Getting Older
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The U.S. Census Bureau reports (here) that Americans are, on average, older, an eight year change in the median age in the course of four decades. The nation’s median age increased by 0.2 years to 38.9 years between 2021 and 2022. “A third (17) of the states in the country had a median age above 40.0 in 2022, led by Maine with the highest at 44.8, and New Hampshire at 43.3. Utah (31.9), the District of Columbia (34.8), and Texas (35.5) had the lowest median ages in the nation. Hawaii had the largest increase in median age among states, up 0.4 years to 40.7.”
A report in The New York Times (here) notes that “In 2000, the median age was 35, and in 1980, the median was 30.”
The Times added, “The new data adds to the evidence that, like many European and Asian nations, the United States is graying, posing challenges for the work force, the economy and social programs. Low birthrates are the main driver of the nation’s rising median age, experts said.”
“Birthrates fell steeply in the first year or so of the coronavirus pandemic. Since then, they have ticked up. Still, since the beginning of the Great Recession, in 2007, fertility has remained very low compared with previous generations. The trend is international, even affecting countries with much stronger social programs than the United States, like Norway, Sweden and Finland, which heavily subsidize child care.”
“And while it shows the American population is older than it ever has been, the nation remains younger than its peers in Europe, where the median age is 44 . . . Immigration has historically kept the United States young, as immigrants are generally working-age adults and often have more children than native-born Americans. While immigration has recovered from rock-bottom levels during the pandemic, it has, overall, slowed since 2016.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
MACRA (The Medicare Access and CHIP Reauthorization Act) Is (Another) Failure in Medicare Physician Payment Experiments
Witnesses told a Congressional Sub-Committee (here) that the 2015 experiment—a substitute for the “Sustainable Growth Rate” which failed 1997-2015 to contain Medicare physician payments—has failed. The wide variety of experiments since 1997, each carrying new administrative expense, great promise at the outset and newer “models” at their terminus, are seen as testament to the ideological indisposition of the government to pay retail, or to exercise price controls, or to provide a predictable index for inflation.
MedPage Today reported that “MACRAs' value-based care programs have not significantly improved the quality of healthcare services,” as well. Alternative Payment Models (APMs) “have also been disappointing” and the Center for Medicare and Medicaid Innovation "found that only six out of its more than 50 APMs have yielded net savings, and only two of those have seen significant quality improvements."
Another witness, a professor of health policy at Harvard, said “MIPS [the Merit-based Incentive Payment System] has been a costly failure. In fact, I don’t recall a more uniformly and resoundingly critiqued payment policy in my career. Many, including MedPAC [the Medicare Payment Assessment Commission], have called for its elimination.”
Three physician members of Congress also commented on the challenges involved in implementing “alternative” payment models.
Rep. Michael Burgess, MD (R-Texas), [an Ob-Gyn] lamented the fact that certain parts of MACRA have been ignored, including the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which was included in the law to help advise the Medicare program on the adoption of APMs.
"The MIPS program is budget-neutral," said Rep. Larry Bucshon, MD (R-Ind.) [a thoracic surgeon]. "What I mean by that is, whoever gets bonuses, you have to have people getting cuts."
"This has helped lead to the morale amongst providers being extremely low," said Bucshon. "I talked to doctors who I have known for decades, and the burnout is high. We're losing quality people, particularly in rural America."
Rep. Raul Ruiz, MD (D-Calif.) [emergency medicine], also addressed the pay decrease. "If you take into account inflation and medical practice, payments to doctors have declined 26% between 2001 and 2023," he said. "This makes it difficult for small, rural, and low-income-serving physician practices.”
One proposed “major repair,” called for in a JAMA Viewpoint piece, (here) involves reshaping the physician fee schedule exercise to account, simply, for inflation. “Medicare payment rates have lagged inflation for 2 decades, and the blame falls squarely on Congress. Although practice costs surged 47% since 2001 and hospitals received approximately 70% increases in Medicare inpatient rates, cumulative updates for physicians’ rates totaling 9%, substantially lagging inflation. Congressional Medicare budget neutrality rules further penalize physicians by reducing payment rates across the board each year in response to changes in expenditures from other new or revised codes.”
In addition, the Viewpoint contends that “Congress must create the same predictable, annual, inflation-based updates for physicians that hospitals, skilled nursing facilities, and hospices already receive,” and that “Those who employ physicians must focus on supporting physicians’ work and eliminating burnout—and stop misusing RVUs to obsessively push productivity while ignoring the experiences of both physicians and patients.”
Robert Berenson and Emanuel Ezekiel note the role of physician fee schedules in fostering what they believe to be unethical behavior among physicians, in another JAMA piece (here) “For all the criticisms surrounding MPFS [Medicare Physician Fee Schedule] fees, a central problem with how the MPFS is generated has not been openly discussed: it embodies and institutionalizes an inherent conflict of interest that incentivizes exaggerations. When physicians’ judgments of time determine their own payment through the MPFS’s relative ranking of services, then inaccuracies, distortions, and false statements become incentivized and accepted as the social norm.”
An example of the Berenson-Emanuel thesis is found in Radiology Business (here), a report on the temptation of fee schedule differentials for radiologists to spend their professional time reading the most profitable studies, rather than those needed most urgently by patients.
MEDICARE, MEDICAID, AND COMMERCIAL HEALTH INSURANCE
CMS Calls for “All Hands on Deck” as 1.5 Million Are Dropped from Medicaid, Already
The Associated Press reports (here) that “Already, about 1.5 million people have been removed from Medicaid in more than two dozen states that started the process in April or May . . . Florida has dropped several hundred thousand people, by far the most among states . . . For people whose cases were decided in May, around half or more got dropped in Arkansas, Idaho, Kansas, Nevada, New Hampshire, Oklahoma, South Dakota, Utah and West Virginia.”
InsideHealthPolicy reports (here) that “CMS begged localities, providers and advocates . . . to help it keep every Medicaid and Children’s Health Insurance Program beneficiary covered, urging stakeholders to spread the word that redeterminations restarted and beneficiaries’ coverage is at risk if they don’t respond to a renewal request for more information.”
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Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org
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