US House of Representatives Votes to Repeal Medicare Sustainable Growth Rate and Strengthen Medicare Access
We at ACCESS Health have been watching the news closely for the last two weeks. The issue of interest was the vote by the United States (US) House of Representatives on March 26 to repeal the Medicare sustainable growth rate formula and to “strengthen Medicare access by improving physician payments and making other improvements.” The bill can be viewed here.
This event is noteworthy in a few ways. One is that the 392 to 37 vote reveals overwhelming bipartisan support for these changes. Another is that, if passed by both houses of Congress, the bill would change the US healthcare payment system significantly. The bill still needs to be passed by the Senate.
If passed, how will the bill affect healthcare in the US? First, the bill repeals the sustainable growth rate formula used by Medicare. The sustainable growth rate formula pegs provider reimbursements to economic growth, as measured by gross domestic product (GDP). In place of the sustainable growth rate formula, the bill proposes value based payment models such as accountable care organizations and bundled payment. Accountable care organizations link doctors, hospitals, and other health professionals together to develop tailored care plans for Medicare patients. These care plans encompass the entire care process, matching the appropriate service to patients’ needs and reducing duplication of efforts. The bundled payment system reimburses care providers based on expected costs for specific clinical issues. This prevents unexpectedly high costs for patients.
Presently, the US healthcare system uses a fee for service model to pay providers. This means providers are paid for each individual service or operation, regardless of necessity or efficacy. As described in Forbes, “[Fee for service] actually rewards providers financially when patients suffer complications or infections, and pays them more if [providers] order unnecessary tests or procedures.”
Changing this system would remove incentives for healthcare providers to push large numbers of services on patients. Replacing fee for service with value based payment models could improve patient outcomes while reducing costs.
In the future, the high percentage of GDP spent on healthcare in the US may fall. According to World Bank data, the United States spent nearly eighteen percent of its GDP on healthcare in 2012, the highest in the world. GDP savings on healthcare would allow higher spending in other areas, such as education.
However, it is still too early to tell whether the bill will pass the Senate. In addition, there are still many challenges to the change. Many healthcare providers still cling to fees for services models of payment. It is also challenging to define key performance values for providers. Will providers aim to reduce readmission rates or improve life expectancies of patients? At this point, performance values are not standardized. Nevertheless, the strong bipartisan support for the bill shows a consensus that the existing sustainable growth rate model is undesirable.
This movement represents a move toward a capitation payment system, which pays providers a set amount for each patient, regardless of service type. Capitation systems are used by countries like Italy, the United Kingdom, and Denmark. In addition to the US, fee for service is used in countries like Japan, Germany, and Canada.
Interestingly, China has used the fee for service system since the 1980s. China has experienced healthcare cost increases, poor quality, and a questioning of medical ethics. These factors have led to experimental healthcare reforms, since the 2000s. City and local governments were encouraged by the central government to redesign the healthcare system, with wellbeing of patients as a main goal. China tried bundled payment systems, with some success. Jining saw a thirty three percent reduction in expenditure, while Shanghai saw a seven to twelve percent reduction in cost per outpatient visit. However, these initial results are not conclusive of the superiority of a capitation system. China continues to experiment with and review healthcare reforms.
If the US moves forward with the repeal of the sustained growth rate for Medicare, other countries facing challenges with fee for service healthcare models may follow suit. The ripples of this bill are potentially larger than domestic US healthcare policy. What do you think of these policy developments? Tell us your thoughts by leaving a comment.
Ideas sometimes seem so simple and obviously great, so you ask yourself ”Why has nobody come up with that before?!”
I came across the innovative Speaking Exchange project, which is about lightening up the lives of elderly, while at the same time giving Brazilian students the opportunity to practice their English skills. Reports about this case seem to go viral on the web these very days (see links below).
I was so surprised and fascinated when I watched this clip about the Speaking Exchange:
The man shows the boy an old photo. “Is this your dad?” the boy asks. “No, It’s me and my wife when we were young”, he answers. “Oh you were good-looking when you were young”, the boy says – pause – “and you are still good-looking!”.
“I look like I’m only 25”, another man says. He and the boy a are laughing, “but I’m 88”. The two are having a nice conversation. In the end, they share a big, virtual hug.
