MedPAC is Washington, DC, shorthand for the Medicare Payment Advisory Commission, and if you subscribe to its e-mail announcement system, you typically get notices early in a week for public meetings to be held later that same week. This is fine for the beltway crowd, maybe, but for years it has kept me from actually attending a public session of this important congressionally chartered organization and seeing it at work. I swear this handy-dandy list of upcoming meeting dates that I just discovered on the MedPAC website did not exist last time I checked.
Thankfully, last Friday the stars aligned and I was able to sit in and watch the second morning session of their day-and-a-half public meeting. I couldn't have been more impressed.
First, I was delighted to learn that in addition to Mary Naylor, geriatric nurse researcher from the University of Pennsylvania (and Foundation grantee, both as a leader of the Penn Center of Geriatric Nursing Excellence and on her Transitional Care work), unbeknownst to me, William Hall, geriatrician, Center of Excellence director at Rochester and long-time go-to guy for the Foundation, has recently joined the committee. It is very heartening to see geriatrics leaders exercising their influence this way, despite the big time commitment it represents.
Second, I heard the MedPAC staff and commissioners grappling with important issues, even on their second day of meetings. They discussed two things near and dear to my heart: the value and design of the Medicare insurance benefit and emerging information on the quality of care received by beneficiaries.
Medicare has a complex and inconsistent set of co-pays and deductibles across services and no limit on the possible annual charges to beneficiaries (no stop-loss), which, coupled with the opacity of prices for health care services, makes 90% of Medicare beneficiaries get some kind of supplementary insurance. This has many bad consequences. As Glen Hackbarth, the MedPAC chair observed, it locks many beneficiaries into buying expensive supplemental policies that have to be more expensive on average than their benefits so the insurance companies can make money. In addition, because the most popular policies are those with the best coverage, supplemental insurance winds up giving beneficiaries “first dollar coverage,” eliminating (most) co-pays, co-insurance, and deductibles. Some argue this good coverage makes beneficiaries too likely to seek services because they have “no skin in the game” – no additional costs for each service. To address this issue, the commissioners and staff are working up alternate benefit packages that would give more predictability and equity, as well as capping out-of-pocket costs with the same total cost to the program. This would make Medicare almost as good as my fairly conventional commercial insurance.
On the quality front, the news was not good in itself, but the fact that MedPAC was looking into it was a pleasant surprise. Careful readers of Health AGEnda will recall that several times in the last year we have looked at rates of hospital admission among Medicare beneficiaries for so-called ambulatory-care sensitive conditions (see here and here). The argument is that admission to the hospital for something like congestive heart failure is itself a sign of poor quality of care because chronic conditions like that should be managed by outpatient primary and specialty care providers. The overwhelming evidence is that our system does a poor job at managing such things. There are many unnecessary hospitalizations – AHRQ estimated 2.4 million annually among Medicare beneficiaries alone.
MedPAC adds to this debate by looking at the rates of such hospitalizations around the country and by adjusting those rates for how sick beneficiaries are. Overall, the national average rate of hospitalization for these “prevention”-sensitive conditions is 17.4%. That number seems pretty high, about half of hospital admissions of seniors given that Medicare beneficiaries are about 35% of admissions overall. What MedPAC did next was to look at the variability in the rates across the some 300 hospital referral regions in the US to see what good and bad rates look like. The mean share of admissions of the best quarter of regions is only 12.9%, whereas the mean of the worst quarter is 21.8%. This is nearly a 9% swing. And remember, this is after differences in rates are statistically adjusted to account for the fact that people in some regions might be sicker on average than others. I can’t think of a reason that we shouldn’t have all regions performing at the average rate of the top quarter of sites. By that metric, we have a long way to go to get consistent, high quality performance from our health system.
Happily, MedPAC and its staff are going to revisit the issue with some new data at its next meetings, which are November 3-4 and December 15-16. Perhaps you can make more of the meetings than I can; and if not, MedPAC has enabled commenting on meeting agendas. You can also access past presentations and transcripts, as well. Let's support our leaders Bill and Mary and the rest of this group of very knowledgeable and talented people as they tackle these important issues. They need to hear from you about how their policies influence your experiences of receiving or providing care.