The Politics of Medicare Part 3: An easy fix that no one wants to touch.
September 19, 2016
It is somewhat perplexing that as Medicare is draining our federal coffers, as we are spending almost a trillion dollars in wasted medical dollars, as we are enriching many doctors and institutions but are falling farther behind in health outcomes, as thoughtful and compassionate health care is being replaced by protocol driven doctors staring at computer screens, our political leaders and candidates are entirely ignoring the need for genuine medical reform. Yes, there are pundits and academics weaving together a patchwork of “reforms” that have yet to save us any money and that typically generate more paperwork and protocols for doctors and patients, raising the dissatisfaction of both. I talk about those at length in my book. As an example, I am part of an organization that hopes to save the system money by rewarding me if my patients follow generic protocols (in other words, they do not make their own choices in terms of care) and they spend less Medicare funds. Just last week the head doctor of the group sent us all an email telling us to try really hard to make sure our patients don’t go the hospital too much or get too many “unnecessary” procedures. And yet, in a cruel irony, Medicare continues to pay and encourage patients to go to the hospital and to see specialists who are paid well to order a lot of procedures, so here we are being judged by something over which we have no control. That is Medicare reform in 2016.
My book, and many of my blogs, outline why aggressive specialist-based care is detrimental to older people despite what Medicare’s protocols, so many medical organizations, doctors, and the media may proclaim. And yet, as I show, Medicare allows and encourages that very type of care. I also discuss simple common sense solutions that would retrieve Medicare from its mire and would improve health outcomes and patient satisfaction. It is very easy to change the system when we understand the problems, and to arrive at that point it is important to talk to practicing doctors and patients. What are the problems that pushing up Medicare’s costs and pulling down its quality? These are a few:
Currently procedure-oriented doctors are being incentivized to perform more procedures, despite their often harmful effects, and are paid astronomical amounts of Medicare dollars to do so. I have discussed this in other blogs, especially in regard to cardiac tests and procedures, and there is nothing in the docket of reforms that in any way confronts the problem. When you allow a cardiologist to decide when his/her patient needs a heart stent (something called self-referral, a blatant conflict of interest), to not hold that doctor accountable for explaining actual risks and benefits of the procedure, for relying on a secret of the AMA to decide what to pay that doctor for the procedure (typically one such procedure is paid as well as an entire day of patients for a primary care doctor like me), and to allow doctors to own the facilities where those procedures are being conducted (such as with colonoscopy; the facility fee is far higher than what the doctor gets for the actual procedure), then you have created an environment where a handful of procedure-oriented doctors are over-testing and over-treating patients, often to the patients’ detriment, and are becoming wealthy by feasting on these procedures, thus draining Medicare’s funds without helping anyone but themselves. Politicians feel as though they cannot assail this policy or they will be subjected to claims—generated by self-interested physician groups—that they are inserting themselves between doctors and patients. Doctors are not saints; currently they are being paid to carry out a great deal of unnecessary interventions, which they are doing in excess. This must stop, and Medicare alone has the power to stop it.
Patients, especially those who are elderly and impaired, are forced into the hospital when they are sick or are unable to care for themselves at home. Medicare will not pay for home care, which is less expensive and usually more beneficial than hospital care, and which is what the vast majority of elderly patients and their families want. Medicare pays for and incentivizes hospital care for patients, doctors, and facilities. This is insane, and fixing it would by itself save Medicare billions of wasted dollars.
We are becoming a medical society dominated by specialists. Studies have shown that in areas with high specialist concentrations care is more expensive, medical outcomes are worse, over-treatment and hospitalization are rampant, and patient satisfaction is reduced. Few students enter primary care fields, and primary care is being pummeled by Medicare reforms, driving many out of the field. The fix to this is actually very simple and is completely in Medicare's hands.
Patients have no means of learning which tests and procedures and medicines are best for them. They must rely on doctors who are not encouraged or taught how to explain actual risks and benefits of interventions, and who are often paid more if the patients are less involved in decision making; on the press which sensationalizes medical studies and relies on academic doctors for information who have incentive to exaggerate results; and on pharmacy ads and the internet which are intentionally deceptive. Thus, despite a lot of talk to the contrary, Medicare is not enabling shared decision making, which by itself would dramatically reduce over-treatment and cost. In fact, Medicare reformers are actually incenting doctors to do just the opposite. Patients are very intelligent; give them the facts, give them multiple options, and they will often pick what is least invasive and thus least expensive. By denying patients that power, the health care is being controlled only by those who profit from our current dysfunctional system.
So, how do we fix this? It’s time we stop relying on complex and convoluted solutions and just tackle each problem directly. There is some movement in a sensible direction, but it is slow and complicated. It does not have to be. Here is a simple way to start, and one that should not offend any politician or cross party lines. Certainly many organizations that pay politicians to advocate for maintaining the status quo—pharmaceutical companies, the AMA and other specialty medical groups, hospital organizations, and others—will fight common sense change. But unless we want Medicare to financially implode and morph into a protocol-driven monstrosity that is antithetical to the needs of doctors and patients, we have to start rationally addressing what is wrong with the system. It is time politicians step up and do the right thing. It is actually very easy!
Eliminate self-referral. Before patients get expensive and potentially dangerous procedures, they will need to see a primary care doctor who is trained to discuss risks and benefits with them. After that visit the patient can decide which course to take and which specialist to see. Physician reimbursement for procedures should be reduced to amounts that are similar to the amount the primary care doctor is paid to discuss the procedure, and doctors should not be able to own or have interests in facilities where procedures are performed.
Medicare will pay for home care to the same degree that it now pays for hospital care. Patients will have a choice of whether to be treated at home or the hospital after consultation with a doctor (in the office or via tele-medicine), and the cost and ease of either option will be similar. Treating a patient at home will be as logistically easy for a doctor to arrange as would a trip to the hospital. Also, hospitals will be directly involved in home care, and they will be paid similarly whether a patient is treated at home or in the hospital.
We will increase the number of primary care doctors in two ways, both of which can be instituted by Medicare immediately. First, it is time that specialists do not earn $200-300 thousand dollars a year more than primary care doctors. This can occur by simply altering how much doctors are paid for procedures, something done in the AMA’s secret committee; doctors who think need to be rewarded as much as doctors who do. Also, Medicare directly subsidizes medical residents at the tune of several hundreds of thousands of dollars per resident by paying hospitals for their training. Therefore, it is time that Medicare pays for more primary care slots, and fewer specialty slots. That is simple enough.
Finally, Medicare can be the instrument that designs and promotes patient-oriented tools that help patients to understand actual risks and benefits of medical interventions. Patients cannot rely on doctors, advertisements, the media, and the internet to acquire information. Similarly, doctors in training need to be taught how to discuss interventions with patients using actual risk/benefit information, something sorely neglected now. Currently Erik Rifkin and I have created such a system with our BRCTs. Other sites include Tamden in Consumer Reports and an internet site called the NNT. Regardless of the specifics, Medicare has the power and ability to generate a simple to understand graphic/discussion that patients can use to advocate for themselves and be active participants in medical discussions.
To some people this is all too simplistic. To others, it gets in the way of the doctor-patient relationship. There will always be those who reject everything that makes sense. They have their reasons. They will try to make it more political than it has to be. But saving Medicare has to be on the top of our political agenda, and it is irresponsible to simply say we will fix it by implementing a hodge podge of burdensome reforms, by claiming that by shoring up the economy it will fix itself, or by expanding it to even more people. The problems are straightforward, and the solutions can be simple. It’s time that politicians sit down, look at each other across the aisle, and have an adult conversation. Really, it’s not very difficult!