The New America Foundation, a left wing think tank in Washington, has just issued a white paper entitled Realigning US Health Care Incentives. It is an attack on Medicare plain and simple. It also is a concerted effort by the managers of large Hospitals to drive the independent physicians out of business and to get them aligned with the hospitals. It is a move using those covered by Medicare to drive a wedge between their health care providers and their needs as patients. The speech today by the current President re-intensifies this attack.
The report starts by stating:
"Health reform must make quality health care and health insurance affordable and accessible to all. In order to achieve the goal of quality, affordable coverage for all, we support: (i) Health insurance exchanges or new marketplaces to help consumers compare and choose the health plan that is right for them (ii) Reforms that end insurance discrimination based on age, sex, and health status, including: guaranteed issue, community rating, and a ban on pre-existing condition exclusions, (iii) Subsidies financed through broadly shared responsibility to ensure coverage is affordable, (iv) A requirement that individuals obtain coverage, once such coverage is accessible and affordable..."
This appears as a broad statement suggesting that they intend to look at health care in general. However they soon target Medicare. Remember that in our previous analysis we have demonstrated that those receiving Medicare have more than paid for their care. They have contributed to the system for forty years and the contribution exceeds any draw that they will make upon the system. At no point do the authors ever take recognition of this fact. Why should they, they want to remove coverage from the elderly and just allow them to go their way despite having contributed to their care well in excess of any other group.
They start their attack by saying:
"Over the next 10 years, we can reduce system-wide cost growth by far more than many think, enough to save $500 to $600 billion in the Medicare program alone. This level of cost growth reduction can be achieved while simultaneously improving the quality and patient-centeredness of care. Over time, this money could help fund coverage expansions, improvements to Medicare and Medicaid benefits and payment rates, and deficit reduction. We describe reforms that will make these savings possible in the remainder of this paper."
Where is the focus on the obese 30 year olds who will cost many times more with their Type 2 Diabetes and resulting mobidities? Not a word of that. They continue:
"Improving health care quality is consistent with reducing health care costs, which is essential to fund coverage expansion and make Medicare and Medicaid more sustainable for generations to come. To reach these goals, we must develop, pursue, and implement strategies to achieve greater value for the American health care dollar. We will not control health care costs until we create clear incentives for providers – the people who deliver care – to focus on quality and efficiency. Likewise, patients must be encouraged to make healthier choices through changes to their incentives. This will require exemplary and even courageous provider leadership and significant cultural change."
What does this mean? Simply they want quality. Frankly we have no idea what quality is. There is the Demming quality which applies to manufacturing, a term which means that we want to lower costs on production by reducing errors. However quality in health care is akin to pornography in law, you know it when you see it. The patient knows quality care by the way the patient is treated, not by whether they live or die. Death can be a quality experience if the human dignity is preserved.
If as this paper and the current Administration propose the dignity is removed and the costs are reduced. One may never again achieve even death with dignity and thus we would argue that quality is lacking. One view of quality is the Pirsig view, with its warts and all, where quality is a contradistinction to quantity, it is the opposite of the Demming model and akin to the legal world view we proposed. Value is another term for quality in the discussion as well and we have equally rejected the value metric as proposed by Porter.
They then look at the comparative clinical effectiveness model. They state:
"We can identify overuse, underuse, and misuse and implement best practice processes....Comparative effectiveness research, best practice information, and decision support tools will enhance the doctor-patient relationship."
We have argued that the CCE proposed here and elsewhere has the potential of being both a means to ration health care and also to push down costs on the providers in an attempt to eliminate the sole or small group provider.
They then address specific proposals:
"Fee-for-service payment is unsustainable. Medicare will lead a concerted effort to end fee-for-service payments for individual services within five to seven years. Further, Medicare will cooperate and collaborate with private payers to transition the entire delivery system away from fee-for-service payment and toward outcome-driven bundled payments that encourage provider accountability through full and partial risk contracts within 10 years..."
