Tag Archives: Medicare

How investing in public health could cure many health care problems

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http://theconversation.com/how-investing-in-public-health-could-cure-many-health-care-problems-84256?utm_medium=email&utm_campaign=Latest%20from%20The%20Conversation%20for%20October%201%202017%20-%2084576980&utm_content=Latest%20from%20The%20Conversation%20for%20October%201%202017%20-%2084576980+CID_49b12b4a2a39e7f173235a40290664ab&utm_source=campaign_monitor_us&utm_term=How%20investing%20in%20public%20health%20could%20cure%20many%20health%20care%20problems

Now that the Cassidy-Graham bill has been pulled, it’s a good time to think about concrete ways to improve health and health care in our country. Despite advances in medicine, U.S. health care spending grew to US$3.2 trillion in 2015, or 17.8 percent of the nation’s gross domestic product. To contain health care costs, the U.S. needs to invest in strengthening the public health system and reconsider approaches to making all Americans healthier.

Making Americans healthier should not be a partisan issue. Conservatives and progressives alike should agree on the importance of keeping Americans healthy – both on principled and financial grounds. The sicker the American people, the more expensive their care, and much of that cost will inevitably be borne by Medicare and Medicaid. Yet major challenges loom.

As the Dean of Columbia University’s Mailman School of Public Health, I have dedicated my career to the health of populations, using science and evidence to transition to a world where health and health care are collective priorities for all. My research and that of others suggests that this situation can be improved, but it will require a major national strategy and commitment to invest in public health – one that can be highly cost-effective.

Just the facts

Take, for example, the toll of chronic disease in the U.S. As of 2012, about half of adult Americans were living with one or more chronic health conditions, according to the Centers for Disease Control and Prevention, and one in four adults had two or more. Treating people with chronic diseases accounts for most of our nation’s health care costs. Eighty-six percent of the nation’s annual health care expenditures are for people with chronic and mental health conditions.

This problem will only grow as the U.S. population increases. And the census projects that the population will increase by 98 million between 2014 and 2060.

At the same time, America’s crumbling infrastructure is putting many Americans’ health at risk. The country’s drinking water systems, which are foundational to health, received a D grade on the 2017 Infrastructure Report Card of the American Society of Civil Engineers. Hazardous waste management and wastewater treatment earned only D+ grades.

The connection between health and infrastructure is strong: Infrastructure greatly affects access to healthy lifestyles. While access to clean drinking water and waste treatment are paramount, there are other examples, too.

Sidewalks and bike lanes encourage physical activity; public parks provide space for exercise and rejuvenation; and public transit is crucial to getting people out of cars, encouraging walking and, of course, reducing pollution and congestion. Subways and buses also enable older adults to reach needed services and remain in their homes longer.

Improvements to infrastructure are typically one-time expenses with recurring benefits. For example, one new sidewalk benefits an entire generation of walkers and runners. Research shows that every $1,300 New York City invested in building bike lanes in 2015 provided benefits equivalent to one additional year of life at full health over the lifetime of all city residents.

Other studies also have shown that preventing illness is far less expensive than paying for treatment. Trust for America’s Health estimates that “an investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annually within five years. This is a return of $5.60 for every $1.” With ever-rising health care costs, how can we overlook such opportunities?

Prevention policies and cessation help

The focus of American health care and health-related research needs to be shifted to include prevention, not just treatment. The “Cancer Moonshot,” which has strong bipartisan support, is a vital step in this direction, providing $1.8 billion in funding over seven years.

Cancer prevention must be a high priority, and the success of this effort could inspire a national consensus around future commitments to tackle other diseases and conditions.

Another prevention priority should be healthy aging. Today there are more than 46 million Americans aged 65 years or older; and by 2060, the number of seniors is expected to more than double, according to the Department of Health and Human Services and the Census Bureau. Promoting healthy aging for older Americans should, therefore, be paramount.

And healthy aging begins far earlier than 65 or 70. Obesity, in particular, may be determined in early childhood, even before. According to research by my Mailman School colleague Andrew Rundle, prenatal exposure to air pollution raises risk for obesity in childhood. His research shows that children who are overweight or obese at age five are more likely to be overweight or obese by age 50. We also know that these adults, and increasingly children too, will be more likely to have diabetes, high blood pressure and high cholesterol.

Efforts at smoking cessation should also be increased. The total economic cost of smoking in the United States is more than $300 billion a year in direct medical care and lost productivity, according to the CDC.

That’s more than we’re spending on the Cancer Moonshot annually.

Thinking big

America has extraordinary research capability. The NIH invests nearly $32.3 billion annually in medical research for the American people. Targeted cancer therapies, for instance, are the focus of much anticancer drug development, according to the National Cancer Institute. Precision Medicine is a top priority at the NIH and other research agencies. Even at $32 billion, Americans are investing in the NIH only 1 percent of what we spend on health care annually. The U.S. should build its advantage by increasing research funding to enhance the potential of breakthroughs in preventing known diseases as well as future threats.

