Healthcare and Technology news
51.5K views | +1 today
Healthcare and Technology news
Your new post is loading...
Your new post is loading...!

Medicare, Reversing Itself, Will Pay More for an Expensive New Cancer Drug

Medicare, Reversing Itself, Will Pay More for an Expensive New Cancer Drug | Healthcare and Technology news |

The Obama administration has decided that Medicare will pay for one of the newest, most expensive cancer medications, which costs about $178,000 for a standard course of treatment.

Patients, doctors, hospital executives and insurers have expressed concern about the high cost of prescription drugs, especially new cancer medicines and treatments tailored to the genetic characteristics of individual patients. Medicare officials recognized the cost and value of one such product, the anticancer drug Blincyto, by agreeing to make additional payments for it starting Oct. 1. The drug is made by Amgen for patients with a particularly aggressive form of leukemia.

The decision suggests a new willingness by Medicare to help pay for promising therapies that are still being evaluated. It is also significant because Medicare officials reversed themselves on every major scientific issue involved. After receiving pleas from Amgen and a dossier of scientific evidence, the officials agreed that the drug was a substantial improvement over existing treatments for some patients.

At issue are special “add-on payments” that Medicare makes to hospitals for new technology whose costs are not yet reflected in the standard lump-sum amounts that hospitals receive for treating patients with a particular disease or disorder.

In a preliminary decision in April, the Obama administration said it did not intend to pay extra for Blincyto because clinical studies were “not sufficient to demonstrate” that it substantially improved the treatment of Medicare patients with acute lymphoblastic leukemia, a cancer of the blood and bone marrow. Medicare officials said Amgen’s application was based on data from “a small sample group of patients whose age demographic is much younger than the age demographic of eligible Medicare beneficiaries.”

But in a final rule to be published in the Federal Register on Aug. 17, the administration says it received “additional information and input” from Amgen and other experts and now agrees with their arguments.

Blincyto “is not substantially similar” to other drugs available to leukemia patients, the administration said, and it “represents a substantial clinical improvement over existing treatment options.”

Jane E. Wirth, 59, of Reno, Nev., a former preschool teacher, said her cancer was in remission after 28 days of treatment with Blincyto, also known as blinatumomab.

“It was amazing to me that it could work so well so quickly,” Ms. Wirth said in an interview. “I had just spent a month going through standardchemotherapy, which did not make the cancer go away. It seemed so hopeless.”

The drug, engineered from two antibodies, harnesses the body’s immune system to help fight cancer. It brings certain white blood cells close to malignant cells so the blood cells can destroy the cancer cells.

Dr. Anthony S. Stein, a researcher at City of Hope National Medical Center in Duarte, Calif., who has treated more than 50 patients in clinical trials of Blincyto, said, “Its mechanism of action is totally different from that of any other approved drug.”

After the Food and Drug Administration approved Blincyto in December, Amgen said the price would be about $178,000 for the recommended two 28-day cycles of treatment, each followed by a two-week break. Medicare says it will now allow a “new technology add-on payment” to hospitals for a fraction of that amount, up to $27,000. Actual payments will vary based on the length of a patient’s hospital stays.

A cycle of treatment begins with intravenous infusions in a hospital. Patients typically continue treatments outside the hospital — at doctor’s offices, at infusion centers or at home, with the help of specially trained nurses — and Medicare will help pay for the drug at those sites, too.

The prices of new cancer drugs often exceed $100,000 a year.

Health policy experts said that President Obama had personally expressed concern in recent weeks about high drug prices and their impact on consumers and federal programs. In February, he asked Congress to authorize the secretary of health and human services to negotiate with manufacturers to determine prices for high-cost medicines taken by Medicare beneficiaries.

poll by the Kaiser Family Foundation released last month found that 94 percent of Democrats and 84 percent of Republicans support allowing the federal government to negotiate with drug makers to get lower prices on medications for those beneficiaries.

