Health Care Reform and Caregivers Refusing Medicare Patients

Robert goes out on a limb and guesses that Lori Montgomery fell for (or is pushing) Republican spin in this article in the Washington Post
Report: Bill would reduce senior care
Medicare cuts approved by House may affect access to providers

A plan to slash more than $500 billion from future Medicare spending — one of the biggest sources of funding for President Obama’s proposed overhaul of the nation’s health-care system — would sharply reduce benefits for some senior citizens and could jeopardize access to care for millions of others, according to a government evaluation released Saturday.

The report, requested by House Republicans, found that Medicare cuts contained in the health package approved by the House on Nov. 7 are likely to prove so costly to hospitals and nursing homes that they could stop taking Medicare altogether.

Congress could intervene to avoid such an outcome, but “so doing would likely result in significantly smaller actual savings” than is currently projected, according to the analysis by the chief actuary for the agency that administers Medicare and Medicaid.

I have read the report (warning pdf) … well actually up to the passage stressed by Republicans and Montgomery. Montgomery’s article focuses on one paragraph deep in the report which begins “It is important to note that the estimated savings for one category of Medicare proposals may be unrealistic.” That’s some serious digging.

The paragraph goes on to discuss what seems to be new additional budgetary flimflam which is assuming that productivity in hospitals and nursing homes grows at the national average (measured productivity grows much more slowly and it doesn’t matter if this is due to unmeasured improved quality of care). That would be part of a large savings of $ 282 billion. The report doesn’t describe what the savings would be if Medicare rates were adjusted to a reasonable forecast of productivity growth.

Now I had assumed that Medicare cuts other than eliminating the Medicare advantage boondoggle were reductions in money effectively given to hospitals (and nursing homes etc) so they could afford to take care of the uninsured. Hospitals’ budgets will be affected by increased health insurance coverage, both by the increases in the total fraction of people insured and the fraction of people with pre-existing conditions insured. This means that the total effect on Hospitals’ budgets can’t be calculated assuming only Medicare payment rates change.

Importantly, the Foster (the author) assumes that reduced Medicare payments will cause hospitals to choose to refuse Medicare patients and not drive Hospitals bankrupt. It is true that relatively lower Medicare rates will cause more hospitals to refuse Medicare patients. How many currently do? I googled
“hospitals which refuse medicare” I got links to articles about physicians who refuse Medicare patients and this link to someone who works at a hospital where they talked about refusing Medicare patients.

Medicare rates are already low. There sure don’t seem to be many hospitals which refuse to treat Medicare patients.

OK so I tried the past tense and googled “hospital did not accept medicare”
This link to someone who says an anonymous hospital told her in 1998 that they didn’t accept Medicare patients.

Quite frankly this doesn’t seem to be a huge problem. The idea that it will get even bigger if Medicare rates fall further below other rates doesn’t seem to me to merit page 1 treatment.

I think Foster is saying that he believes that the new restrictions on Medicare compensation will be waived just as the existing restrictions are waived. He can’t say that Congress is flimflamming so he has to explain how this might be a natural response to unforeseen events in the future. My current guess is that the event will be the perfectly foreseeable complaints from hospitals and nursing homes and that the forecast that Congress will waive the rule is the only forecast a responsible actuary can make.

The Republican/Montgomery/www.washingtonpost.com headline guy spin that elderly people will be denied care if the bill passes is absurd. If that’s the way things worked, the 1997 rule wouldn’t be waived year after year.

There don’t seem to be many reports of hospitals refusing Medicaid either.
No google hits for “hospital refuses medicaid” one for “hospital refused medicaid” to a publication of the National Center for Policy Analysis. Hmmm, where have I heard of that? It’s the so called think tank which fired Bruce Bartlett for heresy.

The document to which I link asserts that Veterans care is queue rationed and that the veterans administration does provide as high quality care as that available to people with private insurance. Non ideological sources rate the veterans administration as the best care provider — number one.

I think that “Hospitals will refuse Medicare and/or Medicaid” is a serious policy concern on a level similar to the “tax cuts cause increased revenues.” And here it is on the front page of www.washingtonpost.com.

Update: Note I am writing about hospitals who refuse Medicare not doctors in private practice who refuse Medicare. My googling and questions were on hospitals which refuse medicare and/or medicaid. Of the first 7 comments, 5 discussed office based practices which refuse medicare. By my count letters “hospital” appear in that order 18 (eighteen) times in the post (sometimes followed immediately by an s). Somehow commenters seem to have overlooked all 18 (eighteen) of them.

This is not a quibble. The provision of the bill which Foster suspects will not be actually applied concerns “institutional” providers of health care not physicians in private practice. I quote from his report

H.R. 3962 would introduce permanent annual productivity adjustments to price updates for institutional providers (such as acute car hospitals, skilled nursing facilities, and home health agencies) using a 10-year moving average of economy-wide productivity gains. [skip] end participation in the program (possibly jeopardizing access to care for beneficiaries).

That’s why I asked about Hospitals refusing medicare patients. There is a big difference between squeezing the entities which can’t be squeezed and squeezing those which can be squeezed (provided they are getting a lot more money due to increased insurance coverage so they won’t go bankrupt).

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