There is reason for optimism. The good news stems in large part from the fact that chronic diseases and conditions – such as heart disease, stroke, cancer, Type 2 diabetes, obesity and arthritis – are among the most preventable of all health problems. At least half of these diseases could be prevented, and we are making strides. Death rates from heart disease, the No. 1 cause of death in America, have been reduced by nearly half, for instance, since 1990, according to the American Heart Association.

The growth and aging of the U.S. population and the epidemic of chronic diseases and conditions pose major challenges for America’s health care costs, no matter how health care is constructed. But a relentless focus on public health – and disease prevention in all its dimensions – is the best way to reduce pressure on costs.

Population Health Advisors

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Click to access Translating_Data_Analytics_into_Population_Health_Insights_BSW.pdf

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Health insurers working the system to pad their profits

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https://www.publicintegrity.org/2015/08/17/17863/health-insurers-working-system-pad-their-profits

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Commentary: taking advantage of Medicare Advantage

One of the reasons the health insurance industry worked behind the scenes in 2009 and 2010 to derail Obamacare was the fear that changes mandated by the law would cut their Medicare Advantage profits. Medicare Advantage plans are federally funded but privately run alternatives to traditional fee-for-service Medicare.

Although the industry’s biggest trade group, America’s Health Insurance Plans, said repeatedly that insurers supported Obamacare, the group was secretly financing the U.S. Chamber of Commerce’s TV campaign against reform. Among the companies most concerned about the law were those benefiting from overpayments the federal government had been making to their Medicare Advantage plans since George W. Bush was in the White House.

Bush and other Republicans saw the Medicare Advantage program as a way to incrementally privatize Medicare. To entice insurers to participate in the program, the federal government devised a payment scheme that resulted in taxpayers paying far more for people enrolled in the Medicare Advantage plans than those who remained in the traditional program. The extra cash enables insurers to offer benefits traditional Medicare doesn’t, like coverage for glasses and hearing aids, and to cap enrollees’ out-of-pocket expenses.

When the Affordable Care Act became law in 2010, the payments to Medicare Advantage plans exceeded traditional Medicare payments by 14 percent. To end what they considered an unfair advantage for private insurers, and to reduce overall spending on Medicare, Democrats who wrote the reform law included language to gradually eliminate the over-payments.  So far, the 14 percent disparity has been reduced to 2 percent.  The final reductions are scheduled to be made next year.

Despite that decrease, the fears by Republicans and insurance company executives that the reductions would lead to a steady decline in Medicare Advantage enrollees have proved to be completely unfounded. In fact, the plans have continued to grow at a fast clip.

In March 2010, the month Obamacare became law, 11.1 million people were enrolled in Medicare Advantage plans—one of every four people eligible for Medicare. That was an increase from the 10.5 million Medicare Advantage enrollees in March 2009. Since then, Medicare Advantage membership has grown by more than 8 percent annually. Now 17.3 million—one in three people eligible for Medicare—are enrolled in private plans.

As Center for Public Integrity senior reporter Fred Schulte has written over the past year, many insurers have discovered that even though the overpayments are being reduced, they can boost profits another way: by manipulating a provision of a 2003 law that allows them to get additional cash for enrollees deemed to be sicker than average.

A risk-coding program was put in place by the government primarily because insurers were targeting their marketing efforts to attract younger and healthier—and thus cheaper— beneficiaries. Under the risk-coding program, insurers are paid more to cover patients who are older and sicker; the idea was to encourage the firms to cover those folks by offering a financial incentive. They get more money, for example, to cover someone with a history of heart disease than they do for someone with no such risk.  Last week Schulte uncovered whistleblower accusations that a medical consulting firm and more than two dozen Medicare Advantage plans have been ripping taxpayers off by conducting in-home patient exams that allegedly overstated how much the plans should be paid.

The Center for Medicare and Medicaid Services has refused to provide information that would enable taxpayers to know just how widespread fraud and abuse in the Medicare Advantage program might be. But CMS announced earlier this year that it will implement plans designed to make it harder for insurers to manipulate the risk scores. As you can imagine, insurers have howled and have put on a full court press to get CMS to scuttle those plans, but so far the agency says it intends to go forward. We’ll see.

This all matters to insurers because more and more of their revenue and profits are coming from the Medicare and Medicaid programs. When Aetna announced a few weeks ago that it planned to buy Humana, which has more than three million Medicare Advantage members—second only to UnitedHealthcare—Aetna and Humana executives said 56 percent of revenues from the combined company would come from the government programs.

Indeed, some of the firms would not be growing at all if it weren’t for their government business. When Aetna announced second quarter earnings earlier this month, the company noted that its membership in Medicare and Medicaid programs was up 8 percent over the same period last year. By contrast, its commercial membership was down from last year.

Despite that dip in commercial membership, Aetna surprised Wall Street with stronger profits than financial analysts had expected.

So don’t expect the Medicare Advantage program to wither on the vine because of Obamacare. If anything, it will continue to grow—as will the profits of the private insurers that participate in the program.