Dr. Steven M. Safyer, president of Montefiore Medical Center in the Bronx, said the Obama administration should use its influence with drug companies to restrain costs. “There are a number of very important breakthroughs with pharmaceuticals that can make a difference between life and death, and the price is too high,” he said.

More than 100 oncologists from cancer hospitals around the country recently issued a manifesto decrying the prices of new drugs.

“Effective new cancer therapies are being developed by pharmaceutical and biotechnology companies at a faster rate than ever before,” they said in a commentary in the journal Mayo Clinic Proceedings. But, they added, “the current pricing system is unsustainable and not affordable for many patients.”

Robert E. Zirkelbach, a spokesman for Pharmaceutical Research and Manufacturers of America, the lobby for drug makers, said that new spending projections issued by the government in July undercut such claims.

“Even with new treatments and cures for hepatitis C, high cholesterol and cancer,” Mr. Zirkelbach said, “spending on retail prescription medicines is projected to remain approximately 10 percent of U.S. health care spending through 2024, the same percentage as in 1960.” In the last two decades, he added, the cancer death rate has fallen 22 percent, thanks in part to new medicines.

No comment yet.!

Obamacare's next 5 hurdles to clear

Obamacare's next 5 hurdles to clear | Healthcare and Technology news |

In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges –including one resolved Thursday – and dozens of repeal efforts in Congress. But its long-term future still isn’t ensured. Here are five of the biggest hurdles left for the law:

  • Medicaid expansion. About 4 million more Americans would gain coverage if all states expand the state-federalMedicaid programs to cover people with incomes at or slightly above the poverty line. Twenty-one states with Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington’s long-term commitment to pay for most of the costs.
  • Anemic enrollment. Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven’t purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance.  Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven’t figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states searching for more money. The penalty for going without coverage rises next year to $695 per adult or 2.5 percent of family income—whichever is larger.
  • Market stability. Nationally, premiums haven’t gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they’re not, expect increases.
  • Affordability. People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The “Cadillac tax,” created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes’ cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.
  • Political resistance. Thursday’s ruling did little to diminish the GOP’s zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. A lawsuit filed by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates – including Sen. Lindsey Graham, R-S.C., and former Florida Gov. Jeb Bush — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.
No comment yet.!

More Patients, Not Fewer, Turn To Health Clinics After Obamacare

More Patients, Not Fewer, Turn To Health Clinics After Obamacare | Healthcare and Technology news |

Nurse practitioner Martha Brinsko helps a lot of patients manage their diabetes at the Charlotte Community Health Clinic in North Carolina.

“Most mornings when you check your sugar, what would you say kind of the average is?” Brinsko asked patient Diana Coble.

Coble hesitated before explaining she ran out of the supplies she needs to check her blood sugar levels, and she didn’t have the gas money to get back to the clinic sooner. Brinsko helped Coble stock up again.

“If you need to get more than one box, get more than one box,” Brinsko said. “But you need to check them every morning so that we can adjust things.”

Coble, who is unemployed, lives with her sister and can’t afford insurance even now that the health law is in place, relies on the clinic for health care.

“They do a great job with everything,” Coble said. “I couldn’t do without them.”

Nancy Hudson was the clinic’s director as Obamacare rolled out and now consults for the clinic. She expected the insurance exchange, or marketplace, established under the Affordable Care Act would reduce the number of uninsured patients the clinic sees. The opposite happened, she says.

“What we found within our patient population and within the community is that a lot of the advertisement and information about the marketplace brought people [in who] didn’t know anything about free clinics and did not qualify for any of the programs within the ACA marketplace,” Hudson says.

And now they get free or low-cost care at the clinic, which is designated by the government at an FQHC, or federally qualified health center.

The health law was designed to cover the poorest people by expanding Medicaid, the federal-state program for low-income people. But the Supreme Court made that optional. The result in states that didn’t expand Medicaid is a gap, where some people make too much money to qualify for Medicaid but not enough to qualify for insurance subsidies. In North Carolina, about 319,000 people, like Coble, fall into the Medicaid gap.

