U.S. Finds Many Failures in Medicare Health Plans
By ROBERT PEAR
WASHINGTON — Federal officials say they have repeatedly criticized, and in many cases penalized, Medicare health plans for serious deficiencies, including the improper rejection of claims for medical services and unjustified limits on coverage of prescription drugs.
The findings, cataloged in dozens of federal audit reports, come as millions of older Americans prepare to sign up for private health plans and prescription drug plans in Medicare’s annual open enrollment period, which will begin on Wednesday and continue through Dec. 7.
About 16 million people, accounting for 30 percent of the 54 million beneficiaries, are in private Medicare Advantage plans, which provide a full range of health care services under contract with the government. An additional 23 million people are in prescription drug plans, which cover only medications.
Federal officials expressed frustration that they were seeing the same kinds of deficiencies year after year. In a memorandum to health plans, Gerard J. Mulcahy, the Medicare official in charge of oversight and enforcement, listed common “areas of noncompliance” identified in program audits.
Medicare officials impose civil fines and take other enforcement actions when they see practices that could harm beneficiaries by delaying or denying access to care. Insurers usually do not dispute the audit findings, but say the care they provide is superior to that in the traditional fee-for-service Medicare program.
Placebos Help. Just Ask This Health Economist.
"I bet you $1,000 that if you just tell me you’re putting Demerol in my I.V. but don’t actually do it, I would still feel a lot better,” I dared the nurse.
It was a humid June night in 2013. I had just arrived at the emergency department of Mount Auburn Hospital in Cambridge, Mass., and wasin the worst pain of my life. A kidney stone was scraping its way down my right ureter, the narrow tube connecting my right kidney and bladder.
Despite my anguish, I was so confident I didn’t need a narcotic painkiller that I was willing to put $1,000 on the line. The reason: I trusted the placebo effect, the relief of symptoms just by believing one is receiving helpful care. (In this case, even though I knew the nurse might be deceiving me, I was going to believe him if he said he was giving me Demerol. That’s essential for the placebo effect to work.)
My colleague Aaron Carroll wrote last week about the importance of placebo-controlled evaluation of medical treatments and devices. We need to know when medical care is better than a placebo.
In comparing a treatment with a placebo, we should also keep in mind that the placebo is not the same thing as the absence of treatment. In research settings, placebos are specifically designed to mimic treatment without the hypothesized few “active” ingredients or procedural steps. They still include a lot of components of care. (Another form of clinical trial is to compare one treatment with another or with “usual” care — the care that would be given in the absence of the treatment being tested.)
Governors’ candidates on the issues: Health care
The next governor will have a lot to say about access to health care, housing and social services for Maine residents, how those services are managed – and who is going to foot the bill.
One of the biggest questions will be whether Maine should join the 28 other states that have expanded Medicaid, as allowed under the Affordable Care Act. Those states – even some led by Republican governors – have taken advantage of the millions in federal dollars available to support expansion.
Republican Gov. Paul LePage has consistently rejected expansion, saying the state is already spending more than it can afford and can’t count on federal support. His opponents, Democratic U.S. Rep. Mike Michaud and independent Eliot Cutler, both favor Medicaid expansion and have criticized LePage for his stance.
That’s only one of numerous differences among the three candidates for Maine governor on issues related to health care.
Michaud and Cutler both say that the Department of Health and Human Services, the largest state agency, has been plagued by scandal and mismanagement under LePage’s watch, although they differ on how to improve the department. LePage counters that DHHS became bloated and inefficient under decades of Democratic rule, and that he would continue with reforms he launched in his first term, if re-elected.
The candidates also have ideas on solving a pair of health care-related problems that are less politically polarizing but no less critical: How to effectively and efficiently house Maine’s growing elderly population and how to deal with a shortage of primary care physicians, especially in rural areas.
Where do the candidates stand? Find out on PAGE A5
Here’s a look at where the three candidates stand on health care issues:
• MEDICAID EXPANSION
Expanded coverage would be mostly paid for with federal money
Medicaid expansion has been wholly political and not just in Maine. Of the 22 states that have not expanded Medicaid, all but three (Missouri, Montana and Virginia) are led by Republican governors. The federal government has promised to cover 100 percent of the expansion population between 2014 and 2016. Supporters of the law say Maine is losing $1 million a day in federal money by rejecting the measure. The reimbursement level is scheduled to be gradually reduced to 90 percent by 2022.