OIG: Acute care hospitals owe Medicare $51.6M, CMS agrees to provider clawbacks

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http://www.fiercehealthcare.com/finance/oig-medicare-overpayment-acute-care-hospitals-audit?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWmpSaVpqZGxPREF5TlRBMiIsInQiOiJCamZSYmt6YkZzc0FcL2J1NWFyaFBTRHdtT2Rwd3BKbnI0OGQ5RW1jWXhEcklUa2RYcjVOU2JhWEJXTFBuRlJEcnJRWXVXd0ROT0drZmF5WG00dkVYNFY2QmtMWk1BTUFXRmVtcmUwWVhHdnNKejA2dlZBMmhYbGVyVW9EazZtZTUifQ%3D%3D

money

A new government report finds that Medicare improperly paid acute care hospitals for outpatient services they provided to patients who were inpatients at other facilities. And now Medicare wants the money back

The Centers for Medicare and Medicaid Services has agreed to claw back the $51.6 million and require hospitals to refund patient copays and deductibles.

The Department of Health and Human Services Office of Inspector General audited (PDF) Medicare payments made between Jan. 1, 2013, and Aug. 31, 2016, and found that in that window CMS made $51.6 million in improper payments to hospitals for outpatient services provided to patients who were inpatients at long-term care facilities, critical access hospitals, inpatient rehabilitation facilities and inpatient psychiatric facilities.

Medicare typically would not pay an acute care hospital for outpatient treatments for a patient who is an inpatient at a different facility, according to the OIG, and instead the services should be rendered through an agreement between the two facilities, with payments going to the inpatient provider.

In addition, Medicare beneficiaries were responsible for $14.4 million in coinsurance and unnecessary deductibles paid to the acute care hospitals, the OIG found.

“Medicare overpaid the acute care hospitals because the system edits that should have prevented or detected the overpayments were not working properly,” the OIG concluded.

“If the system edits had been working properly since 2006, Medicare could have saved almost $100 million, and beneficiaries could have saved $28.9 million in deductibles and coinsurance that may have been incorrectly collected from them or someone on their behalf.”

OIG made three recommendations to CMS to resolve this issue:

  1. Recover the $51.6 million in inappropriate payments.
  2. Have the acute care hospitals refund the patients’ $14.4 million in coinsurance and deductibles.
  3. Identify improper payments outside of the audit window, and recover those as well.

CMS has agreed to these recommendations, OIG said.

OIG conducted the audit as previous investigations showed Medicare made inappropriate payments for outpatient services for people who were inpatients at acute care hospitals, and the organization wanted to see whether the trend extended to other types of facilities.

Healthcare: It’s complicated

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http://www.theactuary.com/features/2017/07/its-complicated/

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It has been a little over seven years since the US began implementing healthcare reform at the national level, following the passage of the Patient Protection and Affordable Care Act (ACA), also known as Obamacare. However, the future of the law’s programmes has never seemed more uncertain now that the United States House of Representatives has passed legislation repealing and replacing many of the ACA’s key provisions.

While the ACA and the proposed replacement legislation are fundamentally different in their approaches to financing and regulating healthcare, they do have one thing in common: both are extraordinarily complicated.

Actuaries have had a front-row seat as healthcare reform has unfolded, and they are in a unique position to help address the challenges our complex system presents – whether that involves setting premium rates, calculating reserves, or just trying to explain healthcare policy to their Facebook friends. After all, actuaries were working to promote the financial stability of our complex healthcare system long before the ACA came along.

Even so, one might ask: Why is the American healthcare system so complicated? Does it have to be that way? Most stakeholders acknowledge that our current system has room for improvement, although opinions vary widely on what to do about that. In part, the complexity of our system is rooted in our history.

The healthcare system that we have today wasn’t formed in one fell swoop. Instead, it has been stitched together gradually over the past century by policymakers working to meet the challenges of their times. For example, the prevalence of employer-sponsored insurance was at least partly driven by price-wage controls implemented by the federal government in the 1940s during the Second World War, together with very favourable tax treatment. When the employer-sponsored market began to flourish, healthcare coverage became unaffordable for the non-working population – in particular, low-income workers, seniors, and disabled individuals – and the Medicare and Medicaid programmes were born. Currently, healthcare in the US is provided and funded through a variety of sources:

  • Employer-sponsored insurance – either self-funded by the employer or insured through a carrier
  • Individual major medical insurance – currently subsidised by the federal government for many individuals under the ACA
  • Medicare, Medicaid, and military health coverage – subsidised by federal and state governments and increasingly administered by privately managed care organisations
  • Other – for instance, the Indian Health Service, care provided to correctional populations, and uncompensated care provided to the uninsured.

 

It’s therefore not surprising that the policies being proposed today are an attempt to fix the problems we currently face, such as expanding access to affordable healthcare, reducing the cost of healthcare, or improving the quality of care received by patients.

However, our system has evolved in such a way that trying to implement a solution is like trying to solve a Rubik’s Cube – it is hard to make progress on one side without introducing new problems into other parts of the puzzle. For a Rubik’s Cube, successful solvers focus on both the local and global picture, and sometimes must make short-term trade-offs to achieve a longer-term solution. Unfortunately, the short-term nature of political pressures make it difficult to implement longer-term strategies for healthcare. Yet, we see many areas where actuaries can be instrumental in addressing the challenges presented by our complex healthcare system.

