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06/30/2010

Reality Check

Recently, and with much fanfare, President Obama touted the delivery of millions of $250 checks from the Federal government to older Americans. These rebates are being sent to Medicare beneficiaries who fall into the gap in prescription drug coverage, “the donut hole,” under the Medicare Part D program. And while these billions of dollars are being advertized to improve healthcare, the reality is that anyone who has studied this issue, or even who appreciates and is willing to admit to human nature, knows that little if any of these funds will find their way to impacting healthcare. Instead these funds are there to provide a positive feeling to those in a troubled healthcare system—a feeling that turns into votes at election time.

The mailing of $250 rebate checks is an example of how far we have traveled from reality. The problem is that what is occurring in healthcare today is so far separated from the real problems and solutions that a reality check is deeply needed.

Getting What You Pay For
Medicare has produced the results that the system pays for since its beginning in 1965. One clear example is the demise of the primary care physician (PCP). While other countries have embraced the PCP as the foundation for coordination of care, Medicare instead has focused on reimbursing specialists dedicated to procedures. The resulting system is dominated by specialists all to willing to focus on their narrow procedures rather than coordinating care in a cost-effective manner.

In addition to fostering the demise of primary care, the system has paid only for the units of care provided rather than the quality. The result again is a provider system focused on volume rather than outcomes. Seemingly aware of this issue, Medicare is now promoting a focus on quality and investing in systems of care, but unless the payments are appropriate to motive a change in behavior, little will come from this investment. This includes the some $40 billion set aside for health information technology

Easy (Wrong) Answers
Another area where a reality check is needed is the rush to easy answers that are often wrong. Currently, Congress is debating the continuation of the Sustainable Growth Rate Formula (SGR), a payment plan declared broken from its beginning. The SGR was based on a simple enough principle: if Medicare expenditures exceed a budgeted amount in a year, then the following year, provider reimbursements will be cut by that percentage. The problem is that this system again favors specialists’ procedures, further negatively impacting primary care providers. Specialists have the ability to more easily increase their number of procedures while primary care providers find it difficult to decrease their visit time to increase their volume of work. With its negative impact on the primary care providers, this formula is further hurting older Americans from being able to find a PCP.

Facing Reality
One last area for a reality check is our fascination with the baby boomers. While the doubling of the number of older Americans over the next two decades is a major change, one that will have even greater and longer impact on the healthcare system is receiving far less attention. Our explosion in our weight will likely have a much more far reaching impact on bankrupting our healthcare systems than our aging population. Yet, no real focus is being paid to this major problem.

It should become increasing clear that we are in desperate need to get very real, very quick. We are facing a crisis that makes our current man-made disaster in the Gulf of Mexico seem trivial. Perhaps the title wave of voter discontent that is forcing incumbents out of their long held political offices is a sign of us waking up. Washington is in dire need of a reality check, rather than billions of dollars in rebate checks.

Dr. Richard G. Stefanacci is an internist/geriatrician and director of the Institute for Geriatric Studies at University of the Sciences. He can be reached at r.stefan@usp.edu.

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