This means that the patient will lose any and all flexibility in selection providers. Thus if one has ovarian cancer or breast cancer and is covered by Medicare then they will tell you who to see and where even if say the best procedures are at Memorial Sloan Kettering rather than your local hospital. You the patient will be shelved and just allowed to die!
They then continue:
"Providers will be held accountable to reasonable cost and quality standards at a specified date...More efficient, value-based incentives will lead to higher-quality, lower-cost care."
The authors use quality and value dozens of times without ever addressing the definition. Is it the Pirsig definition, goodness, or the Demming definition, low failure rate. The patient knows.
They then start with the bundling argument:
"Develop and transition toward bundled payment models. Medicare should begin a concerted and focused effort to develop and implement payment bundles to enable a widespread transition from fee-for-service payment....Eventually, all clinicians will have strong incentives to move toward more integrated models of care that allow them to accept full responsibility and reward for high-quality patient care and patient outcomes...1. Comprehensive services with shared risk....2. Complete chronic care....3. Ambulatory chronic care....4. Acute episode."
These four bundles are discussed. As we have argued before the bundling puts the hospital and the Government in charge It institutionalizes an old paradigm for delivery ensuring lower care quality, here I mean a Pirsigian goodness term, and higher costs. We have argued this in detail with financial models demonstrating the results.
They end with Medicare changes they feel are required:
"Reform Medicare Advantage payments to drive quality and innovation...Improve the quality and patient-centeredness of end-of-life care through advanced planning and palliative care...."
They seem to have difficulty with getting away from the use of quality, without ever defining it. The focus on end of life care is really warehousing the old and dying. Hopefully those on or soon to be on Medicare, and who have paid for what they are due, will understand this fact.
Why the attack on Medicare. Because the Government controls it. What does this mean for non-Medicare patients, well simply if the current Administration gets its way with a Government plan, and then a single payer plan, namely the Government, then Medicare is just the training ground for doing this to everyone! It is the old adage; first they came for the old, and I said they are old anyhow, then they came for the young and I said well no matter they are just young kinds anyhow, and then they came for me, and I had no say at all!
Why is this important, because entities like the New America Foundation are feeders to the White House, they create "policies" and give them a patina of acceptance. What happens when they come for their parents, then their children...but they are them!
The report starts by stating:
"Health reform must make quality health care and health insurance affordable and accessible to all. In order to achieve the goal of quality, affordable coverage for all, we support: (i) Health insurance exchanges or new marketplaces to help consumers compare and choose the health plan that is right for them (ii) Reforms that end insurance discrimination based on age, sex, and health status, including: guaranteed issue, community rating, and a ban on pre-existing condition exclusions, (iii) Subsidies financed through broadly shared responsibility to ensure coverage is affordable, (iv) A requirement that individuals obtain coverage, once such coverage is accessible and affordable..."
This appears as a broad statement suggesting that they intend to look at health care in general. However they soon target Medicare. Remember that in our previous analysis we have demonstrated that those receiving Medicare have more than paid for their care. They have contributed to the system for forty years and the contribution exceeds any draw that they will make upon the system. At no point do the authors ever take recognition of this fact. Why should they, they want to remove coverage from the elderly and just allow them to go their way despite having contributed to their care well in excess of any other group.
They start their attack by saying:
"Over the next 10 years, we can reduce system-wide cost growth by far more than many think, enough to save $500 to $600 billion in the Medicare program alone. This level of cost growth reduction can be achieved while simultaneously improving the quality and patient-centeredness of care. Over time, this money could help fund coverage expansions, improvements to Medicare and Medicaid benefits and payment rates, and deficit reduction. We describe reforms that will make these savings possible in the remainder of this paper."
Where is the focus on the obese 30 year olds who will cost many times more with their Type 2 Diabetes and resulting mobidities? Not a word of that. They continue:
"Improving health care quality is consistent with reducing health care costs, which is essential to fund coverage expansion and make Medicare and Medicaid more sustainable for generations to come. To reach these goals, we must develop, pursue, and implement strategies to achieve greater value for the American health care dollar. We will not control health care costs until we create clear incentives for providers – the people who deliver care – to focus on quality and efficiency. Likewise, patients must be encouraged to make healthier choices through changes to their incentives. This will require exemplary and even courageous provider leadership and significant cultural change."
