Medicare – The Moral Healthcare Blog

Navigating Medicare Policy on Physical Therapy and Other Services – NYTimes.com

For years, some people on Medicare had difficulty getting insurance coverage approved for physical therapy, occupational therapy and other treatments. The prevailing approach was that if the therapy was not helping to improve a patient’s condition, then it was not eligible for coverage.

“They’d get denied because they weren’t improving, or because they had plateaued,” said Judith Stein, executive director of the Center for Medicare Advocacy, a nonprofit consumer group. The situation was especially difficult, she said, for patients with chronic or degenerative conditions, like Parkinson’s disease or multiple sclerosis.

That is changing, as a result of a 2013 settlement of a lawsuit that the center and others brought against the secretary of the Health and Human Services Department, the parent agency of the Centers for Medicare and Medicaid Services, which oversees Medicare. The suit claimed that Medicare billing contractors were inappropriately denying coverage for “skilled” care by applying an “improvement” standard as a rule of thumb.

Because of the settlement, the agency updated its policy manuals last year. The revisions make clear that if treatment is needed to prevent or slow further deterioration in a patient’s condition, “coverage cannot be denied based on the absence of potential for improvement or restoration.” The update applies to therapy provided in nursing homes, in outpatient clinics and at home. (The agency maintains that the revision was not a change, but was made to “clarify” what had been existing Medicare policy.)

Navigating Medicare Policy on Physical Therapy and Other Services – NYTimes.com

Fear Mongering With Medicare – NYTimes.com

The Obama administration’s proposed cuts to Medicare Advantage plans — the private insurance plans that cover almost 30 percent of all Medicare beneficiaries — are fair and reasonable. As it happens, they are also mandated by law. Yet Republicans, sensing a campaign issue, are telling older and disabled Americans that the administration is “raiding Medicare Advantage to pay for Obamacare.” The health insurance industry, for its part, is warning that enrollees will suffer higher premiums, lower benefits and fewer choices among doctors if the cuts go into force.

Some of this could in fact happen, although the industry has cried wolf before and continues to thrive. But the key point is this: Over the past decade, enrollees in Medicare Advantage have received lots of extra benefits, thanks to unjustified federal subsidies to the insurance companies. Now they will have to do with somewhat less, unless the insurers are willing to absorb the cuts while maintaining benefits. Enrollment in these private plans, offered by companies like UnitedHealth and Humana, has more than doubled since 2006, in part because of lower premiums and extra benefits, like gym memberships, that are not included in traditional fee-for-service Medicare.

Fear Mongering With Medicare – NYTimes.com

Doctors Abusing Medicare Face Fines and Expulsion – NYTimes.com

WASHINGTON — The Obama administration is cracking down on doctors who repeatedly overcharge Medicare patients, and for the first time in more than 30 years the government may disclose how much is paid to individual doctors treating Medicare patients.

Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services, said that “recalcitrant providers” would face civil fines and could be expelled from Medicare and other federal health programs.

In a directive that took effect on Jan. 15 but received little attention, Ms. Tavenner indicated that the agency was losing patience with habitual offenders. She ordered new steps to identify and punish such doctors.

A recalcitrant provider is defined as one who is “abusing the program and not changing inappropriate behavior even after extensive education to address these behaviors.” Cases will be referred to Daniel R. Levinson, the inspector general at the Department of Health and Human Services, who has authority to impose civil fines and exclude doctors from Medicare, Medicaid and other programs.

Federal officials estimate that 10 percent of payments in the traditional fee-for-service Medicare program are improper. That would suggest at least $6 billion a year in improper payments under Medicare’s physician fee schedule. But Malcolm K. Sparrow, a Harvard professor and an expert on health care fraud, has said the losses could be greater because the official statistics “fail to accurately capture fraud rates” in Medicare.

A new section of the Medicare manual encourages the use of fines to penalize doctors who generate a pattern of claims for goods and services that they know or “should know” are not medically necessary. Providers can also be barred from Medicare if they bill the program for “excessive charges” or for services substantially in excess of patients’ needs.

In a new report, Mr. Levinson said Medicare officials and contractors should focus on doctors with the highest Medicare billings because they often received improper payments. He said that about 300 doctors received more than $3 million each in yearly Medicare payments and that one-third of them had been singled out for special reviews because of questionable billings.

