If you could design a new Medicare plan from the ground up, what benefits would you include?
An entire year (or three) of nursing home care? Full dental, vision and hearing coverage? Expanded mental health benefits?
Countless politicians have certainly shared their opinions, touting various types of Medicare reform during debates and campaign events. But Marge Ginsburg, founding director of the Center for Healthcare Decisions (CHCD), decided it was time to ask everyday Americans to share their thoughts on how they'd like to see the program change.
Her ultimate goal? To answer the question: "How do we use public input to actually move forward on healthy policy options that are now being considered?"
Her first step towards this aim was to create a unique interactive exercise called "MedCHAT"—a cross between a strategy game and a health care negotiation summit. Over the course of a year, more than 800 Californians of varying ages and from all walks of life attended one of 82 MedCHAT seminars. During these three-hour long sessions, participants crafted hypothetical Medicare programs and discussed which changes they would make to the current program and why.
"We're an individualistic society," says Ginsburg in a recent presentation at the American Enterprise Institute (AEI). "People think about health care very personally. It is personal. Nothing is more personal than your health and well-being and longevity of you and your family members."
But the purpose of MedCHAT is to get people to do just that--chat--about health care in a civilized way, and allow Americans to "move from thinking about [health care] solely in terms of what's in my best interest to what would be in the best interest of all of us," says Ginsburg.
Building a better Medicare
To simulate the tradeoffs involved in creating a nationwide health insurance program, MedCHAT developers split the topic of elder care into 12 different categories (e.g. Complex Chronic Care, Final Phase Care, Long-Term Care, Premiums, Providers, etc.).
Each category had three tiers of coverage to choose from. In each category, one of these three tiers mimicked Medicare's existing benefit. Each tier cost a certain number of "markers," based on its calculated burden on the Medicare system, and participants were given a total of 100 markers to spend creating their plan.
For instance, in the Provider category, participants could spend one marker on tier one coverage, which would allow Medicare patients to only see doctors, nurses, therapists and hospitals within a specific provider group. Any visits to out-of-network providers would have to be paid for out-of-pocket by the patient. Or, they could chose tier two coverage for five markers to give patients the same provider network as they had in tier one, but also allow them to go outside of the network for a treatment, as long as an in-network provider deemed it necessary. Tier three coverage for the Provider benefit cost 10 markers, but would enable patients to see any health care provider that accepts Medicare patients (this is how Medicare Part B currently works).
Participants were initially tasked with creating a program on their own, taking into account only their individual needs or the needs of an aging loved one. Next, they worked in small groups to construct a program to cater to the needs of all older Americans.
After the small group work, all of the participants gathered to discuss their choices and rationale—a crucial step, according to Ginsburg. "Unless you actually understand why people hold the views they do and why they are willing to make tradeoffs between one option and another, then you haven't really understood what those public values are that are key to their thinking."
During the last phase of the MedCHAT exercise, participants revisited their individual programs to make tweaks and develop a plan that could be applied nationwide, hopefully using the perspectives they heard in the group discussion to inform their choices.
Agreeing to agree and disagree
Predictably, there was a good deal of variation in how MedCHAT participants chose to spend their precious markers; but a few common themes did emerge:
A call for change: Most people were in favor of altering Medicare coverage options in 10 of the 12 categories. Only Routine Care coverage and Catastrophic Care coverage were acceptable, as is, to the majority of participants. Currently, Medicare covers the costs of all tests and treatments that are considered part of routine or preventive care. The program also pays for the treatment of conditions that stem from catastrophic events, such as a sudden irreversible stroke or a car accident, even if the benefit is minimal or the treatment only has an outside shot of being successful.
A desire for expanded long-term care coverage: One hotly-debated topic was the need to expand long-term care options for Medicare beneficiaries. "I think we have to address long-term care," says one participant. "I think that we're putting our head in the sand if we're not addressing it." As it stands today, Medicare will cover the first 100 days in a skilled nursing facility only if an older adult needs short-term rehabilitation following a hospital stay. (See more: Medicare Coverage of Skilled Nursing Facility Services) Those who need help to pay for more extended long-term care services must often resort to Medicaid. Sixty-two percent of MedCHAT participants were willing to shell out 12 of their markers to gain a full year of coverage (with 10 percent co-insurance) for nursing home or in-home care, while another 15 percent parted with the 20 markers it took to access three years of long-term care coverage.
A need for new benefits: Many participants lamented the lack of financial assistance from Medicare with regards to dental, vision and hearing care. Medicare doesn't currently pay for routine hearing tests, dental exams or eyeglass exams. The program also doesn't cover the cost of hearing aids, dentures or eyeglasses. Most respondents (85 percent) were in favor of spending three markers to widen benefits to include partial coverage of routine dental care, hearing aids and hearing tests, as well as eyeglasses and vision tests. Another 81 percent allotted a single marker to access coverage for transportation services to and from medical appointments.
A demand for a better death: One area of nearly unanimous agreement was coverage for so-called "Final Phase" care for older adults with ongoing illnesses and who appear to be entering their last year of life. Right now, Medicare offers actively dying patients the option to choose between palliative and hospice care or aggressive treatment in the ICU. However, 65 percent of MedCHAT participants said they would prefer Medicare to only provide coverage for interventions aimed at improving a patient's quality of life (e.g. pain management), not for surgery or other extreme life-saving measures. Only three percent were in favor of keeping the current Medicare coverage for Final Phase care. Why did so many people of all ages oppose Hail Mary medical interventions for older adults who are dying? Because such treatments often don't benefit the patients or their families, but instead offer false hope that can be both medically and financially costly. As one respondent puts it, "One of the problems that we have with the Medicare system is that so much money is spent on programs that have a snowball's chance in hell of doing anything, and people want to cling to this."
Another interesting outcome was that 85 percent of participants, both young and old, were willing to spend some of their precious markers to make sure that the Medicare program would remain viable for another 50 to 75 years to allow their descendants to reap the benefits.
Only Californians participated in this initial round of MedCHAT, but Ginsburg wants to expand the exercises to other states in order to stimulate policy reform dialogue among the America public.
So, how about it? What would you add to your Medicare Wish List? Share your thoughts in the comment box below.