HEALTH REFORM: Dialysis Done Right

Medicare hasn't put the finishing touches on its new dialysis reimbursement policy quite yet (you have until December 16 to get your comments in) -- but has decided to invest in educating the public on various dialysis treatment options. It's part of a longer term effort to give patients more of a say in managing their chronic diseases, and in changing some of the inefficient ways Medicare pays for kidney care.

More than 350,000 Medicare patients with end stage renal disease undergo dialysis. Most patients undergo out-patient treatment three times per week at either an independent or hospital based facility -- in the United States, fewer than a tenth are treated at home. (Rita Rubin of USA Today notes that three treatments per week is the standard not necessarily because it is "optimal but because that's the way it has been done for nearly four decades.")


But Medicare's education campaign will help patients make more informed decisions about where and how often they are treated. 

HEALTH REFORM: Highlights from the Senate Bill

The latest version of Senate health care legislation (pdf available here) crafted by Majority Leader Harry Reid is making its rounds.  There is a lot to review, but an initial read shows the bill is close to the legislation approved by the Senate Finance Committee in early October with a few notable changes: more generous subsidies, a higher threshold for the excise tax on insurers who offer high-cost plans, an increase in the Medicare payroll tax for Americans making over $250,000, and the addition of a long-term care insurance program for people with disabilities.

While this legislation also delays the implementation of insurance market reforms and subsidies (when compared to the Senate Finance legislation) there are a number of provisions that would start helping Americans immediately. In particular, the legislation:  

COST: Medicare Fraud Gets Increased Scrutiny

The government paid $47 billion (that's billion with a B) in false or questionable Medicare claims last year, according to a new federal report obtained by the Associated Press.

The report shows a dramatic increase in Medicare fraud from previous years. In 2008, the government paid an estimated $17 billion in improper claims. So what caused this number to nearly triple in the past year? The most likely culprit is not more fraud attempts, writes the AP, but the increased scrutiny on Medicare claims. The Department of Health and Human Services's new  stricter methodology is part of the Obama Administration's effort to crack down on Medicare fraud.

HEALTH REFORM: How to Control Rising Health Care Costs

In its Room for Debate section, The New York Times asks a group of health experts what one or two provisions could be added to health reform legislation to help contain health care costs going forward. Below is my contribution to the discussion. For more on the issue, you can read my colleague's post on the real versus the ideal options for slowing the growth of health care costs.

The Medicare payment reforms in both the House and the Senate bills will help to slow the growth of costs by rewarding value over volume, as will the proposed Medicare commission and the tax on insurers who offer high-cost health plans, which are in the Senate Finance Committee bill. And both House and Senate legislation also includes “innovation centers” which will allow us to test different payment models and health care processes.

Even with these steps, the reform bills could be strengthened. Specifically:

COST: Can Health Reform Heal the Federal Budget

Can health reform heal our federal budget? Yes, but whatever passes now is just the beginning, and there will always be room for improvement.

That's our takeaway from an excellent event we tweeted this morning hosted by the US Budget Watch, a joint project between the Committee for a Responsible Federal Budget and The Pew Charitable Trusts.

There was a lot of ground covered by a panel of experts moderated by the Washington Post's Ceci Connolly and featuring New America's director of health policy Len Nichols. They tackled everything from raising Medicaid eligibility rates to fixing the Sustainable Growth Rate formula in a fiscally responsible way. But for now, we'll just give you the highlights of the discussion.

QUALITY: A Good Beginning for Better Endings

After all the sound and fury of last August, we're pleasantly surprised that the right hasn't risen again with all sorts of horror stories about the resurrection, so to speak, of the "death panels." Maybe because all that fear-mongering was finally discredited. Maybe we are finally getting just a little bit smarter.

