There they go again. Now that the “death panel” lie has snookered nearly half the country, the Washington Times is going for the other half in an editorial headlined “Death Panels By Proxy.” Cue the scary music for this one:
The offending provision is on Pages 80-81 of the unamended Baucus bill, hidden amid a lot of similar legislative mumbo-jumbo about Medicare payments to doctors. The key sentence: “Beginning in 2015, payment would be reduced by five percent if an aggregation of the physician’s resource use is at or above the 90th percentile of national utilization.” Translated into plain English, it means that in any year in which a particular doctor’s average per-patient Medicare costs are in the top 10 percent in the nation, the feds will cut the doctor’s payments by 5 percent.
Forget results. This provision makes no account for the results of care, its quality or even its efficiency. It just says that if a doctor authorizes expensive care, no matter how successfully, the government will punish him by scrimping on what already is a low reimbursement rate for treating Medicare patients. The incentive, therefore, is for the doctor always to provide less care for his patients for fear of having his payments docked. And because no doctor will know who falls in the top 10 percent until year’s end, or what total average costs will break the 10 percent threshold, the pressure will be intense to withhold care, and withhold care again, and then withhold it some more. Or at least to prescribe cheaper care, no matter how much less effective, in order to avoid the penalties.
My question: Has anyone at the Washington Times actually talked to a doctor lately? Under the current system, lots and lots of people are showing up at physicians’ offices with no insurance at all. And do you know what these medical heroes are doing? By and large, they are treating them anyway. Doctors I have spoken to tell me that it is not at all unusual for them to be writing off 10%, or 20% or even more of the care they give, because their patients simply can’t afford to pay their bills.
So now, the Washington Times would like us to believe that these very same doctors will suddenly start cutting their patients off, sending them out to die, simply to earn a little more money.
Yes, this provision is designed to encourage doctors to think a little more about what kind of treatment is most effective, and to cut back on the waste and overtreatment that experts say account for 30 cents out of every dollar that is spent on medical care in this country. But to call these “death panels by proxy” is simply fear-mongering.
What’s more, the Times is wrong when it suggests the Finance Committee bill puts no focus on quality. In fact, it gives doctors incentives they don’t have now, especially in the management of the chronic illnesses that have been such a factor in driving up health costs. This from former Clinton Administration health adviser Chris Jennings (via Ezra Klein):
… I choose to focus on a couple of other diamonds in the rough. The first would be the funding for prioritization and development of quality measures linked to aggressive reimbursement incentives to physicians for reporting on these measures. (These measures, developed by health professionals, are used to promote best practices for some of the most expensive chronic diseases, such as heart disease, cancer and diabetes). I have concluded that we will never really change the way we deliver health care without the buy-in of the medical profession, which can only be secured if they develop and apply measures that can be used to empower practitioners and hold them accountable through comparative outcomes with/by their peers.
A second, and related issue, is a Finance Committee provision which gives CMS the authority to develop pilot programs to test methods of reimbursing providers for chronic disease management, (including collaborations with the states and the dual eligible program). Today, the easiest course of medical intervention is to prescribe treatment plans that deal with the effects of the disease, high cholesterol, high blood pressure, etc., rather than spending time with patients to help motivate them to take control of their health and manage their own diseases through lifestyle changes. Only when patients begin to understand that they must be the focal point of any intervention to constrain or even reverse the course of expensive chronic illness and, ultimately, produce savings, will we have made progress. The most creative part of this policy is to allow the pilots to be constructed in a fashion that waive strict budget neutrality requirements (because this has killed ideas in the past) AND allows them to expand nationally automatically (without any other legislative action) IF they can prove budget neutrality or better in the budget window. We all know that chronic illness is the primary contributor to our nation’s health-care tab – preventing and managing it is one of the absolute keys in getting the ultimate job done.
Okay, not as sexy as “death panels by proxy.” But it does have the virtue of actually being true.
MONDAY UPDATE: In this morning’s Washington Post, Lori Montgomery has an interesting story on the Medicare debate, which includes this bit of historic background:
That’s what happened after the last major assault on Medicare spending, when Clinton and a Republican Congress approved a package of cuts remarkably similar to the one now on the table. The Balanced Budget Act of 1997 was expected to save $112 billion over five years — a 9 percent reduction in projected spending on par with the 10 percent in the Baucus bill. The cuts wound up saving so much more than expected that Congress reversed some of them in 1999 and 2000, said Jon Gabel, a senior fellow at the National Opinion Research Center.
Service to seniors was largely unaffected, said Robert Berenson, a Medicare expert at the left-leaning Urban Institute who also serves on the congressional Medicare Payment Advisory Commission. “There was anguish from the hospital industry, but I don’t think anybody documented quality problems. And it dramatically added to the solvency of Medicare,” he said, extending the life of the trust fund by 15 years.