Medicare is a victim of its own success, and few people have recognized
the problem. It's hard to see, because it's the result of slow, steady
progress. The problem is simply that older Americans are living longer
with diseases instead of dying from them.
Consider heart disease. At Medicare's inception in 1965, the most common
evidence of heart disease was death from a heart attack. Today, millions
of Americans survive heart attacks, thanks to Medicare coverage for breakthroughs
like defibrillators, bypass operations, and beta blockers -- drugs given
in a hospital to relax the heart. But, as a result, they face a long-term
struggle with chronic heart disease. Millions more find out from cholesterol
screenings and other tests that they have a potential problem that can
lead to a heart attack.
Unfortunately, Medicare has not kept pace with medical progress and the
changing needs of patients. Four out of every five Medicare beneficiaries
have a chronic illness. For the most part, Medicare pays for their care
only when problems erupt and their illness is out of control. Medicare
pays for heart surgeries, but not for the outpatient drugs that prevent
them. It pays for the limb amputations of patients with diabetes, but
not for the extra time doctors have to spend with their patients to help
them manage the diabetes and prevent the infections that lead to amputations.
As a result, people with chronic illnesses are often adrift, and the
quality of their care is unacceptable. According to medical research,
half or more of people with diabetes, depression, and high blood pressure
receive substandard care. Nine of every 10 people with clogged arteries
continue to have high cholesterol, despite the fact that reducing cholesterol
can cut death and disability rates in half.
A prescription drug benefit is crucial, because drugs are effective in
treating chronic illnesses. But it's not enough. Patients don't gain the
skills necessary to manage their illnesses from the typical five-minute
conversation with a doctor. And doctors don't get paid for improving chronic
illness care. In fact, they can lose money by making patients healthier,
because they are paid mainly for tests and procedures on patients who
are sick.
It is time to declare war on chronic illness and stop wasting lives and
money. Patients with chronic illness need doctors and other health professionals
who will take the time to help them control their illnesses. Health care
providers need the tools, technology, and incentives to ensure that patients
get state-of-the-art chronic care.
It's not just Medicare that needs to be fixed. The rest of the health
care system treats chronic illnesses poorly, too. But Medicare is the
logical place to start because it is the nation's biggest health care
program, and Medicare patients suffer disproportionately from chronic
illnesses.
An opportunity for Democrats. Republicans are convinced that privatizing
Medicare is the answer. The initial version of President Bush's Medicare
proposal would have forced seniors to get a new drug benefit by leaving
Medicare's public fee-for-service plan and enrolling in a private plan.
The ensuing outcry over an outright privatization scheme forced the GOP
to pursue a subtler privatization strategy. Republicans hope that not
improving Medicare's public plan will cause its enrollment to dwindle,
as it becomes ever more archaic. Neglect is just the latest version of
letting Medicare's public program wither on the vine, which former House
Speaker Newt Gingrich vowed in 1995 to do.
Privatization by itself, however, won't get the job done. The unfortunate
and ironic fact is that private plans that improve care for chronic illnesses
also shoot themselves in the foot because they attract the sickest, and
thus most costly, patients with the promise of better chronic care. Of
course, Medicare can and often does pay health plans more for sicker patients.
But as long as Medicare's public plan provides low-quality care for chronic
illnesses, private plans won't have an incentive to do much better.
Democrats have a chance to move the Medicare debate beyond a paralyzing
ideological conflict. Public versus private is simply a debate over a
means to an end. Better health and longer life is the real purpose. Democrats
can demonstrate their commitment to this purpose by pursuing improvements
in Medicare for patients in both public and private health plans.
An Agenda for Fighting Chronic Illness. 1) Give doctors bigger
payments and more flexibility to provide new services, such as exchanging
email with their patients, and reward them for how much healthier their
patients become.
Imagine what a simple tool like email could mean to someone with a chronic
illness. On average, seniors see seven different doctors during 15 office
visits each year. Health care quality expert Dr. Don Berwick believes
that 50 percent to 80 percent of these traditional office visits could
be eliminated through less expensive, more convenient alternatives. They
include email, group visits for patients with similar problems, patient
support groups, and information made available on the Internet.
