The Importance of Sitting With Patients
By DHRUV KHULLAR, M.D.
MARCH 19, 2015
I had never seen someone so yellow.
It was as if someone had taken a highlighter to the whites of her eyes and coated her skin with a layer of mustard. In actuality, the cancer in her colon had crept to her liver, where it blocked bile from taking its natural path out of the body, causing the ominous yellow chemical to spill into her blood and tissues. She had left the hospital two weeks ago, hoping to die at home, but came back with worsening pain and bloating in her belly — and because she couldn’t stand to look at herself in the mirror.
“Doctor,” she said softly — it was a title that still didn’t feel quite comfortable to me, a newly minted doctor, especially coming from a patient several decades older than me. “You remind me of my nephew.”
She asked me to sit for a few minutes and, shamefully, I hesitated. I had eight more patients to see before rounds and was already running behind. But I sat — listening to a dying woman’s fondest family memories, my mind racing through a seemingly endless list of boxes I had to check that morning. When my pager went off five minutes later, I excused myself, promising to return in the afternoon to finish our conversation.
But I didn’t.
There were new patient admissions. Emergencies on other floors. Notes to be written, consultants to be called, outside hospital medical records to be procured.
When I got home that night, I kicked myself for forgetting to stop back to see her. I briefly considered going back to the hospital but, exhausted, told myself she’d be asleep by now and vowed to arrive early the next morning to spend extra time with her.
She died that night.
The most draining aspect of medical training, it turns out, is not long hours, brash colleagues or steep learning curves — it’s the feeling that you’re often unable to be there with and for your patients in the way you want, in the way you’d always imagined you would be.
Consumers Getting "Skinned" by Health Insurers
Thursday, 19 March 2015 00:00 By Wendell Potter, Center for Public Integrity | News Analysis
The reason health care costs are so high is because Americans don’t have nearly enough “skin in the game.”
That was the phrase that many of my former colleagues in the insurance industry and I began using in the early 2000s as a way to deflect attention away from us.
Americans — especially American employers — looked to private insurers to help control medical costs. But insurers were failing miserably, and some of them — Aetna in particular — were also failing Wall Street.
Thirteen years ago, investors and Wall Street financial analysts were not happy with the way some managed care companies were running their businesses. They felt that Aetna and other big for-profit insurers were spending far too much of their policyholders’ premiums paying claims. And they didn’t like it that insurers hadn’t been aggressive enough in getting rid of “unprofitable” customers.
One way to satisfy Wall Street was to begin shifting more and more of the cost of health care — and health insurance — to their customers. That meant that sick policyholders in particular would be paying more out of their own pocket for their care.
Our marketing folks came up with an almost Orwellian name for this cost shifting —consumer driven health care. In retrospect, it was a brilliant strategy, and one that got virtually no pushback from lawmakers or regulators. Little by little, year after year — and long before many people outside of Illinois had ever heard of Barack Obama — Americans began putting more of their skin in the health care game. They had no choice.
The strategy has been so successful that insurers are back in Wall Street’s good graces. Their profits keep breaking records, and so does the price of their stock.
But what’s good for them has been anything but good for a growing number of Americans. Out-of-pocket expenses have gotten so high that nearly half of American families don’t have enough money in the bank to pay their deductibles if they get really sick.
Where the Republican Budget Plan Meets Reality on Health Care
The budget proposal released by House Republicans on Tuesday promises it can repeal Obamacare and save the government a lot of money in the process. But the document relies on some vague accounting to justify this claim.
It is easy, of course, to save the federal budget a lot of money by simply eliminating the spending provisions of the Affordable Care Act. Getting rid of the law’s Medicaidexpansion to low-income people and its premium subsidies for middle-income insurance shoppers would save about $2 trillion over 10 years, according to the House budget estimates. That number is published clearly and prominently in the budget’s accompanying tables.
Less explicitly accounted for is the fact that the health law, despite its huge federal spending on insurance expansion, was also designed to reduce the deficit. The law imposed substantial cuts to the Medicare program and raised a series of new taxes, including ones on wages, health insurance and medical devices.
Perfect estimates are difficult at this point, because most of those changes are now integrated into current budget estimates, but it’s safe to say that the law’s Medicare cuts save more than $700 billion over the next 10 years, and the taxes will raise around $1 trillion.
The budget doesn’t ignore those dollars, but it’s awfully vague about how they can be recouped. In contrast with the $2 trillion cut in Obamacare spending that’s spelled out in its own line, there is no specific accounting of the Medicare savings and revenue gains that would be lost in a repeal.