The inevitable focus on the politics of health reform, and the disproportionate amount of attention paid to the public plan, sometimes obscures the many ways that the House and the Senate health plans are ambitious. Not perfect. Ambitious. I've heard experts, people I like and respect, say the legislation does "nothing" to advance the cause of quality of end of life care in America. They are wrong. The House and Senate bill each contain measures that would advance that cause -- not fix it completely, far from it, but they will take us important steps in the right direction. It's too soon to know which of these measures - if any -- will survive a final melding of House and Senate legislation. But let's look at them here because, except for the end of life consults which got way too much of the wrong kind of attention, they haven't gotten adequate attention. In an accompanying guest post. Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in New Hampshire, talks about what these changes can mean for his patients and their families.

HEALTH REFORM: Medicare Reform Will Benefit Seniors

Seniors are a primary target of the misleading rhetoric in the health reform debate. Though the harmful rumors have been proven false time and time again, seniors have had to worry about everything from "death panels" to Medicare cuts. Organizations like the AARP have stepped up to get the truth out to seniors -- health reform will protect Medicare, not diminish it. A recent report from the Center for Budget and Policy Priorities (CBPP), House Health Reform Bill Would Strengthen Medicare, came to the same conclusion. 

The CBPP reports that the House health reform bill would help all beneficiaries, and it highlights the provisions that will improve care for seniors:

HEALTH POLITICS: The Thing Speaks for Itself

Over at InsureBlog, Hank Stern takes exception to Len Nichols' thorough debunking of the recent report produced by PriceWaterhouseCoopers for AHIP.

Like the Latin title of Hank's post (Res Ipsa Loquitur...), most of his points speak for themselves.

If he wants to object to the idea that "Good policy research uses nationally and statistically representative data so that its conclusions reflect behavior of the actual population," that's his prerogative.

If he's ignorant of the IRS tax code that governs the non-partisan work of the Robert Wood Johnson Foundation and the Urban Institute, well, we guess that's fine, too.

But if he thinks there's no difference between the research produced by such independent institutions and stuff that's made to order for private interests, he should take a look at the work PriceWaterhouse did for the tobacco industry in the early 90s. An independent review of that study found "serious methodological problems and errors of omission." (h/t Media Matters) The same could be said of their latest work. AHIP got what it paid for and InsureBlog should be less credulous of the talking points it's buying.

HEALTH REFORM: Evidence-Based Change You Can Believe In

About a year ago, Drew Altman, president and CEO of the Kaiser Family Foundation, wrote an essay about "delivery system" folks and "coverage" folks. When I saw Drew soon after that, interviewing him for an unrelated magazine piece,  I said I thought the overlap in that Venn diagram of coverage and delivery was both bigger than he described it, and expanding faster than he perceived it. I thought that as health reform became something that might really and truly happen the "coverage" camp had a growing appreciation of how delivery system reform, properly done, could improve quality of care while saving money needed to pay for that very same expansion of coverage. And the delivery system camp, at least the people I knew reasonably well, certainly thought it was high time that the United States did what every other developed country on the planet (and some of the not-so-well developed ones) has managed to do: make sure that everybody has decent affordable health coverage.

So it was a pleasant surprise to find Kaiser (which I think of as more on the coverage side) publishing a very useful, worth-reading paper on what we do and do not know about delivery system reform, at least with regard to Medicare.

COST: Helping Cover People in their 50s Might Save Medicare Money

A study in the Annals of Internal Medicine (Hat tip Kit Seelye) finds that people who are uninsured in their 50s and early 60s end up costing Medicare a lot more money when they hit 65. The extra cost is about $1,000 a year -- meaning that the savings would pay almost half the $197 billion it would cost to cover them in the first place.

And because Medicare pays a tad less than half of all health care spending for the elderly, the reduction in total medical spending (not just from Medicare but also out-of-pocket spending and from other insurers) after age 65 may be even greater.

A lot of the costs can be attributed to uncontrolled or poorly controlled diabetes and cardiovascular disease such as hypertension, heart attacks or stroke.The uninsured may also delay surgeries such as joint replacement until Medicare will pay for them."For adults with these chronic conditions," Dr. Michael McWilliams and his colleagues at Harvard Medical School and Harvard School of Public Health wrote," improvements in blood pressure, blood glucose, and cholesterol control associated with gaining coverage may substantially reduce subsequent annual health care costs."