Goals, Outcomes and Kicking the Can Down the Road Again

Recent developments indicate that political agendas will stymie Congress’  struggle with the Gordian knot of health care financing, regulation and deficit reduction.  Under the Budget Control Act (P.L. 112-25), the  debt ceiling legislation passed in August, the deficit committee’s failure to reach agreement is supposed to trigger automatic spending cuts to both defense and domestic programs beginning in 2013.  But, as several posts on this blog have discussed before, Congress’ previous attempts to force spending cuts automatically didn’t work. It has countermanded the payment reductions required by the sustainable growth rate  (SGR) statute every year since 2003 with the “doc fix,”  a temporary correction. But the statutory formula is cumulative, so that each delay in addressing the problem increases the cuts required when the delay expires.

 The rates Medicare pays to doctors are projected to drop by about 27 percent in 2012 unless Congress enacts another doc fix, a much deeper cut than the 20 percent estimated for 2011 if the doc fix wasn’t passed. Although doctors previously supported temporary fixes, the continuing uncertainty  is a disincentive to making the kinds of investments  that would cut costs in the future — in care coordination, monitoring of patients with chronic conditions and information technology.  And in an election year, no one wants to annoy potential contributors.

But the focus on short-term consequences  undermines any effort to resolve the deeper health policy questions that exemplify divisions in the nation as a whole — What responsibilities do  we have for one another? What role does government play in promoting public health and the general welfare? Who should decide what health services are available, to whom, and at what price?

CMS’ recent decision to offer Medicare coverage of screening and treatment for obesity as a free preventive benefit is a commitment to cut costs in the future by spending more now.  The staggering cost of treating heart disease and diabetes greatly outweighs the cost of prevention.  Jay Nawrocki’s recent post discussed a court decision that raises the policy issue in a different way. The court ruling will allow Medicare beneficiaries to challenge agency policy denying further coverage of rehabilitative therapies that would help maintain, but not improve, their level of functioning   

Spending decisions and policy decisions are inextricably intertwined. In fact, one could argue that all government spending decisions are policy decisions. (It’s interesting that federal initiatives  have  created jobs in health care even as patients delayed procedures.  How much should that matter?)

CMS’ efforts over the last several years have tied payment to quality of care, measured objectively with reference to evidence-based practices that reduce the risk of harm to patients and improve health outcomes.  The requirement to report on the use of evidence-based practices, such as giving aspirin to patients who present at an emergency department with systems of heart attack, in order to qualify for the full amount of a payment increase, is a prime example of such a policy.  Denial of payment for the costs of hospital-acquired infections is another. You can bet there will be litigation challenging agency determinations denying Medicare payment for costs attributed to hospital (or healthcare) acquired conditions.

Those who are adversely affected by quality or reporting requirements may argue that the government is interfering with their exercise of their professional judgment. The argument is of a piece with that of the physician who complained to HHS that a reporter abused nonidentifying information from the National Practitioner Data Bank by comparing it with publicly available court documents to report on the doctor’s record of malpractice. 

Given what’s at stake, what would it take to get Congress to have a thoughtful discussion on healthcare spending, the budget and national priorities?