The budget resolution directs Congress to repeal all the Obamacare taxes, but then estimates no accompanying reductions in federal revenue. That silence on the cost of those policy changes suggests that Congress would make up the difference with other revenue changes. Finding a way to preserve the money that would have been raised by those taxes would mean major changes to the federal tax code.
The gathering, which filled the room as well as the outside area led to a hearing filled with the emotions and concerns of Kansans who plead with their state for change.
“With one stroke, you could reduce the number of uninsured in this state by almost a half,” said Jerry Slaughter, a physician testifying on behalf of the Kansas Medical Society in support of the bill.What went unsaid was simple.. while one stroke could reduce the number of uninsured in Kansas - an uninsured person who had a stroke would quickly find themselves on the wrong end of bills they simply couldn't pay.
The Affordable Care Act granted states the authority to expand Medicaid, which provides health coverage to poor and disabled Kansans. The federal government would fund 100 percent of the costs through 2016, then down to 90 percent by 2020.
It was an unlikely witness that stirred buzz in the room, as Finn Bullers, a Prairie Village advocate, joined the hearing coming straight from the ICU, as he put it.
Finn Bullers, a former Kansas City Star reporter, is making headlines for his fight against KanCare, the state’s Medicaid privatization plan, which he says will kill him. He was the subject on a Pitch cover story about KanCare’s impact on the poor, and has been featured by just about every news outlet in the city.
Bullers suffers from a rare form of muscular dystrophy and requires round-the-clock care. The state wants to reduce the number of hours a caretaker oversees Bullers – by 75 percent, according to KCUR – something he told a state panel could have deadly consequences.
“I hate to sound that dramatic,but if this tube comes off I’ve got two minutes tops — and then I die,” he said, according to the Topeka Capital-Journal.
Under Health Care Act, Many Tax Filers Are Discovering Costly Complications
By ABBY GOODNOUGH
MARCH 21, 2015
PITTSBURGH — When he signed up for health insurance through the Affordable Care Act last fall, J. C. Ciesielski estimated his income at $19,400, qualifying him for a federal subsidy that cut his premiums in half. But Mr. Ciesielski, an actor, earned an extra $2,340 from a voice-over job in December, and that welcome bit of income proved problematic when he did his taxes this month.
A tax preparer told Mr. Ciesielski that because he had not informed the federal health insurance marketplace, HealthCare.gov, of his additional income, he had to repay $118 of his subsidy. Mr. Ciesielski, who is being treated for a brain tumor, looked perplexed as he learned the money would come out of his refund check.
“This is definitely the lowest refund I’ve ever gotten,” Mr. Ciesielski, 34, said as he drummed his fingers on the tax preparer’s desk. “But it boils down to I have health insurance, which I desperately need.”
This filing season, for the first time, millions of Americans are facing tax implications — and new forms that even seasoned preparers are finding confusing — related to their health insurance status. The changes are not only complicating things for tax filers, but also costing many of them money.
Why Health Care Tech Is Still So Bad
By ROBERT M. WACHTER
LAST year, I saw an ad recruiting physicians to a Phoenix-area hospital. It promoted state-of-the-art operating rooms, dazzling radiology equipment and a lovely suburban location. But only one line was printed in bold: “No E.M.R.”
In today’s digital era, a modern hospital deemed the absence of an electronic medical record system to be a premier selling point.
That hospital is not alone. A 2013 RAND survey of physicians found mixed reactions to electronic health record systems, including widespread dissatisfaction. Many respondents cited poor usability, time-consuming data entry, needless alerts and poor work flows.
If the only negative effect of health care computerization were grumpy doctors, we could muddle through. But there’s more. A friend of mine, a physician in his late 60s, recently described a visit to his primary care doctor. “I had seen him a few years ago and I liked him,” he told me. “But this time was different.” A computer had entered the exam room. “He asks me a question, and as soon as I begin to answer, his head is down in his laptop. Tap-tap-tap-tap-tap. He looks up at me to ask another question. As soon as I speak, again it’s tap-tap-tap-tap.”
With Expansion of Medicaid, Some States Are Identifying More New Diabetes Case
The number of new diabetes cases identified among poor Americans has surged in states that have embraced the Affordable Care Act, but not in those that have not, a new study has found, suggesting that the health care law may be helping thousands of people get earlier treatment for one of this country’s costliest medical conditions.
