Medicare Policy Needs Viagra

This post is about policy dysfunction, not erectile dysfunction.

Medicare reform is so complicated that it's easy to get lost in arcane minutia. But if we take a big picture view of the two main approaches to containing Medicare costs - the Sustainable Growth Rate (SGR) formula and Paul Ryan's voucher proposal - we see the cost problem for what it is - a symptom of policy dysfunction.

Both approaches embody a basic truth. The U.S. must get a grip on Medicare costs, and accomplishing that won't happen without setting limits. The SGR does that by pinning the tail on physician fees. If per capita Medicare costs rise too much, fees have to come down correspondingly. The Ryan plan pins the tail on Medicare recipients - if costs rise faster than the vouchers they receive, it's their problem to solve.

Both approaches deserve respect for not indulging in the delusion that "waste, fraud and abuse" will do the job. But both are profoundly wrong.

It's not primarily physicians' fees that drive Medicare costs. It's the services we physicians order. Lowering fees across the board puts prudent and profligate physicians in the same boat. The SGR is a make-believe "solution" that Congress repeals every time the formula prescribes a massive fee reduction.

The Ryan plan is similarly misguided. Medicare recipients aren't "consumers" of health care. When shopping for clothes we (I'm Medicare eligible) can choose between Walmart and Nieman Marcus. That's consumerism. But when cancer or heart disease occur we don't "shop" at a cancer or cardiac mall - we seek doctors and nurses we trust and put ourselves in their hands. The negative reaction to Ryan's proposal shows that U.S. society won't accept putting the risk of cost overruns onto Medicare recipients alone any more than Congress accepts putting that risk uniquely onto physicians.

The SGR and the Ryan plan both try to solve a cultural and ethical problem with a simple technical fix. In part because of our reluctance to accept the inevitability of aging, decline, and death, and in part because the medical-industrial complex has sold us on the idea that ever more medical intervention will make us younger, healthier and happier, we haven't yet accepted the fact that we ("we" = physicians, patients and the wider public) must collaboratively manage Medicare (and the entire health system) in a more parsimonious, evidence-based manner.

The fact that a wise and compassionate proposal to pay doctors for visits in which they discuss their patients' goals triggered an eruption about "death panels" demonstrates the depth of the cultural and ethical challenge. Sarah Palin and Newt Gingrich almost certainly knew they were lying in crying "death panel," but the fact that the public responded as strongly as it did shows that the very idea of discussing values about the goals of health care is seen, by many, as an assault on life itself.

The result of Medicare policy dysfunction is a program that too often harms seniors by overtreatment, creates ever-increasing out-of-pocket costs for Medicare recipients, and robs the next generation of opportunities they would otherwise have.

Medicare reforms that are guided by clinical evidence ethical reflection will better serve seniors and society. I continue to believe that advocacy for this approach from within the community of Medicare recipients will embolden political leaders to be more courageous. That kind of advocacy may serve as Viagra for policy dysfunction!

(See here and here for previous posts about Medicare advocacy.)