Medicare Extends Experiment in Paying Doctors

After five years of testing the idea, Medicare officials said Monday that they believe that doctors who coordinate care and keep their patients out of the hospital can help reduce the nation’s health care costs.

Under an experiment begun in April 2005, 10 physician groups were able to improve the quality of care significantly in conditions like heart failure and diabetes while reducing costs by $134 million. The doctor groups, depending on how they fared on various quality measures, were able to share in the bulk of those savings.

In making the announcement, Medicare said it would extend the program, called the Physician Group Practice Demonstration, by another two years from January 2011.

The impetus behind the experiment, whose early results we reported on in a 2007 article, was to see if Medicare could fundamentally change the way doctors are paid.

Instead of simply reimbursing doctors more when they conducted more tests or performed more procedures, Medicare tried to reward them for providing a higher quality of care that saved money by keeping people out of the hospital or emergency department when they did not need to be there.

The same thinking influences some of the current interest by federal officials in accountable care organizations.

“As we work to help bring care coordination to a broader set of providers through Accountable Care Organizations, the lessons learned by this demonstration provide great insight into how to use Medicare’s payment systems to improve quality while reducing costs,” said Dr. Donald M. Berwick, who oversees the Medicare program, in a statement. “We have learned to invest in sustained improvement over time, and that short-term comparisons between start-up costs and measureable results may fail to realize the long-term value of these efforts.”

Two of the physician groups, Marshfield Clinic in Wisconsin and the University of Michigan Faculty Group Practice, have managed to share in the savings for all five years. For the fifth year, four groups received $29 million out of the $36 million they saved Medicare.

Those four also include St. John’s Health System, in Springfield, Mo., and Park Nicollet Health Services, in St. Louis Park, Minn. For Park Nicollet, the nearly $6 million payout will represent the first time that the doctors there will be paid for their efforts, despite having hit all the quality targets for the previous three years.

“Our results provide compelling evidence that paying for outcomes, rather than volume, helps our patients, helps make health care more affordable and saves money for taxpayers,” said Dr. David Abelson, Park Nicollet’s chief executive, in a statement.

Medicare Drug Costs Unlikely to Rise

The average monthly premium for Medicare’s prescription program is not expected to go up next year, the administration said Thursday. The Health and Human Services Department projects the average premium for 2012 will be about $30 a month, hardly changed from $30.76 this year. Officials credited growing use of generics and competition within the program, which is delivered through private insurance companies. Medicare also expects to see costs drop as a number of top-selling brand name drugs get generic competition.

Free Preventive Services

Medicare offers the following preventive services free of charge (no co-pay and no-deductible).

Abdominal Aortic Aneurysm Screenings
A one-time screening ultrasound for people at risk.

Bone Mass Measurements
Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria.

Cardiovascular Screenings
Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels.

Colon Cancer Screenings (Colorectal)
Medicare covers colorectal screening tests to help find pre-cancerous polyps (growths in the colon) so they can be removed before they turn into cancer.

Diabetes Screenings
Diabetes screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Based on the results of these tests, you may be eligible for up to two diabetes screenings every year.

Diabetes Self-Management Training
Your doctor or other health care provider must provide a written order.

EKG Screenings
Medicare covers a one-time screening EKG if you get a referral for it as a result of your one-time
"Welcome to Medicare" Preventive Visit.

Flu Shots
Covered once a flu season in the fall or winter.

Glaucoma Tests
Covered once every 12 months for people at high risk for glaucoma.

Hepatitis B Shots
This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia,End-Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

HIV Screenings
Medicare covers HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test.

Mammograms
Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35–39.

Medical Nutrition Therapy Services
Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service.

Pap Tests and Pelvic Exams
Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years.

Preventive Visits
Medicare will cover two types of preventive visits—one when you’re new to Medicare and one each year after that.

Pneumococcal Shots
Most people only need this preventive shot once in their lifetime.

Prostate Cancer Screenings
Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50.

Smoking Cessation (counseling to stop smoking)
Medicare covers smoking cessation counseling as a preventive service and you'll pay nothing for the counseling sessions.