Tag Archives: Medicare

Medicare Didn’t Investigate Suspicious Reports Of Hospital Infections

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

http://www.npr.org/sections/health-shots/2017/05/09/527432852/medicare-didnt-investigate-suspicious-reports-of-hospital-infections

Almost 100 hospitals reported suspicious data on dangerous infections to Centers for Medicare & Medicaid Services officials, but the agency did not follow up or examine any of the cases in depth, according to a report by the Health and Human Services inspector general’s office.

Most hospitals report how many infections strike patients during treatment, meaning the infections are likely contracted inside the facility. Each year, Medicare is supposed to review up to 200 cases in which hospitals report suspicious infection-tracking results.

The IG said Medicare should have done an in-depth review of 96 hospitals that submitted “aberrant data patterns” in 2013 and 2014. Such patterns could include a rapid change in results, improbably low infection rates or assertions that infections nearly always struck before patients arrived at the hospital.

The IG’s report, released Thursday, was designed to address concerns over whether hospitals are “gaming” a system in which it falls to the hospitals to report patient infection rates and, in turn, the facilities can see a bonus or a penalty worth millions of dollars.

The bonuses and penalties are part of Medicare’s Hospital Inpatient Quality Reporting program, which is meant to reward hospitals for low infection rates and give consumers access to the information at the agency’s Hospital Compare website.

A Medicare Drug Incentive That Leads to Greater Hospitalizations

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

Many studies have demonstrated what economics theory tells us must be true: When consumers have to pay more for their prescriptions, they take fewer drugs. That can be a big problem.

For some conditions — diabetes and asthma, to name a few — certain drugs are necessary to avoid more costly care, like hospitalizations. This simple principle gives rise to a little-recognized problem with Medicare’s prescription drug benefit.

For sicker Medicare beneficiaries, the Harvard economist Amitabh Chandra and colleagues found, increased Medicare hospital spending exceeded any savings from reduced drug prescriptions and doctor’s visits. Consider patients who need a drug but skip it because they feel the co-payment is too high. This could increase hospitalizations and their costs, which would make them worse off than if they’d selected a higher-premium plan with a lower co-payment.

Though just a simplified example, this is analogous to what Medicare stand-alone prescription drug plans do. They achieve lower premiums by raising co-payments. This acts to discourage the use of drugs that would help protect against other, more disruptive and serious health care use, like hospitalization.

Studies show that insurers, many of which are for-profit companies after all, are using such incentives to dissuade high-cost patients from enrolling or using the benefit. There’s evidence this occurs for Medicare’s drug benefit, as well as in the Affordable Care Act’s marketplaces.

 The most popular type of Medicare drug coverage is through a stand-alone prescription drug plan. A stand-alone plan never has to pay for hospital or physician visits — those are covered by traditional Medicare. Another way to get drug benefits from Medicare is through a Medicare Advantage plan that also covers those other forms of health care and is subsidized by the government to do so.

Because of this difference, stand-alone drug plans are less invested than Medicare Advantage plans in keeping people healthy enough to avoid some hospital visits.

A study by the economists Kurt Lavetti, of Ohio State University, and Kosali Simon, of Indiana University, quantifies the cost. Compared with Medicare Advantage plans, stand-alone drug plans charge enrollees about 13 percent more in cost sharing for drugs that are highly likely to help patients avoid an adverse health event within two months. They charge up to 6 percent more for drugs that help avoid adverse health events within a year.

Of course, people have choices about plans. Those who have selected a stand-alone drug plan, as opposed to a Medicare Advantage plan, have done so voluntarily. Why do some make this choice?

One answer is that some people are not comfortable with the more narrow networks Medicare Advantage plans offer, with their fewer choices of doctors and hospitals. By choosing a stand-alone drug plan, they can remain in traditional Medicare, which has an open network.

In addition, consumers are generally more attracted to lower-premium plans than higher ones, even if the difference is exactly made up in co-payments. This may be because premiums are easier to understand than cost sharing. Moreover, premiums reflect a sure loss — you must pay the premium to remain in the plan. A higher co-payment, on the other hand, won’t necessarily lead to a loss because you may not use a service.