One in 10 Americans have diabetes, and nearly a third of cases have not been diagnosed. The disease takes a toll if it is caught too late, eventually causing heart attacks, blindness, kidney failure and leg and foot amputations. The Centers for Disease Control and Prevention estimates that the disease accounts for $176 billion in medical costs annually. The poor and minorities are disproportionately affected.
The health care law aimed to bring many of the most disadvantaged Americans into the medical system by expanding access to Medicaid, the government insurance program for the poor. But with the release of federal health data still months away, it was impossible to know whether the new coverage was having any effect in identifying and treating critical health problems such as diabetes and high blood pressure.
Health Care Systems Try to Cut Costs by Aiding the Poor and Troubled
By SABRINA TAVERNISEA patchwork of experiments across the country are trying to better manage these cases. The Center for Health Care Strategies, a policy center in New Jersey, has documented such efforts in 26 states. Some are run by private insurers and health care providers, while others are part of broader state overhaul efforts. The federal government is supporting some, too, through its $10 billion Innovation Center, set up under the Affordable Care Act.
MINNEAPOLIS — Jerome Pate, a homeless alcoholic, went to the emergency room when he was cold. He went when he needed a safe place to sleep. He went when he was hungry, or drunk, or suicidal.
“I’d go sometimes just to have a place to be,” he said.
He made 17 emergency room visits in just four months last year, a costly spree that landed him in the middle of an experiment to reinvent health care for the hardest-to-help patients here in Hennepin County.
More than 11 million Americans have joined the Medicaid rolls since the major provisions of the Affordable Care Act went into effect, and health officials are searching for ways to contain the costs of caring for them. Some of the most expensive patients have medical conditions that are costly no matter what. But a significant share of them — so-called super utilizers like Mr. Pate — rack up costs for avoidable reasons. Many are afflicted with some combination of poverty, homelessness, mental illness, addiction and past trauma.
They raise a new question for the health care system: What is its role in tackling problems of poverty? And will addressing those problems save money?
“We had this forehead-smacking realization that poverty has all of these expensive consequences in health care,” said Ross Owen, a county health official who helps run the experiment here. “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.”
Now health systems around the nation are trying to buy the boots, metaphorically speaking. In Portland, Ore., health outreach workers help patients get driver’s licenses and give them essentials, such as bus tickets, blankets, calendars and adult diapers. In New York, medical teams are trained to handle eviction notices like medical emergencies. In Philadelphia, community health workers shop for groceries with diabetic patients.
Stigma Around Physician-Assisted Dying Lingers
“Death is nothing at all,” the English theologian Henry Scott Holland wrote a century ago in a reflection that is often quoted at funerals. Death is but life extended, Holland said: “I have only slipped away to the next room. Nothing has happened. Everything remains exactly as it was.”
The words are as haunting today as they must have been in 1910 when Holland delivered them in a sermon. But in the realms of politics, medical ethics, religion and technological innovation, the reality is that death is far, very far, from nothing at all. It is the source of challenging legal and moral questions, perhaps none more searing than whether doctors ought to be permitted to usher incurably ill patients into that next room. Should they be able to help sufferers end their lives by supplying medication that would make looming death come faster?
Five states, in various forms, countenance doctor-assisted dying. Others are considering it. In California, legislation to permit such assistance is scheduled to receive a hearing this week. A lawsuit in New York that seeks a similar result was filed in State Supreme Court last month by a group of doctors and dying patients. The emotional wallop of these issues is self-evident, and it is captured in the latest installment of Retro Report, a series of video documentaries that explore major news stories of the past — looking back at where we have been to see where we may be headed.
Hospitals Are Wrong About Shifting Costs to Private Insurers
by Austin Frakt
To hear some hospital executives tell it, they have to make up payment shortfalls from Medicaid and Medicare by charging higher prices to privately insured patients. How else could a hospital stay afloat if it didn’t?
But this logic is flawed.
Study after study in recent years has cast doubt on the idea that hospitals increase prices to privately insured patients because the government lowers reimbursements from Medicare and Medicaid.
Indeed, one recent study found that from 1995 to 2009, a 10 percent reduction in Medicare payments was associated with a nearly 8 percent reduction in private prices. Another study found that a $1 reduction in Medicare inpatient revenue was associated with an even larger reduction — $1.55 — in total revenue.
