Elder Law Prof Blog

Medicare patients who bring a family member or other companion are more satisfied with care

More than one-third of Medicare beneficiaries appear to be accompanied by family members or companions during medical encounters, according to a report in the July 14 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Such medical visit companions may be associated with improved patient satisfaction, especially among beneficiaries in poor health.  Families are increasingly understood to be relevant to patient care, according to background information in the article. However, little is known about which specific attributes of their involvement are most helpful to patients or result in the greatest improvements in quality of care.

Jennifer L. Wolff, Ph.D., and Debra L. Roter, Dr. P.H., M.P.H., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues studied a sample of 12,018 Medicare beneficiaries 65 years or older who participated in a 2004 survey. These older adults were representative of approximately 30 million Medicare beneficiaries living in the community.

The researchers found that:

• 38.6 percent of participants reported regularly being accompanied to medical visits

• Companions included spouses (53.3 percent); adult children (31.9 percent); other relatives (6.8 percent); roommates, friends or neighbors (5.2 percent); non-relatives (2.8 percent); or nurses, nurse aides or legal or financial officers (less than 1 percent)

• 63.8 percent of companions helped with communication, including 44.1 percent who recorded physician comments and instructions, 41.5 percent who communicated information about the patient's medical condition to the physician, 41 percent who asked questions, 29.7 percent who explained physician's instructions and 3.3 percent who translated the English language

• 28.4 percent of companions were reported to be present for company and moral support, 52.3 percent to assist with transportation, 16.6 percent to help schedule appointments and 8.4 percent to provide physical assistance

Beneficiaries with regular companions were more highly satisfied with their physician's technical skills, information-giving and interpersonal skills. Those whose companions more actively helped with communication rated their physicians' information-giving and interpersonal skills more favorably. This relationship was stronger among patients who reported themselves to be in worse health.

Source:  Reuters Health,
http://www.eurekalert.org/pub_releases/2008-07/jaaj-oaw071008.php

Read journal article: http://archinte.ama-assn.org/cgi/content/abstract/168/13/1409

KFF issues 2008n update on Medicare Advantage

Medicare Advantage plans enrolled a record 9.8 million beneficiaries, more than one in five of the nation’s 44 million people on Medicare as of April 2008. That represents an increase of more than 800,000 beneficiaries in just four months, continuing a period of unprecedented growth for private plans in Medicare since 2003.

This issue brief, prepared for the Kaiser Family Foundation by Marsha Gold of Mathematica Policy Research, Inc., analyzes recent developments in the Medicare Advantage marketplace, including plan choices available to beneficiaries and enrollment trends by plan type and geography.

The brief also examines market share for the companies offering Medicare Advantage plans and the role Medicare Advantage plans play in providing employer-sponsored retiree health benefits.

Issue Brief (.pdf)

HHS OIG report discusses Medicare Pard D and dual eligibles

US DEPARTMENT OF HEALTH AND HUMAN SERVICES, OFFICE OF THE INSPECTOR
    GENERAL REPORTS:

"Availability of Medicare Part D Drugs to Dual-Eligible Nursing Home
Residents" (OEI-02-06-00190, June 2008, .pdf format, 28p.).

Abstract:

This final report provides an assessment of the availability of Medicare
Part D drugs to dual-eligible nursing home residents.  Our review focused
on ongoing implementation issues as opposed to the issues related to the
transition from Medicaid to Medicare that arose in the early stages of the
benefit.  The study is based on structured interviews with a sample of
nursing home administrators, medical directors, and directors of
operations for long-term care pharmacies.

According to most respondents, dual-eligible nursing home residents are
receiving all necessary Part D drugs.  However, nursing homes and
long-term care pharmacies sometimes pay for Part D drugs that are not
covered by plans.  Administrators and pharmacy directors explained that
the drugs they most commonly pay for either are not on the residents plans
formularies or require prior authorization.  In addition, respondents
express concerns that formularies, the prior authorization process, and
copayments may pose problems for dual-eligible nursing home residents.
Concerns also exist that long-term care pharmacies generally do not
disclose to physicians the rebates that they receive from drug
manufacturers.

We recommended that CMS work with plans to ensure that formularies meet
the needs of dual-eligible nursing home residents; continue to work with
plans to improve the prior authorization process; ensure that copayments
for dual-eligible nursing home residents are fully subsidized, as
appropriate; and consider methods to encourage long-term care pharmacies
to disclose to physicians information about rebates that they receive from
drug manufacturers.  CMS concurred with our first two recommendations and
the intent of our third recommendation; it did not concur with our last
recommendation.

Get it here:  http://www.oig.hhs.gov/oei/reports/oei-02-06-00190.pdf

Medicare drug coverage is costing most seniors more

Most seniors in Medicare's prescription-drug program are paying considerably higher monthly premiums for coverage this year, according to a study to be released today. Those in the 10 largest plans -- which account for nearly three-fourths of seniors signed up for drug coverage -- are paying an average of $26.39 a month, or 16% more than last year, according to the analysis by Avalere Health, an information company serving the healthcare industry.

The rise is modest in dollar terms, and some of the top plans actually lowered their premiums for 2008. But on average, the percentage increase for the drug plan is greater than the change in Medicare's Part B premium for outpatient care, which rose only 3% in 2008.

Medicare officials say the prescription program, with more than 25 million beneficiaries, is a successful example of how private companies can improve the delivery of government benefits. They point out that in many cases, monthly premiums are lower than estimated at the program's inception, and they credit that to competition among private plans.  But independent experts say the initial estimates may have been too high for several reasons, including the fact that the government had no previous experience with such a program.

Source and more - Los Angeles Times http://www.latimes.com/news/nationworld/nation/la-na-medicare5-2008jun05,0,1486824.story

Medicare-Medicaid agency announces low-cost equipment providers

The Centers for Medicare & Medicaid Services on Monday released the names of the 325 suppliers that have signed contracts with Medicare to provide certain medical equipment and supplies to beneficiaries in Kansas City and nine other communities throughout the country at significantly lower prices than Medicare pays now.

