The Medicare Solution

April 18, 2019

Still more than a year ahead of 2020 presidential elections, the battle over how to “fix” health care in America is reaching fever pitch.

First there’s Medicare-for-all, now a campaign mainstay.  The concept would drastically expand the number of patients covered by a national health system.  Guaranteeing coverage for all Americans would, in theory, ensure everyone has access to treatment – without high out-of-pocket costs and other barriers erected by private insurance companies.

The Trump administration has different ideas.  It has committed itself to reducing costs associated with the current Medicare system through a series of changes and proposed demonstration projects.  One involves tinkering with how prescription drugs are covered, shifting drugs from Medicare Part B to D.  Another takes a radical approach that imports lower foreign prices for Part B medications—those infused or injected in a hospital or doctor’s office—using an international pricing index.  The ideas generated concerns about the accessibility of seniors’ medicine.

Both approaches, Medicare-for-all and lowering Medicare costs through demonstration projects, aim to ensure patients can see a doctor and afford their prescription medicines.  But perhaps they present a false choice. Must we choose between managing costs or ensuring patient access?

What if, instead, policymakers achieved both aims by focusing on core, commonsense health care principles – and eliminated the red tape that burdens health care providers and impedes patient access?  Reforms might include:

Respecting the Provider-Patient Relationship.  Providers know the individual needs of their patients better than insurance companies, yet doctors’ treatment decisions are constantly questioned.  Rather than delay care waiting for justification to be submitted and approved, insurers could retrospectively review files to look for providers practicing outside professional care standards.

Curbing Abusive Utilization Management.  Completing prior authorizations; submitting records, labs and letters; working through the process of appealing denials—they all keep providers from spending time caring for patients.  Many practices have dedicated professionals whose sole job is keeping up with the unending stacks of forms and paperwork in an effort to assist clinicians. It doesn’t have to be this way.  A system that allows patients to get what their doctor prescribed in a timely manner can improve patients’ health and reduce costly administrative burden on providers.

Protecting Ongoing Treatment Access.  For providers, getting patients on their medication is the first feat; keeping them on it is the second.  Insurers’ use of non-medical switching, which forces patients to change medications for a non-medical purpose, routinely knocks patients from their stable treatment regimen.  Research shows non-medical switching leads to symptom reemergence, increased medical appointments and, for one in ten patients, hospitalization.   

Applying these principles can improve outcomes for patients – a need no one can argue against.  The United State spends more than $10,000 per person annually on health care, more than all other developed countries.  Yet Americans’ health outcomes remain suboptimal.

When patients have timely access to their prescribed medication, they can enjoy a better quality of life, have less workplace absenteeism, and care for themselves and their loved ones.  Conversely, patients with high rates of medication non-adherence are at increased risk for losing control of their conditions and have more doctor’s or emergency room visits. This excess use of health care costs everyone more.

Sixty percent of Americans oppose Medicare-for-all if it results in higher taxes.  And no one wants seniors to have reduced prescription drug coverage under Medicare.  If policymakers are looking for a better way, they might begin by considering principles that protect the patient-provider relationship and improve patient access to optimal care.

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