This would be impossible if hospitals were compensating for lower Medicare revenue by charging private insurers more. (Under different market conditions in prior eras, but not today, a few studies found some evidence that hospitals made up shortfalls from one payer with higher prices charged to another. Some are reviewed in a paper by me in Milbank Quarterly, and older ones are summarized in work by Michael Morrisey.)
The theory that hospitals charge private insurers more because public programs pay less is known as cost shifting. What underlies this theory is that a hospital’s costs — those for staff, equipment, supplies, space and the like — are fixed. A procedure or visit simply takes a certain amount of time and requires a specific set of resources. Therefore, if Medicare, say, does not pay its full share of those costs, a hospital is forced to offset the loss with higher prices demanded of private insurers.
The cost shifting theory goes back decades. But economists have long been skeptical of it, pointing to two key weaknesses. One is that it assumes hospital costs are immutable. We should be just as suspicious of such claims in health care as we would be for any other industry.
How did hospital bills get so complicated?
By LISA ZAMOSKY
As recently as 1969, delivering a baby in Morristown, N.J., could cost parents as little as $235.65 — a flat, all-inclusive rate for a three-day hospital stay and doctors' fees.
I know this because that was the price on the receipt from my birth at Morristown Memorial Hospital. My father recently found it in a pile of old papers.
The minimal charge for the delivery stood out, though it's hardly surprising that prices have risen considerably since then. Today, the total cost of giving birth can run to more than $37,000 for an uncomplicated delivery, and nearly double that for a cesarean section, according to a recent UC San Francisco study.
More remarkable, I thought, was the hospital paperwork from 1969. It looks more like a receipt you'd get from a hardware store than from a hospital.
The simple, one-page document lists my parents' names, the total cost of care and just three options for payment: cash, check or money order. There were no co-pays, co-insurance or deductibles to meet. My parents didn't receive an onslaught of bills once they left the hospital.
That's in stark contrast to the experience that Tori Rivapalacio had after the birth of her son, Diego, just over a year ago.
The 33-year-old employment attorney from San Diego says she has a folder of paperwork a few inches thick. She tried to make sense of the charges, she said, but couldn't, and ultimately gave up.
"You just throw up your hands," Rivapalacio said, referring to the list she got of mysterious medical codes and charges. "You can't even dispute them because they're so confusing."
Maine Voices: Ending the Affordable Care Act would be political malpractice
Almost 75,000 Mainers no longer need to choose between a checkup and a household bill.
BY EMILY BROSTEKSPECIAL TO THE PRESS HERALD
AUGUSTA — Over the past five years, tens of thousands of Mainers have sent a powerful message: The Affordable Care Act is working, and the quality health coverage offered on our health insurance marketplace is a product that consumers need, want and like. They also made it clear that they don’t want this coverage taken away.
Tammy O’Clair, an entrepreneur from Ashland, is one of them. Thanks to tax credits through the health insurance marketplace that made her health plan affordable, Tammy, who has diabetes, now has coverage for the first time in years.
When asked what having that coverage means to her, she said, “It’s just that you (don’t have) that burden laying on top of your shoulders, that you’ve got to pay for everything out of pocket. (Before this) I couldn’t go to the doctors, I couldn’t do what needed to be done, because we couldn’t afford it.”
Since President Obama signed the Affordable Care Act five years ago, 74,805 Mainers like Tammy selected plans or were automatically re-enrolled thorough the health insurance marketplace under the Affordable Care Act.
That means 74,805 people in Maine will no longer need to choose between undergoing a checkup and paying a household bill, or worry that an accident could plunge them into debt or, worse, bankruptcy.
These numbers represent real people in Maine whose lives have changed for the better: People like Tammy, whose health is at stake. She said, “If I didn’t have (this plan), I wouldn’t be getting my insulin.”
What Measures Should Be Used to Evaluate Health Care?
There’s little agreement among patients, providers and insurers
By
MELINDA BECK
http://www.latimes.com/business/healthcare/la-fi-obamacare-tax-forms-20150323-story.html
Five rural Maine hospitals band together to improve care
Posted March 23, 2015, at 11:12 a.m.
Five hospitals in Maine have formed the Maine Rural Health Collaborative LLC with a goal of preserving and enhancing health care within the communities they serve.
The hospitals are: Northern Maine Medical Center in Fort Kent, Cary Medical Center in Caribou, Houlton Regional Hospital, St. Joseph Hospital in Bangor and Mount Desert Island Hospital in Bar Harbor.
The collaborative was formally announced at a March 12 meeting of the five hospital CEOs and members of their boards of directors in Bangor. Tom Moakler, chief executive officer at Houlton Regional Hospital, said the move comes at a period of change in health care.