Doctors Abusing Medicare Face Fines and Expulsion – NYTimes.com

APPRISE: Older Adult Health Insurance Counseling, Allegheny County, Pennsylvania

Older Adult Health Insurance Counseling

APPRISE

APPRISE 412-661-1438 or APPRISE@fswp.org.
APPRISE offices are open Monday through Friday from 9:00 a.m. to 4:00 p.m.
SeniorLine 412-350-5460, toll-free 1-800-344-4319, TTY 412-350-2727 or SeniorLine@alleghenycounty.us
APPRISE is a free health insurance counseling program designed to help Pennsylvanians, age 60 years and older. APPRISE volunteer counselors are specially trained to answer consumer questions and offer education about Medicare, HMOs, long-term care insurance, supplemental insurance, and Medicaid benefits. APPRISE services are free, objective and completely confidential.
APPRISE counselors are available to assist an individual in the following ways:

Determine if a Medicare HMO is right for the individual by explaining the way Medicare HMOs work.

Understand Medicare benefits by explaining what services are covered under Medicare Parts A and B and the Medicare Summary Notice.

Select a Medigap insurance policy by explaining the benefits in each plan and providing a list of companies that sell these plans.

Obtain assistance to pay for prescription drugs through government and private programs that offer this service, and explain the eligibility requirements and how to apply.

Find government programs that will pay Medicare deductibles, co-payments, and Part B premiums and assist consumers with the paperwork.

Understand long-term care by explaining eligibility requirements for government long-term care programs and explaining private long-term care insurance and how to select the best policy.

APPRISE services are free and all information is kept completely confidential. To contact a counselor, contact the APPRISE coordinator at 412-661-1438 or APPRISE@fswp.org. For general information on this and other services for older adults, you may contact the DHS AAA SeniorLine at 412-350-5460, toll-free 1-800-344-4319, TTY 412-350-2727 or SeniorLine@alleghenycounty.us.
Pennsylvania Health Law Project (PHLP)
PHLP 1-800-274-3258 works to overcome barriers to accessing health care coverage and services. They provide:

Health Insurance Coverage, Department of Human Services, Allegheny County

Doctors and Their Medicare Patients – NYTimes.com

In the critics’ most dire scenarios, baby boomers nearing retirement age could find that their current doctors are no longer willing to treat them under Medicare and that other doctors are turning them down as well. Those concerns have always been greatly exaggerated. Now a new analysis by experts at the Department of Health and Human Services should demolish that mythology for good.
The analysts looked at seven years of federal survey data and found that doctors are not fleeing Medicare in droves; in fact, the percentage of doctors accepting new Medicare patients actually rose to 90.7 percent in 2012 from 87.9 percent in 2005. They are not shunning Medicare patients for better-paying private patients, either; the percentage of doctors accepting new Medicare patients in recent years was slightly higher than the percentage accepting new privately insured patients.
Medicare patients had comparable or better access to medical services than the access reported by privately insured individuals ages 50 to 64, who are just below the age for Medicare eligibility. Surveys sponsored by the Medicare Payment Advisory Commission, an independent agency that advises Congress, found that 77 percent of the Medicare patients — compared with only 72 percent of privately insured patients — said they never had an unreasonably long wait for a routine doctor’s appointment last year.
The findings from this survey and others can be sliced and diced in many ways. But the overall picture is clear: nationwide there is no shortage of doctors for Medicare patients. It is likely to stay that way, because Medicare is a big insurer that few medical practices can afford to ignore.

Doctors and Their Medicare Patients – NYTimes.com

Failure to Launch? The Independent Payment Advisory Board’s Uncertain Prospects — NEJM