The suppliers were selected based on a competitive bidding process conducted in 10 U.S. metropolitan areas, including Kansas City. The bids were solicted in 10 product categories, which include various types of durable medical equipment, orthotics, prosthetics and supplies.

A list of the selected contract suppliers can be found online.

"We are pleased that Medicare beneficiaries living in the 10 first-round communities will continue to receive high-quality service and supplies from the suppliers participating in Medicare's competitive bidding program," CMS Acting Administrator Kerry Weems said in a release. "All of these contract suppliers have met our stringent standards, so beneficiaries can be assured they receive their equipment and supplies from legitimate suppliers."

The new competitive bidding program goes into effect on July 1. Because beneficiaries pay 20 percent coinsurance on the cost, they as well as Medicare will directly benefit from the savings.

Based on bids submitted by the selected suppliers, beneficiaries and Medicare will see prices, on average, 26 percent less than Medicare pays for the same items. CMS received bids from 1,005 suppliers. There were just less than 6,200 bids for one or more product categories in competitive bidding areas where the new program is being implemented. CMS offered contracts to 23 percent of suppliers that submitted bids. These suppliers were in the winning price range and met quality and financial standards and disclosure requirements.

Source: Kansas City Business Journal

CMA report discusses true truth about Medicare cost-sharing

>Guidance released recently by the Centers for Medicare & Medicaid Services (CMS) sheds new light on an issue that has created hardships for beneficiaries and challenges for advocates trying to help them. The guidance addresses two issues:  balance billing of Qualified Medicare Beneficiaries (QMBs) and payment of Medicare cost-sharing for dually eligible beneficiaries enrolled in Medicare Advantage plans. For details on the guidance see the CMS Memo "Medicaid Cost Sharing for Medicaid Beneficiaries" at <http://www.medicareadvocacy.org/MedSavProg_08_04.24.ARACostShare.pdf>, as well as the supporting information in "Balance Billing of Qualified Medicare Beneficiaries (QMB) Q & A" and "Capitation for Medicare Cost Sharing in Medicare Advantage (MA) Plans Q & A" at <http://www.medicareadvocacy.org/MedSavProg_08_04.24.ARABalanceBilling.pdf> and http://www.medicareadvocacy.org/MedSavProg_08_04.24.ARACapitation.pdf.

Source/more:  Center for Medicare Advocacy

HHS must release Medicare claims data

Via Kaiser Daily Health Policy Report:

HHS last week in the U.S. Court of Appeals for the District of Columbia filed an appeal of an August 2007 court decision that requires the department to release Medicare claims data on more than 40 million beneficiaries and 700,000 physicians, the Los Angeles Times reports (Alonso-Zaldivar, Los Angeles Times, 4/19).

In August 2007, the U.S. District Court for the District of Columbia ruled that HHS must release Medicare physician claims data for Illinois, Maryland, Virginia, Washington state and Washington, D.C. In the case, Consumers' CHECKBOOK/Center for the Study of Services filed a lawsuit to obtain access to the data. HHS argued that the release of the data would violate the privacy of physicians. However, the court rejected that argument because Medicare claims account for only a portion of the incomes of physicians. According to the court, the release of the data would "help the public make more informed Medicare decisions" and provide "more information of how government funds are spent."

Consumers' CHECKBOOK plans to post the data online for public use. Researchers could analyze the data to determine the number of times physicians perform certain procedures and to compare the mortality rates among patients of certain physicians, and health insurers could use the data to improve their analyses of physician quality (Kaiser Daily Health Policy Report, 8/27/07).

Consumer groups, employers and health insurers support the decision, and physician groups oppose the decision.  The American Medical Association, which has petitioned to join the HHS appeal, maintains that the data could be misleading because they do not take into account differences in patients treated by different doctors, the Times reports.  

Health Beat Blog on the high cost of Medicare "Advantage"

Here's how it starts:

On Monday, the Bush Administration announced that next year payments to private insurers who offer Medicare to seniors will rise by 3.6 percent. This is a mistake. The last thing that the Medicare Advantage (MA) program needs is more money thrown at it. Indeed, MA has turned out to be a money-eating monster—in large part because the government gave it a blank check when the program was born, under the cover of darkness, in 2003.

More here:  http://www.healthbeatblog.org/2008/04/the-high-cost-o.html

MedPAC send recommendations to Congress re reimbursements

The Medicare Payment Advisory Commission on Wednesday voted to approve several recommendations to Congress focused on Medicare reimbursements for skilled nursing facilities and primary care.  The commission recommended amending the Medicare payment system for skilled nursing facilities to add a "separate nontherapy ancillary component" that includes prescription drugs and intravenous therapy. MedPAC also recommended revising the therapy component of the system to base reimbursements on "predicted patient care needs" and implementing a provision for "outlier payments" for unusual financial losses. In addition, the commission recommended a proposal under which HHS Secretary Mike Leavitt would require skilled nursing facilities to report diagnosis information, dates of services on claims filed and "services they furnish separately" on patient assessments. Facilities with the highest profits would receive the largest payment cuts, while those losing money would receive the largest increases.  The commission also recommended an increase in payments to physicians designated by Leavitt as primary care-focused practitioners in an attempt to address a growing shortage of such physicians, CQ HealthBeat reports.  In addition, MedPAC considered a recommendation to establish a pilot program that would provide Medicare beneficiaries with a "medical home" to oversee their care. Under the proposal, physicians would be required to establish their capability to provide primary care; coordinate preventive, maintenance and acute health care services; employ health care information technology for active medical support; conduct care management; provide access and communication to patients at all times; and keep updated records of patients' advance directives, including the types of treatments they should receive if they are incapacitated.

Source:  KFF Daily Health Policy Report, http://kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=51463

NATIONAL BUREAU OF ECONOMIC RESEARCH: The Impact of Medicare Part D on Pharmaceutical R&D

"The Impact of Medicare Part D on Pharmaceutical R&D," by Margaret E.  Blume-Kohout and Neeraj Sood (w13857, March 2008, .pdf format, 17p.).

