- - Wednesday, June 6, 2012


When it comes to medical care, patients - not bureaucrats - know best what works best for them. While that sounds obvious to most Americans, in Washington, unfortunately, it’s uncommon wisdom.

Medicare Advantage was first created as an alternative option to the Medicare fee-for-service program allowing patients the choice to enroll in a private-sector health plan. It now amounts to as much as 28 percent of the Medicare market, roughly $150billion per year. These plans, which usually have out-of-pocket maximums of $6,700 per year to protect beneficiaries from catastrophic medical expenses, serve as a lifeline for millions of American seniors.

Unfortunately, by 2014, when Obamacare goes into effect, the program will be unrecognizable. The new rules will give health insurers a financial incentive to chase arbitrary targets from years before, instead of simply providing Americans with high-quality, affordable care. Because it is dated and ignores the beneficiaries, the information the federal government will provide regarding Medicare Advantage programs will be fundamentally misleading.

Since 2008, Medicare Advantage plans have been graded from one to five stars, with plans rated four stars or greater being eligible for bonus payments from the government. Competition for enrollees plus bonuses for stars are incentives for better performance. It sounds good, right? That’s not how it’s been implemented.

They crunched numbers for cancer and cholesterol screenings for 2010, and flu vaccinations for February through June 2011 - excluding peak flu season in the fall - and applied a complex combination of 34 other measures over six different time periods, all ending three months before the insurance companies had any idea what yardsticks the government was using to measure them.

About the only thing they left out is where to use the divining rod.

If that all sounds more like witchcraft than modern medicine, it’s because it is. In fact, by the time the government issues its criteria for grading the stars plans, insurers would be already past the date at which they can change their plans for the following year.

In 2013, the year before Obamacare goes into effect, Medicare Advantage beneficiaries will find themselves in stars plans based on statistics from 2010 - numbers which were already out of date before the law even passed.

The saddest irony is that under Obamacare, less than half of America’s poor will have access to a four-star plan to begin with. And wasn’t providing them with good health care the whole point of the law in the first place? Isn’t that why Congress called it the Affordable Care Act?

Highly rated plans skew heavily in favor of whiter and wealthier populations. In 2012, Medicare Advantage plans rated four stars or higher are available for 50.9 percent of eligible beneficiaries, in 32.9 percent of all counties. But for counties with poverty rates of 25 percent or higher - the poorest 9.3 percent of counties - only 13.4 percent of beneficiaries have access to four-star plans.

In other words, under Obamacare, the poor, minorities and seniors on tight budgets will face even greater impediments to purchasing good health care plans. Because the stars system will encourage insurance companies to provide only plans that earn four or five stars, and eventually scrap the rest, those people may lose their Medicare Advantage option.

Government works best when it creates fair and sensible rules, and allows companies to compete to deliver quality goods. The rules should be predictable, and they should encourage insurance companies to improve care results in the eyes of the patients themselves, not based on nonsensical Washington yardsticks.

The Medicare Advantage market so many seniors have come to rely on came closer to that before Obamacare became law, but it’s still possible to make it more competitive today.

The purpose of the stars program is respectable: Encourage plans to provide higher quality care for Medicare Advantage patients.

If Medicare structured its incentive program in a manner that allowed Americans to choose the plans that best met their needs, it could reward companies for providing better health care to more people at a lower cost - something we should all celebrate.

Ultimately, that’s not all that hard: Put choices in the hands of the patients, not the politicians.

Rep. Michael C. Burgess, a physician and Texas Republican, is chairman of the Congressional Health Care Caucus.

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