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Mon Dec 17, 2012, 05:47 PM

Damaged Medicare

Damaged Care was the term for the problems that arose from Managed Care, the experiment during the 1990s in which health insurance companies took all comers regardless of pre-existing conditions and then found novel---and sometimes unethical ways---to get the sickest folks off their insurance plans. Their number one way to retroactively cherry pick was to pay doctors to limit care. When the doctors did not limit care enough, the HMOs penalized doctors for prescribing necessary care. They did this in such a way that doctors who cared for the sickest members of our society were forced off the HMOs--taking their costly patients with them. Since poverty and minority status are linked to poor health, the patients affected were often poor, sick minorities and the doctors who served them. Managed Care was a huge disaster---and it fell out of favor. Now, it is just a bad memory for most.

However, in an attempt to control rising Medicare costs, the nation's managed Medicare plans---aka Medicare Advantage plans---and the federal government are embarking upon a "new" payment policy for physicians that is just Damaged Care all over again. In the very near future, if you are on Medicare, your doctor will receive bonus payments if you 1) have well controlled diabetes 2) fill all your medication prescriptions 3) do not have to go back to the hospital soon after being discharged among other things. If you are a patient who can not control your diabetes because you also take steroids for your life threatening asthma, your doctor will face a financial penalty. If you are a patient who can not afford to fill your prescriptions because you are too poor, your doctor will face a financial penalty. If you are a patient with a disease like congestive heart failure, inoperable coronary artery disease, cancer, multiple sclerosis and you are in and out of the hospital, your doctor will....

You get the picture.

Financial incentive and penalty plans like this are only fair if all doctors have the same relative proportion of "well" to "sick" Medicare patients. As a family physician, I can tell you with absolute confidence that each doctor has a different type of practice. The primary care doctor whose patients are wealthy retirees who hang out at the country club stands to make even more money from this system. The family doctor who has a lot of poor, minority and rural patients and the family doctor who specializes in taking care of those with chronic severe illness will find his already low Medicare reimbursements cut.

What does this mean for patients? If you are one of the lucky ones who retires because you can afford to, not because your health gave out, and you live in an affluent part of town and have transportation, you will have no trouble finding a primary care doctor. If you stopped working because of illness, or if you live in a minority or poor or rural community, or if you can not drive and so you have to find a doctor whose office is on the bus line, you will find very few doctors taking new Medicare patients.

"Managed Medicare" is in its embryo stage. It may not turn out as badly as Managed Care (HMOs). The federal government may realize that instead of promoting disease prevention, it encourages family doctors to cherry pick the healthy and turn away the poor and sick. However, the worst care scenario is 1) traditional Medicare drops the bonus/incentive plan while 2) private Medicare keeps the bonus/incentive plan (under guise of encouraging disease prevention). If this happens, all the sickest geriatrics in the country will be on the federally funded program, while the privates will reap a windfall as they collect premiums for folks who don't need care----

And Medicare costs will rise rather than falling.

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