Abstract:

Recent evidence suggests that Medicare Part D has increased prescription drug  use among the elderly, and earlier studies have indicated that increasing  market size induces pharmaceutical innovation. This paper assesses the impact  of Medicare Part D on pharmaceutical research and development (R&D), using time-series data on the number of drugs in preclinical and clinical development  by therapeutic class. We demonstrate that the passage of Medicare Part D was  associated with significant increases in pharmaceutical R&D, especially for  classes with high elderly market share.

http://papers.nber.org/papers/W13857

NSCLC posts Low Income Advocate Alert re Part D

The National Senior Citizens Law Center’s Low-Income Advocate Alert on Medicare Part D, March 2008, is available online at http://www.nsclc.org/areas/medicare-part-d/area_folder.2006-09-28.4596471630.  In this edition you will find information on:

• CMS clarifies formulary guidance on prior authorization requirements, conversion to over-the-counter status, and off-label use.

• 76,000 Low Income Subsidy (LIS) recipients will receive LIS termination notices from the Social Security Administration.

• CMS suspends enrollment and marketing into Health Net Orange plans. 

• Information about Part D plans’ obligations to reimburse incorrect cost-sharing. 

• News specifically for California advocates, including information about Kaiser’s Special Needs Plan for dual eligibles, Medi-Cal coding errors, and an NSCLC guide on Part D transition drug supply policies.

• And much more …

GAO issues report on CMS "hold harmless" rule

Pursuant to section 801(a)(2)(A) of title 5, United States Code, the GAO has issued a report on a major rule promulgated by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), entitled “Medicaid Program; Health Care-Related Taxes” (RIN: 0938-AO80).  It was published in the Federal Register as a final rule on February 22, 2008.

Read the final rule.

Get the GAO report.

Get the Center for Budget and Policy Priorities' report on the rule.

US comptroller chides Congress for sticking its head in the sand on unfunded liabilities

  Comptroller General David Walker on Monday "chided" Congress for "ignoring the long-term financial crisis" for entitlement programs such as Medicare and Medicaid, CongressDaily reports.  In an interview with National Journal Group writers and editors, Walker, who will leave his post next week, said that Congress is "doing nothing about the $53 trillion hole" in funds for entitlement programs during the 21st century.   Walker recommended that the next president appoint a bipartisan commission to develop a proposal to address the issue and submit the plan to Congress. In addition, Walker recommended a "mandatory reconsideration trigger" for a reduction in Medicare spending in the event that spending for the program increases at a higher rate.

Under current law, the president must propose legislation to revise Medicare when trustees estimate for two consecutive years that general fund revenue would finance more than 45% of total program costs within seven years. The law does not require a reduction in Medicare spending. Walker said, "We write a blank check for (health care)," adding, "There is no other country in the world dumb enough to do that."

Source/more:  KFF Daily Health Policy Report, http://kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=50917

 

 

Medicare Payment Advisory Commission's annual March report recommends physician reimbursement increase

The Medicare Payment Advisory Commission's annual March report has recommended a 1.1% physician reimbursement increase for next year and a reduction in payments to Medicare private health plans.  The report assumes that lawmakers again will act to prevent physician pay cuts triggered by the sustainable growth rate formula. Existing law calls for a 10.6% reduction to take effect July 1 and an additional cut of about 5% in 2009.

Physician organizations, including the American Medical Association, welcomed MedPAC's continued support for a positive update. They called for a permanent replacement for the SGR based on increases in physicians' practice costs. But as was the case last year, MedPAC was unable to reach an internal consensus on an alternative to the current formula. "We are where we were," said Mark Miller, PhD, the commission's executive director.  MedPAC's lack of agreement on an SGR replacement is not helping to advance a solution, said Jim King, MD, president of the American Academy of Family Physicians. "As long as they continue to be so vague in their presentation, all it does is continue to confuse the issue."

Read more here:  http://www.ama-assn.org/amednews/2008/03/17/gvl10317.htm

Low income Part D beneficiaries stand to lose subsidies on April 1

From the Center for Medicare Advocacy:The Social Security Administration (SSA) has begun mailing "SSA Medicare Prescription Drug Assistance Notice of Termination" letters to some beneficiaries who are currently receiving the low-income subsidy (LIS) or "Extra Help."  The letters are being sent to beneficiaries who did not provide SSA with information it requested to determine their continuing eligibility for the LIS. About 76,000 beneficiaries began receiving this mailing during the week of March 2. Beneficiaries who do not act immediately upon receiving the letter to request an appeal will no longer receive the LIS to pay for Part D premiums and cost-sharing effective April 1.
SSA requested information in September 2007 as part of its formal redetermination process.  The process, which was completed in February, involved multiple attempts by SSA to contact beneficiaries who were subject to redetermination.  SSA indicates that approximately 80,000 people responded to its follow-up contacts; people who responded should not receive the SSA "Medicare Prescription Drug Assistance Notice of Termination" letter being sent out this week. Beneficiaries who believe they are, or even might still be, eligible for the LIS should contact SSA within 10 days of receiving their letter to request an appeal.  If they do so, they can continue receiving LIS until their appeal has been decided, regardless of whether it is decided in their favor.
Appeals can be filed after the 10 days but not later than 60 days after receiving the SSA letter, but beneficiaries filing after the first 10 days will not continue to receive LIS pending their appeal.  LIS may also continue for beneficiaries who can show good cause why they did not file an appeal within 10 days

Source/more:  http://www.medicareadvocacy.org/PartD_08_03.07.LISTermination.htm

Manufacturing honchos doubt Congressional resolve (caj--?) to reform health care

CHICAGO (Reuters) - Chief executives from the U.S. manufacturing and transportation sectors say something must be done about soaring health-care costs but doubt the ability of Washington to come up with meaningful, bipartisan reform.  "There is a lot of work that needs to be done on the part of the politicians to rein in some of these costs," Lincoln Electric Holdings Inc ( CEO John Stropki said at the Reuters Manufacturing Summit in Chicago this week, adding: "I have very little confidence in Washington."  In some cases, U.S. companies say they are focusing on "wellness" programs to cut health-care costs, including encouraging employees to eat well, exercise and quit smoking.  U.S. health-care costs have seen double-digit increases for much of the past decade and are set to keep on rising.  "Something eventually has to give there," said Wick Moorman, CEO of U.S. railroad Norfolk Southern Corp "This is a critical issue that is confronting our economy."

