What Does Medicare Actually Cover?

I say Bravo for this cogent piece by Henry Kotula laying out the key conceptual driver of exorbitant healthcare prices – inadequate assessment of value for dollars spent. I argue in this Fixing U.S. Healthcare blog that only a national single-payer system would have sufficient reach and clout to assess cost-benefit and then act – over against blowback from vested interests.

Here are some additional factoids:
1. The Oregon Health Plan of 1994 did use cost-benefit analysis to prioritize services. See my previous post: The Big Fix
2. The Affordable Care Act Section 6301 provides for “comparative clinical effectiveness research,” but then prohibits the Secretary from using evidence and findings from research to make a determination regarding Medicare coverage unless “through an iterative and transparent process which includes public comment and considers the effect on subpopulations” (which seems reasonable, and mirrors what was done in Oregon). Link: https://www.gao.gov/hcac/pcor_sec_6301.pdf
3. FDA’s current approach to technology assessment is potentially flawed and susceptible to gaming. See my posts: Even Research Statistics Are Rigged and It’s Not Just About Costly Drugs, It’s Testing Too
4. The U.K.’s National Institute for Health Research does technology assessment and uses results to provide “guidance” on coverage priorities. Link: https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-technology-assessment.htm

Discussions such as this by Henry Kotula add texture to the current debate over healthcare reform. I hope Henry Kotula will keep them coming!  Enjoy this re-post!

HENRY KOTULA

What Does Medicare Actually Cover?

Image result for What Does Medicare Actually Cover?If it followed the path of traditional Medicare, it would end up paying for a lot of coverage that has little medical value.

In the first congressional hearing held on “Medicare for all” in April, Michael Burgess, a Republican congressman from Texas and a physician, called such a proposal “frightening” because it could limit the treatments available to patients.

The debate over Medicare for all has largely focused on access and taxpayer cost, but this raises a question that hasn’t gotten much attention: What treatments would it cover?

A good starting place for answers is to look at how traditional Medicare currently handles things. In one sense, there are some important elements that Medicare does not cover — and  arguably should. But a little digging into the rules governing treatments also reveals that Medicare allows a lot of low-value care — which…

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