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On the Third Hand: Bonuses

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Television historians date the beginning of the decline of “Happy Days” to the episode in which the Fonz water skiied over a shark.

Clearly, if you’re anywhere on the spectrum from being angrily opposed to the Patient Protection and Affordable Care Act (PPACA) to warmly supportive in a nervous way, the U.S. Department of Health and Human Services (HHS), the Urban Institute, the Kaiser Family Foundation and Commonwealth Fund analysts have jumped the shark when it comes to creating projections about how wonderful PPACA will be in 2014 and later years, or how great it would be today, if only it were already gloriously in full effect right at this exact moment.

Shining projections about how great PPACA Universe will be do nothing but make HHS and  the various think analysts seem creepy. Maybe PPPACA will be great or maybe it won’t, but, except maybe when it comes to concrete efforts to draw up state and federal budgets and impact studies, the time for theoretical PPACA projections is over. The time for seeing how the actual law and the actual implementing regulations work is here.

Similarly, I think the time for fulminating furiously about how every last sentence in PPACA is hair from Satan’s foul nose has jumped the shark.

Some readers here believe that just about every tax, and certainly every tax imposed to fund social welfare programs other than disaster relief and epidemic prevention programs, is a form of theft.

I sincerely wish I could give you readers a country, and I think it’s likely that your country would be a fair, prosperous country. In the long run, I assume that every dire prediction you make about how the United States will implode will probably turn out to be true. 

But, honestly: I just don’t have any moral problems with taxes myself. I don’t think Medicare, Medicaid, income taxes, payroll taxes, the existence of HHS, the mere concept of the existence of PPACA, or anything along those lines is immoral. For me, the question is just whether those things work, or whether they’re so complicated, inefficient, bad for people, plain crazy, etc. that the costs outweigh the benefits.

So, arguments that PPACA is Satanic in and of itself, or that an individual health insurance ownership mandate is inherently the work of the devil, or anything along those lines tend to make my mind wander.

One of the programs that PPACA haters really have been hating for the past few months is the Medicare quality bonus program

The bonus program is tied in with PPACA-related cuts to Medicare Advantage funding.

Medicare program managers are trying to use the program to reward Medicare Advantage plans that do a good job on metrics such as enrollee satisfaction and the percentage of enrollees who’ve gotten their blood pressure checked in the past year.

PPACA haters in the House have been holding hearings about horrible and unauthorized the quality bonus program is, saying it’s just an HHS trick to distract plans’ attention away from the overall PPACA Medicare Advantage funding cuts, etc. etc.

But one thing that’s interesting is that the program seems to be forcing Medicare Advantage plan managers to think about health care indicators that someone out there in the universe probably ought to be thinking about. Maybe it’s good for health care costs, and for people’s health and quality of life, if a health plan manager knows a little cash depends on whether enrollees are getting their blood pressure checked.

Analysts at Avalere Health looked at the actual ratings and found that the plans actually improved their performance a whole bunch between last year and this year.

Medicare rates plans on a 5-star scale and will pay extra cash to plans with ratings of 3 stars or higher. The bonuses range from 3 percent for 3-star plans to 5 percent for 5-star plans.

The Avalere analysts found that 119 of the 419 plans that had star ratings both last year and this have improved their ratings, and that only 50 earned lower ratings.

In other words: About 28 percent of the Medicare Advantage plans either made changes that could improve enrollees’ health or at least improved their ability to track the quality of patient care.

The number of plans not eligible for bonuses has dropped to 31 this year, from 63 last year, suggesting that many of the lowest-performing plans either improved their performance or shut down and sent their enrollees to better plans.

One sign that the plans may actually be getting better, not just doing better at working with the star rating system, is that Medicare Advantage plans overall reported better performance on 12 of the 21 patient access and experience indicators.

On the one hand: Maybe the reality is that many of the plans got enrollees to say they had better luck getting appointments quickly by slipping the enrollees rating enhancing drugs. Maybe it will turn out that the plans got the money they used to create the star rating reports by raiding their kidney transplant kitties.

On the other hand: I think, at this point, PPACA critics who hate the bonus program and PPACA programs like it would be more persuasive if they waited till they had numbers showing how the programs wreaked havoc in the real world, not reasonable-sounding arguments poll numbers relating to how the programs will wreak havoc in the future.

If Mitt Romney wins, and/or Republicans end up in firm control of both the House and the Senate, and/or something else happens that gives PPACA critics the ability to repeal parts or all of PPACA: Cool. Repeal PPACA, then post data showing what happened.

If PPACA critics succeed with court efforts to block parts or all of PPACA: Great. Wait till the court ruling takes effect, then post data showing what happened.

But: Post data showing what happened, not projections about what you think will happen. It’s getting old.

On the third hand: The bad thing about waiting until PPACA wreaks havoc, if it wreaks havoc, is that, at that point, PPACA will have wreaked havoc. If PPACA (or PPACA repeal) wreaks havoc, that would be unfortunate.

But, at his point, I think we just have to do something, or not do anything, and then see what happens.

The time for cogent analysis getting us anywhere is over. The pilot for “Health System Change: Data Showing What Actually Happened” is the hot show in town. 

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