Complex times call for complex models

The ACA made sweeping changes that impacted almost every source of coverage listed above. The most profound changes, besides the expansion of Medicaid coverage, were the changes made to the individual and small employer health insurance markets. These already small markets were fractured into several separate pieces (grandfathered business from before the ACA became law, ‘transitional’ business issued before 2014, and ‘ACA-compliant’ business issued in 2014 and beyond). The only constant has been change, with many regulatory changes occurring each year (often after premium rates were set by insurers) and with the stabilisation programmes intended to mitigate risk during this time of change often paradoxically increasing uncertainty. This led some to question whether these markets were inherently too unpredictable to be viable, whereas others felt that the markets were finally starting to stabilise before the election changed everything.

Besides predictability problems caused by regulatory or political factors, two challenges facing health actuaries during these transitional years have been (1) the lag between when market changes are implemented and when data on policies subject to the new rules becomes available, and (2) the difficulty in predicting consumer behaviour in reaction to major changes in market rules such as guaranteed issue and community rating. How many of the uninsured would sign up? How price-sensitive would members be when they renewed their coverage each year? How will changes in other sources of coverage (such as Medicaid expansion) impact the individual market? How will potential actions by competitors affect an insurer’s risk?

Despite the daunting nature of these challenges, actuaries have, out of necessity, found ways to try to address them. For example, faced with the data lag problem, they explored ways to augment traditional claim and enrollment data with new data sources such as marketing databases or pharmacy history data available for purchase. Such sources can be used to develop estimates of the health status of new populations not previously covered by an insurer. Many actuaries also developed agent-based stochastic simulation models that attempted to model the behaviour of consumers, insurers and other stakeholders in these new markets. Such models continue to be used to evaluate the potential outcomes of future changes to the healthcare system, and will probably be essential should efforts to repeal and replace the ACA prove successful.

Information problems: what is a rational actor to do?

Most goods and services in the US have a price tag that consumers can use to ‘shop’ for the option that they feel gives them the best value for their dollar. Healthcare is different. If you ask how much a healthcare service will cost in the US, the answer is “it depends”. List prices such as billed charges for hospitals and physicians and average wholesale prices for pharmaceuticals are increasingly meaningless, given the enormous contractual discounts and rebates that typically apply. The same service may have wildly different prices depending on who is paying for it, and prices may not correlate well with either the clinical value the service provides to the patient or the actual cost to the healthcare provider who renders it. Layered on top of this complex foundation are the often arcane policy provisions that determine a member’s ultimate cost for a claim.

Moreover, even if a patient can determine the cost of treatment at different healthcare providers, making an informed choice often requires clinical knowledge the average person is unlikely to possess. Also, many of the most costly services are non-discretionary and often emergent in nature. In other words, even if a consumer wanted to shop they would be hard-pressed to do so.

All of this means that it is exceedingly hard for various stakeholders – patients, doctors, even insurers – to know the true cost of a service at the point of care, much less manage it. Yet a lot of effort has been spent in trying to better align cost incentives for providers and patients. Past efforts have often used crude methods, such as high deductibles paired with health savings accounts, to create incentives. Current efforts such as value-based insurance designs, which vary cost sharing based on a patient’s clinical profile, use more nuanced approaches to encourage patients to use high-value care. Moving from fee-for-service to value-based payment models for reimbursing healthcare providers has been a focus of both private and public payers in the US.

While such initiatives show promise, they come at the price of even more complexity – and it isn’t always clear that this price is worth paying. The proliferation of more complex benefit designs and provider contracting arrangements can exacerbate the price transparency problems that existed even in the relatively simple fee-for-service world.

Actuaries are well equipped to help insurers, providers and consumers navigate these waters. For example, repricing healthcare claims in an equitable way using actuarial techniques, such as comparing reimbursement rates with a standard fee schedule, is

an efficient way for providers and payers to evaluate cost levels consistently across contracts that may use very different reimbursement methodologies.

Actuaries also have a role to play in developing tools to support clinicians and consumers in understanding the financial dimensions of their healthcare decisions.

Technology: the cause of, and solution to, all our cost problems?

For better or worse, Americans seem determined to seek technological solutions to our health problems, even when lifestyle changes in diet and exercise habits might be just as effective.

Technological advances drive a significant portion of healthcare cost increases, and while many do result in profoundly valuable new therapies, some provide only marginal benefit over existing options at a significantly higher cost. Finding ways to leverage our love of technology to achieve health outcomes more cheaply would be a worthy goal, and one where an actuary could make a difference. Work to use machine learning (for example, in radiology), smarter medical devices, and other data-intensive methods to improve healthcare are still in their infancy, but show promise. From a policy perspective, actuaries could assist in designing novel approaches toward rethinking the incentives for clinical innovation, such as linking payment for new therapies to their clinical value relative to alternatives.

Will the US ever change its relationship status with healthcare from “it’s complicated” to something less ambiguous? In the near term, the answer seems to be “no.” But perhaps we can hope that – with a little help from actuaries – even a complicated relationship can be a good one.

