Medicare Providers Are Essential to Beneficiaries%u2019 Success

Internal Medicine World ReportMarch 2005

Medicare Providers Are Essential to Beneficiaries’ Success

By Mark McClellan, MD, PhD run w/photo

Dr McClellan is the administrator of the Centers for Medicare & Medicaid Services.

As a physician and economist I recognize your challenges in practice and the need for a more facile system to meet those needs in the most cost effective manner. The Medicare Modernization Act (MMA) of 2003 provides the framework for us to ensure that physicians and other health care providers have the flexibility and programs that support the changing nature of care for your patients for now and into the future.

Looking Forward

Prescription Drug Benefit

MMA is best known for the new Prescription Drug Benefit that will be available to all Medicare beneficiaries beginning in January 2006; it will cover 50% of drug costs for a typical beneficiary and an average of 95% of costs for more than 12 million low-income beneficiaries. This coverage will be delivered competitively and we will use the best tools to get the lowest negotiated prices and lowest overall costs for the up-to-date drugs that your patients need. The results will be increased compliance with your orders; lower drug prices, with brand name prices more than 20% below retail, according to the Kaiser Foundation; lower-than-Medicaid prices in California, according to the Consumers Union; and all this amounting to an average of $1200 in savings per person over 18 months, according to Lewin Associates.

In addition to this the new benefit, you should be aware of 3 innovations that MMA offers that may affect your practice.

Prevention Coverage

Until last year, Medicare had fallen behind with regards to proven approaches to help our millions of beneficiaries with chronic illnesses manage their diseases and avoid complications and in identifying better ways to treat our beneficiaries by providing incentives and support for getting better results.

Now, thanks to the provisions of MMA, Medicare has instituted coverage for a variety of prevention screenings, including a “Welcome to Medicare Physical” for new Medicare beneficiaries (up to 6 months after they are initially eligible for the benefit) to provide a baseline of their health status, as well as screening tests for cardiovascular health, diabetes, and cancer (ie, colorectal, mammogram, and annual prostate exams).

We need to encourage individual patients working with physicians and other health care professionals to find the treatments that are best for them at the lowest cost and that provide the best fit based on the evidence.

Medicare Health Support

A new pilot study made possible by the MMA and available initially in 9 sites throughout the country is Medicare Health Support—a program for beneficiaries with chronic diseases, such as congestive heart failure or complex diabetes. Collectively we know that such patients account for the majority of Medicare spending, and too often this spending occurs for services and complications we know how to prevent.

There are proven approaches to managing diseases and preventing complications that often lead to hospitalization. Until recently Medicare only paid for specific services rather than protocols that keep patients well. As part of this randomized, controlled trial we have selected 9 disease management companies to provide approximately 180,000 preselected fee-for-service beneficiaries, with personalized coordinated care to support the physician’s strategies. In 2 sites we are rewarding physicians ifthey achieve population-based performance improvement goals in patient and provider satisfaction.

We will continue to look at proven clinical outcome measures, as well as overall Medicare cost reduction for all test sites. Physicians in these various sites will get free coordinated nurse-verified information and patient educational support, as well as access to clinical information technology systems, such as clinical decision support, to aid their practice.

If you practice in Tampa (Fla), western Pennsylvania, Brooklyn/Queens (NY), Chicago (Ill), the District of Columbia/Maryland, Georgia, Mississippi, Oklahoma, or Tennessee you should know that your fee-for-service patients with diabetes or heart failure may be receiving a letter inviting them to participate in this large, randomized study testing the effectiveness of these care-improvement programs. This disease management effort is meant to support and enhance your existing patient-physician relationship, and we believe it works toward achieving compliance with your orders. We are hoping this evaluation would allow us to study costs, clinical outcomes, and performance measures in real-world beneficiary populations.

More Evidence-based Research

Medicare has already begun to implement steps to evaluate some of the most important questions about effectiveness. Last year we announced some expansions in our coverage of positron-emission tomography (PET) scanning for patients with cognitive impairment. This decision was based on input from independent outside experts, including experts from the National Institute on Aging (NIA) and the Alzheimer’s Association. In one important area—the evaluation of patients with early cognitive impairment—the experts generally believed there was insufficient evidence that the treatment was beneficial. But instead of simply deciding to cover or not to cover the treatment on the basis of that insufficient data, we are going to pay the clinical and experimental costs of a large study to help answer the question properly, with NIA picking up the cost of the infrastructure for collecting and analyzing the data.

We are taking the same approach in other areas, including our recent decisions to pay for new cancer drugs and implantable cardiac defibrillators. In all these cases, we made potentially life-saving new technology quickly available to our beneficiaries. But in those cases where there were still some unanswered questions about exactly how beneficial these treatments were for particular patients, we asked the developers of the products to continue to collect more medical evidence and to make that evidence available to academic experts who could use it to draw some meaningful answers.

Putting the Patient in the Driver Seat

At the Centers for Medicare & Medicaid Services (CMS), we believe it is time we helped patients into the driver’s seat. For this reason, we are providing them with personalized information on benefits, on quality hospitals and plans, and on discounted prices of drugs that particular beneficiaries use so they can work with us to make sure they get the most benefits out of the new, expanded Medicare program. And we are available to help them use this information, 24 hours 7 days a week.

Beneficiaries can call our trained customer representatives anytime at 1-800-MEDICARE, or they can visit the Web site at If they need live, personal, face-to-face help, we are expanding our support for that too.

As providers, I want to reassure you that personalized, evidence-based care is one of my main goals here at the CMS. And I hope that future columns will help you see our continuing commitment to modernize Medicare and provide you with a host of new options and the flexibility necessary to cover what you and your patients need most.

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