Medicare Blog 2: Scouting the Rapids - Part1

Yesterday, I started a series of blogs on Medicare. The thoughts in this series I will be submitting as part of the minutes to the annual Medicare Trustee's Meeting, which was held March 26th. In my last entry, I introduced the metaphor of navigating the dangers of whitewater canoeing and addressing the tenuous future of Medicare.

Disaster is not inevitable. If we act now, we can change the outcome. In health care, the core problem is that costs are rising significantly faster than costs in the economy as a whole.

Health care has done exactly that my entire life. When I was born, it was four percent of the economy. When my son was born, it had doubled to eight percent. When my first Grandson was born two years ago, it had doubled again to 16 percent.

Every piece of evidence shows the trend continuing. The problem is beyond the fact that medical cost growth is faster than that of any other part of the economy. Our problem is also demographic. Our population is aging and as we age, medical expenses grow.

Today, 12 percent of the population is 65 or older. By 2030, nearly 20 percent of us will be seniors. There is nothing we can do to change that.

We have made a decision in our society that the cost of seniors’ health care will be borne primarily by younger people who are still working. When that decision was made, it was assumed there would always be a fresh crop of earners to support the health care of their parents. That is not proving to be true. The demographic reality is there are diminishing numbers of workers per senior. This ratio will decline rapidly once the “baby boom” generation reaches Medicare eligibility age starting in 2011.

Higher and higher costs are being born by fewer and fewer people. Sooner or later, this formula implodes.

The real urgency of this problem starts between now and 2019 when the Medicare Hospital Insurance Trust Fund is projected to become insolvent. There is no backup plan in the law to ensure that hospitals continue to be paid when the Trust Fund is depleted.

Congress will not be able to sit idly by and allow the Medicare program to become insolvent—they will be forced to take action. They will have the old familiar choices of raising taxes, cutting benefits to seniors, or imposing reduced payment rates on health-care providers. Some of these choices represent the ugliest of political dilemmas, pitting a generation of workers against their parents and grandparents.

I will pick up here tomorrow and share the likely perspectives of the generational divide as I continue to scout the river on our current course for Medicare.

Comments

DRGs, RVUs,P4P,PQRI,Mandated Second Opinions, Managed Care,Preventive programs, wellness program, all of these have attempted to control rising costs. We could make cancer, heart disease,and aging illegal. Of course that is ridiculous. As you state a major problem is that demographics have changed, not enough young folks, too many old folks. Mathematically that makes sense, however there are other issues in our entire health care system that contribute to rising costs. Certainly medicare did and does fuel medical inflation. The advances in medicine are largely attributable to federal funding in research and medicare payments.
These advances were funded directly or indirectly by medicare's' payment structure, and the secondary gains of medical equipment R&D.
According to the logic we should have many more children, and encourage young immigrants to come and work here. Instead of having illegal immigrants we need to revise our immigration policies so that legal immigration can be increased. So you see it is all connected....What we need is a health care "czar' that can make all the 'right decisions'.

Posted by: Gary Levin | June 11, 2008 at 11:55 AM

The "old familiar choices" of "raising taxes, cutting benefits to seniors, or imposing reduced payment rates on health-care providers" all seem rather reasonable. What seems most practical is not to choose one of these three options, but a combination of all three. As in any political dilemma, solutions come through compromise. As long as the compromises on each side are reasonable, there is no need for things to turn ugly.

What is also drastically needed is that more people under 65 become fully insured. That way, when they reach 65, their would-be chronic health problems have been controlled, and can therefore be treated in a cheaper and more efficient manner.

Posted by: Daniel Kahane | June 11, 2008 at 06:02 PM

Let’s step back for a moment and take a look at the healthcare system. Where does the care begin? Nowadays, medical history encompasses only what the patient remembers instead what information primary physician has received throughout the years about his/her patient. Most of us go straight to a specialist and bypass a primary physician. Most medical students do not even consider primary medicine because it is not lucrative enough. Secondly, let’s not put all the blame on the government when every entity within the healthcare system has played a role in it. For example, all the physicians who perform too many unnecessary test or treatments, overcharge insurance companies, medical errors, and foremost, the cost of new technologies and DRUGS. Let’s not forget pharmaceutical companies. Has anyone looked at that lately?
What would be the quick fix? Either we pay more or we get more people to pay. Everyone knows what has caused the problem. We can go back and forth pointing fingers. Eventually, there has to be a change from ground up. People from all walks of life need to get involved. Why have some politicians decide how to pay for the necessary care when they don’t have any medical experience? Someone with MBA can not tell me what my patients need. Just as I can not talk economics. But, if you were to get us together, with a mutual understanding and a will to improve the healthcare system, than we might find a solution. And, that will remain the biggest challenge.