Forgotten Heroes: Remembering Dr. Alvin Blount, Who Helped Integrate America’s Hospitals

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http://healthaffairs.org/blog/2017/09/01/forgotten-heroes-remembering-dr-alvin-blount-who-helped-integrate-americas-hospitals/

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Mortar rounds shook the bunker. The 8225th Mobile Army Surgical Hospital (MASH) was crammed with casualties—civilians, Americans, and KATUSAs (Korean Augmentation to US Army). The four surgical tables under the direction of its acting chief surgeon, Alvin G. Blount, often operated around the clock, doing as many as 90 surgeries during sleepless protracted engagements. Blount could shut out the mayhem and focus only on his patient’s needs, as if everything else in the world had stopped. His calm, gentle demeanor commanded respect. His was the first racially integrated MASH unit, and he was its first black chief surgeon. Blount received the Korean War Service Medal for these efforts and would later become part of a group of doctors that helped radically reform US health care. He died earlier this year, the last surviving member of the group that initiated that effort.

The stories of the Korean MASH units would become popularized in a book, a movie, and a popular television series called M*A*S*H that ran from 1972 to 1983 and still appears in syndicated reruns. Yet, in an apparent attempt to assure “historical accuracy,” the television series chose to eliminate the black surgeon that appeared in the book and movie version.

After the war, Blount returned to private practice in racially segregated Greensboro, North Carolina. His Howard University medical school mentor, Charles Drew had warned him, “you boys going south will have to sweat it out, but victory will come.” Despite the US Supreme Court’s 1954 ruling in Brown v. Board of Education of Topeka that separate was inherently unequal in education, “separate but equal” remained the law of the land for hospitals. The Hill-Burton Act of 1946 specifically permitted federal funding for the construction of the two white-only hospitals in Greensboro and made similar provisions for other Southern cities. Black physicians in Greensboro were excluded from medical staff privileges at these white hospitals, one of which was the Moses H. Cone Memorial Hospital, the most well-endowed hospital in the region. Segregation in hospitals remained for another decade as Blount and a few courageous colleagues engaged in a polite and seemingly fruitless struggle against a powerful, entrenched white establishment.

George Simkins, Jr., a dentist and aggressive activist, took charge of the Greensboro chapter of the National Association for the Advancement of Colored People (NAACP) in the early 1950s and sought the help of the NAACP Legal Defense and Educational Fund (LDF) to challenge the city’s segregated hospital system. But recruiting black physicians to join as plaintiffs proved difficult. Some were comfortable with the status quo, and most were concerned about damaging ties with white colleagues, who they relied on for help with their patients. Blount himself was reluctant, but he was close friends with Simkins and knew that the segregated system resulted in lower-quality care for his patients. Blount joined the lawsuit and helped Simkins recruit five other physicians to do the same. These five physicians, in addition to two black dentists, two black patients, Blount, and Simkins, made up the final list of 11 plaintiffs. Michael Meltsner, a young, white protégé of Thurgood Marshall, served as lead attorney.

The suit, filed in US District Court in 1962, argued that Greensboro’s two white hospitals, the Moses H. Cone Memorial Hospital and the Wesley Long Hospital, functioned as an “arm of the state,” having received a total of $2.8 million in federal Hill-Burton program funds. By remaining segregated, the hospitals violated the due process and equal protection clauses of the Fifth and Fourteenth Amendments of the US Constitution. Accordingly, the plaintiffs argued, the Hill-Burton law was unconstitutional because it provided federal funding for the construction of racially segregated institutions. As is customary with any case challenging federal law, the US attorney general was given the opportunity to defend the federal government. Surprisingly, however, Attorney General Robert Kennedy joined the plaintiffs, seizing the opportunity to push the administration’s stalemated civil rights agenda. Despite this unexpected support, the District Court dismissed the suit. The “victory” that Charles Drew had promised seemed increasingly distant.

Blount and his fellow plaintiffs, however, now found themselves at the beginning of a long and unpredictable journey to transform US health care. In a 3:2 decision in 1963, the US Court of Appeals of the Fourth Circuit ruled in favor of the plaintiffs. The hospital defendants appealed to the US Supreme Court, but in a rushed ruling, just days before the Senate began its longest debate on the Civil Rights Act of 1964, the Court chose to not review the lower court decision and let it stand. Title VI of the Civil Rights Act, the most likely provision to be eliminated to assure the bill’s passage, prohibited the provision of any federal funding to organizations that discriminated on the basis of race. By letting the Fourth Circuit decision stand, the Supreme Court effectively made Title VI the law of the land before it had even passed through the legislative branch.

Resistant to any federal interference in their organization, the executive committee of the board of the Moses H. Cone Memorial Hospital recommended to the full board that the hospital return its Hill-Burton funds to the federal government to relieve it of any obligation to desegregate. That recommendation was rejected. Nothing in the Court’s decision, of course, prevented other hospitals from choosing not to apply for Hill-Burton construction funds or from returning funds they had already received. There was also no provision in the law for federal enforcement for those hospitals that had already received federal money. The NAACP LDF or other parties could mount challenges against individual hospitals, but it would be a slow and costly process.

