In 2005, under the Bush administration, the government authorized a Medicare pilot program that selected ten groups for an experiment in improving quality and controlling costs. This was a forerunner of some of the cost-control rules in Obamacare, with groups given bonuses for meeting around fifteen quality measures, and for spending at least 2% less than conventional Medicare spent on a similar group of patients that lived nearby. This is something of a forerunner to the Accountable Care Organization (ACO) model that is one of the prime means by which Obamacare's supporters expect it to control costs.
In 2010, the final year, just four of the 10 sites, all long-established groups run by doctors, slowed their Medicare spending enough to qualify for a bonus, according to an official evaluation not yet made public. Two sites saved enough to get bonuses in all five years, the evaluation shows, but three did not succeed even once.This sounds a lot like random variance to me; some groups have better experience, some worse, but the program does not seem to have achieved anything like the sort of consistent cost reduction that has been promised for the new bill.
She said it is "astounding" that savings were not greater among 10 long-established groups that she said "should have blown it out of the water. . . . It's like, are you kidding me? . . . If it was this tough for this group that I had just assumed would be hands-down winners, what does it say for groups that don't have a long history of coming together?"There's a tendency in health care debates for people to confuse intentions with results. It happens with treatment regimes--we're medicating millions of people with statins, even though the evidence that this reduces mortality is pretty mixed. We have a target, low cholesterol, and we hit it, but this does not mean we're getting the results we want, in the form of longer, healthier lives.
The experiment, she and other health policy experts point out, was less risky financially for the groups than the proposed ACO rules, because the participants were not penalized for overspending. Under the proposal, ACOs that spend too much would have to forfeit some Medicare funding -- from the start or by their third year.