The appeal of lower premiums is an incentive for stand-alone drug plans to reduce them and increase co-payments. But that can dissuade those who need medications from filling prescriptions and taking them.

Part of the purpose of Medicare’s drug benefit is to encourage enrollees to take prescription drugs that can keep them out of the hospital. In July 2003, promoting the legislation that created Medicare’s drug benefit, President George W. Bush articulated this point. “Drug coverage under Medicare will allow seniors to replace more expensive surgeries and hospitalizations with less expensive prescription medicine,” he said.

But the design of Medicare’s drug benefit includes stand-alone plans that aren’t liable for hospital costs, so they don’t work as hard to avoid them. Encouraging more beneficiaries into comprehensive plans — through Medicare Advantage — or offering a drug plan as part of traditional Medicare itself would address this limitation.

 

 

The Future Of Delivery System Reform

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

http://healthaffairs.org/blog/2017/04/20/the-future-of-delivery-system-reform/

Over the past several years, the federal government has put billions of dollars into a variety of programs aimed at improving the way health care is delivered. The Affordable Care Act (ACA) authorized a broad agenda of reform projects, including accountable care organizations (ACOs), bundled payments, value-based purchasing, primary care initiatives, and other payment and service delivery models. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 established new ways of paying physicians intended to promote high-quality patient care.

What will happen to these initiatives under a Congress where Republicans are still seeking to enact major new health reforms and a president who could aggressively use authority granted by the ACA to make sweeping changes in Medicare and other health programs? Does this spell the end of delivery system reform, or could this be a new start with a greater potential to promote efficient and effective health care?

The prospect of ACA repeal has raised concerns among advocates, who argue that the enactment of Medicare-led efforts to promote higher-value care represents a real turning point in the battle to reduce waste and inefficiency. They fear that any reversal of the ACA framework would be a setback to the cause of lower costs and higher quality.

Those fears are overblown. There is bipartisan agreement on the goal of promoting more efficient and effective health care. MACRA, which is aimed at improving the value of physician services through payment changes, was enacted on a bipartisan basis. The debate is over the best way to accomplish the goal, not the goal itself.

We agree that it would be unwise to jettison entirely the delivery system reform provisions of the ACA, but their demise would not be the end of efforts to improve US health care. Rather, we see those provisions as far less consequential than their advocates claim, yet they can serve as departure points for putting in place more effective changes that provide room for private initiative and consumer preferences alongside changes in Medicare’s payment systems.

Summing Up

The cost of health care in the United States has grown rapidly for many years, typically well above growth in the overall economy. Those high costs have not guaranteed high-quality care or good patient outcomes, and our delivery system remains inefficient. What is needed is a process of continuous improvement in the efficiency and quality of the care delivered to patients. That is the core belief motivating the delivery system reform effort, which should be continued even as important features of the ACA come under review.

The key question is how best to pursue more cost-effective care delivery in the United States. At the moment, the federal government is trying to use its leverage to bring about greater efficiency, employing its regulatory powers under the Medicare program. That approach, while understandable, should be amended to make room for more private initiative and consumer incentives. Those are the driving forces for productivity improvement in other sectors of the national economy, and they should be harnessed to produce better outcomes in health care as well.

 

In This Next Phase Of Health Reform, We Cannot Overlook Long Term Care

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

http://healthaffairs.org/blog/2017/03/16/in-this-next-phase-of-health-reform-we-cannot-overlook-long-term-care/

It is becoming apparent that President Trump and the 115th Congress cannot start over with health care reform. Whether you love, begrudgingly support, or fervently hate the Affordable Care Act (ACA), a clean slate is not possible. First, ACA implementation is well underway and has benefited many patients and providers alike. Second, it is unlikely that Republicans in Congress can fully repeal the ACA without a 60 vote, filibuster proof super majority in the Senate. Starting over entirely with health reform is just not feasible.

Trying to address every problem facing the health care system at once is a tall—if not impossible—order. History has taught us that U.S. health reform is an incremental process. With the focus of Congress once again turning to health reform, we have an opportunity to fix the problems with the ACA, and find solutions to health care challenges that the ACA failed to address.