The Medicare legislation enacted less than a year later, however, changed the game. Hospitals could survive without Hill-Burton funds, but they could not “choose” not to be Medicare and Medicaid providers. No hospital would be certified as a Medicare provider without being fully compliant with concrete nondiscrimination requirements. Local civil rights groups whose members included hospital workers served as the final arbiters. Any lapses in enforcement by federal volunteer inspectors or subterfuge by the hospitals would not escape notice.

In less than six months, 6,000 hospitals became fully compliant. Thanks to Medicare, America’s hospitals went from being our country’s most racially and economically segregated institution to our most integrated. Almost all of the separate wooden bench waiting rooms and welfare wards disappeared. Patterns of use of services that had always been shaped by racial and economic privilege began, for the first time, to reflect actual medical need. Over the next 20 years, racial and economic disparities in infant mortality and life expectancy narrowed. In Greensboro, Blount became the first black surgeon to operate at Moses H. Cone Memorial Hospital. Yet, the events that propelled all of these changes have been almost forgotten. Only current political events in North Carolina and nationally have stirred some local reflection about that past.

A statue of Simkins was unveiled on the lawn of the Guilford County Courthouse in October 2016, near where he was jailed for trespassing in 1955 after trying to play golf with friends on the city-owned golf course. Only after his death was he honored as the city’s “Moses.”

In 2016, Blount, at age 94, was the only surviving plaintiff in the Simkins v. Moses Cone Hospital suit. He was still seeing a limited number of patients under the watchful eye of his loyal long-time practice manager, Martha Reid. His office on East Market Street was filled with memorabilia and memories of more than a half century of practice. In October, he was invited to a meeting at the regional nonprofit integrated health system that Moses H. Cone Memorial Hospital became. About 250 health care professionals and community leaders attended, along with Blount’s children. Dr. James Wyatt, a black surgeon and president of the Cone Health medical and dental staff, thanked Blount “for opening doors for me.” Cone CEO, Terry Akin, addressed Dr. Blount: “It seems to me, and to our medical and dental staff, that we needed to take the opportunity to apologize for our role in this chapter of our history and to honor these individuals for challenging us to be our best selves, and for their foresight and courage in changing America.” Cone donated $250,000 to a scholarship fund honoring Blount and the other plaintiffs that will provide support for minority students pursuing careers in health care. It will be administered by the Greensboro Medical Society, one of many local black medical societies across the country that played a key role in the hospital desegregation struggle. A month later, a historical highway marker was unveiled on North Elm Street adjacent to the Moses H. Cone Memorial Hospital, acknowledging the plaintiffs and their role in changing the nation’s hospitals.

Dr. Blount passed away on January 6, 2017, at Moses H. Cone Memorial Hospital after a brief illness. His family marked his passing with a quiet event at the small Episcopal church adjoining the North Carolina A&T State University campus, which served as an early organizing center for the lunch counter sit-in movement. “My life is my memorial,” he had told his practice manager. “No big casket or cemetery plot either—cremation. … Just be sure I’m dead before you burn me.”

His life was indeed his memorial. From caring for wounded soldiers in Korea to feeding arrested Dudley High School students after a lunch counter sit-in, Blount was an endless source of compassion and integrity. He and his wife lovingly raised seven children, and his youngest daughter, Gwen Blount Adolph, now a lawyer in New York, recently reflected on her father’s life: “My daddy was a gentle soul who wanted to do right by everyone.” She recalled the night the arm fell off her brother Alvin’s teddy bear, and he was inconsolable. “We all had this vivid memory of my dad taking needle and thread and operating on Teddy…. We all gathered around, as if it was an operating room. He was so patient, and it was so important to my brother. It was as if everything else in the world had stopped—that was Daddy.”

In these divisive times, it is too easy to be dismissive of the past and despairing about the future. The lives of Dr. Blount and the other Moses Cone plaintiffs tell us something different. They tell us that landmark pieces of social policy such as Medicare, when implemented fairly and compassionately, can promote justice and equality. And they tell us that the power to remedy injustices lies with individuals who are willing to challenge the status quo and further the cause of universal health care for all Americans.

What is a SNP?

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http://bettermedicarealliance.org/snps?utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters

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SNPs are a type of Medicare Advantage plan that are paid and regulated in the same way as other Medicare Advantage plans, but have the authority to provide specialized care to serve beneficiaries who are dually-eligible for Medicare and Medicaid, have certain chronic conditions, or receive long-term care in an institutional setting such as a Skilled Nursing Facility. In addition to providing all Medicare Part A and Part B benefits, SNPs must also exceed these core benefits by providing reduced cost sharing, individualized care plans, and other tailored benefits related to mental health, social services, and wellness.

Appeals court overturns ruling requiring HHS to clear Medicare appeals backlog by 2021

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http://www.beckershospitalreview.com/finance/appeals-court-overturns-ruling-requiring-hhs-to-clear-medicare-appeals-backlog-by-2021.html

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The U.S. Appeals Court for the District of Columbia on Friday overturned an order requiring HHS to clear its backlog of Medicare reimbursement appeals by the end of 2020.

On Dec. 5, 2016, U.S. District Judge James Boasberg granted a motion for summary judgment filed by the American Hospital Association in AHA v. Burwell — a lawsuit that centers on the Recovery Audit Contractor Program.