The school uses its own digital tool for video chatting where conversations are recorded and uploaded privately for teachers to evaluate the talk language-wise.
But there is much more to this than just the language…
It’s fun and warms my heart to listen to their conversations about all the World and his brother.
According to the Public Health Agency of Canada, there are primary risk factors for obtaining a chronic disease. While the following are quite typical to hear, we must be reminded of them: tobacco use, harmful use of alcohol, raised blood pressure (or hypertension), physical inactivity, raised cholesterol, overweight/obesity, an unhealthy diet, and raised blood glucose. The Canadian Best Practices Portal has on their news line a report about diabetes in Canada from the Public Health Agency and mentions some preventative solutions.
According to the Public Health Agency report, there are several factors previously mentioned here that can promulgate the development of type 2 diabetes: namely, obesity, physical inactivity, the risk of an unhealthy diet (less than five servings of vegetables and fruit a day), and smoking. Most of these factors attribute to nearly all of the risks — where others include socio-demographic, environmental, or genetic factors.
With the risk factors in mind, it is notable to say nowadays that a highly at-risk population for obtaining type 2 diabetes is young people — with rates of physical inactivity and consumption of high-fat foods being on the rise. Interventions suggested by the Public Health Agency thus include increasing the time for physical activity in school curricula, instituting educational campaigns (which include the understanding of food labels and to teach youth how to cook nutritious, low-fat foods), providing access to community recreational facilities, networking for improving nutrition and physical activity, providing training to staff and volunteers for the skills required to promote population health, and mandating a local health service (i.e. a diabetes education center) . Notably, they stress a “holistic approach” that encompasses social, economic, environmental, genetic and lifestyle factors associated with type 2 diabetes.
“Type 1 diabetes remains the main form of the disease in this population [children and youth], but type 2 diabetes, historically viewed as an adult disease, has been on the rise globally in children and youth for the last decades.”
Why is the health of the young so important when we should be focusing on the rapid aging rate?
This is a notable question to consider, and my answer is that with the continuous drain of services for elderly due to the widespread aging process, fewer and fewer staff will be able to take care of them. What indeed could we do if the next generations of our world could not even take care of the old because they are not healthy themselves? It is an insight that we all must realize — that although there still remains a lack of focus on the rising aging population, we most certainly shouldn’t turn our heads away from the young.
Public Health Agency of Canada. http://www.phac-aspc.gc.ca/index-eng.php
Canadian Best Practices Portal. http://cbpp-pcpe.phac-aspc.gc.ca/
The Community Transportation Association (CTAA) and the Beverly Foundation of the United States brought forth a quote in their report from rural America: “Many of our innovations are by necessity, not by design.” Being driven by necessity is, unfortunately, a hard and cold fact for innovations in general. Only at the brink of when we are about to run out of a resource are our major leaders interested in bringing something new forward. Concerning transportation — and particularly in rural areas — it is indeed a necessity to consider the elderly population.
A summary of CTAA’s and Beverly Foundation’s findings :
(1) The out-migration of the younger population,
and the in-migration and aging-in-place of the older
population, has resulted in an increase in the
population that is less mobile and less able to drive
or navigate transportation services.
(2) Many seniors, especially those who are frail and
in need of assistance, depend on community
transportation services to get to both life sustaining
and life enriching activities.
(3) Transportation services face numerous
operational and financial challenges in meeting the
transportation needs of seniors.
(4) Transportation services generally address
everyday challenges such as scheduling with everyday
solutions such as technology.
(5) In addition to everyday solutions, many
transportation services successfully introduce new
or novel changes from the standard way of doing
things. Such changes generally are described as
According to this source, the Keys to Innovation (beyond leadership) include A Point of Origin (i.e. Why is this innovation needed? In this case, transportation may be forced to shut down if nothing is done due to a financial crisis with driver salaries, etc.), An Idea Factory (i.e. Where innovations are created. For example, a volunteer driving program), People Markers (i.e. The people define the innovation. For example, riders recruit drivers and drivers recruit riders), and last but not least, a Receptive Culture (i.e. The status of the society’s willingness for change.)
