A Major Misstep for Medicare

Medicare is on a roll. Thanks to forward-thinking action by lawmakers and regulators alike, this 50-year-old program is being reshaped in exciting ways. Value – defined as above-average outcomes delivered at below-average cost – is the new mantra in Washington, D.C., and the results for Medicare are already being seen.

More so than at any time in the past five decades, Medicare beneficiaries are experiencing care that is coordinated, preventive, and increasingly tailored to their specific needs. Payment reforms are accelerating that are migrating the system away from fee-for-service to promote better care integration and coordination across the delivery system. And there’s much more to come: efforts are underway in both Congress and the Administration to improve quality even more while reducing costs for taxpayers.

For admitted policy wonks like me, these are heady days.

Which is why I simply can’t understand the thinking behind a surprising Medicare proposal that would reverse so much of the progress that’s now being made. Issued by the Centers for Medicare & Medicaid Services (CMS), this change would require “prior authorization” before any Medicare home health services can be delivered.

Prior authorization means that a patient can’t receive the care her physician ordered, unless and until a government official has reviewed that order (and a lot of other paperwork besides) and given it his blessing.

Keep in mind that this government bureaucrat, though well-meaning, is not a physician, and doesn’t know the patient or her individual medical needs. Nevertheless, the prior authorization proposal would put him right between the patient and her doctor. Rather than promoting innovation in payment and delivery reforms, this approach brings us back to the failed models of “managed care” from the 1980s and 1990s.

In place of patient-centered care, there would be more paperwork. Instead of fast action to meet pressing clinical needs, there would be delays and frustration. And in contrast to the innovative progress that the Medicare program has been making, there would be a retreat to a model that just doesn’t work. As bad as this idea is, it’s the reality of whom it would hurt most that is the hardest part for me to understand.

Today, approximately 3.4 million of the Medicare program’s most vulnerable beneficiaries depend on home health. These patients have been documented as being older, poorer, sicker, and more likely to be disabled, a minority, or female than all other Medicare populations – combined.

Put another way, the prior authorization proposal puts the oldest and frailest Medicare beneficiaries at greatest risk.

If finalized, this single proposal will extend – not shrink – the waiting time for care to be delivered. It will endanger – not safeguard – frail seniors’ health. It will increase – not reduce – the number of times seniors have to be readmitted to the hospital. And it will raise – not lower – Medicare spending and taxpayer costs.

If we take a look at others’ experience with prior authorization, there is clear evidence that serious delays in care will occur. Durable Medical Equipment providers, for example, report prolonged wait times of up to 10 days for authorization. Ten days. Imagine the host of adverse events – not to mention anxiety and stress – that can occur in the first 10 days following an elderly patient’s discharge from the hospital.

Waiting in her apartment for 10 days (or more) before a nurse is given permission to come, the patient could suffer a fall, miss taking needed medications, become ill again, or languish while her surgical wound becomes infected. Any of these could land her back in an emergency room, and all are highly probable.

Instead of pushing policies that put patients at risk by interrupting their care plan, CMS should promote policies that support more timely and effective coordination of care to improve the health of beneficiaries and the Medicare program as a whole, while simultaneously reducing costs. Prior authorization is an antiquated approach to care coordination that should be left in the past.

It’s clear: CMS’ home health prior authorization proposal is the wrong approach. Instead, Medicare should keep moving forward with value-based reforms that are showing so much promise in improving patient care and reducing spending. That’s the approach seniors – and taxpayers – want and need.