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What Would You Cut?

By Dr. Chris Lillis
. 10 Comment(s)

The recent 2012 Budget passed in the House of Representatives (nicknamed the “Ryan Plan”) is forged from the idea that in order to put America’s fiscal house in order, something needs to be done about Medicare.  Of course there are many ways to begin to reduce the deficit aside from changing Medicare, but to ignore the cost of administering health care to America’s seniors would be akin to ignoring the elephant in the room.  Medicare currently consumes 12% of the federal budget, and with the “baby boomer” generation in the midst of retirement, Medicare liabilities will only grow as more and more people enroll in Medicare.  

Rarely do we see progressive and conservative bloggers agree, but in my reading I find consensus around quotes like this: “The real solution to the deficit problem must fix the long-term Medicare problem. “   The agreement comes from identifying the problem, while the argument comes from how to solve it.

The budget passed by the House, and defeated in the Senate, sought to solve this problem by converting Medicare to a program of vouchers.   The effect would be to shift a large portion of health care costs from the Medicare program to seniors, and the country does not seem to be on board.  The Affordable Care Act, passed last year into law, has several provisions to reduce spending through the Medicare program, but will only “bend the cost curve” of health spending through the successful future implementation of some of the pilot programs it provides for. 

Ergo, the inspiration for this blog post.  I stumbled across this fantastic forum yesterday, and I am struck by how freely these experts discuss ideas that were sensationally rejected during the debate leading up to the passage of the ACA.  This by no means suggest I disagree with these authors – in fact many of their suggestions make sense to me.  But were these writers to run for political office, I would expect their opponents would revive the chants of “rationing” and “death panels” in a heartbeat.

We as physicians need to play a major role in bending the cost curve.   Lists like this seem to be a great starting point for physicians to lead in reducing health costs. 

The strength of Doctors for America is our ideas coupled with our ideals.  So I ask you, the reader, to leave your comments with suggestions aimed at reducing Medicare costs, while still protecting the health of seniors.  Maybe we can even publish our own lists and share your ideas with the folks in Washington. 

How do you suggest cutting the costs of Medicare?

Share Your Comments

 

  1. Laura Davies

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    I would ensure that everyone at every point of contact in the health care system has a signed end of life directive, with a named power of attorney for health care.
    Further, I believe there should be no feeding tubes placed on people on hospice without their explicit wish (from them, not their family). Same with dialysis.
    Just because we can do things does not mean we should.
  2. zee beams

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    laura illustrates an important point. the vast majority of health care spending happens at the end of life, and most often on futile care. i can choose amoxicillin over cefixime all i want, ( and i usually do), but the impact of that choice is like a tiny speck of dust in the universe of dollars spent on health care.
  3. zee beams

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    similarly, the largest portion of government spending is on the military. when balancing a budget, you have to look at the largest slice of the budget pie, and whittle it down. you just have to. it's not fun, but it has to happen.

    i would end at least one of several wars we are fighting. we are spending 10's of billions of dollars on the war in afghanistan. might be a place to start cutting. that's what i'd cut. war spending. it's a win-win solution. we win budget cuts, and we win less dead 19 year olds.
  4. Chris Lillis

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    Hey Laura,

    While I agree with you 100%, how can we get around the accusations of "rationing" and "death panels" from political opponents?
  5. Sujatha Prabhakaran

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    Vouchers, unless insurance companies are mandated to keep administrative cost at the level of Medicare (2-8% compared to 11-45% for private insurance), will have to limit the amount of care participants receive. So probably not the answer.

    I agree with Laura that finding ways to address costs of end of life care and hospitalizations should probably be the highest priority if you're talking about medicare. As well as working on care coordination for dual eligibles to improve their outcomes and limit redundant services will also be important.
  6. Fred Messing

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    A critically important intelligent discussion about quality and costs! Some thoughts:

    Automatic liability protection needs to be provided for physicians who practice evidence-based care, other than for gross negligence, including not ordering fruitless end-of-life procedures. Liability reform is a Republican mantra, so this aspect may help balance the "death panel"/rationing accusations to some degree.

    2014 expansion of Medicaid is very concerning! Health services is the fastest-growing expense for most states, and expenses and utilization are clearly not anywhere near under control. Interim Federal subsidies for expanded Medicaid are an illusion: the Federal deficit has exploded, and taxpayers will be footing the bill for this added coverage whether through IRS or State taxes, along with reductions for Medicare beneficiaries and providers. Although improved universal coverage is obviously a desirable long-term goal, this timetable and coverage mechanism REALLY need to be re-thought.

    Americans, whether covered by Medicare, Medicaid or private insurance, need to assume greater responsibility for staying healthy and following medication and care protocols. Preventable/controllable chronic diseases are huge economic drains, in addition to the toll they take on the individual. Additional financial and other incentives need to continue to be rapidly developed to reward those individuals who really make the effort. (Penalties are a lot more difficult and sensitive; not as good a direction if they can be avoided, but some obvious ones (smoking for example?) might be appropriate.)
  7. Ram Krishnamoorthi

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    @Dr. Messing, thank you for saying some tough things that many people are afraid to acknowledge. May I pose some questions to you:
    1) regarding protection from liability for practice evidence-based care, how much would you expect to save? what mechanism/ structure would you envision? a set of laws that recognized specific evidence-based guidelines? which guidelines? for example, for prostate cancer screening, the Amer Urology Association, the American Cancer Society, and US Preventive Services Task Force all provide very different guidelines, with the former two being vague in some aspects. I imagine the politics of choosing which guideline set would be pretty rancorous. Or... would you envision a board of medical professionals to review torts before they went to trial to see if there was evidence or sound science behind the medical decisions, on a case by case basis? The Affordable Care Act issues grants to states who set up systems using this model, seeing whether they work to lower costs of the malpractice system and make it fairer. But how much will that really make a dent in the fast-rising rate of health care costs?