Source:  Reuters, http://www.reuters.com/article/Manufacturing08/idUSN2859337320080228

GAO report says that Medicare Advantage beneficiaries may pay more despite gov't subsidies

In 2007, plans projected that relatively little of their rebates would be spent on additional benefits compared to cost-sharing and premium reductions. Of the average projected rebate amount of $87 PMPM, plans projected they would allocate about $10 PMPM (11 percent) to additional benefits, about $61 PMPM (69 percent) to reduced cost sharing, and about $17 PMPM (20 percent) to reduced premiums.
Using funding from both rebates and additional premiums, plans covered a variety of additional benefits not covered by Medicare FFS in 2007, including dental and vision benefits. On the basis of plans’ projections, GAO estimated that rebates would pay for approximately 77 percent of additional benefits and additional beneficiary premiums would pay for the remaining 23 percent.

MA plans projected that, on average, beneficiaries in their plans would have lower cost sharing than Medicare FFS cost-sharing estimates, although some MA plans projected that their beneficiaries would have higher cost sharing for certain service categories, such as home health care and inpatient services. Because cost sharing was projected to be higher for some categories of services, beneficiaries who frequently used these services could have had overall cost sharing that would be higher than under Medicare FFS.

On average, MA plans projected that they would allocate about 87 percent of total revenue ($683 of $783 PMPM) to medical expenses; approximately 9 percent ($71 PMPM) to non-medical expenses, including administration, marketing, and sales; and approximately 4 percent ($30 PMPM) to the plans’ margin, sometimes called the plans’ profit. About 30 percent of beneficiaries were enrolled in plans that projected they would allocate less than 85 percent of their revenues to medical expenses.

Whether the value that MA beneficiaries receive in the form of reduced cost sharing, lower premiums, and additional benefits is worth the additional cost is a decision for policymakers. However, if the policy objective is to subsidize health care costs of low-income Medicare beneficiaries, it may be more efficient to directly target subsidies to a defined low-income population than to subsidize premiums and cost sharing for all MA beneficiaries, including those who are well off. As Congress considers the design and cost of MA, it will be important for policymakers to balance the needs of beneficiaries and the necessity of addressing Medicare’s long-term financial health.

In commenting on a draft of this report, the Centers for Medicare & Medicaid Services expressed concern that the report was not balanced because it did not sufficiently focus on the advantages of MA plans. GAO disagrees. This report provides information on how plans projected they would use rebates and identified instances in which MA beneficiaries could have out-of-pocket costs higher than they would have experienced under Medicare FFS.

Report:  http://www.gao.gov/new.items/d08359.pdf?source=ra

Comment:  The privatization of Medicare costs beneficiaries and taxpayers and enriches insurance companies.  End of story.

Part D structure is undermiining Medicare's long term financial security--duh

When President Bush signed the Medicare drug prescription law in 2003, describing it as "the greatest advance in health care for America's seniors," he was criticized because the plan could prove to be hugely costly and someday end up wrecking the Medicare budget.  Some critics were concerned about the law's mind-boggling complexity and provision, known as Part D, which subsidizes the supply of drugs by private insurers without allowing Medicare to negotiate prices. And others thought that rushing to a new entitlement to guarantee Bush's second-term re-election without really understanding what we would be paying in perpetuity was irresponsible.

At first look, the plan has fulfilled its goal of providing drug coverage to Medicare beneficiaries. According to the Centers for Medicare and Medicaid Services, 40 million seniors now have prescription drug coverage. A study from IMS, a pharma-industry data collection firm, shows that seniors in Part D plans filled about 486 million prescriptions in 2006, boosting use of the most profitable chronic disease drugs.  Drugs for high blood pressure and high cholesterol accounted for 122 million prescriptions. More than 20 million prescriptions were for drugs to treat diabetes, pain, cancer and ulcers. And rounding out the top 10 were antibiotics, hormones, blood thinners, and drugs for seizures and psychiatric disorders.

But the program has failed to protect low-income Americans from high out-of-pocket costs for their medications, according to a 2007 survey of 16,000 seniors by the Kaiser Foundation, Commonwealth Fund, and Tufts-New England Medical Center. And program costs that critics had feared would exceed government projections by as much as $750 billion by the end of the decade have materialized sooner than expected.

According to the House Oversight and Government Reform Committee, the implementation of Part D contributed to an 18.7 percent increase in Medicare spending in 2006, the fastest rate of growth since 1981 and double the rise in 2005, while overall health spending had increased only 6.7 percent. Privatizing delivery of drug benefits, the committee added, "has been costly and inefficient and enriched the drug companies and the insurance industry at the expense of seniors and taxpayers." Program costs would have been $11.7 billion less, if plans obtained rebates compared to those negotiated by Medicaid and the Veterans Administration.

Source/more:  SF Chronicle, http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/02/27/EDBJV8O9K.DTL

KFF rounds up editorials on Bush Medicare "reform"

      Several newspapers recently published editorials and an opinion piece on a Medicare proposal recently announced by the Bush administration.  Summaries appear below.  

• Daytona Beach News-Journal: A "rich nation should care for its elderly in return for their lifetime of productivity for the country," but, "as the tax structure and Medicare stand today, the program may become unaffordable," according to a News-Journal editorial. The editorial states, "Keeping things as they are won't work," but "drastic changes aren't necessary, either." According to the editorial, a "combination of modest tax increases and adjustments within the programs can assure solvency far into the future." The editorial concludes, "The administration's overarching goal is to privatize the program, not to make it permanently solvent as one of the more successful government programs of the last 40 years," and, as "Medicare beneficiaries have every reason to back fair Medicare reform," they "also have every reason to doubt that this administration can be trusted to deliver" (Daytona Beach News-Journal, 2/22).
• New York Times: The Bush administration "has just made several proposals -- some sensible, some not -- to reform Medicare financing and spending," but the "exercise is seriously hobbled by an ill-advised 2003 law that prevents consideration of some of the best and fairest ways to begin fixing Medicare," according to a Times editorial. Because of the way the law is structured, the editorial states, "Congress can't bolster Medicare with money generated by closing corporate tax loopholes or letting the president's tax cuts for the wealthy expire" because those measures would increase the amount of general fund support for the program and push it "over the arbitrary 45% cap." The editorial continues, "The worst proposals, a slew of provisions to restrain medical malpractice awards, look mostly like a jab at the trial lawyers who support the Democratic Party" and are "not apt to save the program much money." In addition, the "administration has made no effort to reduce the lavish and unjustified subsidies granted to the private health plans that participate in Medicare," and their elimination "could save Medicare far more general revenue money than reducing drug-program subsidies would," according to the editorial. The editorial concludes, "Congress needs to focus on ways to restrain the relentless rise in health care costs that is bedeviling all health insurers, including Medicare," and "Congress and the administration need to be able to consider all possible sources of revenue for Medicare -- on their own sound and equitable merits" (New York Times, 2/25).  