MPH student/ Oncology nurse

Posted by: C.S. | June 16, 2008 at 09:35 PM

The system is broken! With more retired people than those working, there is no way to pay for increasing cost of medical care. Not only is it not right to force the younger generation to cover the increasing cost of an older generation, unless drastic changes are made, the working generation will be worse off when they retire!

Furthermore, it is UNREASONABLE to assume the physicians take a reduced payment for increasing volume of patients with increasing medical problems. Do you realize how expensive it is to become a physician? or how expensive it is to maintain a quality practice? This is the light of the fact that the public demands error-free medical care, early detection of problems (i.e. cancer), and a happy resolution to all illnesses without charging the patient or the system. If, however, there is an error (even by omission) the public demands the physicians head on a silver platter! Now how can you detect disease early, prevent disease, fix current problems, and never (EVER) make a mistake or miss a subtle finding? America needs to realize that You Get What You Pay For!!

If you want free medicine, go to Canada! There is a reason all the seriously ill patients come to America for health care instead of staying in their socialized medical countries. When you socialize medicine, or, for that matter, cut physician reimbursement, you will create a very severe 2 tiered system. If you have cash, you will be seen in a timely manner, receive quality care from a physician, timely tests, and great follow-up. If you want to use insurance (or governmental health), you will wait and wait, and wait and receive care from an overworked physician assistant or nurse practicioner, few tests/procedures, and poor follow-up.
The real answer is in high deductable, tax-free personal Health savings insurance. Make the families and churches and local communities responsible for health, not the governement. Why do I have to pay more for my insurance (that I don't use) when there are so many milking the system that have cause their own health issues (obesity, smoking, diabetes, heart disease, high blood pressure to name a few). I mean if you smoke, you should not receive any community medical coverage for health conditions related to the smoking. If you are obese and have diabetes, you are on your own! Now that would save the system ALOT of money!!

All I can say is Good Luck America! When the physicians stop seeing patients, and you cannot get anyone to go to medical school (it is no longer worth the time, money, and stress)we can all thank the government for their socialism!

Posted by: ERdoc | June 22, 2008 at 10:38 AM

I am not sure if you have noticed that people of a lower socioeconomic status, older patients, and patients with chronic conditions are causing the high cost (some of it). Increase in deductibles and copayments would make it even worse. Those people CAN NOT AFFORD IT anyways. And then, when the condition gets worse, they will end up in a community hospital ER where they have to be taken care of.

Health Savings Account? Hmmm… I am young, healthy, and do not use my insurance much. Why would I put money aside now, when I need it for grad school, rent, car, and so on? On the other hand, if it’s something that’s mandated then I have to do it. COMMON SENSE! My point is, everybody has to pay!!! Part timer, full-timer, everyone. How much? That should depend on the income.

Socialized medicine? Well, it is a known factor that all other industrialized countries have socialized medicine. And they also have better health outcomes. They might not have the best resources, I agree. And those few ones that do come over for treatments, oh well, there are few from here who go to Canada to get their prescription drugs. And why do we always talk about Canada? What about France (according to WHO has the best healthcare system), UK, Germany, Japan, just to name few.

No healthcare professional should EVER forget that we need to take care of patients regardless of the reasons for their condition or their ability to pay. That is our job!!