He ordered HHS to incrementally reduce the backlog of 657,955 appeals pending before the agency’s Office of Medicare Hearings and Appeals over the next four years, reducing the backlog by 30 percent by the end of 2017; 60 percent by the end of 2018; 90 percent by the end of 2019; and to completely eliminate the backlog by Dec. 31, 2020.

HHS filed a motion Dec. 15, 2016, asking the judge to reconsider his decision. HHS argued it would be impossible to reduce the appeals backlog on the schedule provided by the court without improperly paying claims, regardless of merit. In January, Judge Boasberg denied HHS’ motion for reconsideration.

In late January, HHS filed an appeal in the case, seeking to avoid the district court’s order enforcing the plan to clear the appeals backlog by the end of 2020.

On Friday, the appellate court sided with HHS.

Since HHS said it was impossible to lawfully comply with the district court’s order, the appellate court ruled it was “an error of law” and “an abuse of discretion” for the district court judge to order HHS to abide by the schedule to clear the Medicare appeals backlog.

“In sum, it was an abuse of discretion to tailor the mandamus relief without tackling the Secretary’s claims that lawful compliance would be impossible,” states the appellate court’s opinion.

The appellate court held that on remand the lower court should determine if compliance with the timetable to reduce the Medicare appeals backlog is impossible.

Doctor Shortage Under Obamacare? It Didn’t Happen

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When you have a health problem, your first stop is probably to your primary care doctor. If you’ve found it harder to see your doctor in recent years, you could be tempted to blame the Affordable Care Act. As the health law sought to solve one problem, access to affordable health insurance, it risked creating another: too few primary care doctors to meet the surge in appointment requests from the newly insured.

Studies published just before the 2014 coverage expansion predicted a demand for millions more annual primary care appointments, requiring thousands of new primary care providers just to keep up. But a more recent study suggests primary care appointment availability may not have suffered as much as expected.

The study, published in April in JAMA Internal Medicine, found that across 10 states, primary care appointment availability for Medicaid enrollees increased since the Affordable Care Act’s coverage expansions went into effect. For privately insured patients, appointment availability held steady. All of the gains in access to care for Medicaid enrollees were concentrated in states that expanded Medicaid coverage. For instance, in Illinois 20 percent more primary care physicians accepted Medicaid after expansion than before it. Gains in Iowa and Pennsylvania were lower, but still substantial: 8 percent and 7 percent.

Though these findings are consistent with other research, including a study of Medicaid expansion in Michigan, they are contrary to intuition. In places where coverage gains were larger — in Medicaid expansion states — primary care appointment availability grew more.

“Given the duration of medical education, it’s not likely that thousands of new primary care practitioners entered the field in a few years to meet surging demand,” said the Penn health economist Daniel Polsky, the lead author on the study. There are other ways doctor’s offices can accommodate more patients, he added.

One way is by booking appointment requests further out, extending waiting times. The study findings bear this out. Waiting times increased for both Medicaid and privately insured patients. For example, the proportion of privately insured patients having to wait at least 30 days for an appointment grew to 10.5 percent from 7.1 percent.

The study assessed appointment availability and wait times, both before the 2014 coverage expansion and in 2016, using so-called secret shoppers. In this approach, people pretending to be patients with different characteristics — in this case with either Medicaid or private coverage — call doctor’s offices seeking appointments.

Improvement in Medicaid enrollees’ ability to obtain appointments may come as a surprise. Of all insurance types, Medicaid is the least likely to be accepted by physicians because it tends to pay the lowest rates. But some provisions of the Affordable Care Act may have enhanced Medicaid enrollees’ ability to obtain primary care.

The law increased Medicaid payments to primary care providers to Medicare levels in 2013 and 2014 with federal funding. Some states extended that enhanced payment level with state funding for subsequent years, but the study found higher rates of doctors’ acceptance of Medicaid even in states that didn’t do so.

The Affordable Care Act also included funding that fueled expansion of federally qualified health centers, which provide health care to patients regardless of ability to pay. Because these centers operate in low-income areas that are more likely to have greater concentrations of Medicaid enrollees, this expansion may have improved their access to care.

Other trends in medical practice might have aided in meeting growing appointment demand. “The practice and organization of medical care has been dynamic in recent years, and that could partly explain our results,” Mr. Polsky said. “For example, if patient panels are better managed by larger organizations, the trend towards consolidation could absorb some of the increased demand.”

Although the exact explanation is uncertain, what is clear is that the primary care system has not been overwhelmed by coverage expansion. Waiting times have gone up, but the ability of Medicaid patients to get appointments has improved, with no degradation in that aspect for privately insured patients.

Commentary: Why Republicans will always struggle to repeal Obamacare

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http://www.reuters.com/article/us-lemieux-healthcare-commentary-idUSKBN1AJ286

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With John McCain’s dramatic “no” vote, the Health Care Freedom Act (HFCA) died early last Friday morning and with it any hope of repealing the Affordable Care Act (ACA) for the foreseeable future. While conservatives might prefer to blame incompetent vote-whipping in the Senate, the ACA could prove resilient for the same reason Medicare and Social Security have: most voters prefer not to wonder if they will be able to eat when hungry or see a doctor when sick. Any program that gives more economic security to a broad, politically powerful group will be dangerous to meddle with, even in these polarized times.

