Big Dog, Big Doo-Doo
By Maureen K. Reed, M.D., F.A.C.P.
The biggest problem in the current health care system? Let’s talk payment. And given that Medicare is the biggest dog on the block, let’s talk Medicare payment. Its woes are legion and well-known: A morass of complexity. A methodology that rewards doing rather than thinking and listening. A formula created decades ago that systematically punishes states like Minnesota that have low costs for care delivery.
Within the health care world, the consequences of the Medicare payment system are far-reaching, lethal, and expensive. It seriously discourages preventive care. It encourages futile, inefficient, and duplicative treatments. It is indifferent to which form of care is best or of greatest value. It discourages coordination of care. It creates a huge gap in earning potential between cognitive and interventional specialties and arguably is responsible for the demise of primary care. It drives overcapacity of medical infrastructure. It spawned an industry of coding consultants and regulators. It requires armies of FTEs in every medical facility to document, code, and bill and in every insurance company to check, re-check, and deny claims. It devalues the contributions of nurses, pharmacists, therapists, and other health professionals. And it drives dedicated, hard-working professionals to deep cynicism as they chase the “production” formula.
Because of those consequences, Medicare payment is a main engine of overuse and misuse. This in turn drives health costs ever higher, with health care now playing the role of budget-buster for government, institutions, businesses, and families. As health care costs increase and consume a larger and larger portion of everyone’s budget, fewer dollars are available for transportation, education, business development, public health, and real wages.
So what’s the answer to the woes of the current Medicare payment system? Frankly, there are many. All are imperfect, but almost all are better than the status quo. Most have been discussed at length in recent issues of prominent medical and business journals. They include global payment, capitation or partial capitation, all-payer or single-payer regulation, value-based payment, and more.
The resistance to changing Medicare payment often takes the form of technical criticism of a proposed alternative. But resistance has less to do with the many technical challenges of developing and converting to a new payment method that it has to do with human challenges such as fear of losing income, status, and power. And in this day and age, resistance to Medicare payment reform also has to do with the deep desire on the part of some political leaders to deny success to those on the other side of the political aisle.
We must address Medicare payment reform not as a discussion of technicalities but as a discussion of the political and human dilemma that is at the heart of the resistance to payment reform. How do we do this? Analyzing the payment reform problem through the lens of author Paul Kivel’s classic political triad of “who benefits, who pays, and who decides” is a good place to start.
Then we should couple Medicare payment reform with other political issues that demand immediate resolution. Health care reform is one such burning issue, and we must not let this opportunity pass. It would be most unfortunate indeed if Medicare payment reform went the way of mental health parity, languishing for years until finally being attached to unrelated-but-urgent legislation.
Additionally, we in Minnesota should find allies wherever they exist and vigorously insist on reforming the underlying Medicare inequities. We should insist on a broad Medicare waiver that allows our state or region to engage in extensive and immediate payment reform that cannot even be contemplated by most other states. And in so far as possible, we should offer solutions that place payment reform in the hands of bodies less political than Congress. This is not a new idea; but the current urgency of health care reform gives this approach more potency.
Finally, we should not be so wedded to our own favorite method of payment reform that we are unable to engage in the political compromise necessary to end the current fee-for-service system. Medicare payment is one Big Dog. It’s time we held our noses, donned plastic gloves, and got on with the not-so-pleasant task of cleaning up the mess.
Maureen Reed practiced internal medicine for more than 20 years, was previously the medical director at HealthPartners, and served on the 2007-2008 Governor’s Health Care Transformation Task Force. She is a DFL candidate for Minnesota’s 6th Congressional District.