A Growing Need

Long-term care for America’s growing elderly population is a critically important issue for Congress to address in health reform proposals currently taking shape. While the ACA’s insurance expansion focused on providing coverage for the uninsured, the law’s progress on long-term care has been minimal. The ACA tried to address long-term care (LTC) by creating a voluntary system of LTC insurance, but the ill-fated CLASS Act was ultimately determined to be financially unviable and abandoned.

Although policy solutions have been elusive, the need for long-term care is constantly growing. According to current estimates, over two-thirds of elderly Americans will need LTC assistance at some point in their lives. Between 2014 and 2040, the portion of Americans over age 65 is expected to increase from 14.5 to 21.7 percent. At upwards of $60,000 annually, long-term care costs can quickly exhaust personal savings.

As policymakers throughout our history have debated health reform, these efforts have almost entirely centered on questions of medical coverage. They ask which benefits to cover, how much the coverage should cost, and how we can ensure people are not locked out of coverage because of their health status. We must take the same approach to LTC, examining the availability and affordability of services. LTC services include nursing home care and in-home care, as well as what is often referred to as “long-term services and supports” (LTSS). LTSS include assistance with daily activities, such as eating, bathing, dressing, doing laundry, paying bills, and taking medications.

Current Republican health reform proposals appear to do little to push the ball forward on long-term care. As Congress considers proposals to reduce federal spending on Medicaid, they should carefully consider the role of Medicaid in financing LTC.

 

By law, hospitals must now tell Medicare patients when care is ‘observation’ only

Posted on by • Posted in Uncategorized • Tagged , , , , , • Leave a comment

http://www.fiercehealthcare.com/regulatory/by-law-hospitals-now-must-tell-medicare-patients-when-care-observation-only?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiTlRrd09UVTNNMlEyWlRkayIsInQiOiJNUWd0R2JcL0hydzN1TUp5N3I3eFpjaGtST1wvNzk5bWdBU1JmdWl1WFwvSzNWYk1XUmdoOWhBaHBpRE0xMzFLdGFUaUljcWVwNjdjVE80N3RVWkZnckFucVVzeDhpdk9GazBsXC9SXC9GSmI1bUtuRGdnd3AwazBQRWNlY1NQcERvcEF6In0%3D

Doctor talking to senior patient and her husband

Under a new federal law, hospitals across the country must now alert Medicare patients when they are getting observation care and why they were not admitted—even if they stay in the hospital a few nights. For years, seniors often found out only when they got surprise bills for the services Medicare doesn’t cover for observation patients, including some drugs and expensive nursing home care.

The notice may cushion the shock but probably not settle the issue.

When patients are too sick to go home but not sick enough to be admitted, observation care gives doctors time to figure out what’s wrong. It is considered an outpatient service, like a doctor’s visit. Unless their care falls under a new Medicare bundled-payment category, observation patients pay a share of the cost of each test, treatment or other services.

And if they need nursing home care to recover their strength, Medicare won’t pay for it because that coverage requires a prior hospital admission of at least three consecutive days. Observation time doesn’t count.

“Letting you know would help, that’s for sure,” said Suzanne Mitchell of Walnut Creek, California. When her 94-year-old husband fell and was taken to a hospital last September, she was told he would be admitted. It was only after seven days of hospitalization that she learned he had been an observation patient. He was due to leave the next day and enter a nursing home, which Medicare would not cover. She still doesn’t know why.

“If I had known [he was in observation care], I would have been on it like a tiger because I knew the consequences by then, and I would have done everything I could to insist that they change that outpatient/inpatient,” said Mitchell, a retired respiratory therapist. “I have never, to this day, been able to have anybody give me the written policy the hospital goes by to decide.” Her husband was hospitalized two more times and died in December. His nursing home sent a bill for nearly $7,000 that she has not yet paid.

The notice is—as of last Wednesday—one of the conditions hospitals must meet in order to get paid for treating Medicare beneficiaries, who typically account for about 42% of hospital patients. But the most controversial aspect of observation care hasn’t changed.

“The observation care notice is a step in the right direction, but it doesn’t fix the conundrum some people find themselves in when they need nursing home care following an observation stay,” said Stacy Sanders, federal policy director at the Medicare Rights Center, a consumer advocacy group.

