Too many
Medicare patients are unaware that the quality of their health care
is in jeopardy. The almost 40 million older adults and disabled
persons who are covered by Medicare are subject to the most
aggressively managed and overregulated health plan in the United
States. In fact, the federal health care regulations, rulings, and
paperwork pertaining to Medicare require over 111,000 pages, many
times more than even the federal income tax code. The complexity of
the system makes it difficult for both patients and their health
care providers to understand what procedures and treatments will be
covered under Medicare, and which ones will be ruled "medically
unnecessary."
According to 1997 statistics from the
Health Care Financing Administration (HCFA), over 19 percent of all
denied physician and supplier claims are for services deemed
"medically unnecessary." And this amount increases to 45 percent if
claims that are denied for "reason of statutory exclusion" are
excluded. Auditors for the U.S. Department of Health and Human
Services' Office of Inspector General reported in February 1999
that if HCFA rules and regulations were followed in all cases, even
more claims would be denied for lack of "medical necessity."
Members of Congress determine in
legislation what can be covered under Medicare and at what price.
They have avoided making the tough decisions affecting patients,
however, by shifting responsibility for Medicare coverage to HCFA,
which, in turn, regulates the delivery of health care by imposing
voluminous rules, regulations, and guidelines on doctors,
hospitals, and other health care providers. It is a profound
mistake to think that Medicare patients are insulated from the
negative effects of this huge regulatory system in Washington. If
Members of Congress are genuinely concerned with improving health
care for all Americans, they should examine the many roadblocks to
quality care that the Medicare system imposes on those who provide
health care to senior citizens and disabled Americans. For
example:
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In Medicare, "medical necessity" often is
determined by distant bureaucrats using standards that are
arbitrary and ill-defined.
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Doctors who treat Medicare patients face a
Catch-22 dilemma of choosing treatments based on their best
professional judgment and facing fraud and abuse charges if the
Medicare bureaucracy says the treatments were "unnecessary," or if
it prescribes the treatments. This undermines the professional
independence of physicians and imposes a de facto gag rule.
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Patients who challenge Medicare denials of
their claims face an arduous review and appeals process. For
Medicare Part B claims, which covers physicians' and other
outpatient services, the average time for administrative law judges
to render a decision is 524 days.
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Even if an appeal is decided in their
favor, Medicare beneficiaries can hope to recover only the cost of
the benefit itself, regardless of the extent of injury that
resulted from the claim's original denial.
The
real fix for Medicare is not more rules and regulations, another
insufferable pile of paperwork, some palliative treatment, or
tinkering at the edges. Radical surgery of the program's
bureaucratic control is needed. The best approach to the problem of
patient care in both the private and public sectors is the
expansion of patient choice, which would enable individuals and
families to pick the kinds of plans and benefits they personally
want and need.
The
National Bipartisan Commission on the Future of Medicare came close
to a formal recommendation of expanding choice when 10 of its 17
members supported a model for reform similar to the consumer-driven
system enjoyed by federal employees, Members of Congress, and
congressional and White House staff--the Federal Employees Health
Benefits Program. In Medicare, choice would mean patients could
keep the traditional plan, choose a superior private plan, or bring
their private health plan with them into retirement for primary
coverage but obtain a government contribution to offset its
cost.
Today, real Medicare reform is medically
necessary and should put patients first. Members of Congress should
create a new system based on choice and competition that respects
the personal liberty and privacy of Medicare patients as well as
the medical expertise of their doctors.
Sandra Mahkorn, M.D.,
M.P.H., M.S., is Visiting Fellow in Health Policy at The Heritage
Foundation.