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Medicare's Checkup: Sit Down, There's Good News and Bad News

MAY 6, 2005 -- Medicare enjoys higher satisfaction ratings than private insurance plans—but also has disparities from state to state—and could achieve consistently higher performance ratings if quantitative national targets were set for the program, according to speakers at a forum Friday on Capitol Hill.

Such targets could include a 75 percent flu vaccination rate, said Sheila Leatherman, a former United HealthGroup executive who now teaches at the University of North Carolina. The co-author of an analysis of 400 studies on Medicare quality, Leatherman said the Medicare Payment Advisory Commission (MedPAC) should be charged with setting those targets.

She even suggested changing the "P" in MedPAC from "Payment" to "Performance."

"You wouldn't even have to change your brand," she told MedPAC Chairman Glenn Hackbarth, another speaker at the event.

The subject of quality in Medicare is fertile ground for policy makers, not only because of the political clout seniors have with Congress, but also because of the growing medical literature on the efficiency of treatment in the program, a growing set of quality performance measures, and Medicare's potential as a proving ground for widescale implementation of innovations that have bubbled up from the private sector and that, in turn, could be more widely applied in the commercial sector if they pan out broadly in Medicare.

The Medicare overhaul law (PL 108-173) launched a number of pilot projects testing those innovations, and aims to spread them both through the private plan "Medicare Advantage" and traditional fee-for-service sides of Medicare. Meanwhile, MedPAC is pursuing a strategy of writing a broad set of recommendations to make Medicare more efficient through gains in quality.

Looming over the effort is the advancing shadow of a baby boomer generation approaching Medicare eligibility, bringing with it a sharp upswing in costs.

The analysis prepared by Leatherman and Douglas McCarthy, president of Issues Research, Inc., consists of 60 charts showing Medicare's progress and deficiencies in quality of care. "Although the federal government's current Medicare quality efforts represent a promising start, they need to be intensified and accelerated to improve care not only for Medicare beneficiaries but for all Americans," Leatherman said.

"This chartbook makes the case for a concerted effort towards a national agenda for quality that sets out explicit targets to achieve and by when," said Karen Davis, president of The Commonwealth Fund, which paid for the study. "[Medicare] needs to be an innovative leader in improving the quality of American health care by making information on quality and efficiency more widely available and rewarding health care providers for high performance."

The review credits Medicare with providing enrollees greater access to care, giving more people a usual source of care, and increasing the use of preventive care, including a tripling of the rate of mammograms over the past decade for women over 65.

But flu vaccination rates vary widely by state—80 percent of Medicare enrollees in Minnesota received flu shots, but only 60 percent in Nevada did. "Among the states, rates of timely antibiotic administration [for pneumonia patients] varied by 31 percentage points from lowest to highest," the analysis said.

National rates for certain types of care were low in some cases, according to the analysis. Hospitals met guideline standards for treating pneumonia less than one-third of the time for Medicare fee-for-service patients.

In 1999–2000, only one-quarter of elderly adults with high blood pressure had it controlled. Other research showed that fewer than one-third of 1,801 older patients treated for depression at 18 clinics received recommended treatment. However, the results in this study were not necessarily nationally representative, the researchers said.

But "compared to privately insured nonelderly adults, elderly Medicare beneficiaries were more likely to rate their insurance highly and to be satisfied with their care, and were less likely to report problems with coverage and access to care," Leatherman and McCarthy said.

Another speaker at the event sponsored by the Alliance for Health Reform observed that few doctors are trained to oversee the complex health care needs of the elderly. The nation's supply of geriatricians—physicians specifically trained to effectively coordinate care for the multiple chronic conditions that afflict many seniors—is one-fifth what it should be, said Dr. Christine K. Cassel, president of the American Board of Internal Medicine. Noting the large role Medicare plays in funding the training of physicians generally, Cassel suggested that it help fund more training of geriatricians.

John Rother, senior policy analyst at AARP, said that while there is some good news in the study, "to me this is a wake-up call. Much of what is documented here is unacceptable for 21st century medicine. We are letting people die unnecessarily."

Hackbarth reacted by calling attention to the advice he says he frequently gives to his two teenaged children: that who they are is judged by what they actually do. By that standard, the U.S. health care system values highly freedom of choice of provider, "clinical autonomy," larger numbers of office visits, technology, and short waiting times for care.

But "what we don't seem to value is quality" as assessed against standard measures, Hackbarth said. While Medicare has delivered great value over the years, "we could do so much more," he said.

The MedPAC chairman emphasized data showing that states with high quality of care in Medicare have the lowest costs, while those with the lowest quality have the highest costs. "That's not good news," he said. Hackbarth also expressed concern over data showing that while rates of death within 30 days of hospital admission declined for eight medical conditions from 1995 to 2000, they increased for six of the conditions between 2000 and 2002. And in another study, rates of preventable hospitalization increased for five of 10 medical conditions from 1995 to 2002, he said.

Hackbarth called for a variety of improvements, including investments in developing performance measures, more data comparing the quality of providers, and linking payment to performance on quality measures. "The level of intensity of the effort needs to increase markedly," he said.

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