Wednesday, October 09, 2013
This is getting scary
I like to think that I've had a productive research career so far, that the methods I've developed are promising, and that I have a chance in the years I have left to help people take better care of themselves, work more effectively with their physicians, prevent some bad outcomes, and even save us all money in the process. But I've only been able to do this because the American people have valued medical and health services research, and been willing to pay for it. If that isn't true any more, my work is over. I'm not sure what other kind of job I can get right now, but I need to start thinking about it. That's kind of sad.
Anyway, in case you didn't know it, the work we do is essential if we're going to provide a decent level of Medicare benefits to the growing elderly population in the coming decades. That is a legitimate concern. No, not the spending on food stamps and environmental protection and food safety and veterans benefits and Headstart and diplomacy and highways and bridges and all that stuff that the Republicans have already cut and are demanding to cut further. But the long-term fate of Medicare is a real problem.
But here's the fact: we don't have to limit benefits or make seniors pay more out of pocket or even means test Medicare. (Which maybe sounds like social justice but is a very bad idea politically and would save scarcely any money.) We can get most of the way there by getting more bang for our bucks. Figuring out how to do that is what we do. And we actually understand the problems, unlike the interchangeably ignorant Rand Paul and Paul Ryan.
Here are a couple of examples from the new JAMA. They're very wonky, and I think you'll be stopped at the abstract anyway, which is probably a blessing. Lewis Lipsitz discusses the so-called 3-Night rule, and Steven Landers discusses the future of Medicare home health benefits.
The 3-Night rule is that in order to qualify for care in a Skilled Nursing Facility (SNF), you first have to spend 3 nights in the hospital. Back when the rule was created, it usually took that long for proper assessment and stabilization of whatever acute episode the person had suffered. The rule was intended to make sure people didn't receive skilled nursing care, which is quite expensive, unnecessarily. But, nowadays, it's often the case that somebody come into the ED and they can quickly receive whatever acute services they need and could be immediately sent on to a SNF without even being admitted. However, if that happens, Medicare won't cover the bills in the SNF, which few families can afford. What often happens is that doctors end up keeping people for three nights, just so they'll qualify, but hospital care is even more expensive than SNF care. Also, being in the hospital is bad for you, especially if you're old and frail.
So why not just bag the rule? Well, a funny thing can happen. If people who are in a nursing home but not receiving skilled nursing care, the nursing home gets a relatively low reimbursement. If the person has some sort of a setback, the facility can decide to start charging the SNF rate even if the person doesn't really need skilled nursing care. If they have to send them to the hospital instead, and get a doctor's authorization, they can't get away with that. The result is that waiving the 3-Night rule so far has not consistently demonstrated cost savings. But, if you structure payment and regulation correctly, you could indeed get both cost savings and better experiences and outcomes for patients. It takes policy wonks to figure out how to do this correctly, and well-designed trials and data analysis to prove what works and what doesn't.
There are similar issues with home care: how to get people the services they need, that can keep them at home and out of the hospital or nursing home, without overpaying or inviting fraud. If we can figure out how to do these things correctly, along with many other challenges, we can make Medicare much more sustainable while taking better care of people. But that takes a) investment up front and b) honesty and wisdom from politicians who prefer to exploit fears about Medicare to scare people into voting against their own interests. I'm talking to you Paul Ryan.