• John Goodman, Wall Street Journal: "Rarely in Washington does the president get to propose legislation that Congress is required to fast track," but such an "opportunity exists right now" with a proposal to address "the rising costs of Medicare," Goodman, president of the National Center for Policy Analysis, writes in a Journal opinion piece. According to Goodman, reductions in Medicare physician and hospital reimbursements "do not improve care and have not worked to contain costs in the past." In addition, although proposals to "promote electronic medical records, price and quality transparency, limits on malpractice awards and means-testing" for Medicare prescription drug benefit premiums are "commendable," they are "far from adequate," Goodman writes. Among other proposals, he writes, Medicare should "reward doctors and other health care providers who raise quality and lower costs" through "improving patient communication and access to care and teaching patients how to be better managers of their own care"; provide beneficiaries who have chronic diseases with "training, easier access to information, and the ability to purchase and use in-house monitors," efforts that would help them "manage their own care as well as, or better than, conventional physician care and at lower costs"; and revise the reimbursement system to remove the "many barriers to innovations in using those treatments efficiently and effectively" (Goodman, Wall Street Journal, 2/23).                         

Via KFF Daily Health Policy Report.

CMA seeks associate director for advocacy

The Center for Medicare Advocacy, the country’s foremost Medicare advocacy organization seeks an experienced attorney for a new, senior management position in its Connecticut office. The Associate Director for Advocacy will be responsible for the day-to-day supervision of the lawyers and advocates in the organization’s Connecticut office. The person in this position will coordinate the organization’s administrative appeal activities, including acting as liaison between data staff and legal staff, and will lead the interplay between the Center’s direct advocacy, policy work, and litigation. This person will also work with the management team to help develop the organization’s direction and funding.

Proven ability to work successfully with diverse personalities and to multi-task required.  Prior management and administrative law experience desirable.

The Center for Medicare Advocacy is a national, nonprofit advocacy organization that works to advance fair access to Medicare and quality health care.  The Center is headquartered in Connecticut, with offices in Washington, DC and throughout the country.  The Connecticut office is located in a beautiful area in Mansfield, Connecticut about 45 minutes from Hartford, less than 2 hours from Boston, and 3 hours from New York City.  For more information about the Center for Medicare Advocacy, visit www.medicareadvocacy.org .

Competitive salary range, depending on experience, excellent pension, health insurance, and other benefits.  EOE/AA.

This is an immediate opening, but we may be willing to wait for the right candidate.
Please send resumes and two references by March 28 to:

Carolyn Boyle, Administrator
Center for Medicare Advocacy, Inc.
PO Box 350
Willimantic, Connecticut 06226
Or cboyle@medicareadvocacy.org

CRS Report: Medicare: FY2009 Budget Issues

Abstract:  Each February, the President submits a detailed budget request to Congress for the following federal fiscal year, along with projections for the five-year budget window. The budget informs Congress of the President's overall federal fiscal policy, based on proposed spending levels, revenues, and deficit (or surplus) levels. The budget request lays out the President's relative priorities for federal programs, such as how much should be spent on defense, education, health, and other federal programs. The President's budget may also include legislative proposals for spending and tax policy changes. While the President is not required to propose legislative changes for those parts of the budget that are governed by permanent law, such as Medicare benefits, these changes are generally included in the budget. The President's 2009 budget estimates current law Medicare net outlays of $413 billion in FY2009. The budget includes Medicare legislative proposals with estimated savings of $12.2 billion in FY2009 and $178 billion over the five-year budget window. The President's budget also includes Medicare administrative proposals with estimated savings of $645 million in FY2009 and $4.7 billion over the five-year budget window, which brings the estimated savings from the total Medicare budget proposals to $12.8 billion in FY2009 and $183 billion over the fiveyear budget window. Proposals include savings achieved through reductions in many of the Medicare payment updates. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA, P.L. 108-173) requires the Medicare Board of Trustees to examine and make a determination if general revenue Medicare funding is expected to exceed 45% of Medicare outlays for the current fiscal year or any of the next six fiscal years. An affirmative determination in two consecutive annual reports is considered to be a Medicare funding warning in the year in which the second report is made. The President has indicated that he intends to submit the required legislative proposal, due within the 15-day period following the budget submission to Congress. As part of the budget, the President has proposed reducing Medicare provider payments by 0.4% beginning in any year that the general revenue Medicare funding is expected to exceed 45% of Medicare outlays. This reduction would increase each year, until the percentage falls below the 45% trigger level. This report will be updated.

