June 25, 1999 | News Releases on Health Care
WASHINGTON, JUNE 25, 1999-The failure of the federal bureaucracy that runs Medicare to adequately define what services the program will pay for is jeopardizing the quality of health care of nearly 40 million older Americans, according to a new analysis by The Heritage Foundation.
The Health Care Financing Administration (HCFA) frequently denies reimbursements for care it deems "medically unnecessary" but does not provide doctors and patients with sufficient information to determine what services fit that description, says Heritage Visiting Fellow Dr. Sandra Mahkorn. Doctors who treat Medicare patients face the dilemma of choosing treatments based on their best professional judgement, and risking fraud and abuse charges if HCFA says the treatments are "unnecessary."
"Doctors and Medicare providers must decipher more than 111,000 pages of rules and regulations to figure out how to treat a Medicare patient," says Mahkorn. "The question of what's 'medically necessary' should be answered by patients and medical professionals, but unfortunately it's being dictated by bureaucrats in language only they can understand."
Mahkorn says HCFA's focus on wringing savings from Medicare is putting pressure on doctors and hospitals. Such practices result in "evicting" patients as quickly as possible following surgery or other procedures.
"Doctors on the front lines of medical care often become demoralized by pressures to practice medicine backwards," she says. "Compliance with reimbursement guidelines becomes more important than care for patients. Under the current system, doctors are forced to fit the patient to the plan rather than fitting the plan to the patient."
Mahkorn tells of a Wisconsin physician who advised an elderly patient to continue taking aspirin to cause gastrointestinal bleeding. The reason: Without the finding of blood in the gastrointestinal tract, the patient would not have fit HCFA's 1997 criteria for a medical procedure the doctor thought medically necessary.
In some cases, HCFA bases its decision to cover certain medical tests on the results of the tests. Nearly half of all Medicare carriers, the Heritage study said, will not pay for a prostate-specific antigen test if the diagnosis turns out to be an enlarged prostate rather than cancer.
Mahkorn says HCFA gets away with these questionable cost containment practices because there is no viable private alternative to Medicare for America's seniors. She suggests that Congress perform "radical surgery" on the Medicare bureaucracy by expanding patient choice, which would enable individuals and families to pick the plans they want with the benefits they need. "Choice," Mahkorn says, "would mean that patients could keep the current plan, choose a private plan, or bring their private health plan with them into retirement for primary coverage, but obtain a government contribution to offset its cost."
"HCFA should not be dictating to older Americans what type of medical treatment they need any more than federal bureaucrats should be telling doctors how to care for their patients," she says.