Medicare/Medicaid: What to do?

[Toomey2020]

To me, these two topics is where I'm very weak. I'm interested to learn more about them from a Republican and Democrat view. What is the problem in these two programs now? How do you fix them?

 

[Greenbeard]

The problem with Medicare and Medicaid is largely the problem that affects all payers: they buy care from the American delivery system. Don Berwick hit on it in one of his exit interviews last week:

But you see, Phil, I don’t think Medicare is broken. I don’t think Medicaid is broken. They’re very important social programs of good intent that are accomplishing largely what they intend to accomplish. Health care is broken. The delivery system isn’t working. That’s the problem.

We set up a delivery system which is fragmented, unsafe, not sufficiently patient-centered, full of waste, unreliable, despite … great efforts of the workforce. We built it wrong. It isn’t built for modern times.

Medicare doesn’t need fixing. Health care needs fixing. And that’s the agenda that I’ve been trying to focus on in my whole career, and also as administrator. Now, Medicare and Medicaid have opportunities to provide incentives and information and encouragement to get us those changes, but the problem of American health care is not Medicare, it’s the delivery system. And now, thank goodness, we seem to be en route toward better delivery options, better delivery configurations. It’s only a matter of: Are we going to get that fast enough?

The first steps for them to take revolve around changing the way Medicare/Medicaid (and, ultimately, everyone) does business to get more value out of the health care system and thus stretch health care dollars further. If you're actually interested in probing that concept a little further, a while back I started a thread looking at how one current private industry leader does some of this: "http://www.usmessageboard.com/healt...-care-costs-through-better-care-delivery.html"

The first tentative steps toward making that possible for Medicare and Medicaid are the ones that became law 21 months ago: the electronic health record incentives (and the Regional Extension Centers that have been helping providers to adopt the technology), shared savings with providers who find ways to deliver high-quality care at a lower cost, payments based on value instead of just quantity of procedures, reductions in preventable hospital re-admissions, the Multi-Payer Advanced Primary Care Initiative, greater transparency through the various "Compare" tools, bundled payments to mitigate volume-based incentives, quality reporting, reductions in hospital-acquired conditions, the creation of the IPAB, improvements in patient safety, a host of new tools for fighting fraud, and so on.

The crucial step after that is to make sure we're supporting the infrastructure for and the spirit of a learning health system (a concept the Institute of Medicine has been pushing pretty hard) so that we can expand upon what works and avoid that which doesn't. One might be a little pessimistic about the prospects of this happening, given the political system's recent response to one of the guys who brought the continuous quality improvement ethos into the health care system (and its most vocal advocate)--but I choose to be an optimist. The health care system can do better and it will. And the nation, including Medicare and Medicaid, is going to save a good deal of money when it does.