Understanding the new Medicare
By Charlotte Yeh, M.D.
It turns 40 years old this year, serves 42 million people, and is the nation's largest health insurer. And it keeps getting better.
With the passage of the Medicare Modernization Act in 2003, Medicare has undertaken its most profound changes since being enacted in 1965. More than 700 pages of law have transformed the program for patients, physicians and their practices, and all Americans.
While the new prescription drug benefit is getting much attention, the modernization act also enhances payments to providers, provides new preventive benefits for patients, offers more personal choices, and supports demonstration programs to test more effective and efficient ways of caring for patients, including those with chronic illnesses.
For example, Medicare now covers a cardiovascular screening every five years and a blood sugar test for people at risk of getting diabetes. For those whose Medicare Part B coverage (medical insurance for physician services, outpatient care, physical and occupational therapy and some home health care) began on or after January 1, 2005, Medicare provides a one-time preventive physical exam, including an electrocardiogram, within the first six months that they have Part B. Other preventive services include screenings for several types of cancer, flu and pneumococcal (pneumonia) vaccinations, bone mass measurements, and glaucoma tests.
Simply put, Medicare aims to put patients and their providers back in the driver's seat.
Medicare has recently approved 143 new Medicare Advantage Plans, offering more benefits and providing greater savings to beneficiaries. And beginning in 2006, for the first time, all 42 million Medicare beneficiaries will be eligible to participate in a Medicare prescription drug plan. For those who enroll, coverage begins in January, and estimates are that those participating will see their drug costs cut in half.
People will have a choice of plans operated by private companies, and all plans will cover both brand name and generic drugs. Plans must accept all Medicare beneficiaries in their service area and offer them all the same benefits and premiums.
For physicians, important changes to Medicare include payment reforms, electronic-prescribing, changes to the appeals process, new technology coverage, and claims processing contractor reform.
Electronic prescribing bringing information technology to the physician-patient-pharmacist relationship of prescribing medications saves time and money, but most important, it increases patient safety by reducing medical errors. Standards are being established for e-prescribing to help physicians, hospitals, and pharmacies work together, and prescription drug plans will be required to support e-prescribing.
Medicare is working toward recognizing innovations in quality of care, evidence-based evaluation, and new medical technology. New methods, including payment incentives, to reward physicians who provide the best care for their patients, are being tested. By working with physicians' groups and other private organizations, Medicare hopes to find the best quality measures and provide support for improvement.
The focus on quality has also led to developing programs to compare the quality of care in hospitals and nursing homes. The new information provides consumers with standardized assessments of the care that nearly 4,200 hospitals across the country provide to adult patients. Hospitals are providing crucial data through a provision of the modernization act that gives them a financial incentive to report quality of care data.
Similarly, nursing homes are undergoing evaluation, according to a set of 14 quality measures. Such examinations can help patients and their families compare the quality of care in nursing homes nationwide.
Medicare is also conducting and sponsoring demonstration projects to test and measure the effects of potential program changes. Current projects address coverage of certain prescription drugs, rural community hospitals, and chronic care improvement, among others. Six organizations have been chosen for a three-year demonstration project to help beneficiaries with complex medical needs improve their quality of life and prevent complications of their illnesses. The programs will begin enrollment in the fall.
So, with all the new offerings and changes, where can one turn for more information?
Visit the Medicare website at www.medicare.gov for information on all of our initiatives. For data on hospital quality, see www.hospitalcompare.hhs.gov. Nursing home data is available at www.cms.hhs.gov/quality/nhqi.
And for information about the new changes to Medicare, the information hotline at 1-800-MEDICARE should serve you well. Patients who need personalized counseling about their Medicare options in Massachusetts may contact SHINE (Serving Health Information Needs of Elders) at 1-800-AGE-INFO.
Charlotte Yeh, M.D., is Regional Administrator for the Centers for Medicare & Medicaid Services, Region I, based in Boston. Physician Focus is provided as a public service by the Massachusetts Medical Society. Readers should use their own judgment when seeking medical care and consult with their physician for treatment. Comments are welcome at PhysicianFocus@mms.org. For more information, visit www.massmed.org.
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