As the decline of infrastructure was apparent in rural America — and the rate with which the elderly population rose higher than when compared to urban America (also considering the differential between the youth leaving vs. the older staying) — the elderly in these areas have been having a challenge. Limitations include the lack of novel treatments and care, destination travel (with the factor of time — especially for long medical trips), and social isolation. But despite these enormous challenges, the Beverly Foundation and CTAA claimed that rural America is “doing a lot with a little,” so to speak.
Recently, the New England Journal of Medicine (NEJM) released their 200th anniversary article titled, “Therapeutic Evolution and the Challenge of Rational Medicine,” by Greene et al. . This article gives us a walkthrough of how medicine has evolved in the past 200 years: specifically, from patient-centered in approximately the first century and a half, to pathogen-centered in the last fifty or so years. Traditionally, western doctors had an in-depth knowledge of herbs — and a wide range of (often bizarre) treatments, ranging from the application of the “Devil’s dung” plant to the practice of bloodletting, i.e. “breathing a vein,” to assist in the curing of a disease. While some of these treatments are arguably questionable, specifically the well-versed knowledge of traditional western doctors focused more on the human perspective, and, as a result, may have been a vital ingredient to the overall well-being of the patient. This component appears lost today — where our healers are efficaciously oriented toward targeting a specific pathogen, with very specific aims. This compartmentalization of focus (generating doctors with specific knowledge about specific subjects) leaves patients with any other possible ailments or concerns to hang in the dark. While the light of the brilliant doctor who shines in his specific field of focus may isolate and treat the primary cause of a disease, the flashlight he is shining with on the patient may just as well blind the patient to any other factors just as important that could improve general well-being. The flashlight will of course cast shadows of its own. As the article in NEJM subtly points out, there can be no medicine without both therapeutic enthusiasm and therapeutic skepticism, and skepticism has flourished in the rationale of science ever since the chilling specter emerged from medicines such as thalidomide, Diethylstilbestrol, Vioxx, and Avandia [ibid]. These drugs were developed for specific purposes, i.e. to prevent morning tiredness, to act as an antidiabetic, etc., and while the focus of developing these drugs may have been done through well intention, the outcomes clearly revealed something menacing lurking in the shadows.
“As the locus of disease has narrowed from the afflicted person to the molecular mechanism, and the target of magic bullets has followed suit, physicians have faced regular reminders of the limits of the reductionist approach.” 
As we have been endlessly discovering smaller and smaller particles; and smaller and smaller actions that lead to larger reactions, one might wonder if this approach is the best to solely focus on. What may be an additional approach more fitting for our new century? The Shanghai Center for Systems Biomedicine has released an interesting article titled, “Toward new drugs for the human and non-human cells in people,” by Zhao et al. . This explores the realization that the human body is only sparsely comprised of actual “human” cells. There is in fact a multitude of lifeforms that live within us and work in synergy with our body. For example, our metabolism is aided by lifeforms such as veillonella, bifidobacteria, and lactobacilli. Zhao et al. explain that humans are “superorganisms” due to the fact that we are 10% human cells and 90% microbes (primarily in the intestines).
“‘Super'” in that sense means ‘above and beyond.’ Scientists thus are viewing people as vast ecosystems in which human, bacterial, fungal and other cells interact with each another.” 
Therefore, when microbes significantly affect our genetic actions and reactions through gene regulation; i.e. on and off switching, this directly affects our immune response — and thus affects how diseases or disorders manifest. Due to this complexity, scientists realize how the reductionist approach can certainly fail — as all individuals will have a different response to treatment. We are complex beings and thus require complex interventions, and that certainly does not mean we should delve further to find even smaller particles or specialize ourselves even more. We should, on the contrary, seek a more holistic approach. For example, our own nutrition, diets, medications, mental state and physical activity (or lack thereof) completely affect the manifestation of our microbe populations within our bodies — and thus completely affect which genes are expressed and which are not. There is nature just as much as there is nurture. The so called “functional metagenomics” proposed by Zhao et al.  for developing new medicines that affect our microbes (and I say “our” for simplicity, because these organisms work together with us) are showing promise through traditional Chinese medicine (TCM) — an archaic yet thriving art of medicine that continues to prosper and grow in popularity even among the general scientific community as time passes. In the case of gene-environment reactions, most chronic conditions are involved. Here, Zhao et al. claim the gut microbiome is vital and TCM is tailored to target both the host as well as the synergistic microbes — thus being a holistic medicine, as treatments are not specifically tailored such as the conventional drug approach, which targets in an isolated fashion typical receptors within the “druggable genome.”
