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Medicare is turning 50. Here's how to fix it
On July 30, 1965, President Lyndon B. Johnson signed Medicare into law to ensure that older Americans could receive health care at a time when half did not. However, as Medicare approaches its 50th birthday, the program is beginning to show its age.
Medicare, the federal health-insurance program for Americans over 65, currently has 53 million beneficiaries and by 2025 will have 70 million - one out of every five Americans. Medicare expenditures, which now exceed $500 billion, are projected to grow even more rapidly and reach nearly $900 billion by 2025 to meet the demand.
Yet, even today, many Medicare beneficiaries cannot access the care they need and frequently have to rely on expensive, inconvenient and impersonal institutional care rather than patient-centered home care which is cheaper and more convenient. Medicare's reimbursement policies have been slow to incorporate rapid advances in technology (e.g., point of care diagnostics) and telecommunications (e.g., video conferencing).
To provide better care at lower cost will require updated models and policy changes that enable overdue disruption to occur. One such model is the "hospital at home." Developed by Dr. Bruce Leff, a geriatrician at Johns Hopkins, and colleagues, the model provides hospital-level care (including physician and nurse visits, diagnostic testing, and intravenous therapies) to older Americans with common conditions, such as pneumonia and heart failure, in their homes. A recent study in Health Affairs found that the model provides comparable or better clinical outcomes than a traditional hospital, results in higher patient satisfaction, and reduces health-care costs by nearly 20 percent. Despite its proven success, widespread adoption is limited as Medicare only reimburses for hospital-level care in an institutional setting.
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Another disruptive model is the virtual house call, which uses the same video-conferencing technology (like Skype) that grandparents use to communicate with their grandchildren to connect patients to physicians. Currently, over 40 percent of Medicare beneficiaries with Parkinson disease, a common neurological condition, do not see a neurologist. Yet, those that do not are 20 percent more likely to fracture a hip, be placed in a skilled nursing facility, and die.
Virtual visits can overcome distance and disability barriers and connect individuals with Parkinson disease and other conditions to specialists directly in their home. However, while Medicare currently reimburses about $160 for a neurology follow-up visit in a hospital-based clinic and $80 for a follow-up visit in a community-based clinic, it pays $0 for a physician to see a patient virtually in her home. As the burden of chronic conditions, especially Alzheimer disease, increases, the demand for such models that benefit patients, caregivers, and families will rise.
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Other disruptive models could include an emergency room just for seniors and a partnership to care for retired NFL players and aging military veterans with neuropsychiatric disorders as a result of their profession. Keith Mitchell, a former All-Pro linebacker and now nationally-known yoga teacher, is developing an integrative care program that addresses their needs by combining traditional clinical care with mindfulness training. Together these disruptive models will bring us closer to realizing Medicare's original vision of enabling older Americans anywhere to receive care.
What's needed are policy changes that enable these advances to take hold. Among these changes are reimbursing and even incentivizing for in-person or virtual home care. Integrated health plans like the VA and Kaiser Permanente are covering such care, and more states are mandating that private insurers do the same. Consequently, Medicare is increasingly left alone in its refusal to encourage such innovation. Similarly, state licensing boards are restricting access to care for many patients who happen to reside in a different state (and sometimes across a river) from clinicians that can help them.
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In addition to new policies, governments must work with private industries, including insurance and technology firms, health-care providers, and non-governmental organizations to create new models of affordable, accessible health care services. Many representatives of these industries, policy makers and thought leaders will be at the inaugural d.health Summit for aging Americans on Friday, May 29 at the New York Academy of Sciences in Manhattan. Of course, one summit will not solve the issues alone. But with emerging technologies, novel approaches, and new partnerships we can address the healthcare needs of an aging population. Medicare has not reached old age yet. However, just like the senior population it serves, it needs modernization if it hopes to live a more productive life.
Commentary by Ray Dorsey, a doctor and professor of neurology at the University of Rochester Medical Center. Follow him on Twitter @dhealth2015.
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