Publications by Robert A. Berenson for Retirement Policy

This report compares ten provider survey tools designed to measure the extent to which a practice is a 'patient-centered medical home' (PCMH). These tools are primarily used for recognition purposes (i.e., to qualify for entry into a payment pilot or demonstration), as opposed to for practice self-improvement, research/evaluation, or quality measurement. Our analysis, Our analysis, conducted for the Centers for Medicare and Medicaid Services, compares these ten tools' operational details (e.g., price, whether a site visit is required) and their content emphases (i.e., the different practice capabilities that the tools emphasize). We conclude by discussing issues for payers to consider when selected a PCMH recognition tool.

Some of projected Medicare spending growth over the next decade (6.5 percent per year) can be explained by the retirement of the baby boomers; moreover, provisions in the Affordable Care Act will reduce spending per enrollee to about 3.5 percent. We agree with the analysis of the Congressional Budget Office that concluded that privatization initiatives would actually increase health care spending and shift costs to beneficiaries themselves. We argue that it is possible to reduce Medicare spending growth further by selected policies such as increasing home health co-insurance, reforming cost sharing provisions, increasing premiums for beneficiaries earning more than 300 percent of the federal poverty line, increasing the age of eligibility, reducing fraud, and better management of Medicare's dual eligibles.

Medicare coverage determinations can influence the appropriate use of medical technology and the creation of better evidence to support clinical and health policy decisions. In this paper, the Urban Institute's Robert Berenson and co-authors Sean Tunis, Steve Phurrough, and Penny Mohr argue that the process for making coverage decisions in the Medicare program falls short of its potential to contribute to improved health outcomes for beneficiaries. The paper, funded by the Robert Wood Johnson Foundation, offers several achievable steps in five topic areas to improve the coverage process.

This status report on the patient-centered medical home covers such topics as: What is a medical home? Where did the concept come from? How are medical homes assessed and paid? Do medical homes actually work? How does the health reform law encourage medical homes? The paper, funded by the Robert Wood Johnson Foundation, concludes that the medical home model has the potential to transform health care delivery, but organizations promoting the model should tread carefully because enthusiasm for the approach may not be borne out in evidence of success. Pilots should be completed and evaluated, and the model should be recalibrated before it is broadly expanded.

The Patient Protection and Affordable Care Act will affect seniors in a number of ways. They will benefit from reductions in cost sharing for prescription drugs and for preventive services. There will however be reductions in current benefits some seniors now gain from Medicare Advantage plans and increases in premiums for high income people. Provider payment rate cuts if extended for several years could have implications for access to care. Many new provisions that will affect payment and delivery system reforms and most likely benefit seniors but could also potentially harm access to care.

This joint study by the Urban Institute and the Medical Group Management Association demonstrates that it is possible to simulate physician compensation as if all physician services were paid under the Medicare Fee Schedule and to compare the results with the actual compensation. This analysis confirms substantial differences in actual hourly and annual compensation across specialties, and that, under simulated Medicare compensation, the compensation ratios across specialties are narrowed very little. The non-surgical, procedural specialties, particularly cardiology, continue to do relatively better under the Medicare Fee Schedule than under current reimbursements that includes Medicare as well as other payers.

Growing evidence demonstrates that certain approaches to financing and paying for chronic care coordination for patients are effective not only for improving patient well-being but can also reduce health care spending. However, chronic care approaches should vary for different patient populations and can be carried out effectively by diverse organizations and professionals reflecting the heterogeneity of health care delivery throughout the US. The Report considers the different populations in need of care coordination, summarizes current evidence of effectiveness, describes the various entities that can serve as focal points for coordinating care, and details the possible financing and payment options that can support these approaches.

In testimony before the Senate Finance Committee, Robert Berenson, M.D. explores possible reasons that integrated care organizations that include multispecialty group practices have not become a major feature of the U.S. health system despite prominent success stories. These organizations are often penalized financially for undertaking activities that reduce costs because the benefits of efficiency are not internalized to the organization. Berenson makes the case that current payment incentives embedded in Medicare and private payer approaches promote behavior that may not benefit patients, such as rewarding preventable hospitalizations and producing a mismatch between the services patients need and those that fee schedules encourage.

Senior fellow Robert Berenson, testifying before the House Ways and Means Health Subcommittee on physician payment reform options in Medicare, argued that long-term approaches need to include bundled payments as an alternative to traditional fee-for-service payments, especially for primary care physicians caring for patients with chronic conditions. Because these reforms are operationally challenging and will require demonstrations of effectiveness, Berenson also suggested reforms to the existing resource-based relative value scale (the basis for the Medicare Fee Schedule) that could be implemented immediately.

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) raised payment levels for established Medicare Advantage (private) local plans and would-be regional preferred provider organizations (PPOs). Even though plans on average receive about 108 percent of what would have been spent for the same beneficiaries in traditional Medicare, the Centers for Medicare and Medicaid Services (CMS) added another 2.3 percent in 2004 and 4.0 percent in 2005 in its implementation of risk-adjusted payments. Although MMA gives a clear preference to private plans to start a fundamental restructuring of Medicare, the question remains whether Congress will maintain overpayments to private plans when faced with the pressure to reduce budget deficits. (Robert Berenson. December 15, 2004. Health Affairs web exclusive.)

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