“The advent of the Affordable Care Act, changes in reimbursement and a number of other complex issues are reshaping the landscape for hospitals and other health care providers across the nation,” Moakler said in a news release announcing the collaborative. “Our hospitals here in Maine are coping with these changes while facing unique challenges in providing health care to a rapidly aging and low-income population, particularly in rural parts of the state. By working together in a collaborative fashion we can all benefit from each other’s experience, standardize best practices and protect quality, accessible care.”
According to a recent report by the American Hospital Association, 72 million Americans, or 22 percent of the nation’s population, live in rural areas and depend on their local hospital as an important and often the only source of care. Rural hospitals often are also their communities’ largest employers.
Mary Prybylo, CEO at St. Joseph Hospital in Bangor, said the health collaborative will look for ways to improve access to care, particularly preventive services.
Grover Norquist sees bipartisan doc fix deal as 'model of success' in privatizing Medicare
By Kay Tillow
Daily Kos, March 23, 2015
Daily Kos, March 23, 2015
House Speaker John Boehner (R-Ohio) and Minority Leader Nancy Pelosi (D-Calif.) have worked out a deal, a permanent “doc fix” that would repeal automatic cuts in Medicare payments to physicians. Their bipartisan solution, if enacted, will plunge a stake into the heart of traditional Medicare, according to health policy expert Don McCanne, M.D., of Physicians for a National Health Program.
Social Security Act amendments passed more than a decade ago once again threaten to slash Medicare payments to physicians, this time by 21.2 percent, as of April 1, 2015. These provisions require automatic cuts based on a formula called the “sustainable growth rate.”
Each time these cuts threaten to kick in, Democrats and Republicans alike look for a solution to stop the harmful cuts. Now Boehner and Pelosi have agreed on a permanent solution, a plan that stops those cuts, but at the unacceptable price of inflicting devastating damage on Medicare.
The Boehner/Pelosi-backed bill, H.R. 1470, “SGR Repeal and Medicare Provider Payment Modernization Act of 2015” is cosponsored by progressive James McDermott (D-Wash.), anti-Medicare Republican Paul Ryan (R-Wis.), and seven others from both parties. The bill would replace the current formula for physician reimbursements with a new Merit-based Incentive Payment System (MIPS).
MIPS is an administrative nightmare, says McCanne.
Expensive consultants will game the system bringing in additional incentive payments while those who work with disadvantaged patient populations will find it difficult to score higher points, predicts McCanne. Those who serve less wealthy populations will see negative payment adjustments by up to 9 percent.
Proposed SGR deal would advance GOP goal of privatizing Medicare
By Harris Meyer
Modern Healthcare, March 18, 2015
The proposed bipartisan House deal to repeal and replace Medicare's hated sustainable growth-rate physician-payment system offers Republicans a chance to make two significant benefit changes they've long sought. Now it remains to be seen if they can accept and lock in that victory.
It also raises the question of what Democrats, if they help enact the SGR bill, would have left to offer when Republicans come back the next time—probably quite soon—with more and bigger demands to revamp and reduce Medicare spending.
The deal crafted by House Speaker John Boehner and House Minority Leader Nancy Pelosi would pay for a $70 billion portion of the SGR overhaul partly by increasing Part B premiums for higher-income beneficiaries and requiring those with Medigap supplemental coverage to spend at least $250 out of pocket before coverage kicks in, according to Modern Healthcare's Paul Demko, who first reported the details last week.
Even though President Barack Obama previously proposed similar Medigap changes in his 2016 budget, senior advocacy group AARP expressed “very serious concerns” about those changes and the increased means-testing of premiums. Some Senate Democrats also voiced reservations.
The Center for American Progress (PDF) has cautioned that revising Medicare supplemental coverage rules to impose higher costs on seniors would hurt lower-income beneficiaries. It urged that any such changes be applied using means-testing, sparing beneficiaries at lower income levels. Beyond that, AARP and other groups that support Medicare fear that too much means-testing could erode political support for the program among middle- and upper-middle-class Americans.
But Boehner and the conservative Americans for Tax Reform see the measures as an important first step toward dramatically restructuring Medicare. Meanwhile,House Republicans separately unveiled their 2016 budget proposal that would transform Medicare into a defined-contribution voucher program (which they call premium support), convert Medicaid into a capped state block-grant program, and repeal the Affordable Care Act.
