We now include some of the items in the Baucus proposal we discussed in the last entry and Medicare.
1. Added Features to Medicare
Baucus proposes the following added features:
"Coverage for a Personalized Prevention and Wellness Plan. Beginning January 1, 2011, Medicare would cover a health risk assessment and wellness visit with a primary care provider for all beneficiaries every other year. During this visit, beneficiaries would receive a personalized health improvement plan and schedule for Medicare covered and recommended preventive screenings.
Coverage of Preventive Services. Cost-sharing would be removed for preventive services recommended by the U.S. Preventive Services Task Force (USPSTF). The proposal would give the Secretary authority to modify coverage of existing preventive services consistent with USPSTF recommendations.
Incentives for Healthy Lifestyles. The proposal would require the Secretary to establish a five-year initiative to explore providing incentives to Medicare beneficiaries who improve their health status and complete scientifically-based healthy lifestyle programs. The programs would target specific risk factors including high blood pressure, high cholesterol, tobacco use, overweight or obesity, diabetes, and falls prevention."
As to the above:
(i) Medicare never covered annual physicals. Thus if a patient was to get coverage they would have to present with an ailment and the physician would have to record it as such. This became a problem because it is critical to catch problems early. Just because a patient has Diabetes, one cannot test for a PSA level unless there was some complaint. The physicians then "played" the system with the patient stating they had a urinary problem. This is now taken care of.
(ii) Preventive services is a potential conundrum. Take Type 2 Diabetes, what are the preventive services, nutritional and diet counseling? This has a potential for abuse.
(iii) Lifestyle is always good but it is a bit too late for many by the age of 65. Try getting a 70 years old morbidly obese patient to loose weight. You might just as well get the to fly!
2. Payment Controls
Baucus then goes on to describe payment controls as follows:
"Hospital Value-Based Purchasing. The proposal would establish a value-based purchasing program for hospitals starting in 2011. Under this program, a percentage of hospital payment would be tied to hospital performance on quality measures ...
Physician Value-Based Purchasing. This provision would make improvements to the Physician Quality Reporting Initiative (PQRI) program, including requiring all eligible health professionals to participate ...
Medicare Home Health Agency and Skilled Nursing Facility Value-Based Purchasing. CMS is currently testing value-based purchasing models for these providers. ...
Quality Reporting for Other Providers. This provision would set providers – long-term care hospitals, inpatient rehabilitation facilities, PPS-exempt cancer hospitals and hospice providers – on a path toward value-based purchasing by requiring the Secretary to implement quality measure reporting programs ...
Strengthening the Quality Infrastructure. Additional resources would be provided to HHS to strengthen the quality measure development processes for purposes of improving quality, informing patients and purchasers, and updating payments under federal health programs...."
All of these efforts relate to meeting metrics as established by the Government. Frankly one wonders why this has not already been done. The law does not have to be changed to effect this. As we have also noted the most explosive growth area in Medicare is home health care. The logic was to get the patient out of a hospital and into the home where it would be less costly. We have shown that hospitals are still growing at 4-6% per year where home health care is growing at 10-15% per year. Somehow this is not working.
3. Payment Methods:
This is where the problems begin. Physicians will not participate in Medicare if they find that they will not be paid. As I have argued on multiple occasions the bundling issue is a barrier to having competent physicians. No physician worth their salt will subject themselves to the indentured servitude of a bundling system run by hospitals. Hospitals are the problem and not the solution.
The Baucus proposal states:
"Accountable Care Organizations. Groups of providers who work together to improve the quality of care they deliver to Medicare beneficiaries would be able to keep half of the savings they achieve for the Medicare program over a three-year period.
National Pilot Program on Payment Bundling. This provision would direct the Secretary to develop a voluntary pilot program encouraging hospitals, doctors, and post-acute care providers to achieve savings for the Medicare program through increased collaboration and improved coordination of patient care by allowing the providers to share in such savings.
Reducing Hospital Acquired Infections. Starting in 2011, hospitals in the top 25th percentile of rates of hospital acquired conditions for certain high-cost and common conditions would be subject to a payment penalty under Medicare.
Reducing Avoidable Hospital Readmissions. This provision would direct CMS to track national and hospital-specific data on the readmission rates of Medicare participating hospitals for certain high-cost conditions that have high rates of potentially avoidable hospital readmissions. Starting in 2011, hospitals with readmission rates above a certain threshold would have payments for the original hospitalization reduced by 20% if a patient with a selected condition is re-hospitalized with a preventable readmission within seven days or by 10% if a patient with a selected condition is re-hospitalized with a preventable readmission within 15 days.
Transitional Care Program. This provision would fund eligible hospitals and community-based partnership organizations that provide patient-centered, evidence-based transitional care services to Medicare beneficiaries at the highest risk of preventable re-hospitalization."
The last three are readily doable now. We have argued that they should and must be done and they lead to substantial costs savings. As to the first two, the group and bundling plan, that is a mandated change which would push the best physicians out of Medicare service. The net result would be that Medicare would be served by those willing to deal at a least common denominator. They will result in lower quality care.
There are changes proposed to Medicare Advantage and Medicare Part D. We refer the reader to those elements.