What does this mean? Simply they want quality. Frankly we have no idea what quality is. There is the Demming quality which applies to manufacturing, a term which means that we want to lower costs on production by reducing errors. However quality in health care is akin to pornography in law, you know it when you see it. The patient knows quality care by the way the patient is treated, not by whether they live or die. Death can be a quality experience if the human dignity is preserved.
If as this paper and the current Administration propose the dignity is removed and the costs are reduced. One may never again achieve even death with dignity and thus we would argue that quality is lacking. One view of quality is the Pirsig view, with its warts and all, where quality is a contradistinction to quantity, it is the opposite of the Demming model and akin to the legal world view we proposed. Value is another term for quality in the discussion as well and we have equally rejected the value metric as proposed by Porter.
They then look at the comparative clinical effectiveness model. They state:
"We can identify overuse, underuse, and misuse and implement best practice processes....Comparative effectiveness research, best practice information, and decision support tools will enhance the doctor-patient relationship."
We have argued that the CCE proposed here and elsewhere has the potential of being both a means to ration health care and also to push down costs on the providers in an attempt to eliminate the sole or small group provider.
They then address specific proposals:
"Fee-for-service payment is unsustainable. Medicare will lead a concerted effort to end fee-for-service payments for individual services within five to seven years. Further, Medicare will cooperate and collaborate with private payers to transition the entire delivery system away from fee-for-service payment and toward outcome-driven bundled payments that encourage provider accountability through full and partial risk contracts within 10 years..."
This means that the patient will lose any and all flexibility in selection providers. Thus if one has ovarian cancer or breast cancer and is covered by Medicare then they will tell you who to see and where even if say the best procedures are at Memorial Sloan Kettering rather than your local hospital. You the patient will be shelved and just allowed to die!
They then continue:
"Providers will be held accountable to reasonable cost and quality standards at a specified date...More efficient, value-based incentives will lead to higher-quality, lower-cost care."
The authors use quality and value dozens of times without ever addressing the definition. Is it the Pirsig definition, goodness, or the Demming definition, low failure rate. The patient knows.
They then start with the bundling argument:
"Develop and transition toward bundled payment models. Medicare should begin a concerted and focused effort to develop and implement payment bundles to enable a widespread transition from fee-for-service payment....Eventually, all clinicians will have strong incentives to move toward more integrated models of care that allow them to accept full responsibility and reward for high-quality patient care and patient outcomes...1. Comprehensive services with shared risk....2. Complete chronic care....3. Ambulatory chronic care....4. Acute episode."
These four bundles are discussed. As we have argued before the bundling puts the hospital and the Government in charge It institutionalizes an old paradigm for delivery ensuring lower care quality, here I mean a Pirsigian goodness term, and higher costs. We have argued this in detail with financial models demonstrating the results.
They end with Medicare changes they feel are required:
"Reform Medicare Advantage payments to drive quality and innovation...Improve the quality and patient-centeredness of end-of-life care through advanced planning and palliative care...."
They seem to have difficulty with getting away from the use of quality, without ever defining it. The focus on end of life care is really warehousing the old and dying. Hopefully those on or soon to be on Medicare, and who have paid for what they are due, will understand this fact.
Why the attack on Medicare. Because the Government controls it. What does this mean for non-Medicare patients, well simply if the current Administration gets its way with a Government plan, and then a single payer plan, namely the Government, then Medicare is just the training ground for doing this to everyone! It is the old adage; first they came for the old, and I said they are old anyhow, then they came for the young and I said well no matter they are just young kinds anyhow, and then they came for me, and I had no say at all!
Why is this important, because entities like the New America Foundation are feeders to the White House, they create "policies" and give them a patina of acceptance. What happens when they come for their parents, then their children...but they are them!
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