Health care spending in the U.S. has been out of control for several decades. It’s unsustainable and the two candidates for president have conflicting approaches.
The Romney/Ryan way is to ration care by cost. If you don’t have the money you are out of luck, we might let you go to an ER.
The Obama administration’s reform, modeled ironically after the Massachusetts law which once was Romney’s great achievement, decreases spending by focusing on improved efficiency. This Health Affairs piece highlights the approach to one of the most expensive patient care groups, the Medicare/Medicaid dual eligibles.
Here’s what ineffective care in our current non-system looks like:
Mary, like most of her counterparts, has never had a primary care relationship because primary care with the skills, intensity, and organization to meet her needs doesn’t exist. Instead Mary, like most of her peers, receives care from an array of specialists — in her case, Neurology, Pulmonary, Orthopedic, Gastrointestinal, and Endocrine specialists in three different non-communicating hospital systems — with no one capable of, or responsible for, providing the totality of her care. Thus Mary’s years of so-called “independent living” have been characterized by multiple recurrent hospitalizations for entirely predictable complications: pneumonia (in one case requiring a 14-month stay in a Medicaid-funded, post-acute respiratory rehabilitation hospital); poorly controlled diabetes; seizure management; and functional GI problems, with overall health, and functional decline.
These are the most expensive patients to care for and at present we do little to coordinate and anticipate their problems.
Massachusetts has instituted programs, many of which are in the President’s health care reform program to provide better, and it should be noted less expensive care to these patients. An assessment of their approach showed:
- According to a Lewin Associates study commissioned by the SNP Alliance, hospital admissions and days were 56 percent of the risk-adjusted Medicare dual-eligible FFS experience (2009 to 2011).
- The NCQA risk-adjusted 30 day hospital readmission rate in 2010 was 4 percent compared with the median Medicare Advantage program rate of 13 percent (99th percentile).
- The permanent nursing home placement rate for nursing home certifiable members between 2009 and 2011 was 34 percent of that seen in a Nursing Home Certifiable frail elder population in FFS care.
- The seven year annual average total medical expense increase is 3.3 percent and 2.8 percent for nursing home certifiable and ambulatory, enrollees respectively, well below the Medicare trend.
- CMS Quality Star Ratings of 4.5 Stars ranked in the 90th percentile of all Medicare Advantage Plans and the 99th percentile of all Medicare Advantage Special Needs Plans in 2010 and 2011.
- Multiple evaluations of the younger disability care program over many years found a high degree of satisfaction, a 60 percent reduction in hospitalizations, and a 50 percent reduction in surgical flap procedures for pressure sores in a spinal cord injured subpopulation.
Medicynical Note: The President’s health reform not only assures health care coverage, but has the capability to encourage more efficient services.
The Romney approach, farms out coverage to private insurers. His does not mandate use of community ratings to determine rates. That means a private insurer could and would charge whatever they wanted to dissuade people from choosing their plan–they really, really don’t want sick people in their covered patient pool. Furthermore, with the dismantling of Medicare and to a great extent Medicaid that Romney envisions there would be no pressure to develop better, more efficient care for these patients.
This election is crucial for health care in the U.S. and more than a choice of insurers is at stake. In the end I suppose we’ll get what we deserve!
Medicynic 
