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Friday, September 30, 2011

Thinking Outside the Box on Medicare

            My friend John and I got together for coffee recently and figured out how to Save Medicare. Everybody exhale.
            Unlike Congressman Paul Ryan, we began with the premise that the promise of Medicare (it will take care of you from 65 to the grave) needs to be kept. The question, then, is how to do that in a sustainable, cost-effective way. We (oh, all right, John, it was your idea) decided to approach that by consolidating government services and greatly reducing the profit motive. By now you’ve probably figured we’re not Republicans.
            Still, it’s hard to argue with the notion that private enterprise run riot bears a fair portion of the blame for the high cost of health care. The Medicare prescription-drug law passed a few years ago, for instance, forbids the federal government to use its buying power to bargain with drug companies for lower prices. A lot of people think government is inefficient, but mandating inefficiency and higher costs to the taxpayer is something that makes no sense unless you look at the federal government as a welfare provider to large corporations.
            By contrast the Veterans Administration hospital system requires the government to use its bargaining power with drug companies and results in significantly lower prices. Which raises the logical question as to why Medicare doesn’t follow the VA model of having government provide the services directly, rather than reimbursing a huge number of privately owned hospitals, clinics and medical practices with a wide range of treatment policies and billing practices.
            Suppose for a moment that Medicare were run like the VA, with regional hospitals and clinics focusing on its target patient population. Some provision could be made for contracting out services in sparsely populated areas, but that shouldn’t be too hard to work out.
            The advantages, in concept, would be considerable. The facilities could be run by a core of experienced doctors, with interns and younger residents doing much of the work, perhaps in exchange for a break on the cost of their medical education. With one billing system, one patient-records system, and one proscribed-treatment system (subject to physician review), the savings should be significant. The quality of medical care, owing to a focus of concentration, should be pretty good. In the event it turned out not to be, people could complain to their Congress member and have more hope of relief than they would if they complained to an HMO.
            If we acknowledge that the rising cost of health care has to be dealt with by making substantive changes, why not this one? Like the other ideas, it wouldn’t be perfect, but it incorporates the advantages mentioned above along with transparency. With one system dealing with health care for the elderly, we could get a pretty good handle on what it really costs. From what I’ve been able to understand about the Ryan proposal, one of its glaring weaknesses is that it doesn’t account for the cost of treating people whose primary coverage has run out.
            In the current political climate, suggesting a greater role for government is a tough sell. It shouldn’t automatically be so. Having a single layer of administration and accountability is common-sense management, and there’s no way to get that degree of  simplicity through the multitude of private services out there.
            The original sin of Medicare was keeping treatment in the hands of the private sector. That allowed people to keep the doctor they had, but at considerable and increasingly unaffordable cost. I like my doctor a lot, but between keeping him and keeping Medicare, I know which way I’d go.