Posted by: C.S. | June 30, 2008 at 04:41 PM

The following are ideas to better public health. The following is to answer how to keep Medicare and Medicaid financially afloat longer.
There are three types of learners. There are those who listen well. There are those who have to see things in writing or in graphs. Then there are those who learn by “hands on.” In my opinion, doctors’ visits are either too short or are done with the patient requiring doing a lot of listening. Perhaps DVDs for those patients and family members without a fast computer could be handed out to view at home. Or the DVD could be played at the doctor’s office or health facility. A Bubbled answered sheet could be filled out by patients and their family members after watching the DVDs.
For those who own a fast computer, CDs with graph handouts or pamphlets giving a reliable government health care web site could also be handed out by the health care professional. Patients’ doctors could hand out a health care web site address, such as the CDC’s web site, to patients and their families. Live streaming videos on various diseases prevention and management could be played on a government health web site such as the CDC web site. The DVDs, CDs or live streaming videos could teach people how to control and prevent diseases.
The patients and their family members could be awarded coupons to healthy foods; prescriptions, fitness equipment and/or doctor’s visit costs after watching the video and answering some questions on a particular disease. The money spent on healthy foods coupons to fruits and vegetables and perhaps healthy foods cookbooks could do the following. The savings of paying for type2 diabetes complications, for example, would more than make up the extra spending on healthy foods. The coupons could be handed out at doctors’ offices, or pharmacy stores. The coupons could also be printed on the patients’ own printer at the end of the handed out CDs or after watching the live streaming video shown on a reliable government health care web site.
If a patient does quit smoking or lose some weight, perhaps the coupon savings on such items as fitness equipment and some doctor’s visits could be paid in full. Some stationary bikes and walking treadmills could cost as little as a doctor’s visit. This would cost many times less than a type-2 diabetic complication. The educational videos could teach patients how to slowly get started exercising on these exercise equipment. The videos could teach family members what to buy at the grocery store. With other diseases, videos could teach family members on how to deal with a love one’s disease and how to help manage it.
This could help patients and their family members prevent complications from diseases through better health and wellness education.
This second part has to deal with paying for community health care and keeping Medicare and Medicaid afloat longer.
Medicare and Medicaid should be divided into divisions based upon lifestyle causing diseases. There should be a Medicare and Medicaid division that pays for smoking related diseases. There should be a Medicare and Medicaid division that pays for diseases based upon patients being over weight, such as type-2 diabetes. There should be a Medicare and Medicaid division that pays based upon alcohol related diseases, such as uninsured drunk driving cases. Each division should begin taxing products that can be associated with a set of diseases, such as emphysema and lung cancers for cigarette products. A tax could be raised on fast food to pay for future type2 diabetes as another example. A tax could be raised on alcohol products to pay for emergency services for alcohol related services and diseases.
Getting people to quit smoking or quit drinking should be fully paid by these health insurances. Perhaps DVDs could be played at tobacco and alcohol store outlets on ways to quit those unhealthy products.
Perhaps DVDs could play the down side of continuing using these products. Again coupons to quit smoking products, for example, could be handed out at these stores and bars.
The benefits for paying for lifestyle based diseases, such as emphysema, could pay a smaller percentage of the costs. Taxes on health related diseases could be raised on products associated with the various diseases. This way, the main Medicare and Medicaid portion that can pay for disease not caused by lifestyle could be held financially afloat longer into the future.
Then we all win with better health education through technologies as mentioned. Then we also keep the main portion of Medicare and Medicaid afloat longer through this kind of payment plan.

Posted by: David Thelen | July 10, 2008 at 11:27 AM

The solution to health care is not to throw more and more money at to cover the expenses of the few. There are far too many who abuse the current government systems as it is (and all the socialized countries in Europe are moving away from socialism because they are going broke!) The solution is to make everyone individually responsible. If your are dumb enough to buy a house you cant afford, you lose it. If you are dumb enough to not save for your medical care....

It is not my responsibilty as a hard working, economically fiscal person to pay for the mistakes and irresponsibilities of the community. If we are going to play "for the good of the community" game, I want free housing and free food for everyone as well!! Didn't the founding fathers say life (food, shelter, medical care), liberty (the right to pay into the system or not), and the pursuit of property?
If the government insists on supporting people, then create a system of hospitals, clinics, urgent care centers where you can go for "free" care. You can wait for 24 hrs and have limited options for treatment and testing, but it is "free." If you want to pay, the sky is the limit and the consumer will decide (not the government or the insurance company).
If we are going to "equally" share in the cost of medicine, then we should "equally" divide the resources (which europe is beginning to do). Meaning, if you are over 65, you are down the list for treatments/care (gotta save the resources for the young who have a longer life expectancy). If your life style is poor (drug, no job, criminal record, etc) your down on the list for care (gotta save the resources for the contributing members). If you are paying a larger portion into the system, you get a larger panel of treatment options (you deserve it..you paid for it!!).
Sadly, though, the country seems determined to destroy the medical system and drive quality docs out of the field. what will the ever impatient American Citizens going to do when their demand for quality customer service is not existant? They will see nurse practicioners and physician assistants who couldn't make it through medical school, and second tier docs (all the competitive, intelligent college students will chose a more lucrative, less controlled field of employment)

Posted by: ERdoc | July 10, 2008 at 01:00 PM