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The Voice of Jack McCallum.
There have been recent suggestions that Medicare Advantage plans are receiving excessive reimbursement from CMS as a result of “up coding” in the risk adjustment system. There are a number of reasons why these suggestions are inaccurate and counterproductive.
Lancet recently published a fascinating study of surgery in the last year of life in Medicare members. During 2008, 1,802,029 Medicare beneficiaries over 65 years of age died; one of every three of those had a surgical procedure during his or her last year of life. The study did not sort out the reasons the procedures were done, but there is a short list of possibilities. Some are likely valid, and some are less so. Surgery in the elderly can be done to relieve pain, to improve function, or to prolong life. You might point out that prolonging life or improving function in the last year of life doesn’t make much sense, but remember, no one actually knew at the time that it was the last year of life. Other reasons for doing these procedures are harder to support and include doing things just because you know how to do them (the “everything looks like a nail if you are a hammer” argument), family pressure (“You have to do everything to save her.”), and money (“There is an opening in the surgery schedule and a bed in the ICU.”).
There was one other interesting part of the study—geographical variation. These late life surgeries were 1/3 as common in Honolulu as in Gary, Indiana. The rates were especially high around the southern end of Lake Michigan and in the Rio Grande Valley in south Texas. Geographic variations are much more consistent with decisions made for cultural and financial reasons than with decisions based on clinical factors.
Most of the rhetoric surrounding the Medicare financial crisis has concentrated on cutting plan profits and decreasing provider reimbursements. There has also been a push for preventive care with the tacit (and unproven) assumption that prevention will improve health and decrease expense in the elderly. There has been some discussion (albeit hesitant) of increasing the contribution from beneficiaries or increasing the age of eligibility. What has not been emphasized is spending what is in the system more effectively. The high rate of surgery in the last year of life is one of several examples of spending a great deal of money with questionable impact of either quality or length of life. Until we have the political and societal will to have those discussions, Medicare’s financial dilemma will remain unsolved.
Last week the President outlined his proposal for salvaging Medicare. He suggested cutting $248 billion in expenditures over the next ten years. Significantly, that is only 4% of the $6.3 trillion estimated to be spent on the program in that decade. The money is to come from two places: The majority (90%) is from decreased reimbursement to providers and drug companies. The rest ($24 billion) is to come from charging beneficiaries more. What struck me was the deafening silence about spending smarter.
The Kaisers and the Mayo Clinics of this world have repeatedly demonstrated that good care is cheaper than bad care. It is worth thinking for a minute about the economics of good and not so good medicine. The plans are being urged—well, forced—to consider quality, but mostly from the point of view of HEDIS indicators that are heavily weighted toward preventive care and maintenance care in chronic illness. There is no question that those measures can improve quality of life, but the evidence that they will save money in an aging population is less compelling. There is, however, some evidence that good case management can save money, especially measures that decrease repeat and unnecessary hospitalizations and that cut down on complications of medical care.
One area that gets less attention, but one that I think would have the greatest financial impact, is to quit paying for care that has not been shown to be of benefit. Examples include very expensive chemotherapeutic agents that have not been proven to prolong life significantly, stents for completed MI’s and strokes, or complex back surgeries for elderly patients with degenerative disease of the spine. The list is much longer than that, but I would venture to guess that just those three would produce more savings than the President’s plan.