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The Uninsured

The Uninsured. Many Specialists Won’t See Kids With Medicaid. Bisgaier J, Rhodes KV. N Engl J Med 2011;364:2324-2333. Under- Insurance. Rising Economic Inequality. Persistent Racial Inequalities. Rationing Amidst a Surplus of Care. Unnecessary Procedures. Variation in Medicare Spending:

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The Uninsured

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  1. The Uninsured

  2. Many Specialists Won’t See Kids With Medicaid Bisgaier J, Rhodes KV. N Engl J Med 2011;364:2324-2333

  3. Under-Insurance

  4. Rising Economic Inequality

  5. Persistent Racial Inequalities

  6. Rationing Amidst a Surplus of Care

  7. Unnecessary Procedures

  8. Variation in Medicare Spending: Some Regions Already Spend at Canadian Level

  9. ACOs:A Rerun of the HMO Experience?

  10. Profit-Driven ACO’s:Medicare HMOs Provide a Cautionary Tale

  11. Despite Medicare’s Lower Overhead, Enrollment of Medicare Patients in Private Plans Has Grown

  12. Private Medicare Plans Have Prospered by Cherry Picking

  13. Medicare’s Attempt to Improve Risk-Adjustment of HMO Payment Pre-2004 - HMOs were “cherry-picking” when payment adjusted only for age, sex, location, employment status, disability, institutionalization, Medicaid eligibility 2004 – Risk adjustment formula added 70 diagnoses

  14. Risk Adjustment Increased Medicare HMO Over-Payments$30 billion Wasted Annually “We show that . . . risk-adjustment . . . . can actually increase differential payments relative to pre-risk-adjustment levels and thus . . . raise the total cost to the government. . . . The differential payments . . . totaled $30 billion in 2006, or nearly 8 percent of total Medicare spending. . . . recalibration [of the risk adjustment formula] will likely exacerbate mispricing.” Source: NBER #16977

  15. Profit-Driven Upcoding Makes Accurate Risk Adjustment Impossible: High Cost Providers Inflate Both Reimbursement and Quality Scores by Making Patients Look Sicker on Paper

  16. Assumptions Implicit in P-4-P Performance can be accurately ascertained Individual variation is caused by variation in motivation Financial incentives will add to intrinsic motivation Current payment system is too simple Hospitals/MDs delivering poor quality care should get fewer resources

  17. Pay for Performance “I do not think its true that the way to get better doctoring and better nursing is to put money on the table in front of doctors and nurses. I think that's a fundamental misunderstanding of human motivation. I think people respond to joy and work and love and achievement and learning and appreciation and gratitude - and a sense of a job well done. I think that it feels good to be a doctor and better to be a better doctor. When we begin to attach dollar amounts to throughputs and to individual pay we are playing with fire. The first and most important effect of that may be to begin to dissociate people from their work.” Don Berwick, M.D, Source: Health Affairs 1/12/2005

  18. “We found no evidence that financial incentives can improve patient outcomes.” Flodgren et al. “An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviors and patient outcomes. Cochrane Collaboration, July 6, 2011

  19. Investor-Owned Care:Inflated Costs, Inferior Quality

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