Medicare officials have wrestled for years with complaints about observation care from patients, members of Congress, doctors and hospitals. In 2013, officials issued the “two-midnight” rule. With some exceptions, when doctors expect patients to stay in the hospital for more than two midnights, they should be admitted, although doctors can still opt for observation.

But the rule has not reduced observation visits, the Health and Human Services inspector general reported in December. “An increased number of beneficiaries in outpatient stays pay more and have limited access to [nursing home] services than they would as inpatients,” the IG found.

The new notice drafted by Medicare officials must be provided after the patient has received observation care for 24 hours and no later than 36 hours. Although there’s a space for patients or their representatives to sign it “to show you received and understand this notice,” the instructions for providers say signing is optional.

Some hospitals already notify observation patients, either voluntarily or in more than half a dozen states that require it, including California and New York.

Traditional Medicare is cheaper

Posted on by • Posted in Uncategorized • Tagged , , , • 1 Comment

http://www.academyhealth.org/blog/2017-03/traditional-medicare-cheaper

phys-svcs-pmnt

OK, you knew that already. But what are the implications for access to care?

t probably won’t come as a surprise to you that traditional Medicare (TM) pays lower health care prices than commercial market insurers. We’ve known this for quite some time. A significant issue, however, is whether lower TM rates lead (or could lead) to reduced access to care for Medicare beneficiaries.

Jacob Wallace and Zirui Song took up the issue in a Health Affairs paper published last year. They examined health care price and utilization of outpatient imaging and outpatient surgical procedures across the 65-year divide — when most people become eligible for Medicare. Their data included just over 200,000 individuals captured in Truven Health Analytics’ 2007–2013 Medicare and Commercial Claims and Encounters database with broad-network, commercial market insurance before age 65 and TM from age 65 onward.

As shown in the chart just below, unadjusted, per beneficiary, quarterly spending trends for outpatient imaging and procedures are about the same before and after Medicare eligibility, but there is a large discontinuity when Medicare eligibility begins. In the last quarter before age 65, spending for a privately insured patient is about $119. At age 65, on Medicare, that drops 25% to about $89. After adjusting for age, quarter, year, and individual fixed effects, the relative change upon Medicare eligibility is even larger: 32%.

 

Repeal & Replace: Missing the Medicare Forest for the Obamacare Trees

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment

http://www.realclearhealth.com/articles/2017/02/24/repeal__replace_missing_the_medicare_forest_for_the_obamacare_trees_110464.html?utm_source=RealClearHealth+Morning+Scan&utm_campaign=bf5d282de4-EMAIL_CAMPAIGN_2017_02_24&utm_medium=email&utm_term=0_b4baf6b587-bf5d282de4-84752421

Image result for Repeal & Replace: Missing the Medicare Forest for the Obamacare Trees

The Trump Administration has promised to deliver to the American people a healthcare plan that is, in President Trump’s own words, “much less expensive and far better” than Obamacare. But While Obamacare is expected to spend over $900 billion from 2018 to 2027, focusing solely on the Obama administration’s signature achievement ignores bigger fiscal challenges; Namely, the Medicare program.

Our insurance program for the elderly and disabled – Medicare – is expected to cost $900 billion in 2024 alone. From 2018 to 2027, this comes to a whopping $8.5 trillion—an order of magnitude larger than the cost of the ACA. Beyond the topline price tag are a number of endangered programs.

Medicare’s hospital insurance trust fund, commonly known as Part A, is expected to run out of money in the next 10 years. This would mean an immediate reduction in benefits when the money runs out—2028, according to the program’s actuaries. Meanwhile, the funds that Medicare uses to pay for physician services (Part B) and prescription drug benefits (Part D) are consistently growing as a share of revenue.

 

Hospitals target nutrition, other social needs to boost health

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , • Leave a comment

http://www.usatoday.com/story/news/politics/2017/02/17/hospitals-target-nutrition-other-social-needs-boost-health/98042112/

Physician Joshua Sharfstein, former Maryland Secretary

Tom Shicowich “really, really, really liked Coca-Cola” before he began a new nutrition program targeting his Type 2 diabetes and weight. Being on a “very tight budget,” he couldn’t afford the fruit and vegetables he cut up for a living at his part-time grocery store job. Dinner was often a pizza or fast food meal he picked up on the way home.

