A Call To Doctors From Medicare/Medicaid Chief: Advocate For The Poor

By Audrey Dutton, The Idaho Statesman, Boise

April 11--Just a few months after President Barack Obama got Congress to pass his health care overhaul plan, he appointed Dr. Donald Berwick during a congressional recess to run the Centers for Medicare and Medicaid Services. Berwick held the job from July 2010 to last December. He left when it became clear that Republicans would block his confirmation.

Berwick was in Boise in late February, speaking at a summit at St. Luke's Regional Medical Center. After meeting with health industry professionals, he said in an interview with Business Insider that Idaho lawmakers should consider long-term health outcomes and new federal matching funds when they budget for the 235,000-patient Idaho Medicaid system.

Q: Physicians have talked about prohibitively low Medicaid reimbursements for a while, and last year the state cut Medicaid again. How can doctors continue taking Medicaid patients and still fund their practices?

A: I think checking back on the economics and the ethics is really important to do. For physicians, I know they're struggling now. [But] I think physicians need to speak up for the poor. In the end, the whole idea behind Medicaid is a national commitment to protecting your neighbor. That we are committed to helping people who are in the most stressed circumstances in their lives.

Q: The 2010 health care reform law -- the Affordable Care Act -- would add tens of thousands of Idahoans to Medicaid in 2014. How can Idaho afford to keep paying doctors with that sudden expansion?

A: There's a little bit of a phasing issue here. When we come to 2014, when the Affordable Care Act takes full effect, the Medicaid expansion which people are worried about is essentially federally funded. So, between the [disabled-, senior-adult or low-income family] eligibility criteria Idaho started with, and the [addition of low-income adults] ... all of that's federal money for the first three years. Then it goes to 90 percent federal ... forever.

If the partnering that Medicaid represents between the state and federal government goes away [because of Medicaid benefit or eligibility cuts], you end up with burdens for communities, for the state, for very needy people who really do have serious medical needs. If you don't meet those needs, their diseases get worse, they get sicker and their costs will go up in the end, and of course you're enabling suffering more.

Q: You're saying we should take the long view, that it's more expensive in the long run to cut Medicaid or turn away patients?

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A: That's true in the economics of the community, the economics of the state, the global economics -- someone will pay [for treating the ill]. For the individual doctor struggling to have her practice or his practice survive, I understand a very low rate of pay makes it hard tomorrow, not next year. ... But at some point the country has to touch the moral question, which is: Are we committed to care for the poor?...

The way out of this box is ... what we call the triple aim: better care, better health and lower cost through improvement of care. This is particularly true of the Medicaid population and particularly true for dual-eligibles ... people who qualify for both Medicare and Medicaid. The way you [become a dual-eligible] is you're in trouble. You're disabled and have chronic illness, or you're elderly and poor and have a chronic illness. These dual eligibles represent only about 17 percent of the beneficiaries . They account for 40 percent of state Medicaid costs. ...

A smart state would be focusing on the needs of these dual eligibles and making sure they're in integrated, coordinated care that really meets their needs. That way they stay out of the hospital, they function at a higher level, their costs go down.

Q: There is some concern in the Treasure Valley that as the hospital systems acquire more physician groups and independent doctors, it is inflating costs. Is there any truth to that?

A: If you envision the health care system we all want and need that is both better for our health and our care and lower cost ... you need strong primary care. That primary care could be a physician group practice affiliated with a hospital, or it could be a free-standing group.

This whole idea of a country that is shifting its attention from the hospital as the core of the system to the primary care setting, medical home -- your own physician, your own nurse -- that's a very important idea. So the health of the physician practice does count. And there is concern that ... we may end up in a system that's still too hospital-centric.

I think smart hospitals and hospital systems aren't going to go that way. They're going to move their thinking into being a much more ... integrated system, that they really value what the doctors and primary care systems are doing.

In Idaho, you have a pretty strong commitment, I think, to small physician groups that are on their own. And I think it's possible to construct a strong, integrated system within that, as long as there's things like integrated electronic medical records and very good cooperative relationships between independent physicians and hospitals.

Q: What other ways are there to reduce costs?

A: The forms of waste right now are many.

One is overtreatment. We now know, scientifically, there's lots of things that happen to people that don't help them at all. You get an antibiotic but you have a viral cold? That's not helping you. Antibiotics don't kill viruses. When you get a test that you don't need, [that] you could have waited and you would have gotten well without the test?

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The second is coordination failures. If you have a chronic illness today, your care is very likely to be fragmented. You go to one doctor, and they don't know what the other doctor did. Or you're in the hospital, you go home and nobody tells your primary care doctor what happened. Nobody comes to your home to help you set up the equipment or to take your meds. That costs tons of money because you get complications, and [you] go back into the hospital.

Another would be complications in care -- safety problems like infections in hospitals or post-operative complications. These complications, which are often very avoidable, when they happen they raise costs.

Q: Does the Affordable Care Act really help with that?

A: Value-based purchasing is the theme. Medicare will pay more to hospitals that have lower infection rates and lower complications and better [outcomes], and less to hospitals where there are a lot of these complications.

The same thing happens with doctors in a couple of years. It's called the value modifier. It adds a factor to physician payment related to the quality of the care and the metrics that are being used.

On the coordination side, there you have a bunch of new initiatives in payment, like accountable care organizations, bundled payment, medical homes.

These are all new ways to pay so the doctors in hospitals get rewarded [for good, coordinated] care.

Q: As lawmakers weigh budget priorities, wanting to save money but also wanting people to be healthy, what arguments should they consider?

A: They should consider drawing on the federal contribution to better care for the Medicaid beneficiaries, both through the [Medicaid] expansion of the Affordable Care Act but also these new demonstrations and opportunities to work, say, with [dual-eligibles using federal grants and programs]. They should work hand-in-glove with the federal government, which I think now has the capability to help states at a level that has never been true before.

Audrey Dutton: 377-6448


(c)2012 The Idaho Statesman (Boise, Idaho)

Visit The Idaho Statesman (Boise, Idaho) at www.idahostatesman.com

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