LEPAGE has consistently vetoed Medicaid expansion bills passed by the Legislature. He said Maine’s Medicaid system is among the most expensive in the country already, and expanding it would cost the state $75 million a year. He’s also not convinced the federal government will keep its promises to give Maine an estimated $3 billion in reimbursement for expansion costs. LePage pointed out that Maine just recently paid off $500 million in hospital debt that he said was created by the last Medicaid expansion. “Maine must re-prioritize its welfare system and rejecting Obamacare’s welfare expansion is a major step in doing so,” he said.
MICHAUD said if elected governor he would introduce a Medicaid expansion bill to provide coverage to 60,000-70,000 Mainers on his first day in office because, “Not only is it the morally right thing to do, it’s the fiscally responsible thing to do.” “Medicaid expansion can help Maine close the gap in health care coverage and help strengthen our economy. It will save our state hundreds of millions of dollars over 10 years and help our people to live healthier, more productive lives,” he said.
CUTLER also said Maine should expand Medicaid out of fairness and moral obligation. “Because of our failure to expand coverage,” he said, “nearly 70,000 Mainers have no access to preventive health care services, reimbursements to Maine hospitals are reduced, uninsured people are forced to go to the emergency room for care, and the hospitals are forced to write off millions in unpaid medical bills and charge higher costs to the rest of us.” Cutler said he would take it one step further and work toward creating a universal health care system.
Got Insurance? You Still May Pay A Steep Price For Prescriptions
by Julie Applebee
Sandra Grooms recently got a call from her oncologist’s office. The chemotherapy drugs he wanted to use on her metastatic breast cancer were covered by her health plan, with one catch: Her share of the cost would be $976 for each 14-day supply of the two pills.
“I said, ‘I can’t afford it,’” said Grooms, 52, who is insured through her job as a general manager at a janitorial supply company in Augusta, Ga. “I was very upset.”
Even with insurance, some patients are struggling to pay for prescription drugs for conditions such as cancer, arthritis, multiple sclerosis or HIV/AIDS, as insurers and employers shift more of the cost of high-priced pharmaceuticals to the patients who take them.
Increasingly, health plans – even those offered to people with job-based coverage--require hefty payments by patients like Grooms. In some plans, patients must pay 20 to 40 percent or more of the total cost of medications that insurers deem to be specialty drugs and place in the highest tiers of patient cost sharing.
The trend is controversial, prompting a civil rights complaint in Florida, legislative action in a few states and debate over how to slow the rapid rise of spending on prescription drugs without hurting consumers or stifling development of new treatments.
Proponents say the high-priced drug tiers encourage patients to select lower-cost medications, just as similar efforts in the past decade led to a dramatic rise in the use of lower-cost generics.
Brendan Buck, spokesman for the industry group America’s Health Insurance Plans, said insurers rely on cost sharing tiers in their policies “as a way to keep premiums down for consumers and promote more cost-effective health care choices.”
In some cases, drugs placed in the highest tiers have equally effective alternatives that are in a lower cost tier, he said, adding that high drug prices have spurred the use of specialty tiers: “If a drug maker is concerned that its treatment is on a higher tier than they would like, the solution is to lower the price.”
Many Medicare Outpatients Pay More At Rural Hospitals, Federal Report Says
by Jordan Rau
Many Medicare beneficiaries treated at primarily rural “critical access” hospitals end up paying between two and six times more for outpatient services than do patients at other hospitals, according to a reportreleased Wednesday by the inspector general at the Department of Health and Human Services.
There are more than 1,200 critical access hospitals, which are generally the sole hospital in rural areas and can have no more than 25 beds. Medicare pays them more generously so they won’t go out of business. In Illinois, 50 hospitals, more than a quarter, hold this designation.
Medicare requires patients to pay 20 percent of the amount a critical access hospital charges. At other hospitals, patients also pay 20 percent coinsurance, but it is based on the amount Medicare decides to reimburse the hospital, which is almost always significantly below what the hospital charges.
As a result, Medicare patients in 2012 receiving an electrocardiogram at a critical access hospital owed an average of $33, while patients at other hospitals had to pay $5, according to the report. Patients getting an initial infusion into a vein had to pay $56 on average at a critical access hospital, while patients at other hospitals paid $25.
Many supplemental insurance policies for the elderly pick up the tab, but one in seven Medicare recipients lacks such a policy. In addition, these higher medical costs are ultimately factored into the premiums insurers set.
The United States is No. 1 – But in What?
American politicians are fond of telling their audiences that the United States is the greatest country in the world. Is there any evidence for this claim?
Well, yes. When it comes to violence and preparations for violence, the United States is, indeed, No. 1. In 2013, according to a report by the Stockholm International Peace Research Institute, the U.S. government accounted for 37 percent of world military expenditures, putting it far ahead of all other nations. (The two closest competitors, China and Russia, accounted for 11 percent and 5 percent respectively.) From 2004 to 2013, the United States was also the No. 1 weapons exporter in the world. Moreover, given the U.S. government’s almost continuous series of wars and acts of military intervention since 1941, it seems likely that it surpasses all rivals when it comes to international violence.
