who will see them. Merely having insurance does not mean there are clinicians willing to accept those patients.  Medicaid has notoriously been viewed as paying poorly for medical services, although some states have taken steps to alleviate that road block to care. This problem of access to clinical care, especially for wellness or primary care is also rampant for Medicare participants. If they don’t have private insurance, it is very difficult for a Medicare patient to find a clinician who will accept them into their patient mix. This phenomenon is reflective of the poor reimbursement CMS provides for its primary care clinicians.

Another one of the methods that states have used 1115-Waiver provisions to change their Medicaid plans is to offer private insurance coverage, but this is hardly more cost effective, since the administration costs are three times as high as what the Centers for Medicare and Medicaid (CMS) charge, with no cost containment. This could however increase access to doctors who are willing to treat Medicaid patients.

Medicare as the Policymaker for Health Care Treatment and Payment
CMS, which administers health care for Medicare and Medicaid, is by far the largest health care program in the United States. Administrative cost for CMS run about 6%, as opposed to 18% for the private insurance sector. In addition to administering health care programs for the elderly and the poor, two constituents whom the private insurance sector has historically had little interest in insuring, CMS also finances demonstration projects with clinics throughout the country to figure out how to improve health care. An example of such a project is the Advanced Primary Care Demonstration Initiative[2], which is looking at patient-clinician engagement to improve health outcomes and pay clinicians for coordinating well patient care. There are also similar projects for the Accountable Care mandates, which reward clinics that produce better clinical results than those who are more marginal. These efforts are possible with a large enough patient population and an integrated patient tracking system, which coincidentally, is representative of a national health care program.

Fraud Detection-The Government Has the Bigger Stick
Medicare is the number one detector of fraudulent billing for health services in the country and it is essential that this bully pulpit be preserved. In The Battle Over Health Care[3], big pharmacy is now cited as the number one defrauder of the government and hence the United States people, even ahead of the perennial defense industry. Do any of us really trust the drug companies to police themselves, or for that matter any of the medical suppliers? In a fragmented Medicare system fraud detection would be more difficult not less.

Patient Safety-Do You Want to Leave it up to the Private Sector?
 In Rosemary Gibson’s and Janardan Prasad Singh’s brilliant, The Battle Over Health Care, numerous frightening examples abound of drug company, medical device supplier, and hospitals actually harming patients. Perhaps most egregious are the methods some of these companies (most of the abusers are for-profits) use to avoid accountability when they harm patients. A bright spot on this tarnished map is the University of Michigan Health Systems, which has a protocol mandating that its clinicians/facilities which harm patients; take responsibility, offer transparent information on what occurred, offer a settlement to the patient/family(without litigation), apologize, and provider free ongoing health care.[4] It is this type of candor which would go a long way toward improving patient safety in American health care. Imagine clinicians and hospital administrators who fess up rather than lawyer-up.

Though Medicare certainly has its detractors and is not lithe when it comes to adopting changes, it is more economical than any private sector health insurance program, and it covers  high-risk populations like the elderly and those with end-stage renal disease. Medicare drives policy changes throughout the entire United States health care system by determining how it will pay for services. This is ultimately the way the country can start to reduce its health care costs, by negotiating with drug companies, eliminating fraud, and equally important, unnecessary procedures. Because Medicare changes also impact private sector insurance companies, it is an essential component of health reforms and well as other national health care initiatives. CMS, which administers both Medicare and Medicaid, provides the nationwide health care partnership to test and deploy health care program changes. Through this surveillance process we can learn what works for the disparate U.S. health care system and attempt to lower costs and improve not only primary health care, but also preventive care. Too much of the U.S. health care dollar is spent on late-stage disease treatment versus patient health maintenance. If we hope to be competitive in a world economy, we must bring the per capita cost of our health care in line with the rest of the world and turning it over to the private sector foxes is not the answer.

For more discussion on this health care article, feel free to comment below. This article was written by Roberta E. Winter, the healthpolicymaven, and may be reprinted with her permission. Feel free however to share it voraciously with your friends and family.
Also, for those who want to read more of The Battle Over Health Care go to the New York Journal of Books for my review, by following this link:

Samantha Artiga, David Rosseau, Barbara Lyons, Stephen Smith, and Daniel Gaylin, Can States Stretch the Medicaid Dollar Without Passing the Buck? Lessons from Utah, Health Aff., March 26, 2006, vol. 25, no. 2. p. 532-540
[3] Rosemary Gibson and Janardan Prasad Singh, The Battle Over Health Care, chapter 2, page 24
[4] Rosemary Gibson and Janardan Prasad Singh, The Battle Over Health Care, chapter 13, page 163