Six months after getting free healthy groceries every week through the Geisinger hospital near his rural Pennsylvania home, Shicowich has cut his blood sugar level from nearly 11 to close to a normal level of 7. The 6′ 5″ former high school track team competitor has lost 35 pounds but is still nearly 200 pounds from his target weight of 250 pounds.

The Geisinger Health System is on its way to making its own numbers. On March 1, Geisinger plans to expand its five-patient pilot project to 50 more of its sickest and highest-cost diabetes patients. So far, all of those participating in Geisinger’s Fresh Food Pharmacy have lost weight, lowered their body mass indices, decreased their use of medication, lowered their cholesterol and improved their hemoglobin A1C levels, says Andrea Feinberg, an internal medicine doctor who is “clinical program champion.”

Geisinger is what’s known as an accountable care organization, which makes it fully responsible for the insurance and all health costs for their patients. They employ the doctors and own the hospitals and insurance company. The better-known Kaiser Permanente is another example. That means unlike other hospitals, their profits aren’t based upon patients’ visits and treatments.

“It is no coincidence that the health systems and hospitals that are doing it the best have aligned their incentives more closely to the health of their patients,” says Joshua Sharfstein, a pediatrician who is a former secretary of health for Maryland and top Food and Drug Administration official. “It’s very hard to ask a hospital that’s getting paid for every preventable admission to invest in ways that would eliminate those admissions.”

Read more:

The confused future of health care

Posted on by • Posted in Uncategorized • Tagged , , , , • 1 Comment

The confused future of health care

021317_acaalternativesforum_3_605

With a new administration in Washington, it’s widely accepted that the Affordable Care Act (ACA), otherwise known as Obamacare, isn’t likely to survive in its current form. But nobody seems to know whether it will be replaced or repealed, or what shape health care coverage will take in the future. The experts who met for a Kennedy Schoolpanel on the subject Monday evening didn’t presume to answer those questions, but they did pinpoint the crucial issues for the transition.

While they disagreed on possible replacements, they agreed that any solution will take time to create, agree upon, and roll out.

The panel on “Alternatives to the Affordable Care Act” began with a look at the benefits and drawbacks of Medicaid. According to Katherine Baicker, the C. Boyden Gray Professor of Health Economics at the Harvard T.H. Chan School of Public Health, expansion of Medicaid under Obamacare led to a decline in certain chronic diseases — but that also cost money, because the newly insured used more care. “This forced policymakers to think about how much they cared about the benefits to the insured, versus the costs of that care. That brought politics into it, and economists aren’t so good at politics.”

Two panelists represented opposite philosophies. Jonathan Gruber, the Ford Professor of Economics at Massachusetts Institute of Technology and a former Obama administration consultant on the health act, and Avik Roy, co-founder and president of the Foundation for Research on Equal Opportunity, argued respectively that government oversight of health care is the only sure way to leave fewer citizens behind, and that the free market, aided by block grants and tax credits, could do a better job.

Roy, speaking via Skype, said that Medicaid has failed the poor by directing too much funding to higher-income groups that don’t need it. Further, Roy said, doctors in many states avoid treating Medicaid patients because they can make more money on wealthier private patients. “Our argument is to say let’s take the money that we are sending to the Medicaid program and send it directly to the patients, so they can choose the program that serves their needs.” Tax credits and health savings accounts, he said, would give the poor more choices than Medicaid does.

“Poor people can’t do anything with health savings accounts,” Gruber replied. “If you have a $10,000 income, you can’t put $3,000 into a savings account.” He said that if you take away the individual mandate, one of the cornerstones of Obamacare, you lose the funding to insure the poor unless another mechanism is put in place. “We can’t escape the mathematics of insurance: 80 percent of the pool is paid by 20 percent of the people. Any alternative to Medicaid has to address affordability, it has to address adverse selection (i.e., people who opt out), and it has to address the architecture of the plan. But there is no alternative to the right of the ACA that does not increase un-insurance. It cannot be done.”

