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Medicare: The Successful BackstoryCase Study

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Evidence-Based Research of How Medicare Is Working for Patients and Physicians.

Access to good physicians and timely scheduled care appointments are particularly important to people who are enrolled in Medicare as this population consists of seniors and adults who have permanent disabilities, both of which are likely to need regular and advanced care. Moreover, when people enrolled in Medicare need to locate new physicians, they are especially vulnerable to the toll of frustration, confusion, and expenditures of energy triggered by delays in this process. The portrayals of Medicare policy problems by the media are compared in this discussion with evidence-based research by reputable organizations. The discussion addresses the particular financial pressures that are derived from policymaking and the influence of special interest groups. For those Medicare recipients who are not well served by the current system, which seem to be driven as often by political motives as actual financial incentives or disincentives, one policy related solution is proffered.

Current Situation

The Henry J. Kaiser Foundation conducted a comprehensive review of the evidence of Medicare patients' access to physicians in 2013. Although the media coverage indicates otherwise, the current situation of this matter is quite robustly positive. When considered on a national level, good access to physicians by Medicare enrollees is the norm. Indeed, 96% of Medicare beneficiaries surveyed said that they had a usual (frequently visited) source of care, which was generally a physician's office or a physician's clinic. Scheduling timely appointments for specialty care and also for routine care is experienced by roughly 90% of the Medicare enrollees surveyed. Medicare seniors fared better than their privately insured peers (50 to 64 years of age), reporting that they "never' had to wait a longer time for appointments than what they wanted. Only 2% of the Medicare patients who looked for a new doctor reported having a difficult time finding a new physician when they needed to, and this proportion was smaller than the rates reported by their privately insured peers, aged 50 to 64 years. Recently acquired physician survey data shows that 91% of physicians accept new Medicare patients, and that this rate is comparable to that of new patient acceptance rates of patients enrolled in private, non-capitalized insurance. The correlation across the states suggests that the rate of physician acceptance is more of a local market factor than a unique issue of Medicare. Physician data from Medicare also shows that less than 1% of clinically practicing physicians have formally "opted out" of the Medicare program. The data also shows that the highest opt out rate occurs with psychiatrists at 42%.

One important indicator of the status of healthcare for people enrolled in Medicare is foregoing medical care. Higher rates of postponing or foregoing visits to doctors are associated with Medicare enrollees who are under the age of 65 and have a permanent disability. High rates of foregoing visits to the doctor are also seen with these patients: 1) Have Medicaid, as they are dually eligible for Medicare and Medicaid, or do not have supplemental coverage; 2) are Black; 3) have lower incomes; 4) are in poor or fair health; and/or 5) have five or more chronic conditions. It is important to recognize that a majority of patients within these vulnerable subgroups do not report that that they forego visits to their physicians when need to be seen.

The evidential review conducted by the Kaiser Foundation derived data from highly credible sources, the majority of which are listed categorically below:

Government Surveys

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surveys

Medical Expenditure Panel Survey (MEPS) Household Component

Medicare Current Beneficiary Survey (MCBS)

Medicare Payment Advisory Commission (MedPAC) survey

National Ambulatory Medical Care Survey (NAMCS)

National Health Interview Survey (NHIS)

Non-Government Surveys

Commonwealth Fund Biennial Health Insurance Survey

Kaiser Family Foundation Survey of Medicare Beneficiaries Under Age 65 with Disabilities and Medicare Seniors

Health Tracking Household Survey (HTHS)

Health Tracking Physician Survey (HTPS)

The Physicians Foundation Survey of America's Physicians

National patient and physician surveys, along with other sources, indicate that Medicare beneficiaries experience good access to the services of physicians, and that their access is comparable to that of patients with private insurance. Furthermore, a large majority of physicians accept new Medicare patients, and relatively small numbers of physicians have opted out of the Medicare program in any formal way. Some issues are evident in local markets and the consequences of these local issues on Medicare beneficiaries warrant more granular research (see Appendix A - States Not Expanding Medicaid). Also, there remains a considerable need to address the access concerns that impact some of the most vulnerable Medicare beneficiaries.

