Reforming Medicare

[Greenbeard]

In considering ways to improve Medicare, I'm going to return to a theme I've touched on before: promoting value at all levels of the health system. Recent reforms to Medicare (and Medicaid) have made some progress in this direction, primarily on the payer side, in part by beginning to reward modes of delivery that have already shown themselves to improve quality and cut costs.

But there are other ways to pursue value, for instance by putting the impetus on the consumer. Take value-based insurance design (V-BID):

Concept

The basic V-BID premise is to align patients’ out-of-pocket costs, such as copays and premiums, with the value of health services. This approach to designing benefit plans recognizes that different health services have different levels of value. By reducing barriers to high-value treatments (through lower costs to patients) and discouraging low-value treatments (through higher costs to patients), these plans can achieve improved health outcomes at any level of health care expenditure. Studies show that when barriers are reduced, significant increases in patient compliance with recommended treatments and potential cost savings result.

Today, MedPAC, the independent group of experts who advise Congress on Medicare, released their June report (they release reports in March and June every year). In the third chapter, they walk through some of the shortcomings of Medicare's current payment structure and raise a topic they've broached before:

For the longer term, the Medicare program needs to move toward a redesigned benefit that gives individuals incentives to use higher value care and avoid using lower value care. These determinations must be evidence based. Several years ago the Commission recommended that policymakers establish an independent, public–private entity that would produce information to compare the clinical effectiveness of a health service with its alternatives (Medicare Payment Advisory Commission 2008). Along the same lines, PPACA established the Patient-Centered Outcomes Research Institute to identify national priorities for comparative clinical effectiveness research and to sponsor comparative- effectiveness research efforts. In addition, Medicare could examine the factors that affect beneficiaries’ health care decisions and use that information to help transform the structure of health care delivery.

Policymakers have become more aware that not all health care services have the same value, but identifying which services are of higher or lower value can be difficult. The term “value based” is applied to strategies for reimbursing providers (value-based purchasing) and cost-sharing options designed to encourage beneficiaries to use high-value health care services or providers and to discourage use of low-value services or providers (value- based insurance design). Testing these approaches would help policymakers decide which of them could steer beneficiaries more effectively toward the use of high-value health care services or away from services of low value.

Some insurers have begun setting different levels of cost sharing for the same medical intervention based on its clinical benefit to the individual (Chernew et al. 2007, Fendrick et al. 2001). When there is evidence that specific therapies are comparatively more effective and appropriate for certain patients, lowering their cost sharing to help increase their adherence could improve health outcomes. If greater adherence leads to fewer exacerbations of the patient’s condition, this approach could also lower spending. At the same time, where evidence suggests that medical therapies are less effective, increasing beneficiaries’ cost sharing could deter use of those services. Designs of this kind would lead to overall lower spending only if it helped to reduce medical interventions when the costs outweigh the clinical benefits. However, many services do not save money, although they are cost- effective. In a previous report, we discussed the literature testing key elements of this benefit design (Medicare Payment Advisory Commission 2010). In sum, the extent to which this benefit design could reduce Medicare program spending depends on beneficiaries’ underlying health risk, the cost of adverse outcomes, beneficiaries’ responsiveness to copayments, and the effectiveness of medical therapies at reducing risk (Chernew et al. 2010).

They don't develop explicit recommendations but rather they walk through some of the implications that will have to be considered and questions that will have to be answered if Medicare does eventually move to incorporate more V-BID (and they rightly point out that several variables will come into play).

 

[Gadawg73]

Reform A: Inform citizens of the facts. The $$ everyone pays into Medicare, Social Security or ANY government program is A TAX. NO ONE is entitled to receive anything if the country CAN NOT PAY THEIR BILLS. The government has made promises THEY CAN NOT KEEP ANYMORE. Accordingly, new rules will be implemented immediately.
Reform B: Means test for all seniors for Medicare. ALL seniors with income over $70,000.00 a year ($85,000 for married) receive 50% ONLY. Insurance companies will not be allowed to DENY claims from seniors claiming Medicare as primary in this situation. Forcing our grandchildren to pay the medical bills of today's wealthy seniors is a crime.
Reform C: End all "therapy" at assisted living facilities and out patient facilities. I have seen this for years and this is the biggest rip off ever. Occupational therapy and other therapy for 88 year old seniors is a waste. Billions of dollars saved.
Reform D: End all mood stabilizer and anxiety, etc. medications for seniors immediately. Billions more saved. We have become a doped up society. End it.
Reform E: If families do not want DNR orders on their loved ones then they can pay to keep 88 year old Gramps alive in ICU at 10K a day but we are broke and can not afford it. We are now spending as a nation 60% of ALL health care dollars on 4% of the population and end of life care to keep seniors alive is the fastest growing segment of those expenditures. At this rate in 25 years 85% of all health care dollars will go to those 4%.
Reform F: Health clinics for basic doctor practictioner care. Tens of billions saved here.