• Fixing Medicare

    Austin and I have a piece over at Bloomberg View:

    The U.S. spends $2.8 trillion a year on health care, about 18 percent of the economy. As recently reported, some of that spending is on Medicare-reimbursed eyelid lifts — a procedure that sometimes serves a medical need but often is for cosmetic enhancement.

    Most would agree Medicare should pay for medical need, not to make seniors look better. How could the program better distinguish between the two?

    This instance reflects a more general challenge about public (or even private) coverage of health care: how we use collective funds to pay for more of what we need and less for the things that don’t enhance health but that some may want.

    Go read!


    • I couldn’t lift my eyelids high enough to uncover my pupils completely, so the “medical need” was established when an optometrist mapped my field of vision. As fas as I am aware, this is how the doctors in this particular large Texas plastic surgery group establish who pays, whether the patient has private insurance or Medicare. If there is no medical need, the patient pays out of pocket.

    • I’m always a bit worried when we promulgate rules allowing insurers to indiscriminately deny coverage for all “cosmetic” proceedures. Clearly, insurance shouldn’t cover things that are wanted strictly out of vanity–like breast implants for a woman who already has normal healthy breasts. But too often there are individuals who have a major disfigurement that will dramatically reduce their quality of life by, for example, attracting harassment and ridicule, and that can easily be fixed by cosmetic surgery, but can’t get the procedure because the insurer considers it “cosmetic.” An example that comes to mind is surgery to correct gynecomastia in men, which isn’t covered except in rare complications.

    • As Ray has pointed out, Medicare has rules for determining who qualifies for lid lifts. They also cover breast reconstruction (or prostheses and mastectomy bras). Neither of those procedures is actually cosmetic. Granted, you could claim that a patient qualified who didn’t, but that would be Medicare fraud and despite some claims I’ve heard, the docs that I know are scared of being caught for fraud by Medicare. Cataract surgeries, for instance, can only be performed when eyesight deteriorates to a certain threshold. It would be nice if back surgeries were required to meet their own set of criterion. If anything I see orthopedic surgery far, far more frequently overused than eyelid surgery.

      The problem that I have had with eyelid surgery is a little different. The eyelid surgeons in my area all try to upsell the patients with add on, out-of-pocket cosmetic surgery and give them the idea that they will look funny if they don’t have additional work done. They don’t, though. However, eyelid surgery is better than holding your eyelids up with your fingers while you watch TV.

      Nobody overuses bowel surgery 😉