Monday, January 10, 2011

Guest Blog: Does Medicare get prevention right in 2011?

Dr. Ed Pullen is a family physician who practices at Sound Family Medicine in Puyallup, WA. The following piece is excerpted from a previously published post on his blog, DrPullen.com.

**

Starting in 2011, Medicare will eliminate co-payments and deductibles for certain preventive services for older Americans. This is great news for primary care physicians. I’m a family physician, and have struggled for years with the fact that just about every private insurance plan covers an annual physical exam, but Medicare did not. What this accomplished was bringing in my relatively healthy 30-something patients for a physical exam each year, while my 70 year-olds (for whom far more preventive services were recommended) were not covered for a preventive exam ever.

So as primary care physicians we tried to our best to squeeze preventive care into visits for other complaints. At every-3-month visits of my diabetes patients, I’d try to save enough time to review immunization status, assure breast and/or colon cancer screening was up to date, help men decide if they wanted prostate cancer screening. Now I’m looking forward to being able to ask my seniors to schedule a preventive care visit and being able to focus on these issues without having to eke out time in a problem oriented visit.

Still, I have to say that if the goal is to provide incentives to older Americans to go to their physicians for services that will really make a difference in their health problems, I think Congress got it wrong. If we want to reduce the burden of expensive medical complications, I believe the most efficacious preventive services we can offer in health care are secondary prevention and disease management. I’d love to think that by primary prevention, education, and physical exams, I can help patients improve their health and subsequently reduce costs and improve outcomes. The problem is that there is little evidence that this is the case.

Offering a free annual Medicare preventive care visit may find some treatable cancers, improve immunization rates, and make us feel like we are being proactive. But finding a way to give incentives to our poorly controlled diabetics to control their blood sugars, blood pressure, and LDL cholesterol would save a lot more lives and prevent a lot more hospitalizations. And getting our post-MI patients in for LDL management, BP control, and smoking cessation help would have a much bigger impact.

Maybe Medicare should offer reduced copay or deductible on quarterly visits for everyone with a diagnosis of diabetes. Maybe add a no-copay benefit for diabetics who take an ACE or an ARB, have a hemoglobin A1C under 8% and have an LDL under 130. How about no copay or deductible for diabetic eye exams, free generic BP medications from a list of recommended options, and free generic statins for patients who meet risk profile cutoffs? I’m not a population modeling actuary with sophisticated algorithms to determine just which of these type of interventions would be most effective. I can’t help but believe, though, that objective modeling could provide a data-based framework on which to set up a plan to improve health at the lowest possible cost.

3 comments:

  1. Speaking of the lowest possible cost, if the cable company ran Medicare, they could give extra hours or premium channels for certain health behaviors. Subscribers could bet cable hours or premium channels on meeting certain health goals, e.g. weight, A1c, tobacco free lifestyle. Could they do better than physicians? Would it be cheaper? Just a thought.

    ReplyDelete
  2. The thing to remember about this annual health exam is that it's not really a true physical. It has very specific guidelines for what is to be tested. Memory, depression screening, and was supposed to include end of life care discussion, but they took it out. Not that we shouldn't be doing these things, but if you are looking for motivating to improve the health of our patients and truly do prevention, we need to think twice.

    What that's going to do is result in our diagnosing dementia earlier which is GREAT but our medicare patients in the donut hole will not be able to afford the expensive meds for it. Then what do we do?

    I agree there are things that could make a bigger impact.

    ReplyDelete
  3. Unfortunately this is the reality of medicare, when in fact it should be the other way around. :(

    ReplyDelete