A pioneering physician in Portland, Ore., Chuck Kilo offers unlimited
email and telephone contact, along with same-day appointments in an office
without a waiting room. An annual fee of $300 also covers what Medicare
does not: state-of-the-art chronic illness care. Kilo works closely with
his patients and their other health professionals to develop a comprehensive
treatment plan, monitor progress, and assess the results in a continuously
improving process.
In a similar effort, the American Diabetes Association recognizes physicians
who practice state-of-the-art care for people with diabetes and report
their results for verification. Employers like General Electric have projected
significant savings from this program. They have begun paying $75 to workers
and retirees and $100 to doctors who enroll in it.
Ideally, every patient should be able to benefit from the comfort, convenience,
and continuity that are part of high-quality care for chronic illness.
At the very least, however, Medicare should help people with multiple
chronic illnesses by paying doctors more when they offer new services
like email and when they agree to be held to the highest standard of care.
2) Medicare's administrators should be accountable for improving the
quality of health care in every community.
Outdated methods of paying for and regulating health care prevent good
care for people with chronic illnesses. For example, patients whose chronic
illnesses spin out of control often end up in a hospital or a nursing
home. The funding streams for doctors, hospitals, and nursing homes are
all separate, so potential downstream savings from better chronic illness
care can't be spent up front.
One novel organization, Elderhealth in Baltimore, Md., combines the funding
streams for the doctors and hospitals that care for the elderly poor.
Elderhealth provides transportation to regular care in a clinic that takes
care of all the health care needs of the patients. It has reduced hospitalizations
by 61 percent and enabled many people to continue to live at home instead
of in a nursing home.
Such innovation, unfortunately, is more accidental than deliberate, because
Medicare's administrator, known as the Centers for Medicare and Medicaid
Services (CMS), is bogged down by its two main mandates from Congress:
Pay the bills and enforce the rules. CMS rarely finds the opportunity,
incentive, or flexibility to be innovative.
Congress should enable CMS to become a proactive manager instead of a
reactive regulator. It should enact the "CompStat" model, which
helped New York City dramatically reduce violent crime rates, starting
in the early 1990s. CompStat makes New York police precinct commanders
responsible for reducing crime, as measured by local crime statistics.
Similarly, Medicare should hold its local administrators responsible for
improvements, based on performance data that is based on scientifically
proven care that makes people healthier. (Similar data is already collected
on private health plans.)
Congress should also give CMS flexibility with regulations to make improvements,
as long as the administrator doesn't increase costs over a 10-year budget
window. CMS could then pay providers more up front to improve care for
chronic illnesses and save money over time. It could focus specifically
on the patients with five or more chronic conditions, who account for
more than two-thirds of Medicare's budget.
3) Patients with chronic illnesses need a prescription drug benefit
that not only pays for costly drugs, but also ensures that they are prescribed
safely.
Patients with multiple chronic conditions have the greatest prescription
drug costs. Along with the poor, they deserve to be the top priority for
a new drug benefit. Legislation recently introduced by Rep. Cal Dooley
(D-Calif.), based on a Progressive Policy Institute proposal, would do
just that. It would cover all beneficiaries once their drug costs reach
a high limit and provide comprehensive coverage for low-income beneficiaries
through Medicaid.
As The New York Times editorial board has said: "If Congress
does nothing else this year, it needs to help these people [the poor and
patients with high drug costs] without forcing them to leave traditional
Medicare."
Congress also needs to protect patients from harm. Older Americans with
five or more chronic conditions each fill almost 50 prescriptions a year.
They are the most likely to be among the tens of thousands of seniors
who are killed or injured every year because they receive the wrong drug
or dosage or a toxic combination of drugs. In some cases, patients unknowingly
receive a generic version of a drug from one doctor and a brand-name version
from another.
The solution here is to make better use of information technology, just
as many other fields have used it to reduce costs and improve service.
Patients should have control over their prescription drug records held
by pharmacists and health plans, so they can readily give their doctors
a current list of their medications and avoid unnecessary prescriptions.
Patients and doctors could also use these computerized records for automated
checks for potential problems.
By improving medical reimbursements for chronic illness care, by holding
Medicare's managers accountable for quality and costs, and by deploying
information technology, Democrats -- members of the party that founded
Medicare -- will have fulfilled their historic responsibility to enable
Medicare to meet the new challenge of chronic illness.