Although the number of Medicare beneficiaries experiencing difficulties as describe below is small in absolute terms, the policy purpose is to provide services equitably and, to the extent that it is desirable, uniformly. For the minority of Medicare beneficiaries who experience any of the substantive problems described, solutions to the policy problem must take a different tack. Critics of the Patient Protection and Affordable Care Act (ACA) talk about a perfect storm in healthcare: The shortage of primary care providers continues at a time when the ACA is adding 32 million people to the healthcare insurance rolls, and disparities in access and care exist for people enrolled in Medicare and, especially, in Medicaid (Fairman, et al., 2011).

One promising solution to ensuring that adequate numbers of well-trained medical staff will be available to head off the expected wave of new enrollees is to broaden the scope of nursing practice (Fairman, et al., 2011). Research has shown time and again that, "wellness and prevention services, diagnosis and management of many common uncomplicated acute illnesses, and management of chronic diseases such as diabetes can be provided by nurse practitioners at least as safely and effectively as by physicians" (Fairman, 2011). Resentful and non-Medicare-participating physicians have expressed the belief that the practice on medicine, whether paid for privately or through insurance, must occur under the aegis of licensed physicians, not health care administrative clerks or policy making boards of directors or CFOs of insurance companies. While this is a fair and prudent position, to extend such logic to nurses is conceptually flawed. The robust findings of rigorous research led the Institute of Medicine (IOM) to call for nurses' scope of practice in primary care to be expanded (Fairman, 2011) (see Appendix B -- State Scope of Practice Regulations). An important aspect of the IOM recommendation is the establishment of more efficient pathways for nurses to obtain advanced training and education after their licensure (Fairman, 2011). In a clarifying move, the IOM has called for discontinuation of hospital diploma programs, instead ensuring that bachelor's degrees are conferred through pre-licensure nurse education programs (Fairman, 2011).

Should nursing organizations achieve their goal of broadening the scope of nursing practice in meaningful ways, considerations about Medicare fees and healthcare insurance company capitation payments still undergird the provision of services in the healthcare sector. Brief explanations of the most significant factors in service payments for Medicare beneficiaries are provided below.

Fee-for-service. Fee-for-service expenditures for physicians are a share of the total spending on Medicare, and these expenditures have been quite stable. For instance, in 2009, fee-for-service expenditures were 13% of the $491 billion spent on Medicare (Iglehart, 2011). The obvious policy problem with the fee-for-service model is that it establishes an inherent incentive for increasing the number of patients seen by physicians over any given period. Accordingly, the fee-for-service formula is not designed to increase the quality of care, but only to increase the quantity of physician-delivered care (Iglehart, 2011).

Capitation payments. A health insurance company and a medical provider can determine in advance, through a capitation contract, what the premiums will be for services delivered to patients: this type of health insurance expenditure is called capitation payments. A hospital, a clinic, or an individual physician receives the defined, per patient capitation payments, which are remain the same each month for a full year according to the advance calculation; this is true regardless of how often, or even if, the patient needs services ("Investopedia," 2015). Typically, capitation agreements stipulate the capitation payments based on certain characteristics of the patients, such as the ages of the healthcare insurance plan enrollees ("Investopedia," 2015). Calculating costs so that specific attributes of patient groups drive the capitation payments enables healthcare providers to be compensated according to anticipated similar ailments for the patient group ("Investopedia," 2015). The capitation payment schedules, then, are viewed as following actuarial logic.

Sustainable Growth Rate

The sustainable growth rate is a measure of the degree that an enterprise can grow without borrowing money ("Investopedia," 2015). Once Congress has passed this rate, it must borrow funds or raise taxes to facilitate growth ("Investopedia," 2015). Congress has strongly resisted complying with its own mandate over many years; rather, the conservative Congress has looked to structural and systematic ways to reduce benefits, thereby pushing the burden of Medicare costs back to the consumer base: physicians and patients. However, as the discussion… [END OF PREVIEW]

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