    2) Regarding the expansion of Medicaid and the goal of universal coverage. It seems that of all the controversty surrounding health care costs, rationing, and government regulatory control, the most expedient way to improve coverage rates for the working class is by expanding Medicaid. The money for supporting this increase has already been budgeted, *provided that states do not try to sidestep the need to enroll as many eligibles as they can. States' budget problems are absolutely real, dire issues. And the expensive health care system is one huge contributor. But the problem isn't Medicaid. It's the expensive health care system itself. Covering more people will increase preventive service use, improve managemetn of chronic disease, and improve access to end-of-life palliation and long term care.

    3) The need for Americans to take more responsibility for their health is agreed upon by most physicians and other observers of our health system. How do we craft incentives to promote this? When Michelle Obama recommends healthier eating, nay-sayers scream "nanny state." When physicians spend time counseling on obesity and safety, they are paid less than if they code for a number of diseases due to these problems.

    The political fights are No less fierce for any of these solutions than they were for the original battles over health reform. We *must recognize that everyone has to get dirty to dig this thing out of the ditch. Easy answers, there are none. We must first convince our colleagues to roll up their sleeves and share in the sacrifice.
  8. fred messing

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    Some very astute points! While this clearly isn't intended as a debate on the issues, but my responses would be:

    1. The liability protection should extend to widely agreed-upon professional guidelines/protocols. These wouldn't need to be "universally accepted" protocols, but sufficiently supported to make the physician's decisions reasonable and defensible. These clinical authorities would clearly differ by specialty, and where there isn't a widely accepted care approach for a particular diagnosis/problem, this particular standard wouldn't apply.

    Yes, I do think this could materially impact at least some of the significant wasted medical expenses system-wide if the various specialties take responsibility for actively developing evidence-based best practices where they appropriately can. This is certainly not intended to restrict an individual physician's use of personal professional judgement, but it can hopefully provide some comfort level that he or she wouldn't be sued for following a widely accepted care protocol irrespective of family or other pressures. Two areas that immediately come to mind are emergency rooms and intensive care units.

    2. Unfortunately, I don't agree that Medicaid as currently structured is the right model for expanded coverage. I sure wish I knew the right answer, but in my opinion conventional Medicaid isn't it. The coverage expansion plans in place will dramatically stress a system that is working poorly and negatively impact those people with other insurances vying/competing for care. I sincerely doubt these problems will be answered in the next 30-36 months when the massive increases in coverage are programmed!

    3. I agree with you. This suggestion requires a change in the philosophy and economics of healthcare insurance. However, many employers around the country are already doing some of this to lower their health insurance costs, so several incentive models are out there. Some employers price insurance coverage higher and then provide rebates for particular activities such as periodic blood pressure screenings, exercise program participation, weight management programs, smoking cessation, etc. They don't necessarily require complete success to qualify, but they do try to reward the serious efforts.

    Thanks.
  9. Ram Krishnamoorthi

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    Dr. Messing,
    I guess I would like to hear you expand on #2 above, but you're correct, this isn't a debate forum. Specifically, what is it about conventional Medicaid or Medicaid as it currently structured' that doesn't feel right to you. My guess is that the reimbursement rates are much lower than other insurers, incluidng Medicare, and providers are 'stuck' with them because the gov't requires providers to take Medicaid once they accept it in the first place. Is that correct? The health care system that is certainly working poorly (fragmented care, focus on volume instead of value, etc.) can best be reformed through the large purchasing power of Medicare and Medicaid, whose interest it is to promote a higher quality system. When private insurance is required to take wider pools of Americans and are regulated in their MLR and the premium rates (regulations that are a little arbitrary, I think), then they may have this interest as well. But private insurance companies have long been screaming at hospitals and physicians to cut their costs and have been unsuccessful, because their customers love their doctors and their medical care and hate their insurance. Recipients of Medicare and Medicaid love their insurance because they would have nowhere else to go. I do believe it comes down to some fundamentals of rights to health care access, and then the battle is over money... as usual.
  10. fred

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    (I'm a former large-hospital CEO, so my comments are from that perspective rather than as a physician.)

    Currently, Medicaid is essentially an individual "defined benefit" entitlement health plan. In an ideal world with unlimited dollars, I think we're agreed that everyone should have a high quality comprehensive plan whether through private insurance or some type of governmental option, subsidized for those who can't otherwise afford it. But (...at least for now) we live in a real world of very finite resources.

    Medicaid costs remain the fastest growing expense item for most states. Costs seem to be held down, but hardly effectively "controlled", by some combination of setting more stringent eligibility standards, denying services where they can, and reducing provider reimbursements. While everyone (at least theoretically) has access to true emergency care, this obviously leaves major holes for preventive, chronic, and other non-emergency diagnostic and treatment services. Making many more people eligible for Medicaid in 2014 might make ethical sense, but not having any effective sustainable plan to pay for it makes terrible fiscal sense.

    Some years ago, Oregon for one undertook the very difficult step of trying to identify how a series of healthcare services would potentially benefit the largest number of medically indigent people based on having different levels of available public health dollars.This approach was heavily criticized as a form of 'rationing" and not covering some hyper-expensive procedures, which is true. However, at least to me, that is one way of more ethically and appropriately allocating limited available funds to have the broadest positive health impact on the most people. I'm not suggesting that this is a "pretty" or necessarily universal solution, but I'm just saying that we should have some innovative approaches in place that actually provide appropriate care in an affordable way before digging the nation's financial hole deeper with no palatable way of getting out.

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