The increased beneficiary cost-sharing included in the SGR reform proposal could work hand-in-hand with the larger House GOP Medicare plan by prodding seniors to choose the lower-cost private Medicare plans envisioned under the budget blueprint. That would advance their long-held goal of turning Medicare into a privatized, means-tested welfare program and getting the government out of the health insurance business.
Some conservatives clearly were thrilled at the prospect of advancing their Medicare overhaul goals through the SGR bill, and urged other conservatives to accept the added 10-year costs to the federal budget and pass it. “I could care less about the 10 years,” Ryan Ellis, tax policy director of Americans for Tax Reform (which is headed by conservative stalwart Grover Norquist), told the National Journal. “You would never measure entitlement reform in a 10-year window."
http://www.pnhp.org/print/news/2015/march/proposed-sgr-deal-would-advance-gop-goal-of-privatizing-medicare
Center for Public Integrity, March 23, 2015
The Obama administration went to great lengths last week to inform us that it recovered $3.3 billion in fraudulent payments to Medicare health care providers in fiscal year 2014. Officials even went so far as to give an advance copy of their report to The Wall Street Journal, which, like the Center for Public Integrity, has been investigating Medicare fraud and abuse.
In a story that appeared in the Journal before the official release of the report, WSJ reporter Stephanie Armour wrote that the recovery “was part of an effort by the Obama administration to improve enforcement and prevent abusive billing practices.” That effort is run jointly by the Department of Health and Human Services the Justice Department.
HHS secretary Sylvia Burwell was quoted in the story as saying that “we’ve cracked down on tens of thousands of health care providers suspected of Medicare fraud,” an effort she said is helping to extend the life of the Medicare Trust Fund.
That’s good news, of course. Taxpayers benefit when doctors and other health care providers get caught trying to rip off the government.
But when it comes taking on big and well-connected insurance companies that have been ripping off the Medicare program for years, the administration has been far less aggressive in catching, much less punishing, the abusers.
As the Center for Public Integrity reported last week, officials in the Obama administration were advised as long ago as 2009 that a formula the government uses to pay private insurers that participate in the Medicare Advantage program “triggered widespread billing errors and overcharges” that waste billions of tax dollars every year.
There was no press release issued by the administration about that 2009 report; in fact, the administration buried it. The report probably never would have surfaced at all had the Center for Public Integrity not filed a Freedom of Information request seeking records going back several years regarding payments to Medicare Advantage plans.
The Medicare Advantage program is a privately run alternative to standard Medicare. Close to a third of Medicare-eligible Americans are now enrolled in insurance company-operated Medicare Advantage plans. People enrolled in these plans typically pay less out of pocket for their care—which explains their appeal—but also typically have a smaller network of providers to choose from.
As Center reporter Fred Schulte explained in his March 13 story, the federal government pays these private health plans a set monthly fee for each patient based on a formula known as a risk score. Risk scores were put in place by the government to measure the state of Medicare Advantage enrollees’ health. “Sicker patients merit higher rates than those in good health,” Schulte wrote.
Schulte’s investigation into risk score payments last year uncovered evidence that the government has been overpaying private insurers for years. That’s because the risk scores can be manipulated by insurers to make it appear that enrollees are sicker than they actually are. Just last week, the Government Accountability Office estimated that “improper payments” to Medicare Advantage plans totaled more than $12 billion in 2014 alone.
When Schulte came across the unpublished 2009 report, he asked CMS why it was never made public.
http://www.pnhp.org/print/news/2015/march/fed-war-on-health-care-spending-abuse-needs-to-include-medicare-advantage
Modern Healthcare, March 18, 2015
The proposed bipartisan House deal to repeal and replace Medicare's hated sustainable growth-rate physician-payment system offers Republicans a chance to make two significant benefit changes they've long sought. Now it remains to be seen if they can accept and lock in that victory.
It also raises the question of what Democrats, if they help enact the SGR bill, would have left to offer when Republicans come back the next time—probably quite soon—with more and bigger demands to revamp and reduce Medicare spending.
The deal crafted by House Speaker John Boehner and House Minority Leader Nancy Pelosi would pay for a $70 billion portion of the SGR overhaul partly by increasing Part B premiums for higher-income beneficiaries and requiring those with Medigap supplemental coverage to spend at least $250 out of pocket before coverage kicks in, according to Modern Healthcare's Paul Demko, who first reported the details last week.
