October 08, 2017

Is Medicare Entering the 21st Century?

       The do-nothing Congress may be doing something. In the immediate aftermath of the Senate’s third and hopefully final failure to “repeal and replace” the Affordable Care Act, the Senate actually passed a health care bill unanimously. With little public fanfare, it approved CHRONIC (the Creating High Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017). This bill, if it is not eviscerated or rejected by the House, takes a few important steps in the right direction.
         As a useful summary in the Health Affairs blog explains, the bill supports changes in four domains: home based care, managed care, telehealth, and accountability. In the arena of home based care, the law extends the successful “independence at home” demonstration project for two years, increasing the number of participants from 10,000 to 15,000. This is a relatively small modest program that does something critically important for some of our sickest and most complex patients—it moves the nexus of care from the hospital and the office into the home.
         In the area of managed care, the law does something quite remarkable. It incentivizes further use of Medicare Advantage programs, a long-standing Republican objective since they see Medicare Advantage as a way of privatizing Medicare. But one of the ways it does this is to allow programs to expand benefits to include social supports and help with activities of daily living. It’s a tiny wedge that could signal the beginning of a recognition that social factors contribute to health. This is the message of the book, The American Health Care Paradox by Elizabeth Bradley and Lauren Taylor  in which they argue that the reason Americans spend so much more per capita on health care than any other developed nation—and achieve poorer results—is that we substitute medical benefits for social benefits, to the detriment of well-being. We are a long way from allowing federal money to be used to pay for gardening supplies, say, so that a person with dementia would be happy puttering around at home and not become agitated and restless, perhaps triggering pharmacological treatment or even nursing home care, as has happened in the UK. But it’s a start.
         The telehealth expansion is another one of those strategies, such as electronic medical records, that on the surface is very appealing, but for which the evidence of effectiveness is mixed. It feeds nicely into the conviction that there are technical fixes to the American health care system, rather than major structural problems that must be addressed. Probably not the best use of scarce resources, but not a terrible idea.
         Finally, the Act mandates that the GAO carry out three investigations to assess the consequences of various strategies that have been piloted or proposed. One of these is a special reimbursement code for physicians to formulate a comprehensive care plan for patients with certain serious conditions. Another is whether Medicare Part D should lift its ban on drugs that help patients lose weight. The GAO is usually thorough and unbiased in its evaluations. All sound efforts at systematic evaluation—as opposed to wholesale, uncritical adoption of policies and programs—should be supported.
          Will the House pass the bill? Will it discover the most interesting parts of the legislation, ie the provision that lets Medicare Advantage programs offer benefits that are not “medical” in the conventional sense? We shall see. Tell your representative that if s/he wants to take credit for something, this would be a good place to start.

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