October 15, 2009

Balking at Baucus?

Democrats and Republicans alike are balking at the Baucus proposal, the latest health care reform proposal to emerge from Congress. Not surprisingly, this enormous bill has something for everyone to hate. It attempts to legislate improvements in access and quality while simultaneously addressing cost.

But what is sometimes lost in the furor is that there are actually two kinds of costs that reform must deal with: the cost of implementing the new programs (principally the cost of requiring that most Americans have health insurance, which means subsidizing premiums for individuals with low incomes); and the rising cost of health care, principally the Medicare program, which is expected to run out of money in 2017.

The Baucus proposal has a price tag of $774 billion over 10 years (though in the last few days, various modifications have added another $28 billion), which refers to the first kind of cost. But how does the Baucus proposal address the second cost issue, containing spending?

The Congressional Budget Office predicts that total spending on health care will reach 36 percent of gross domestic product by 2035, with Medicare costs alone comprising 8 percent of GDP. The vast majority of the increase in Medicare costs will be attributable to increased spending per enrollee, not to the aging of the population. And the single most important factor accounting for the increases is the emergence, adoption, and widespread diffusion of new medical technologies.

Some of these technologies are clearly beneficial; others are beneficial to some of those who receive the new drugs or devices, but are unnecessary or even harmful to numerous others for whom they are also prescribed. And some of the beneficial technologies produce only a very small benefit but at an extremely high cost, as set by the pharmaceutical or device manufacturing industries. Effective Medicare cost control will need to go beyond appealing proposals of dubious financial benefit such as expansion of preventive services and elimination of Medicare fraud (though this could save as much as $17.2 billion per year if fraud were totally eradicated).

What else does the Baucus bill suggest? It makes three significant proposals that actually might work. Collectively, they seek to modify the culture of medicine by altering the way medical care is delivered and how it is paid for.

The beauty and the peril of its strategy is to create an infrastructure for designing a program rather than actually spelling out what the program will be. The beauty is that it does not require making politically unpalatable claims, for example that CMS may need to stop reimbursing for technologies that are not cost effective. The peril is that the various centers and institutes the plan will spawn may not in fact do what they need to in order to control costs. Just what are these centers and institutes?

The most familiar one, because it is also found in the “Affordable Health Choices Act” of both the Senate and the House, is a nonprofit patient-centered outcomes research institute. This would conduct research comparing the clinical effectiveness of medical treatments. To be effective, its work would need to translate into the CMS reimbursement policies: it would have to become an extra-government agency along the lines of the much-maligned but crucially necessary British National Institute for Health and Clinical Excellence (NICE).

The second new institution is an independent Medicare commission charged with submitting proposals for reducing excess Medicare cost growth. Strong wording would effectively require Congress to do what the commission requested or come up with a fiscally equivalent alternative. This is an example of the politically astute approach of leaving open just what the independent commission would recommend.

The third institution is an innovation center within CMS to test, evaluate, and expand different payment structures and methodologies to foster patient-centered care, improve quality, and slow Medicare cost growth. Among other endeavors, the center is mandated to pilot the development and evaluation of a system of bundled payments for a single episode of care – that is, a single payment covering care in the office, the hospital, and the skilled nursing facility. For bundling to work, doctors, nursing facilities, and hospitals will need to band together to form accountable care organizations, and Baucus promotes the establishment of these organizations by offering them a share in the cost savings they generate.

Will the research institute, the commission, and the innovation center, with it assorted pilot programs, do the job? Without knowing just what they will recommend, it is impossible to be sure. But their focus will be on the right areas: figuring out what works and what doesn’t, determining who benefits from new technologies and by how much, and developing systems of care that assure that patients get the interventions that work but not those that don’t. It’s our best shot to date.

This article appeared on the Hastings Center HealthCareCostMonitor on September 24, 2009.

Read more: http://healthcarecostmonitor.thehastingscenter.org/murielgillick/baulking-at-baucus/

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