Health Care Reform Update: Medicare Reform – Rationality versus Rationing
by Alta Price, M.D.The private insurance industry and their supporters, like our own Senator Chuck “pull the plug on grandma” Grassley, are doing their best to scare the elderly into believing that health care reform threatens Medicare. Of course, nothing could be further from the truth – health care reform is going to save Medicare! It is partly because of increases in Medicare payments to doctors that the American Medical Association endorsed HR 3200. The private insurance industry and their Republican allies in Congress opposed the creation of Medicare in the first place, and have been trying to privatize Medicare or otherwise destroy it ever since.
Medicare is so large and complex it makes it much easier to convince people that a specific provision in a health care reform bill somehow means something bad for Medicare recipients. Much of the nonsense about rationing care comes from utterly innocuous proposals – at least for patients – having to do with improving the quality of care doctors and hospitals deliver. These proposals are important to doctors, because they could mean bureaucratic hassles with no actual improvement in the way doctors practice. In other words, they are irrational and irritating. But they have nothing to do with rationing. Furthermore, these types of programs already exist in Medicare. I challenge anyone to show me how a quality improvement requirement that I put a numeric code into a computer to indicate that I have “staged” a breast or colon cancer appropriately in one of my pathology reports could ever lead to a patient being denied care. Now I may think putting that code in a computer in no way improves the quality of my pathology report and may be a waste of my time. But you all should let doctors worry about those provisions since there is negligible impact on patients.
When President Obama talks about paying for health care reform by cutting waste and abuse out of Medicare this can also make people worry that Medicare will have to cut benefits. But believe me, there is plenty of waste in the system that could save Medicare money without touching benefits. I am hopeful that some provisions, including the comparative effectiveness ones that generate so much hysteria in opponents of reform, could bring a little rationality to Medicare and save the program billions of dollars.
I am very logical, and I am irked by irrational behavior. Early in my practice I was a Laboratory Director of a small hospital in rural Colorado. Medicare would pay us a set fee for the lab tests we provided, based on what were called “usual and customary charges.” We had a list of tests and the fees they would pay. This list had fees for “biochemistry profiles,” which were groups of tests commonly ordered by doctors and that could all be performed at the same time by one instrument. They had a fee for an 18-test profile, 17-test profile, 16-test profile, and so on. At the time we were doing a 17-test profile. But on the fee schedule, it turned out Medicare would pay more money for a 16-test profile than a 17-test profile. So we dropped one test and Medicare started paying us more. Now does that make any sense? I thought then and still do that Medicare needs to be made rational!
One of my pet peeves is that Medicare will pay $2000 for a drug that performs no better than a $35 drug. Private insurers would not do this. (Just like the Blue Dogs do some things right, so do private insurance companies.) My husband is a retinal surgeon, and has used a $35 drug to treat macular degeneration. But about half of the retinal surgeons use a $2000 drug, costing Medicare literally hundreds of millions of dollars (I think it is several billion a year). And according to an article in the New York Times, “A Rule on Eye Treatment is Likely to Cost Millions,” Medicare is going to change the way they pay for the cheaper drug, reimbursing doctors only $7.20 for the $35 drug. Medicare will cover the whole $2000, though. Is it rational for Medicare to encourage doctors to switch to a drug that will cost Medicare hundreds of millions of dollars, increase patient’s costs, and provide absolutely no medical benefit to the patients?
There are many ways President Obama and the Democrats in Congress can cut Medicare costs without touching Medicare benefits and find some of the money needed to extend health care to everyone. But whatever they can do to make the program more rational will not only save money, it will remove a source of irritation for many doctors.
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