It appears that for the next age — moving on from an efficacious, isolated approach in primary care — we are not going back to a patient-centered approach which began in traditional western rational science, but rather a “super organismic” track that attempts to integrate as many human and non-human factors as possible.
1. Jeremy A. Greene, M.D., Ph.D., David S. Jones, M.D., Ph.D., and Scott H. Podolsky. M.D. Therapeutic Evolution and the Challenge of Rational Medicine. N Engl J Med 2012; 367:1077-1082. September 20, 2012. DOI: 10.1056/NEJMp1113570
2. Zhao L, Nicholson JK, Lu A, Wang Z, Tang H, Holmes E, Shen J, Zhang X, Li JV, Lindon JC. Targeting the human genome-microbiome axis for drug discovery: inspirations from global systems biology and traditional Chinese medicine. J Proteome Res. 2012 Jul 6;11(7):3509-19. Epub 2012 Jun 5.
Dean Kamen’s Segway® Personal Transporter (PT) unleashed waves of enthusiasm with its release in 2001 quite frankly as a vehicle for the new age. The self-balancing gyrometers — with their fascinating ability to sustain an upright position — posited a truly bizarre realization for our populace: that times are changing and we need to be ready for it.
This realization certainly does not exclude the elderly population, whom have gone perhaps through the most changes humanity have ever faced in history; with such a dramatic recombination of technology in this past century.
If you browse through search engines and correlate the Segway with the elderly, you won’t find many innovations concerning our aged population. You will find concerns on how the elderly view such devices as the Segway — particularly the operator not being able to control it safely enough in order to prevent collisions with said elders. Forums may reveal that Segways are user-friendly for the elderly if they wish to operate them for themselves, however, safety and bug issues are always notable. It is difficult to find information, if any, regarding devices such as these specifically tailored for those in our population who require more care in their designs for mobility.
Personal Transportation Vehicles such as the Segway have brought a hallmark of inventive changes for the general population. Now, however, with a global, dramatically aging population, focus needs to be directed on the safety and effectiveness of such devices for those with more frail or limited mobility.
Today gives rise to a new state of mind for the baby boomers. As our elderly are expected to retire during ages 60-65; start playing golf, cleaning the garage and priming up the garden, it brings forth question: Do they want to do this for the rest of their years?
According to Global Action on Aging (GAA) of New York, the elderly appear to have a strong incentive to contribute to society by having a will to stay in the workforce. Trends have shown that working men between ages 62 and 74 in the past decade have risen by about 40%, whereas working women in these ages and in this same time period have risen by 60%. A large proportion of elderly in the States report low amounts of savings, and though while financial reasons are a large contributor to the elderly staying in the workforce, apparently it is not the only one. “All the research we’ve done shows that, even when the money issue is put aside, people don’t want to do nothing.” – Tammy Erickson, author of “Retire Retirement: Career Strategies for the Boomer Generation” (Harvard Business School Press, 2008)
“Call it a second phase, an encore, a reinvention. Just don’t call it retirement. More people are entering their mid-60s — stuck, perhaps, with dismayingly skimpy savings accounts, but blessed with sound health and many years ahead of them — and deciding that retirement doesn’t top their agenda.” – Katy Read, The Courier-Journal
“My speculation is that the more mature the individual, the more self-reflective or self-aware they are, the more likely to recognize that they need to retool, to kind of reinvent themselves.” – Jeff Hudson, program director for continuing education and customized training at Normandale Community College in Bloomington, Minnesota
Perhaps the wave of baby boomers caused a silver evolution and revolution in and of itself; consciously, or unconsciously, as a self-protective mechanism by our elders themselves, to help contribute to the aging world. If it be conscious, however — striven with willpower — it will probably make the outcome much more successful. Willpower is the tool needed to reinvent yourself for a reinventing future, whether is it re-educating yourself, taking on a new initiative, or quite simply charting out a new path to meet your dreams.
People Don’t Want to Retire: Many Seniors Prefer Reinventing Themselves
Former Seattlites are Reinventing Themselves in the Hills of San Miguel