Conservative activists and pundits who don’t want to contend with that reality may point to the president they were dealt: Donald Trump knew essentially nothingabout health care and he alternated between disengagement and crude bullying of wavering senators ahead of the vote.

Blaming Senate Majority Leader Mitch McConnell is less convincing. McConnell is a masterful legislative strategist and it took his maneuvering to bring a bill supported by less than 30 percent of the public to within one vote of passing. Indeed, McConnell may only have come even that close because he skipped the normal committee hearing process, protecting the proposal from more public and media scrutiny.

The real lesson here is that once major social programs are in place, it’s simply very hard to eliminate them.

In his 1994 book “Dismantling the Welfare State?” the political scientist Paul Pierson showed that major social welfare programs were very resilient, and conservative attempts to repeal them generally failed. This was true even in parliamentary systems with fewer choke points to stop repeal than the American system.

In the United States, the clearest example is Social Security. Before becoming president, Ronald Reagan had a desire to make it a voluntary program, but he quickly abandoned any thoughts of radically restructuring the program after taking office. Instead he oversaw a bipartisan plan to protect the program’s solvency through a combination of regressive tax increases and benefit cuts. When the Republican controlled-Senate narrowly passed a one-year freeze to seniors’ annual cost-of-living adjustment freeze during Reagan’s second term, the president abandoned the unpopular proposal, letting it die in the House of Representatives.

George W. Bush, after winning re-election in 2004, made Social Security privatization his signature domestic issue. Bush travelled the country, making the case for a system of voluntary private accounts to partially replace Social Security for young workers. But the idea was politically toxic, actually becoming less popularthe more Bush discussed it. Congressional Democrats, who had collaborated with Republicans on major domestic legislation during Bush’s first term, came out against the proposal en masse. Republicans controlled both houses of Congress but they refused to take responsibility for highly unpopular changes to a cherished program. No Social Security privatization bill came close to a vote. Republicans have not actively pursued the goal since.

Nor have Republicans had any success at attacking the Great Society’s cornerstone health policy, Medicare. Sometimes they actively go in the opposite direction. In George W. Bush’s first term, Bush worked with Republicans to pass a corporate-friendly expansion of Medicare to partially cover payments for prescription drugs. Tea Party activists consider this one of the Bush era’s major betrayals of small government conservatism. But even arch-conservatives like Rick Santorum voted for the law. The politics were irrefutable: senior citizens vote, mostly Republican, and they fill a lot of prescriptions.

In 2011, now-Speaker of the House Paul Ryan proposed a plan to convert Medicare into a system in which seniors received vouchers (whose value would decrease over time) to purchase health insurance on private markets. The proposal was extremely unpopular and created a major backlash. Ryan has never officially abandoned some form of vouchers as a goal, but he has not put any Medicare restructuring on his legislative agenda since taking the Speaker’s gavel. The Ryan budget’s threat to Medicare, however, proves a reliably spooky specter for Democrats to invoke when sending fundraising emails or appealing to older swing voters.

Social programs are often not fully appreciated by their beneficiaries until someone proposes getting rid of them. Facing an existential threat made the Affordable Care Act much more popular – as then-Speaker of the House Nancy Pelosi predicted, support for it increased once people found out what was in it. The Republican proposals to replace the ACA, conversely, are staggeringly unpopular. As recently as last year, more Americans disapproved of the ACA than supported it, but its approval ratings are now over 50 percent, while the repeal bills started out unpopular and became more so.

The majority support for the ACA wasn’t soft, either. Supporters of the ACA were far more motivated than its opponents during the repeal struggle, putting their time and sometimes their bodies on the line, such as when disabled people were ejected from the offices of members of Congress.  This helps to explain why moderate Republican Senators Susan Collins of Maine and Lisa Murkowski of Alaska (not to mention Democratic senators representing states that Trump won in landslides such as West Virginia and Montana) were unwavering in their opposition. The weekend after the HCFA was voted down, Murkowsi was repeatedly greeted by supporters, some in tears, thanking her for her no vote, while Nevada Senator Dean Heller was rewarded for his “yes” vote by seeing his approval rating plummet to 22 percent.

This doesn’t mean that supporters of the ACA should be complacent. Even when Republicans have failed to eliminate major social programs, they have been able to make them less generous in ways that caused real harm, Reagan’s Social Security adjustment included. Trump is signaling that he will damage the ACA administratively, and 19 states are still refusing the ACA’s generous Medicaid expansion.

Moreover, the failure to eliminate major welfare programs is a tendency, not an iron law. In 1996, President Bill Clinton signed a welfare “reform” bill that led to more than 6 million mothers with children losing welfare benefits.

That was possible partly because welfare, unlike Obamacare, only benefits the poor, who are politically disempowered.

Still, Republicans just came closer to passing a partial repeal of the ACA than many would have thought possible.

The battle over healthcare is far from over, but the repeated failures of the GOP efforts to repeal it prove the political durability of the social safety net.