How health care overhaul could change Medicare

October 2, 2009 By CARLA K. JOHNSON , AP Medical Writer
In this photo taken Sept. 30, 2009, Chicago businessman Stewart Grill, 75, poses in his downtown condominium. The congressional plans for health care overhaul could mean a major restructuring of Medicare. What many seniors want to know, including Grill, is this: Can lawmakers pull this off without reducing benefits? (AP Photo/M. Spencer Green)

(AP) -- Businessman Stewart Grill, 75, believes there's waste in Medicare. He's just skeptical Congress can find and eliminate it without touching what he likes about his government health care plan.

"The talk of potential savings is a little beyond comprehension," Grill said. "Why hasn't it been saved before? It's virtually impossible to save $500 billion and not do any cutting of benefits."

The congressional plans for overhaul could mean a major restructuring of . Dozens of changes are being proposed in hopes of transforming the program from one that rewards doctors for each procedure they do into one that improves people's health and keeps them out of the hospital.

The changes should save money. What many seniors, including Grill, want to know is this: Can lawmakers pull this off without cutting benefits?

Like most seniors, Grill has his Medicare premium deducted from his check. He sees it as a good deal, but he's worried about Medicare's future.

His knee doctor no longer takes Medicare patients. And he has to pay two other doctors directly and wait for Medicare to reimburse him. He sees those doctors' policies as warnings that Medicare's reliability may be growing shakier.

A lifelong independent politically, Grill said he knows that slowing the rate of growth in Medicare can keep it solvent longer. He thinks that's good for him, and good for his children and grandchildren.

"The figures are so large and so hard to comprehend," Grill said. "The biggest overall problem I see is nobody wants their own ox gored."

Here's a look at the proposals and how they might affect him and other seniors:

-Medicare Advantage

More than 10 million seniors - nearly 1 in 4 - are covered by Medicare Advantage, an alternative that pays for-profit insurance companies to run their own versions of the . But the government is spending 14 percent more per patient in Medicare Advantage, so Congress wants to cut some of that - up to $160 billion over 10 years.

That means seniors covered by the plans may lose extra benefits like hearing aids and health club memberships. Some commercial insurers may pull out of Medicare Advantage, forcing some seniors to switch plans.

"There's no way to sugarcoat it and say there's no harm here," said Dr. Robert Berenson, a Medicare official during the Clinton administration and a senior fellow at the Urban Institute.

Everyone in Medicare pays $3 a month extra to subsidize the Medicare Advantage plans, the Leadership Council of Aging Organizations estimates.

Berenson tells seniors in Medicare Advantage it's a matter of fairness: "You've been getting extra benefits for many years beyond what the program really promised you."

-Preventing illness

Free preventive services would be more common in Medicare under the congressional plans. Medicare would pay 100 percent for mammograms, diabetes classes and other preventive services. The Senate bill would include a free annual wellness exam too.

"It starts to change the nature of the relationship from one where you go to the doctor when you're feeling sick to one that's more focused on proactive prevention," said Ken Thorpe, executive director of the Partnership to Fight Chronic Disease.

Paying doctors fairly sharpens the focus on prevention. Democrats in the House and Senate want to delay scheduled decreases in doctors' fees and provide bonus payments that would make it more lucrative to see Medicare patients.

-Staying out of the hospital

Nearly one in five Medicare patients lands back in the hospital within a month of getting out, costing billions annually.

To attack the problem, social workers in Chicago telephone patients after they leave Rush University Medical Center. The social workers find out what patients need to avoid repeat hospital trips. They help arrange rides to doctors and make sure seniors can afford their medicine.

"It can be one call or 30 calls," said Robyn Golden, who directs the hospital's older adult programs. "We call the providers to make sure they're following through when the patient says they're not."

Congress wants more hospitals to think like this. The leading Senate legislation would penalize hospitals with the highest readmission rates by reducing Medicare payments for repeat visits that could have been avoided.

-Coordinating care

A recent study found the typical primary care doctor must coordinate their Medicare patients' care with hundreds of other doctors. But rarely does any one doctor take charge of one patient's care from start to finish of a health problem.

"As it is now, the doctor asks the patient, 'What did the specialist say?'" said Joseph Baker of the nonprofit Medicare Rights Center.

Proposals in the House and Senate would set up pilot programs to better coordinate care with the goals of saving money and improving quality. Buzzwords are "medical homes" and "accountable care organizations," but the goals are the same, Baker said, "a more seamless provision of care without the bumps or gaps people experience now."

-Filling prescription drug gap

When Congress created the Medicare drug program it left a coverage gap called the "doughnut hole." More than 3 million Medicare beneficiaries a year hit this gap and start paying the full cost of their drugs until they qualify for catastrophic coverage.

Drug companies have promised a 50 percent discount on brand-name prescriptions for people in the doughnut hole. House Democrats want to eliminate the gap entirely by 2023.


On the Net:

Leadership Council of Aging Organizations:

Medicare Rights Center:

Partnership to Fight Chronic Disease:

©2009 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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