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CRS report analyzes S. 2499, the Medicare, Medicaid, and SCHIP Extension Act of 2007

On December 29, 2007, the President signed S. 2499, the Medicare, Medicaid, and SCHIP Extension Act of 2007 (P.L. 110-173). This Act was passed by the House on December 19, 2007, and by a voice vote in the Senate on December 18, 2007. The Act makes changes to the nation's three major health programs, Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP), as well as other federally funded programs. The most prominent provisions in the Act were to (1) suspend the Medicare physician payment cut scheduled to take effect and (2) provide SCHIP funding through March 2009. P.L. 110-173 mandates a 0.5% increase in the Medicare physician fee schedule for the six-month period from January 1, 2008, through June 30, 2008, and provides FY2008 and FY2009 SCHIP funding allotments through March 31, 2009. The Act also extends a number of expiring provisions and programs. These extensions affect Medicare plans and providers and Medicaid payments and programs. The Act also includes funding for some miscellaneous activities. The Act's Medicare extensions include incentive payments for certain physicians, and extensions of current law provisions for Medicare Special Needs Plans and cost-based plans. A variety of extensions also affect how long-term care, rural, and acute care hospitals are paid or classified. Other extensions affect Medicare payments for certain services and providers, outpatient physical therapy services, speech language pathology services, certain pathology laboratories, brachytherapy services, and therapeutic radiopharmaceuticals. The Act also includes Medicaid provisions designed to extend certain payments and programs, such as Medicaid disproportionate hospital share (DSH) allotments for Tennessee and Hawaii, the Transitional Medical Assistance (TMA) program, and the Qualifying Individual (QI) program, among other provisions. Miscellaneous provisions include using Medicare funds to make grants to State Health Insurance Assistance Programs, Area Agencies on Aging, and Aging and Disability Resource Centers. The Act also establishes the Medicare Payment Advisory Commission (MedPAC) as a congressional agency. The Act provides a number of offsets to pay for the spending increases, including a reduction in the Medicare Advantage stabilization fund in 2012. The Act also includes provisions affecting Medicare's responsibility as a secondary payer for covered services, Medicare payments for Inpatient Rehabilitation Facilities (IRFs), payments for most Medicare part B drugs, payments for certain diagnostic laboratory tests, and Medicare Long-Term Care Hospitals. This report provides short descriptions of the provisions contained in P.L. 110173.

Get it from Open CRS, http://opencrs.cdt.org/document/RL34360

Maryland low income seniors to get drug subsidies

About 7,500 low- and moderate-income seniors in Maryland would be eligible for a subsidy for their prescription drugs under a  plan announced yesterday by Gov. Martin O'Malley (D) and health-care leaders.  A deal reached with CareFirst BlueCross BlueShield, the region's largest nonprofit health insurer, would help senior citizens close a gap in Medicare drug coverage known as the doughnut hole. The Medicare benefit, passed by Congress in 2003, covers annual costs up to $2,510, but seniors then have to pay all of their drug costs until their total spending out of pocket hits $4,000. Coverage kicks back in after that.  The gap, designed to hold down costs, has proved unpopular. Health advocates say seniors are left with bills for vital drugs they cannot pay. Many are forced to go off their medication, endangering their health, critics say.  The subsidy offered under the agreement announced yesterday would cover seniors with incomes from Social Security benefits or retirement plans up to 300 percent of the federal poverty level -- about $30,000 for a single person. CareFirst has agreed to pay the annual $7 million cost of the program.  The average benefit would amount to $1,000.

Source:  Washington Post (16 February 2008)
Full story: http://www.washingtonpost.com/wp-dyn/content/article/2008/02/15/AR2008021503600.html

NSCLC posts CMS letter re 2008 Medicare Part D Low-Income Subsidy Income and Resource Standards

Get it here: 

http://tinyurl.com/32kelf

CMA issues report and recommendations aimed at protecting members of Medicare private "Special Need Plans."

In fulfillment of a grant from The Commonwealth Fund, the Center for Medicare Advocacy recently issued a report and recommendations aimed at protecting members of Medicare private plans known as "Special Need Plans."  The documents are available from the Center’s website at http://www.medicareadvocacy.org/SNP%20Conference/Home.htm.

According to the Center's recommendations, all Medicare Special Needs Plan (SNP) enrollees must be assured that their special needs are actually met by SNPs. To that end, the Center recommends that these plans guarantee SNP-specific beneficiary protections, standards for care, and coverage. Further, all of these SNP-specific protections must be enforceable, and actively enforced, by the Centers for Medicare & Medicaid Services (CMS).

Created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Special Needs Plans (SNPs) have proliferated since 2004, the first year of operation, due in part to the revenue they generate for plans. In 2004, 11 SNPs were approved by CMS. In 2007, 477 SNPs were approved, enrolling over 800,000 beneficiaries.  As of November 2007, CMS has approved 775 plans to be SNPs in 2008, with enrollment now exceeding 1 million beneficiaries.  On December 29, 2007, President Bush signed a law  which placed a moratorium on new SNPs through December 31, 2009.

In marked contrast with "regular" Medicare Advantage (MA) plans, which are prohibited from discriminating among Medicare beneficiaries in their enrollment, SNPs are designed to serve, either exclusively or disproportionately, specific Medicare subpopulations. SNPs must be coordinated care plans and they must offer all benefits of Medicare Parts A, B and D. Aside from these two conditions, SNPs operate with few requirements from either the law or implementing regulations and with little oversight of how or whether they deliver what they promise.

We hope that you will find the Center’s recommendations useful and that you will share this information broadly

Center for Medicare Advocacy: President Punts Medicare...

The President punted on Medicare in his State of the Union address, lumping together Medicare with Medicaid and Social Security and telling Congress to fix them.    The Center for Medicare Advocacy works on behalf of Medicare beneficiaries to ensure they get the health care they need. "We are happy to take up the President's challenge," says Judith Stein, Executive Director of the Center for Medicare Advocacy. "The way to support traditional Medicare and end billions of dollars in unnecessary government spending is to cut the $150 billion subsidies being paid to private Medicare plans. This windfall to private corporations undermines traditional Medicare, threatens its future, and burdens taxpayers," says Stein.  "Instead of giving $150 billion to corporations, give it back to taxpayers,"  Stein states.  "If the President's challenge is real, the answer is clear.  Stop pretending privatizing Medicare saves money and offers better care. Cut this 'earmark' to private insurance companies. This will sustain Medicare, and help the economy."  "Congress and the President should support traditional Medicare, says Stein. "It is a proven, cost-effective way to provide access to health care for older people and people with disabilities."  "In fact," Stein continues, "traditional Medicare is a model for a fair, uniform, and cost-effective health insurance program."
                   
Judith Stein is available for comment.

