Ryan’s Proposal for Medicare -- Shifting Risk to Seniors

noreply@blogger.com (Bill Haskell) — Fri, 15 Apr 2011 13:18:00 +0000

by Maggie Mahar and Naomi Freudlin

original posted at Healthbeat blog

“Humanity is a well with two buckets,” said Wylie, “one going down to be filled, the other coming up to be emptied.” Murphy Samuel Beckett

Maggie Mahar and Naomi Freudlin at Healthbeat Blog weigh in on Congressman Ryan’s proposal for Medicare, Medicaid, and the budget proposal.

In “Ryan’s Proposal for Medicare -- Shifting Risk to Seniors;” http://www.healthbeatblog.com/2011/04/ryans-proposal-for-medicare-shifting-risk-to-seniors-.html Maggie Mahar compares Ryan’s plan to a 401k and its difference with a pension or turning Medicare from a defined benefit plan into a defined contribution plan with the seniors bearing more of the risk and cost.

“Under Ryan’s proposal, however, the 50-year-old 401-k investor who took a beating in the stock market over the past four years now has something else to worry about. He would be expected to “manage” his health insurance, along with his savings. Just as the typical 70-year-old is not a professional money manager, he is not trained as a human resources expert. Yet it would be up to the retiree to choose an affordable plan that provides adequate coverage and access to a network of doctors and hospitals that offer high-quality care. Today, Medicare guarantees that it will cover an essential set of benefit.

if Ryan’s plan became law, it would be up to the individual to decide whether he wants to sign up for a plan with a lower premium and a fairly to high deductible, gambling that he will be able to afford the deductible when he needs care. (Much may depend on his 401-k is doing).”

Maggie again questions whether today’s healthcare business can change much under Ryan’s plan to keep costs under control when the indistry’s basis for profitability is the quantity of services, procedures, and pharma sold rather than the benefit received from them. Ryan’s plan brings little to the table in controlling this rising cost other than shift it to the elderly and disabled who have little ability to control the passed on healthcare expenses from insurance companies other than not get treatment.

Naomi Freundlich also at Healthbeat Blog discusses how Ryan’s plan for Medicaid would impact the poor; “Medicaid Savings in Ryan’s Plan Would Come At the Expense of the Poor” http://www.healthbeatblog.com/2011/04/medicaid-savings-in-ryans-plan-would-come-at-the-expense-of-the-poor.html

“There is little in Ryan’s budget proposal to support just where these savings will come from, but it’s easy to imagine that state caps on Medicaid enrollment, cuts in covered benefits and lowered physician reimbursement, along with an increase in co-pays for beneficiaries will all play an essential role.

Under the Ryan budget proposal, the health reform law would be repealed—and with it would go the federal funding that would finance some 96% of the cost of this expansion. Block grants require that the federal government pay each state either a fixed dollar amount or cap payments at a specific level, with the state responsible for all Medicaid costs that exceed the cap. If Medicaid costs rise due to increases in enrollment, economic recessions, or even health epidemics like HIV/AIDS, the federal share would remain the same.”

Maggie Mahar comments on Paul Ryan’s claim of Alice Rivlin supporting his budget proposal and its imact on Medicare. “Alice Rivlin Does Not Support Ryan’s Plan to Bury Medicare” http://www.healthbeatblog.com/2011/04/alice-rivlin-does-not-support-ryans-plan-to-bury-medicare.html

“’on ‘CNBC’s Morning Joe,’ Paul Ryan claimed Alice Rivlin, Clinton’s OMB director, as an ally: ‘Alice Rivlin and I designed these Medicare and Medicaid reforms’ he announced. ‘Alice Rivlin is a proud Democrat at the Brookings institution. These entitlement reforms are based off of those models that she and I worked on together.’

POLITICO reported that ‘The other main difference is in the rate of growth in subsidies for beneficiaries entering the new exchange system: ‘In the Ryan version, he has lowered the rate of growth and I don’t think that’s defensible,’Rivlin declared.’It pushed too much of the cost onto the beneficiaries.’”

No Assumptions for a Change

noreply@blogger.com (Bill Haskell) — Thu, 14 Apr 2011 23:21:00 +0000

Guest Post From Robert Bowman, M.D.