Even though President Barack Obama previously proposed similar Medigap changes in his 2016 budget, senior advocacy group AARP expressed “very serious concerns” about those changes and the increased means-testing of premiums. Some Senate Democrats also voiced reservations.
The Center for American Progress (PDF) has cautioned that revising Medicare supplemental coverage rules to impose higher costs on seniors would hurt lower-income beneficiaries. It urged that any such changes be applied using means-testing, sparing beneficiaries at lower income levels. Beyond that, AARP and other groups that support Medicare fear that too much means-testing could erode political support for the program among middle- and upper-middle-class Americans.
But Boehner and the conservative Americans for Tax Reform see the measures as an important first step toward dramatically restructuring Medicare. Meanwhile,House Republicans separately unveiled their 2016 budget proposal that would transform Medicare into a defined-contribution voucher program (which they call premium support), convert Medicaid into a capped state block-grant program, and repeal the Affordable Care Act.
The increased beneficiary cost-sharing included in the SGR reform proposal could work hand-in-hand with the larger House GOP Medicare plan by prodding seniors to choose the lower-cost private Medicare plans envisioned under the budget blueprint. That would advance their long-held goal of turning Medicare into a privatized, means-tested welfare program and getting the government out of the health insurance business.
Some conservatives clearly were thrilled at the prospect of advancing their Medicare overhaul goals through the SGR bill, and urged other conservatives to accept the added 10-year costs to the federal budget and pass it. “I could care less about the 10 years,” Ryan Ellis, tax policy director of Americans for Tax Reform (which is headed by conservative stalwart Grover Norquist), told the National Journal. “You would never measure entitlement reform in a 10-year window."
http://www.pnhp.org/print/news/2015/march/proposed-sgr-deal-would-advance-gop-goal-of-privatizing-medicare
Bipartisan Deal on Health Care Issues Hits a Snag Among Senate Democrats
By JENNIFER STEINHAUER and ROBERT PEAR
WASHINGTON — The deal is as politically remarkable as it is substantive: a long-term plan to finance health care for older Americans, pay doctors who accept Medicareand extend popular health care programs for children and the poor. It was cobbled together by none other than House Speaker John A. Boehner and Representative Nancy Pelosi, the leader of House Democrats, who rarely agree on anything, with the apparent blessing of a majority of their respective members.
Then along came a surprising impediment: Senator Harry Reid of Nevada, the minority leader, along with other Senate Democrats, objected to abortion restrictions in the bill and limits to an extension of a health insuranceprogram for children. They have begun to undermine what was poised to be a sweeping bipartisan solution to several policy problems that have long vexed Congress.
It is a role in which Mr. Reid is becoming increasingly comfortable as he exploits his leverage in the minority to thwart his political opponents, even if that means an unusual split with Ms. Pelosi.
The House is expected to vote on the plan Thursday, but its fate in the Senate is unclear. The disagreements over the bill — aired in an unusually open fashion among leaders of the same party — were surprising and unsettling for Ms. Pelosi, whose staff members were privately questioning Mr. Reid’s strategy.
Fed war on health care spending abuse needs to include Medicare Advantage
Commentary: Obama administration bragging about anti-fraud efforts, but Center report showed bigger dollars are being lost elsewhere
By Wendell PotterCenter for Public Integrity, March 23, 2015
The Obama administration went to great lengths last week to inform us that it recovered $3.3 billion in fraudulent payments to Medicare health care providers in fiscal year 2014. Officials even went so far as to give an advance copy of their report to The Wall Street Journal, which, like the Center for Public Integrity, has been investigating Medicare fraud and abuse.
In a story that appeared in the Journal before the official release of the report, WSJ reporter Stephanie Armour wrote that the recovery “was part of an effort by the Obama administration to improve enforcement and prevent abusive billing practices.” That effort is run jointly by the Department of Health and Human Services the Justice Department.
HHS secretary Sylvia Burwell was quoted in the story as saying that “we’ve cracked down on tens of thousands of health care providers suspected of Medicare fraud,” an effort she said is helping to extend the life of the Medicare Trust Fund.
That’s good news, of course. Taxpayers benefit when doctors and other health care providers get caught trying to rip off the government.
But when it comes taking on big and well-connected insurance companies that have been ripping off the Medicare program for years, the administration has been far less aggressive in catching, much less punishing, the abusers.
As the Center for Public Integrity reported last week, officials in the Obama administration were advised as long ago as 2009 that a formula the government uses to pay private insurers that participate in the Medicare Advantage program “triggered widespread billing errors and overcharges” that waste billions of tax dollars every year.