1. Added Features to Medicare
Baucus proposes the following added features:
"Coverage for a Personalized Prevention and Wellness Plan. Beginning January 1, 2011, Medicare would cover a health risk assessment and wellness visit with a primary care provider for all beneficiaries every other year. During this visit, beneficiaries would receive a personalized health improvement plan and schedule for Medicare covered and recommended preventive screenings.
Coverage of Preventive Services. Cost-sharing would be removed for preventive services recommended by the U.S. Preventive Services Task Force (USPSTF). The proposal would give the Secretary authority to modify coverage of existing preventive services consistent with USPSTF recommendations.
Incentives for Healthy Lifestyles. The proposal would require the Secretary to establish a five-year initiative to explore providing incentives to Medicare beneficiaries who improve their health status and complete scientifically-based healthy lifestyle programs. The programs would target specific risk factors including high blood pressure, high cholesterol, tobacco use, overweight or obesity, diabetes, and falls prevention."
As to the above:
(i) Medicare never covered annual physicals. Thus if a patient was to get coverage they would have to present with an ailment and the physician would have to record it as such. This became a problem because it is critical to catch problems early. Just because a patient has Diabetes, one cannot test for a PSA level unless there was some complaint. The physicians then "played" the system with the patient stating they had a urinary problem. This is now taken care of.
(ii) Preventive services is a potential conundrum. Take Type 2 Diabetes, what are the preventive services, nutritional and diet counseling? This has a potential for abuse.
(iii) Lifestyle is always good but it is a bit too late for many by the age of 65. Try getting a 70 years old morbidly obese patient to loose weight. You might just as well get the to fly!
2. Payment Controls
Baucus then goes on to describe payment controls as follows:
"Hospital Value-Based Purchasing. The proposal would establish a value-based purchasing program for hospitals starting in 2011. Under this program, a percentage of hospital payment would be tied to hospital performance on quality measures ...
Physician Value-Based Purchasing. This provision would make improvements to the Physician Quality Reporting Initiative (PQRI) program, including requiring all eligible health professionals to participate ...
Medicare Home Health Agency and Skilled Nursing Facility Value-Based Purchasing. CMS is currently testing value-based purchasing models for these providers. ...
Quality Reporting for Other Providers. This provision would set providers – long-term care hospitals, inpatient rehabilitation facilities, PPS-exempt cancer hospitals and hospice providers – on a path toward value-based purchasing by requiring the Secretary to implement quality measure reporting programs ...
Strengthening the Quality Infrastructure. Additional resources would be provided to HHS to strengthen the quality measure development processes for purposes of improving quality, informing patients and purchasers, and updating payments under federal health programs...."
All of these efforts relate to meeting metrics as established by the Government. Frankly one wonders why this has not already been done. The law does not have to be changed to effect this. As we have also noted the most explosive growth area in Medicare is home health care. The logic was to get the patient out of a hospital and into the home where it would be less costly. We have shown that hospitals are still growing at 4-6% per year where home health care is growing at 10-15% per year. Somehow this is not working.
3. Payment Methods:
This is where the problems begin. Physicians will not participate in Medicare if they find that they will not be paid. As I have argued on multiple occasions the bundling issue is a barrier to having competent physicians. No physician worth their salt will subject themselves to the indentured servitude of a bundling system run by hospitals. Hospitals are the problem and not the solution.
The Baucus proposal states:
"Accountable Care Organizations. Groups of providers who work together to improve the quality of care they deliver to Medicare beneficiaries would be able to keep half of the savings they achieve for the Medicare program over a three-year period.
National Pilot Program on Payment Bundling. This provision would direct the Secretary to develop a voluntary pilot program encouraging hospitals, doctors, and post-acute care providers to achieve savings for the Medicare program through increased collaboration and improved coordination of patient care by allowing the providers to share in such savings.
Reducing Hospital Acquired Infections. Starting in 2011, hospitals in the top 25th percentile of rates of hospital acquired conditions for certain high-cost and common conditions would be subject to a payment penalty under Medicare.
Reducing Avoidable Hospital Readmissions. This provision would direct CMS to track national and hospital-specific data on the readmission rates of Medicare participating hospitals for certain high-cost conditions that have high rates of potentially avoidable hospital readmissions. Starting in 2011, hospitals with readmission rates above a certain threshold would have payments for the original hospitalization reduced by 20% if a patient with a selected condition is re-hospitalized with a preventable readmission within seven days or by 10% if a patient with a selected condition is re-hospitalized with a preventable readmission within 15 days.
Transitional Care Program. This provision would fund eligible hospitals and community-based partnership organizations that provide patient-centered, evidence-based transitional care services to Medicare beneficiaries at the highest risk of preventable re-hospitalization."
The last three are readily doable now. We have argued that they should and must be done and they lead to substantial costs savings. As to the first two, the group and bundling plan, that is a mandated change which would push the best physicians out of Medicare service. The net result would be that Medicare would be served by those willing to deal at a least common denominator. They will result in lower quality care.
There are changes proposed to Medicare Advantage and Medicare Part D. We refer the reader to those elements.
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