Yet 3 years after the ACA’s enactment, the IPAB still has no members. Secretary of Health and Human Services Kathleen Sebelius described “active discussions” about IPAB nominees in February 2012 and said last month that the administration was “consulting” Congress regarding “potential members.” But President Obama has not yet nominated anyone for the IPAB, and Republican congressional leaders have refused to provide any recommendations for appointees. Even if Democrats settle on nominees, the controversy surrounding the IPAB will make their Senate confirmations, which are subject to filibuster, extraordinarily difficult. Presidents historically have made appointments when the Senate is in recess, and President Obama conceivably could fill some IPAB slots in this manner. But recess appointments are temporary, lasting only until the end of the next congressional session. Moreover, in January 2013, the U.S. Court of Appeals for the District of Columbia issued a ruling severely restricting the President’s constitutional authority to make such appointments. The Obama administration is appealing that decision to the Supreme Court; meanwhile, in May, another federal appeals court echoed the D.C. Circuit’s narrow interpretation of recess-appointment power. Even if the legal obstacles are circumvented, relying on recess appointments could undermine the IPAB’s theoretically nonpartisan character. However, if no members are appointed, the power to recommend changes to Medicare when spending targets are exceeded does not disappear: it reverts to the secretary of health and human services.

Since Medicare spending is currently not projected to exceed the ACA’s targets, there is no need for the administration to appoint members now. Yet the difficulties in launching the IPAB point to a more fundamental problem. The board’s appeal lies largely in its aspiration to remove politics from Medicare — to create a policymaking process that is informed by experts and insulated from electoral pressures, interest-group demands, financial considerations, and partisan divisions. But given Congress’s extreme partisan and ideological polarization, the ongoing fight over the ACA, the legacy of mythic “death panels,” and recriminations over Medicare reform, the IPAB’s rough start should not be surprising. This is not the sort of political environment in which an independent board charged with making controversial decisions about one of America’s most popular social programs is likely to thrive. These dynamics are unlikely to recede soon, which means that the IPAB is stuck in purgatory, neither operational nor canceled — an institution designed to be above politics that cannot escape the political binds holding it back.

The longer-term picture is, as always, cloudier. Perhaps President Obama will pursue recess appointments. A new president and Congress could, in 2017 and beyond, unshackle the IPAB in response to deficit pressures and the search for Medicare savings. And if Medicare spending growth accelerates, the IPAB’s role could expand. Yet a new president could also refuse to appoint any members or enforce the spending targets, and Congress could repeal the IPAB in 2017. The IPAB’s demise would, in that scenario, deal a symbolic blow to health care reform and cost containment. But the impact on Medicare expenditures and national health spending would be negligible. For all the hype, the Congressional Budget Office currently forecasts no savings from the IPAB over the next decade.

Regardless of the IPAB’s future, one thing is clear: rather than removing politics from Medicare, the board’s difficult early journey has underscored just how entrenched politics are in health care policy.

Failure to Launch? The Independent Payment Advisory Board’s Uncertain Prospects — NEJM

Immigrants Contributed An Estimated $115.2 Billion More To The Medicare Trust Fund Than They Took Out In 2002–09

Many immigrants in the United States are working-age taxpayers; few are elderly beneficiaries of Medicare. This demographic profile suggests that immigrants may be disproportionately subsidizing the Medicare Trust Fund, which supports payments to hospitals and institutions under Medicare Part A. For immigrants and others, we tabulated Trust Fund contributions and withdrawals (that is, Trust Fund expenditures on their behalf) using multiple years of data from the Current Population Survey and the Medical Expenditure Panel Survey. In 2009 immigrants made 14.7 percent of Trust Fund contributions but accounted for only 7.9 percent of its expenditures—a net surplus of $13.8 billion. In contrast, US-born people generated a $30.9 billion deficit. Immigrants generated surpluses of $11.1–$17.2 billion per year between 2002 and 2009, resulting in a cumulative surplus of $115.2 billion. Most of the surplus from immigrants was contributed by noncitizens and was a result of the high proportion of working-age taxpayers in this group. Policies that restrict immigration may deplete Medicare’s financial resources.

Immigrants Contributed An Estimated $115.2 Billion More To The Medicare Trust Fund Than They Took Out In 2002–09

Overruns Forcing Lower Payments to Some Providers in Stopgap Health Program – NYTimes.com

WASHINGTON — The Obama administration said Monday that it was cutting payments to doctors and hospitals after finding that cost overruns are threatening to use up the money available in a health insurance program for people with cancer, heart disease and other serious illnesses.

The administration had predicted that up to 400,000 people would enroll in the program, created by the 2010 health care law. In fact, about 135,000 have enrolled, but the cost of their claims has far exceeded White House estimates, exhausting most of the $5 billion provided by Congress.

