Among the more Byzantine are the rules concerning Medicare and Medicaid coverage. The two so-called "entitlement" programs govern health-care access for millions of Americans -- Medicare providing coverage to seniors and Medicaid largely to lower-income Americans. In addition to the guidance one might expect of a huge federal bureaucracy such as the
One such regulation is Medicare's rule requiring patients stay at a hospital for at least three consecutive days before the program will pay for them to be treated at a skilled nursing facility. The rule dates back decades, from a time when the conventional medical wisdom was that if someone needed care, the best place for them was a hospital. But hospital care is expensive, and current trends call for hospitalization only in the direst of circumstances. Insurers don't want to pay for hospital care and because, especially for the elderly, longer stays can have as many downsides as positives, it often makes sense to allow a quicker transition to assisted-living or skilled-nursing facilities.
The rule is outdated and costly. Longer hospital stays are unduly expensive, and if insurers say they won't pay for the extra days, the patient is put on the hook to either pay for those days or not qualify for coverage of the needed care to follow.
But because of the Affordable Care Act, patients in some areas can bypass that rule and get the proper level of care when they need it. Remember, the point of the ACA was to fundamentally change the health-care system to reduce costs, largely by encouraging access and getting people preventive and routine care that will keep them from becoming sicker, requiring more-expensive treatment.
Thus, the ACA encourages the implementation of new health-care models, such as accountable-care organizations. Under that model, care providers get a set amount per patient per year. Instead of rewarding hospitals for pushing tests and procedures, it incentivizes them to provide care more efficiently, while keeping the patient healthy.
A year ago, 10 Vermont hospitals, along with other health providers, agreed to form such an organization: OneCare Vermont. All the state's Medicare and Medicaid patients are included in the arrangement. And one of the benefits is that OneCare Vermont can override Medicare's rule governing how long a patient must remain hospitalized.
Last month, OneCare granted
In the overall scheme of reducing health-care costs, it's still a very small step, one affecting only a tiny fraction of people. But every step counts, and the larger picture is that OneCare Vermont and other accountable-care organizations -- or other industry models not yet available -- may hold the key to effectively reducing costs industry-wide.
Health care may be complicated, but some simple notions, such as giving providers a reason to keep people healthy, can help.
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