Gail R. Wilensky, senior fellow at Project HOPE and former director of Medicare and Medicaid, added that other countries have adopted strategies that probably would not be accepted here. Also speaking via Skype, she said, “There are alternative strategies to delivering health care, such as putting tight limits on technology. The light tech centers and digital imaging could be put under government control. You could theoretically lower costs that way. But if people were uncomfortable with the mandate, with government telling them what to buy, imagine what the reaction would be to that.”

Another question is whether patients would make the smartest decisions in an open health care market. Gruber said that under President George W. Bush, many elders simply chose the cheapest available plan, often with unfortunate results. Roy countered that low-income patients are often the shrewdest health care shoppers. “It is unreasonable to expect patients to be doctors,” Baicker said. Wilensky concurred, saying “I’ve talked to many patients with health savings accounts, and they found it incredibly difficult to know what they were buying.”

Everyone agreed, however, that the ACA is not near being definitively repealed or replaced. Chandra asked all four panelists when they expected a new plan to be in place. Estimates ranged from next winter to 2019. “One big difference is that Democrats were all united behind Obamacare, but there is no Republican consensus,” Roy said. “They’re against Obamacare, but they’re not sure what they’re for. There is literally nobody in Washington who knows what the new plans will look like, and I give it a 50-50 chance that they even come to agreement.”

One possible solution, Wilensky said, is to bring together all the affected parties — policymakers, physicians, and at-risk patients — in town-hall-type meetings that look into new solutions. “There are a lot of things that don’t make sense,” she said, “and in this country we’ve tried most of them.”

Medicaid’s Role for Medicare Beneficiaries

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

Medicaid’s Role for Medicare Beneficiaries

Figure 2: Health and functioning of Medicare beneficiaries who receive Medicaid compared to other Medicare beneficiaries

Key Takeaways
 This brief describes the role that Medicaid plays for 10 million Medicare beneficiaries to help inform upcoming debates about proposals to restructure Medicaid financing in ways that could reduce federal funding.What is Medicaid’s Role for Medicare Beneficiaries?

  • Medicaid covers needed services that Medicare does not, such as long-term care in nursing homes and the community.  Medicaid also helps make Medicare affordable by covering Medicare premiums and/or cost-sharing, which can be high for people with low incomes.

Who are the Medicare Beneficiaries Who Receive Medicaid?

  • Nearly three in four Medicare beneficiaries who receive Medicaid have three or more chronic conditions, such as diabetes or heart disease, which can require regular doctor appointments, medication, and/or medical tests.
  • Over 60% of Medicare beneficiaries who receive Medicaid need help with daily self-care activities, such as eating, bathing, or dressing, which are important for independent living.
  • Nearly six in 10 Medicare beneficiaries who receive Medicaid have a cognitive or mental impairment, such as dementia, which can create the need for supports to live safely at home.

How Much Does Medicaid Spend on Medicare Beneficiaries? 

  • Medicare beneficiaries account for 14% of Medicaid enrollment but 36% of Medicaid spending, as a result of their more intensive health needs and service use compared to other Medicaid beneficiaries.
  • Nearly three-quarters of states devote more than 30% of their total Medicaid spending to Medicare beneficiaries, and spending for Medicare beneficiaries comprises more than 45% of Medicaid budgets in six states.

Looking Ahead

Because Medicaid spending for Medicare beneficiaries is disproportionate to their enrollment, policy changes that lead states to limit per enrollee Medicaid spending or cut costly services could especially affect these beneficiaries.  Medicare beneficiaries who receive Medicaid are poorer than other Medicare beneficiaries, and many have intensive medical and long-term care needs as a result of old age, disability, and chronic illness.  Medicare beneficiaries rely on Medicaid to cover expensive but necessary services, especially long-term care in the community and nursing homes, that are generally not available through Medicare or private insurance.  They also depend on Medicaid to make Medicare affordable because Medicare’s out-of-pocket costs can be high for those with low incomes.  In addition, because the share of state Medicaid budgets devoted to Medicare beneficiaries varies by state, any changes that limit federal Medicaid financing will impact individual states differently. Because changes to Medicaid’s financing structure could have significant consequences for enrollees and states, the potential implications warrant careful consideration for their impact on Medicare beneficiaries.