KFF updates Part D Plan Tracker with 2008 info

To help people monitor changes in private plans in Medicare, the Kaiser Family Foundation has updated its interactive online resource, the Medicare Health and Prescription Drug Plan Tracker, with new 2008 data. The Tracker provides local, regional and national information about Medicare Advantage plans, including HMOs, regional and local PPOs, private fee-for-service plans, and special needs plans.  It also includes current information on stand-alone prescription drug plans offered, along with updated 2007 enrollment     data for Medicare Advantage and stand-alone prescription drug plans. The online tool can be used to monitor changes in Medicare Advantage enrollment over time within counties, states and nationally.

http://www.kff.org/medicare/healthplantracker/index.jsp

Center for Medicare Advocacy alert: new poverty guidelines will affect Medicare/Medicaid eligibility

New federal poverty level (FPL) guidelines published January 23, 2008 will affect eligibility levels for many public benefits, including health benefits for older people and people with disabilities. 73 Fed. Reg. 3971, (January 23, 2008).  The new numbers are effective when published, but each program that relies on them may use a different effective date.

The published poverty levels merely state a dollar figure for different sized family units.  They do not address issues of what income is included, what deductions from income are allowed, who is included in a family unit or other use issues.  These questions are addressed by the individual programs relying on the poverty guidelines.  The amounts given below apply to the 48 contiguous states and Washington, DC.  Rates for Alaska and Hawaii are slightly higher.  A complete list of FPLs is available at <http://aspe.hhs.gov/poverty/08poverty.shtml>

Federal health programs affecting older people and people with disabilities that rely on federal poverty guidelines:

Full Medicaid:

Poverty Level Aged and Disabled (PLAD):  States can choose to provide full Medicaid benefits to aged and disabled individuals with incomes up to 100% of the federal poverty level (FPL).  For states choosing 100% FPL as their ceiling, eligibility levels for 2008 will be $866.67/month ($10,400/year) for an individual; to $1166.67/month ($14,000/year) for a couple.

Amounts protected for the at-home spouse of a Medicaid nursing facility resident:  Medicaid law allows for certain levels of income and resources to be protected for the community spouse of a nursing facility resident whose care is paid for by Medicaid and who otherwise would have to pay most of her/his income to the facility.  The minimum amount of income protected is 150% FPL for two people ($1,750/month); states must use this amount beginning July 1, 2008 and they may use it immediately. If they do not use it immediately, they will continue to use $1,711.25.  Other protected amounts for 2008, not linked to FPL, are maximum monthly protected income, $2,610, minimum resource allowance, $20,880, and maximum resource allowance, $104,400.

Medicare Savings Programs:

Qualified Medicare Beneficiaries (QMBs):  States must be responsible for all Medicare cost-sharing for Medicare Beneficiaries with incomes up to 100% FPL and limited resources.  For this group, the increase will also be to $866.67/month ($10,400/year) for an individual; $1,166.67/month ($14,000) for a couple.

Specified Low-income Medicare Beneficiaries (SLMBs):  States must pay the Medicare Part B premium for Medicare beneficiaries with incomes between 100% FPL and 120% FPL and limited resources. The new limit for this group will be $1,040/month ($12,480/year) for an individual; $1,400/month ($16,800/year) for a couple.

Qualified Individual (QI): States have a limited amount of money from which they must pay, on a first come, first served basis, the Medicare Part B premium for Medicare beneficiaries with incomes between 120% FPL and 135% FPL and limited resources.  The limit for this group is $1,170/month ($14,040/year) for an individual; $1,575/month ($18,900/year) for a couple.

Qualified Disabled and Working Individual (QDWI):  States must pay the Medicare Part A premium for certain working disabled Medicare beneficiaries who have exhausted their entitlement to premium-free Part A benefits and whose incomes do not exceed 200% FPL.  The new limit for this group is $1,733.33/month ($20,800/year) for an individual; $2,333.33/month ($28,000/year) for a couple.

Add $20 to each of the monthly amounts listed above to determine the actual eligibility limit, since applicants are allowed a $20 disregard from any income before their income is measured against the poverty levels.  Couples only get one $20 disregard.

Part D Low-income Subsidies:

Full Subsidy:  Medicare Part D provides a full drug subsidy with low co-payments to Medicare beneficiaries with incomes up to 135% FPL and limited resources.  For those individuals, the 2008 eligibility limit is $1,170/month ($14,040/year) for an individual; $1,575/month ($18,900/year) for a couple. 

Partial Subsidy: Medicare Part D provides a partial subsidy of premium, deductible and co-insurance to Medicare beneficiaries with incomes up to 150% FPL and limited (but higher than allowed for full subsidy) resources.  The income limit for this group is $1,300/month ($15,600/year) for an individual; $1,750/month ($21,000/year) for a couple.

As with the Medicaid and MSP monthly amounts, add $20 to account for the disregard.

Unlike rules for Medicare Savings Programs, which allow for a family unit of only one or two, eligibility rules for  Part D subsidies will recognize larger family units, to the extent that those family members rely on the applicant or her spouse for one half of their financial support.  To calculate the levels for larger family units, start with the yearly amount for one ($10,400), add $3,600 for each additional family member, multiply by the applicable percentage of poverty (135% or 150%) and divide the result by 12 for a monthly amount.

The 2008 poverty guidelines will be used to compute Part D low-income subsidies for the rest of 2008 and for the early months of 2009, until new guidelines are published.  Applications filed in late 2007 that "failed" 2007 income tests have been held by the Social Security Administration for evaluation using the 2008 guidelines.

Source:  Center for Medicare Advocacy, http://medicareadvocacy.org/

AMA says Medicare payment reform is critical

Renewed urgency around balance billing comes amid increasing frustration with efforts to reform the Medicare payment formula—especially the component that requires Medicare to remain budget neutral. 

With health system reform looming as a central issue in the 2008 presidential race, members of the AMA House of Delegates focused on strategies to advance the AMA's own proposals. Medicare reform, state health care reform initiatives, the AMA's longstanding opposition to a "single-payer" system of health care, and pending legislation to reauthorize the State Children's Health Insurance Program dominated debate at last month's interim meeting of the AMA House of Delegates in Honolulu (see also Physicians Face Drastic Cut in 2008 Medicare Payment). Indicative of the urgency felt by delegates surrounding health care reform efforts was a resolution that would have had the AMA sponsor a forum on health care reform for all the major presidential candidates at the AMA's annual meeting in June 2008.