Under a new policy issued by Kathleen Sebelius, the secretary of health and human services, “health care facilities and providers will get paid less” for providing the same services to patients in the federal program, known as the Pre-Existing Condition Insurance Plan.

In most cases, payments to health care providers will be capped at Medicare rates, which are substantially less than the commercial insurance rates they have been receiving. The new policy generally prohibits doctors and hospitals from increasing charges to consumers to make up the difference.

Michael T. Keough, the executive director of the North Carolina Health Insurance Risk Pool, said the new policy was one of several steps taken recently by federal officials to control spending.

“They are trying to stanch the hemorrhaging,” Mr. Keough said.

The federal government notified some states last month that it was setting a ceiling on costs that would be reimbursed from June through December of this year. In effect, state officials said, the new limits shift the financial risk of the program from the federal government to those states.

Congress established the program to provide coverage to people with pre-existing conditions who had been uninsured for at least six months, and Ms. Sebelius has said, “It literally saves lives.”

The program provides a transition to 2014, when most consumers will be able to obtain insurance regardless of their pre-existing conditions.

Federal officials froze enrollment in the program in February, but costs continued to grow rapidly.

Overruns Forcing Lower Payments to Some Providers in Stopgap Health Program – NYTimes.com

It is worth remembering, that these patients had run out of options for access to treatment before the program.

Want to know the future of Obamacare? Take a look at Fort Dodge, Iowa.

In Fort Dodge, this is changing. UnityPoint Health (which was, until this week, named Iowa Health System) is one of the 32 Pioneer Accountable Care Organizations that volunteered to have part of their Medicare payments tethered to a set of quality metrics.

While UnityPoint has hospitals across the state, it decided to focus its ACO effort on a relatively small segment of its population to limit the health system’s exposure to the possibility of losing money on the endeavor.

“If we completely missed the mark, we knew it wouldn’t be disastrous from a financial standpoint,” UnityPoint President Bill Leaver said. “We knew it wouldn’t be overwhelming, but a good size to start with.”

The Pioneer ACOs launched Jan. 1, 2012, and for the first year, the program only required them to report quality metrics. Their payments would not yet depend on how well they met 33 measures.

The most difficult part of preparing to move to a system that pays for value rather than volume in Fort Dodge was asking doctors to rethink how they do their jobs. They would be encouraged to delegate relatively routine care, for example, to other advanced practitioners, while focusing their own work on care management.

“That is harder work than we thought,” Leaver said. “For physicians, they run the office and they’re the captain of the ship. Instead of seeing a strep patient now, you might have other people working for you that you’re going to deploy.”

Overall, Leaver describes his experience with the ACO Pioneer program as “generally positive.” What he likes most about the program is that, when the hospital gets a lump sum for each patient, it has more control over treatment. The health system can prescribe treatments that Medicare would not traditionally reimburse.

Want to know the future of Obamacare? Take a look at Fort Dodge, Iowa.

Will Boomers Bankrupt Our Health Care System? Myths and Facts | Health Beat by Maggie Mahar

Well worth reading, with some great Uwe Reinhardt graphics!

When the three-day conference ended yesterday, it also was apparent that developed countries share many of the same problems. One that stands out is the fact that our populations are aging. Each country faces the same question: how will a shrinking workforce possibly pay for the medicine their nations’ retirees will need?

This brings me to Princeton economist Uwe Reinhardt’s speech on the very first day of the conference. The only American to speak at WHCCE, Reinhardt focused on what he called “the folklore that people bring to the health care policy table.” By nature an iconoclast, Reinhardt spent the next 20 minutes shattering some of the myths that have become part of the received wisdom among policy-makers.

Begin with the notion that an aging population is a major factor driving health care inflation. In the U.S. this is accepted as a justification for why the nation’s health care bill now equals more than $2 trillion dollars—and why we must expect it to climb ever higher.

Bad news is often more gripping than good news, and “if you want to be a popular speaker you need to feed the paranoia of your audience,” Reinhardt observed, pointing to the first slide of his Power Point presentation—a chart illustrating just how quickly we can expect a horde of wrinkly boomers to take over the nation. Some stooped and shriveled, others proudly bloated, these former members of the Pepsi generation will be far more demanding, we’re told, than the World War II veterans who preceded them.