There was no press release issued by the administration about that 2009 report; in fact, the administration buried it. The report probably never would have surfaced at all had the Center for Public Integrity not filed a Freedom of Information request seeking records going back several years regarding payments to Medicare Advantage plans.
The Medicare Advantage program is a privately run alternative to standard Medicare. Close to a third of Medicare-eligible Americans are now enrolled in insurance company-operated Medicare Advantage plans. People enrolled in these plans typically pay less out of pocket for their care—which explains their appeal—but also typically have a smaller network of providers to choose from.
As Center reporter Fred Schulte explained in his March 13 story, the federal government pays these private health plans a set monthly fee for each patient based on a formula known as a risk score. Risk scores were put in place by the government to measure the state of Medicare Advantage enrollees’ health. “Sicker patients merit higher rates than those in good health,” Schulte wrote.
Schulte’s investigation into risk score payments last year uncovered evidence that the government has been overpaying private insurers for years. That’s because the risk scores can be manipulated by insurers to make it appear that enrollees are sicker than they actually are. Just last week, the Government Accountability Office estimated that “improper payments” to Medicare Advantage plans totaled more than $12 billion in 2014 alone.
When Schulte came across the unpublished 2009 report, he asked CMS why it was never made public.
http://www.pnhp.org/print/news/2015/march/fed-war-on-health-care-spending-abuse-needs-to-include-medicare-advantage
Now the Hard Part: The Rate of Health Care Enrollment Seems Set to Slow
By MARGOT SANGER-KATZ
MARCH 23, 2015
When Congress passed the Affordable Care Act in 2010, the law was expected to cover 21 million people in new insurance marketplaces by 2016. Despite the early problems, enrollments are essentially on track. But some prominent analysts worry that the pattern so far suggests that future enrollment could be sluggish.
Last year, states that ran their marketplaces saw big coverage gains compared with states that relied on the federal government to manage insurance sales for them. That makes sense considering that the federal website was a technical disaster and those states invested far less in getting the word out to eligible populations.
But this year, the states in the federal system caught up, with some experiencing substantial gains in the percentage of eligible residents who selected plans on HealthCare.gov. The state exchanges that thrived last year, in contrast, saw mostly marginal gains.
Over all, state and federal exchanges look fairly similar in the percentage of eligible people they have enrolled — on average, 43 percent of eligible people in the states in the federal system picked health plans, compared with 38 percent in the state-run marketplaces — but the 2015 increases look much, much smaller for the state marketplaces.
If the states did everything right in the first year and have stalled, what does that say about what we can expect from all the states in Year 3?
“I think the concern about running out of momentum is legitimate,” said Jon Kingsdale, the former executive director of the health exchange in Massachusetts, before the Affordable Care Act, and now a director at the Wakely Consulting Group. Mr. Kingsdale said that states should be aiming to sign up 65 to 75 percent of eligible residents. “If we end up running out of gas before 50 percent, that’s very disappointing.”
http://mobile.nytimes.com/2015/03/24/upshot/now-the-hard-part-the-rate-of-health-care-enrollment-seems-set-to-slow.html?em_pos=small&emc=edit_up_20150324&nl=upshot&nlid=1311158&ref=headline&_r=1&referrer=
Medi-Cal rolls could swell under Obama's deportation relief plan
By SOUMYA KARLAMANGLA
President Obama's executive actions on immigration, which have sparked a fierce political backlash nationwide, could also provide an unlikely boost for another of his goals: increasing health insurance signups.
Immigrants living in the U.S. without permission can't enroll in Obamacare, but an unusual policy in California allows those granted temporary relief from deportation to sign up for Medi-Cal. That means up to half a million more Californians could apply for the state's low-income health program, according to data released Wednesday by UC Berkeley and UCLA.
"It's huge for reducing the ranks of the uninsured," said Sonya Schwartz, a research fellow at Georgetown University Health Policy Institute's Center for Children and Families. Because California is the biggest state by population and a leader in the rollout of the Affordable Care Act, insuring hundreds of thousands of additional people "has implications for the whole country too," she said.
Although immigrant and health advocates support insuring this largely poor population, others worry that the state medical program will be unable to keep up with demand.
Medi-Cal has ballooned in recent years and now covers more than 12 million people, almost a third of the state's residents. That has raised concern about the state's ability to keep paying for the program — which costs the state $18 billion a year — while maintaining enough doctors to care for millions of newly insured patients.
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