Source/more:  Psychiatric News, http://pn.psychiatryonline.org/cgi/content/full/42/24/4?etoc

OIG report says Part D plans aren't accurately tracking out of pocket costs as required by law

In a recent study, the Office of Inspector General (OIG) for the Department of Health and Human Services found that Medicare drug plans have not met all requirements for tracking out-of-pocket spending by beneficiaries in the Medicare Part D prescription drug program. Accurate tracking of beneficiaries’ true out-of-pocket (TrOOP) costs is critical to ensuring appropriate cost sharing under the Part D
program.

See the press release  or the full report.

Medicare fraud reaches epidemic proportions, but CMS doesn't care....

Through a variety of billing schemes, phony medical supply companies and payoffs to unscrupulous doctors and patients, these thieves now steal an estimated $60 billion a year in taxpayer money that is supposed to finance health care for 43 million American seniors and the disabled.  "The legitimate Medicare recipient is hurt— the legitimate business that's dispensing this and serving patients is hurt, every taxpayer is hurt, and we need to come down on this with both feet," said U.S. Secretary of Health and Human Services Michael Leavitt.  Another official, putting it more bluntly, said, "The system is broken."  And referring to the level of fraud, he added, "It's an epidemic."

False billing continues despite complaints
One of the patients dramatically affected by the widespread fraud is 82-year-old Muriel Sherman. During the last three years, Sherman received dozens of statements from Medicare indicating that the system was billed for tens of thousands of dollars in medicine and medical equipment in her name — care and equipment she never got and didn't need. It began after someone stole her Medicare patient identification number. She suspects the theft occurred at a facility where she went for treatment.

Flipping through page after page of Medicare benefits statements, Sherman insisted that none of the charges were real. "It's all phony," she said. Among other things, the bills indicate she is taking medicine for AIDS, a disease she doesn't have. "The FBI says if I was getting this amount of medicine, I'd be dead," she said. On her behalf, Medicare was also billed for a wheelchair, artificial knees, ankles and an eye, plus other medicines for diabetes. "None of it is real."

Sherman's biggest gripe is that her repeated complaints to Medicare were not acted upon quickly. "They don't want to know you when you call on the telephone," said said.  She also complained that discussions with law enforcement officials never resulted in the prosecution of any of the fraudulent billers. "For these people to do this and not be apprehended is an absolute insult to me and to everyone else," she exclaimed. 

Source/more:  http://www.msnbc.msn.com/id/22202073/

Ed:  Is CMS more concerned with encouraging "personal responsibility" for health care costs than with prosecuting criminals?  I think so...

People:  if you think Medicare fraud is being accomplished using your personal information, contact a lawyer who specializes in "qui tam" actions, pronto!  You'll get up to 1/3 of the total amount recovered!

Medicare audits feared, detested...

Florida and New York hospital officials are leaping onto legislation sponsored by California lawmakers that would temporarily halt a controversial Medicare auditing program.  The commission-based program has been operating for more than two years on an experimental basis in the three states and is set to expand permanently to 20 more in March.  But because of the California experience – in which rehabilitation hospitals have been forced to surrender tens of millions of dollars for past services deemed by auditors to be medically unnecessary – Democratic Rep. Lois Capps of Santa Barbara and Republican Rep. Devin Nunes of Visalia recently introduced legislation that would place the program on a one-year moratorium to investigate the problems.  While New York and Florida have not had the depth of problems that have the California Hospital Association complaining, officials in those states said the program has not gone smoothly there, either.  The increasing anxiety has elevated the auditing program to a top agenda item of the American Hospital Association. Don May, the association's vice president for policy, said association lobbyists are actively pressing for passage of the Capps-Nunes bill. 

Source/more:  Sacramento Bee,  http://www.sacbee.com/111/story/520053.html

Most beneficiaries will pay more for Part D meds

From the Center for Medicare Advocacy, via ABA Senior Lawyers Division newsletter: An August 13, 2007 press release from the Centers for Medicare & Medicaid Services (CMS) declared victory for Medicare Part D, claiming that the average premium of $25 was nearly forty percent (40%) lower than had been predicted when the drug benefit was first enacted into law. The CMS Press Release, while accurate, does not tell the entire story. In 2008 most beneficiaries will be paying substantially more for their drug coverage, and many will be getting less coverage.

The full article is available at: http://www.medicareadvocacy.org/PartD_07_11.01.PtDChanges.htm.

OIG study finds that 56% of Part D drugs are generics

US DEPARTMENT OF HEALTH AND HUMAN SERVICES, OFFICE OF THE INSPECTOR
    GENERAL REPORT: "Generic Drug Utilization in the Medicare Part D
    Program" (OEI-05-07-00130, November 2007, .pdf format, 30p.).

Abstract:

We found that Part D achieved a high level of generic drug use during the
first two quarters of 2006.  Under Part D, generic drugs were dispensed 88
percent of the time when generic substitutes were available.  However, 37
percent of prescriptions were for drugs that have no generic substitutes,
limiting opportunities to dispense generics.  Overall, 56 percent of all
drugs dispensed were generic drugs.

Our findings indicate that variation in the rate of single-source drug
prescribing primarily accounted for variation in generic drug utilization.
Therefore, to achieve increases in generic drug utilization, Part D plans
may realize gains by encouraging the prescribing of multisource drugs,
which have generic equivalents.  However, such efforts should be
undertaken with caution to ensure that beneficiaries maintain access to
appropriate treatment.

In response to our draft report, CMS generally concurred with our
findings.  CMS noted differences between our and CMSs calculation of
generic drug utilization and suggested that this may be because of its
inclusion of multisource brand name drugs in its measure of generic drug
utilization.  We did not include multisource brand name drug utilization
data in our measure of generic drug utilization because these data are
inconsistent with the definition of generic drugs under Part D.

http://www.oig.hhs.gov/oei/reports/oei-05-07-00130.pdf