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Dr. John E. Kern

Medicare Advantage works

At a town hall meeting in July, President Barack Obama echoed some of my thoughts about what our health care system needs. He said, "We need to invest in prevention and wellness that help Americans live longer, healthier lives." He said, "We should change the warped incentives that reward doctors and hospitals based on how many tests or procedures they prescribe. … We've got to create a simplified, more effective system where they are reimbursed for quality care."

For 17 years I have been working in a medical practice that does those things. I am a primary care doctor, and my patients are seniors covered by Medicare Advantage.

In many ways, Medicare Advantage is a model for the kind of system the president and many of the most passionate advocates of reform say we need. Yet ironically, in Congress' desire to cut medical costs, some people are trying to eliminate it — or at least make deep cuts. The reason is that those plans cost the government more than original, fee-for-service Medicare. But Medicare Advantage plans also provide more services. Every day, I see how it results in better care and healthier people — which should mean lower costs over the long haul.

For the past few days, I've taken notes as I see patients. I have accumulated quite a list of why it's important to keep this form of Medicare going.

Most of the items on my list are a result of two facts: First, under Medicare Advantage, more patients have a "medical home," a doctor who ensures they get the services they need in the right setting. Second, many Medicare Advantage plans pay doctors a set amount per patient, with the incentive to keep patients healthy.

Contrast that with original, fee-for-service Medicare, where the incentives are the opposite — wait until the patient gets sick, then fix the problem. The more tests and procedures, the more money the doctor makes.

Here are some examples of what I have seen:

• We have one patient who was frequently admitted to the hospital for unstable congestive heart failure. We put her in a disease management program, had her buy an inexpensive bathroom scale, and now a nurse calls her every day to get her weight and ask about shortness of breath so we know whether to adjust her medication. This keeps her well and at home.

• One of our patients was always mixing up her medications, which led to uncontrolled blood pressure and diabetes. Now she brings her medication to us and someone sets up her pill box. Her chronic conditions are controlled.

• Discharge from hospital to home is a confusing time for patients. Nationally, one in five seniors re-enters the hospital within a month. In my practice, it's more like one in 20 because my nurses call patients immediately after they get home, explain medication changes, make sure they've picked up prescriptions and that medical equipment has been delivered and home health services started. That usually prevents them from having to be re- admitted.

• Our nurses call some patients regularly, so they develop real relationships. One patient recently said she had been scared by her diagnosis and needed someone who could tell her whether she was in trouble or if a symptom was typical. Another patient said this relationship kept her from going to an emergency room several times.

• Many patients get fitness club memberships as part of their Medicare Advantage benefits.

Original, fee-for-service Medicare has never been geared to prevention or disease management, but that is what we emphasize. This is an important part of controlling costs. The "extra" money politicians talk about in Medicare Advantage plans pays for this, and it's well spent — the Centers for Disease Control says 70 percent of all medical costs go toward preventable conditions, like Type 2 diabetes and cardiac care.

I know there are problems in our health care system, but surely we know not to change the parts that work. Medicare Advantage is one of the parts that work. Every day, I see the difference it makes in patients' health and in their lives.

Dr. John E. Kern is medical director of JSA Medical Group and served on quality management and/or peer review committees at St. Petersburg General Hospital for 14 years.

Medicare Advantage works 08/14/09 [Last modified: Friday, August 14, 2009 7:08pm]

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