Health for life

So, how bad is it?

While HHS Secretary Sebelius Affordable Care Act nostrums help the Obama Administrations muddling of policy and election year politics, CMS Chief Actuary Richard Foster has stepped forward (see page 277) with some blunt language about Medicares solvency.  As the Disease Management Care Blog understands it, official projections on just when the money runs out are based on current law. 

Thats the rub:  

"While the Part B projections.... are reasonable in their portrayal of future costs under current law, they are not reasonable as an indication of actual future costs. Current law would require a physician fee reduction of an estimated 30.9 percent on January 1, 2013—an implausible expectation."

"[W]hile the Affordable Care Act makes important changes..., there is a strong likelihood that certain of these changes will not be viable in the long range. Specifically, the [anticipated] annual price updates for most categories of non-physician health services will be adjusted downward each year by the growth in economy-wide productivity. The best available evidence indicates that most health care providers cannot improve their productivity to this degree—or even approach such a level—as a result of the labor-intensive nature of these services."

"Without unprecedented changes in health care delivery systems and payment mechanisms, the prices paid by Medicare for health services are very likely to fall increasingly short of the costs of providing these services. By the end of the long-range projection period, Medicare prices for ... many services would be less than half of their level under the prior law. Medicare prices would be considerably below the current relative level of Medicaid prices, which have already led to access problems.... Well before that point, Congress would have to intervene to prevent the withdrawal of providers from the Medicare market.... "

"Finally, the economic outlook remains more uncertain than usual. Due to the sensitivity of HI trust fund operations to wage increases and unemployment, the current slow recovery from the recent recession adds a significant further element of uncertainty to the trust fund projections."

"Hello, Dr. Smith? This patient has a fever..."

Read this New England Journal Perspective by Drs. Ouslander and Berenson on Reducing Unnecessary Hospitalizations of Nursing Home Residents, and its easy to conclude that the enlightened application of better documentation, quality assurance, payment orm, administrative policies, decision support, guidelines, appropriate downjobbing and delegation of responsibility will keep many sick and feverish nursing home residents away from the unnecessary expense of emergency rooms and hospitals.

Were that it was so simple.  Such is the unreality of many Journal authors inhabiting the oxygen-deprived academisphere.

When residents of nursing homes get sick, they require a significant amount of nursing attention.  Since busy, salaried (and sometimes understaffed) nursing home personnel arent compensated for the additional work of documenting, monitoring and worrying about that sick patient down the hall, they have every incentive to transfer sick patients elsewhere.  No amount of macroeconomic policy making bells and whistles is likely to change that.

When physicians and other non-physician providers are alerted by the nursing home personnel that a patient is sick, they have been taught that the best approach is to evaluate the patient in person. That takes time and effort.  While they may be compensated for the additional work of a bedside evaluation, its not enough to make up for the additional work of documenting, monitoring and worrying about that sick patient down the hall.  So, they also have every incentive to agree with the nurse and transfer the patient to a setting where a bedside evaluation is available.  At 2 AM, the answer is to move that bedside to the local emergency room.

Would the bells and whistles that Ouslander and Berensen be enough to keep the nursing homes and the doctors from sending most sick patients to the emergency room?  Based on the simple realities described above, the answer is no.