Several years ago, I was talking with a hospitalized patient whose kidneys were failing about the difficulties she faced accessing care. She was reluctant to see a primary care physician because she did not have insurance so preferred to wait until things got really bad. During that hospital stay, I had to give her the bad news that she would need dialysis. Unexpectedly, she actually smiled. She knew she could now get insured through Medicare. After I left her room, I had a conversation with my residents about how Medicare, the landmark legislation that has stood the test of time, is much more than just health insurance to some people. It was hope for a cure.
Medicare turns 50 years old this year. For half a century it has been our nation's insurance plan for our seniors and those with end-stage renal disease on dialysis. While Medicare has been the primary way that our nation's seniors afford healthcare, my patient's story also highlights how Medicare is far from perfect. There is much to be done in the next 50 years.
So what does Medicare 2.0 look like? Currently, Medicare places a higher dollar amount on volume as opposed to value. This means we are paid more when a diabetic patient gets an amputation than when the diabetic patient is kept out of the hospital with better control. My patient's example is a stark one. One day you don't need dialysis and you are uninsured, the next day you have end-stage renal disease but, congratulations, you have insurance. This is the method of congressional testimony that influenced this decision.
Fortunately, change is on the horizon. Recently, the Center of Medicare and Medicaid Services has stated their goal of moving from volume to value for 30% of their payments. It is the hope that bundled payment will incentivize healthcare systems to keep Medicare beneficiaries healthy and out of hospital. With bundled payment will surely come changes in how physicians are reimbursed. While certain fears loom, the status quo is unbearable. Too much time every year has been spent by policymakers, physicians, and Medicare recipients on worrying about whether their doctor will accept Medicare because of the ongoing debates on what to do with the SGR, or the sustainable growth rate, which caps the growth in Medicare spending so it doesn't exceed the increase of growth in GDP. Because healthcare spending always outpaces general spending, this has left physicians scrambling every year to avoid a massive salary cut and a congressional 11th hour "fix"17 times since 1997!
It has been 9 years since I personally testified to the House Energy and Commerce Committee on my birthday about the need to fix the dysfunctional reimbursement system. Clearly, I did not get my birthday wish. And on April 1st (and no this is not an April Fool's Joke), because of a failure by the Senate to act before recess on an unprecedented bipartisan House Bill to rehaul the way Medicare pays doctors, a 21% cut in Medicare physician reimbursement goes into effect. While the Senate plans to deliberate upon returning from recess, this is a lot of wasted time and effort in a system trying to reduce waste.
In fact, Medicare would benefit from a massive kaizen event, with an effort to eliminate red tape, paperwork, and practice hassle. As any medical intern will tell you, the rule for Medicare patients to spend 3 nights in the hospital before they can be eligible to get coverage for rehabilitation does not make any sense. Fortunately, there are experiments underway to get rid of this rule.
So while I celebrate the 50th year of Medicare this year, I look forward to these future changes and seeing how things develop over the next 25 years ... at which point I will hopefully still be eligible for Medicare.
Vineet Arora, MD, MAPP, is a hospitalist physician at the University of Chicago where she seeks to improve the quality, safety, and value of care delivered by medical trainees. She is also the Director of Educational Initiatives at Costs of Care www.costsofcare.org, a 501(c)(3b) organization that aims to deflate medical bills for patients, and an author of the recently published book, "Understanding Value-Based Healthcare."