No Assumptions for a Change

Assumptions are often incorrect and the assumptions are incredibly inaccurate in primary care and in basic health access. When one starts with the assumption of more pay, then it is easy to rationalize more training or more complexity of care - even when there is little evidence other than assumption.

Primary care is often more difficult than specialty care.

A major reason is that the design of health care in the United States destroys primary care delivery. Reasons for primary care to be challenging are the complexity of the patients, the lack of support staff, the lack of primary care trained support staff, the lack of experienced support staff, the broad scope of primary care, the lack of respect for primary care by those who clearly have little clue regarding primary care delivery, and participating in smaller operations that are neglected by the health care design.
The fragmentation of care with even more fragmentation on the way is a problem. The required context of care includes major care provided by Americans most left out of the designs for health and education – who often cannot access care other than the basics.
The reimbursement for primary care that is less than the rapidly increasing cost of delivering primary care forces primary care practitioners to do additional efforts outside of primary care to support their primary care practices.
The decision to pay more for care other than primary care is arbitrary. This design was set up beginning 100 years ago by those who envisioned domination of all of health care and who assumed their superiority. Even in the 1940s medical leaders still understood the challenges facing generalists – because some generalists still were in leadership positions and other leaders had been generalists prior to their specialization. Once the entire context of selection, training, and practice support was designed subspecialist, this understanding was lost and the current assumptions reigned unchallenged.
The subspecialty and academic forces reached their domination in the last decades, rebounded from the managed care reforms with even greater domination – and the United States has all of the cost, quality, and access consequences now that cripple our nation and its people.
There is supporting evidence for primary care complexity as greater at the current time. This includes the fact that two-thirds of primary care graduates (28,000 from six sources) depart primary care. All types are departing primary care with 55 – 85% of graduates after graduation other than family medicine graduates (who have fewest other options). There is lower national health spending on primary care (5% is all there is) and the locations where primary care workforce is highest percentage also receives lowest health care spending at 5% for rural locations and 5% for underserved locations. Established
primary care practitioners have continued to depart primary care even during the 1990s periods of increasing policy support (PA, IM),
Few that are found in direct patient care primary care delivery from nurse, advanced nursing, nurse practitioner, PA, and IM training. Pediatric and medicine pediatric training both now yield less than a majority for primary care as well. In all of these types as well as in family medicine, a minority fraction of the training is spent on primary care. Primary care basics are taught, but it takes a lifetime of dedication to patients and to primary care delivery to even begin to comprehend primary care. Compare primary care and specialty care after a decade of care delivery. Who is worth more - my vote is for a dedicated primary care practitioner in a continuity location with a continuity team? Perhaps many if not most would contest this, but most comparisons are apples and oranges as primary care is so poorly understood.Training that yields primary care as a side effect of specialty care is also apples and oranges as the RN, NP, PA, MD, and DO primary care should be primary care in selection, in training, and in a lifetime of care delivered.
The US needs a foundation of primary care – a balance between primary care and other care. The designs must support this. Even 80% of physicians support more funding for primary care delivery (Leigh) but when asked to give up a few percentage points of reimbursement (that might not even impair pay), physician support melted away.
Once again I would note that nations need designs for care that serve nearly all in a nation nearly all of the years of their life in nearly all locations not a design that serves few for a few years in a few locations.
And there is always a nice video to review such as We're Number 37 in health outcomes (www.youtube.com/watch?v=yVgOl3cETb4), not to mention a health care design that cripples our economy, all levels of government from schools to federal, our children, and our children's children.
The current design ensures more graduates from NP, PA, DO, and MD with each passing year as well as higher percentages entering non-primary care as well as higher percentages of primary care graduates entering non-primary care. What we have is more like fantasy as compared to assumption.
Robert C. Bowman, M.D (http://www.basichealthaccess.org/)

Angry Bear - Healthcare

Ryan’s Proposal for Medicare -- Shifting Risk to Seniors

Naomi Freundlich also at Healthbeat Blog discusses how Ryan’s plan for Medicaid would impact the poor; “Medicaid Savings in Ryan’s Plan Would Come At the Expense of the Poor” http://www.healthbeatblog.com/2011/04/medicaid-savings-in-ryans-plan-would-come-at-the-expense-of-the-poor.html

No Assumptions for a Change