This record is paralleled on the domestic front, where the United States has more guns and gun-related deaths than any other country. A study released in late 2013 reported that the United States had 88 guns for every 100 people, and 40 gun-related deaths for every 400,000 people―the most of any of the 27 economically developed countries surveyed. By contrast, in Britain there were 6 guns per 100 people and 1 gun-related death per 400,000 people.
Yet, in a great many other areas, the United States is not No. 1 at all.
Take education. In late 2013, the Program for International Student Assessment released a report on how 15-year old students from 65 nations performed on its tests. The report showed that U.S. students ranked 17th in reading and 21st in math. An international surveya bit earlier that year by the Organization for Economic Cooperation and Development found that the ranking was slightly worse for American adults. In 2014, Pearson, a multinational educational services company, placed the United States 20th in the world in “educational attainment”―well behind Poland and the Slovak Republic.
American healthcare and health fare even worse. In a 2014 study of healthcare (including infant mortality, healthy life expectancy, and mortality from preventable conditions) in 11 advanced industrial countries, the Commonwealth Fund concluded that the United States ranked last among them. According to the World Health Organization, the U.S. healthcare system ranks 30th in the world. Other studies reach somewhat different conclusions, but all are very unflattering to the United States, as are studies of American health. The United States, for example, has one of the world’s worst cancer rates (the seventh highest), and life expectancy is declining compared to other nations. An article in the Washington Post in late 2013 reported that the United States ranked 26th among nations in life expectancy, and that the average American lifespan had fallen a year behind the international average.
What about the environment? Specialists at Yale University have developed a highly sophisticated Environmental Performance Index to examine the behavior of nations. In the area of protection of human health from environmental harm, their 2014 index placed the United States 35th in health impacts, 36th in water and sanitation, and 38th in air quality. In the other area studied―protection of ecosystems―the United States ranked 32nd in water resources, 49th in climate and energy, 86th in biodiversity and habitat, 96th in fisheries, 107th in forests, and 109th in agriculture.
American households are getting wrecked by medical debt
When Deanne Overvold’s husband, Lee, started complaining of back pain late last year, she thought the painkillers his doctor prescribed would be the end of it. Five months later, a round of lab tests would reveal that Lee, 60, wasn’t just suffering from a backache — he was diagnosed with acute myeloid leukemia, a fast-moving bone marrow cancer.
“You never realize the cost of catastrophic illness until you’re in it,” says Deanne, 60. “It’s rather devastating to go from being able to pay the bills to wondering how you’re going to take care of the next month."
In their 30 years of marriage, the Overvolds had each taken on traditional household duties — Lee worked and managed the finances, while she cared for their two sons at home. At the time of his diagnosis, Lee earned $120,000 a year working in sales for an energy company in their hometown, Fontana, Calif. The rigor of his treatment regimen forced him to leave his job on disability, which cut the family’s income by 40%. Very quickly, his hospital bills consumed their emergency savings and the couple began drawing on his retirement benefits much earlier than expected.
“At least five of his cancer specialists weren’t covered by our insurance,” Deanne says. “And one day the hospital would charge $300 for one drug and the next day it would cost $750. It’s like it just keeps coming and you can’t stop it.”
Lee died in August, less than six months after his diagnosis. Deanne was left with more than $100,000 in hospital and physicians’ bills, she estimates -- an amount far too inadequate for her savings to cover. Six years away from reaching full retirement age herself, she’s begun looking for full-time work for the first time in more than two decades.On the recommendation of a friend, she enlisted the help of a financial advisor who specializes in helping widows and widowers.
“We had planned to retire at 67 and we had everything planned out,” Deanne says. “Now, there is no plan.”
Spiraling medical debt
http://finance.yahoo.com/news/american-households-are-getting-wrecked-by-medical-debt-143119252.html
U.S. hospitals not prepared for Ebola threat
By RoseAnn DeMoro October 13 at 12:22 PM
RoseAnn DeMoro is executive director of National Nurses United.
With reports that a nurse who treated Ebola patient Thomas Eric Duncan in Dallas has been infected, one thing urgently needs to be made clear: Our hospitals are not prepared to confront the deadly virus.
It is long past time to stop relying on a business-as-usual approach to a virus that has killed thousands in West Africa and has such a frighteningly high mortality rate. There is no margin for error. That means there can be no standard short of optimal in the protective equipment, such as hazmat suits, given to nurses and others who are the first to engage patients with Ebola-like symptoms. All nurses must have access to the same state-of-the-art equipment used by Emory University Hospital staff when they transported Ebola patients from Africa, but too many hospitals are trying to get by on the cheap.
In addition, hospitals and other frontline providers should immediately conduct hands-on training and drills so that personnel can practice, in teams, vital safety procedures such as the proper way to put on and remove protective equipment. Hospitals must also maintain properly equipped isolation rooms to ensure the safety of patients, visitors and staff and harden their procedures for disposal of medical waste and linens.
Poll: Many insured struggle with medical bills
By Ricardo Alonso-Zaldiver and Jennifer Agiesta
The Associated Press, Oct. 13, 2014
The Associated Press, Oct. 13, 2014
WASHINGTON (AP) -- Having health insurance is no panacea for high medical costs. Overall, 1 in 4 privately insured U.S. adults say they don't have much confidence in their ability to pay for a major, unexpected medical expense.
A new poll from The Associated Press-NORC Center for Public Affairs Research may help explain why President Barack Obama faces such strong headwinds in trying to persuade the public that his health care law is working to hold costs down.
The poll found the biggest financial concerns were among people with so-called high-deductible plans that require patients to pay a significant share of their medical bills each year before insurance kicks in.
Such plans already represented a growing share of employer-sponsored coverage. And now, they're also the mainstay of the new health insurance exchanges created by Obama's law.
Edward Frank of Reynoldsville, Pennsylvania, said he bought a plan with a $6,000 deductible last year through HealthCare.gov. That's in the high range, since deductibles for popular silver plans on the insurance exchanges average about $3,100- still a lot.
"Unless you get desperately ill and in the hospital for weeks, it's going to cost you more to have this plan and pay the premiums than to pay the bill just outright," said Frank, who ended up paying $4,000 of his own money this spring for treatment of shoulder pain.
"The deductibles are so high, you don't get much of anything out of it," said Frank, who is in 50s and looking for a new job.
The poll found that people are responding to the hit on their wallets in ways that may not help their health:
- Nineteen percent of all privately insured adults said they did not go to the doctor when they were sick or injured, because of costs. Among those with high-deductible plans, the figure was 29 percent.
- Seventeen percent skipped a recommended test or treatment; it was 23 percent among those with high-deductible plans.
- Eighteen percent of all adults went without a physical exam or other preventive care, 24 percent among those with high-deductible plans.
Sandra Chapman, a warehouse worker from Memphis, said she had to go without cholesterol medication last year because of issues with her prescription coverage. Instead of taking pills, she changed her diet.
"They only cover certain stuff and, I don't know, the rules change all the time," said Chapman, in her early 30s.
Health and Human Services Secretary Sylvia Mathews Burwell said last week that part of the problem is that many consumers don't understand what they are buying when they purchase health insurance, or how to use their plan once they get their cards in the mail.
For example, there should be no reason to skip routine preventive care, since the health care law requires insurers to provide it at no charge to the patient.
"People need to understand how to use their health care," said Burwell. "We need to spend time educating people."
Health Premiums And Costs Set To Rise For Workers Covered At Work
By MICHELLE ANDREWS
Fall is enrollment season for many people who get insurance through their workplace. Premium increases for 2015 plans are expected to be modest on average, but the shift toward higher out-of-pocket costs overall for consumers will continue as employers try to keep a lid on their costs and incorporate health law changes.
Recent surveys of employers suggest that premiums will rise a modest 4 percent in 2015, on average, slightly higher than last year but lower than typical recent increases.
"That's really low," says Tracy Watts, a senior partner at benefits consultant Mercer.
Even so, more employers say they're making changes to their health plans in 2015 to rein in cost growth; 68 percent said they plan to do so in 2015, compared with 55 percent just two years earlier, according to preliminary data from Mercer's annual employer benefits survey.
They are motivated in part by upcoming changes mandated by the health law. Starting in January, companies that employ 100 workers or more generally have to offer those who work at least 30 hours a week health insurance or face penalties.
"The more people you cover, the more it's going to cost," says Watts.
In addition, consultants who monitor benefits say, employers are moving to avoid a 40 percent excise tax on expensive health plans — those with premiums that exceed $10,200 for individuals or $27,500 for families — that will take effect in 2018.
More employees can expect to be offered high-deductible health planslinked to health savings accounts or health reimbursement arrangements in 2015. Nearly three-quarters of companies with more than 1,000 workers offer such plans, according to the 2014 Towers Watson/National Business Group on Health employer health care survey. Nine percent said they planned to add them in 2015.
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