“Over half of the people that we see would’ve been eligible for Medicaid expansion had the state elected to exercise that option,” says Ben Money is president of the association that represents North Carolina’s community health centers.

North Carolina is among the 21 states, including many in the South, that are currently saying no to Medicaid expansion. Louisiana is another.

Dr. Gary Wiltz, the CEO of 10 community health centers in the southwestern part of Louisiana, says demand has surged. “We’ve gone from 10,000 patients to 20,000 in the last six or seven years, so we’ve doubled,” he says.

Wiltz says other things are at play, too. The economic recovery hasn’t reached many of the poorest people, and some who do qualify for Obamacare subsidies say their options are still too expensive.

“The need keeps increasing, and I think that’s reflected throughout all the states,” he says.

Wiltz, who also heads the board of directors for the National Association of Community Health Centers, says clinics are packed even in states that expanded Medicaid. After all, most of the clinics treat Medicaid patients too.

The Charlotte clinic’s Nancy Hudson says there’s another part of the health law helping fuel the growth: additional funding for community health centers.

Hudson found out last week her clinic is getting about $700,000 to expand in partnership with Goodwill.

“Many of their clients did not have any access to health care,” she says. “They can’t train and sustain a job if they don’t have the basic needs taken care of, and health care is one of them.”

Nationwide, the federal government estimates its latest round of funding will lead to about 650,000 people getting better access to health care.

This story is part of a reporting partnership with NPR, WFAE and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

No comment yet.!

Medicare paid doctors $90 billion in 2013, up 17 percent: officials

Medicare paid doctors $90 billion in 2013, up 17 percent: officials | Healthcare and Technology news |

Medicare, the government-run health insurance program for elderly and disabled Americans, paid physicians $90 billion in 2013, up 17 percent from $77 billion in 2012, U.S. healthcare officials reported on Monday.

Physician payments accounted for less than one-fifth of Medicare's 2013 net outlays of $492 billion, which rose from $466 billion in 2012. Payments to hospitals for the top 100 inpatient stays cost Medicare $62 billion in 2013, while the rest went for drugs, privately run Medicare Advantage plans and other program costs.

The payments went to about 950,000 doctors, nurse practitioners and other individual healthcare providers who participate in the program. That was up from 880,000 providers in 2012.

The hospital data offer a glimpse of what ails America's elderly - and the quality shortfalls in U.S. healthcare.

The single-greatest hospital expense was to replace knees, hips and other joints in 446,148 operations, with $6.6 billion paid to hospitals.

The second-greatest hospital payment, $5.6 billion, went for 398,004 cases of septicemia, or blood poisoning, often a sign of poor in-patient care.

In a significant change from the data released last year, the Center for Medicare and Medicaid Services differentiated between what it paid physicians for their services and what it paid to cover the costs of drugs they administered. Some physicians had complained that they were portrayed as exorbitant billers because the cost of drugs was included in what Medicare paid them.

Among physicians, the highest-paid specialists were radiation oncologists, who received an average of $403,512 from Medicare for their services. That was closely followed by dermatologists ($331,108), vascular surgeons ($329,874), and ophthalmologists ($326,621).

In contrast, medical oncologists, who treat cancer patients with chemotherapy and generally coordinate their care, received an average of $181,747. The previous year's data portrayed them as some of the top Medicare billers, but that largely reflected reimbursements for the cost of drugs - an average $473,926 in 2013.

The data showed that patients who lament how little time they get with their physicians are not imagining it. Dermatologists billed for the most office visits lasting only five or 10 minutes (nearly 30 percent of total visits), whereas oncologists had almost no visits that short.

Medicare patients averaged six physician visits in 2013, but that varied significantly by state. Patients in New York, New Jersey, Florida, and Tennessee saw their doctors nearly seven times that year; those in northern New England, the Dakotas, Idaho, Montana, and New Mexico averaged fewer than four visits.

No comment yet.!

How Many People Has Obamacare Really Insured?

How Many People Has Obamacare Really Insured? | Healthcare and Technology news |

One of the key questions surrounding Obamacare is just how many people have been newly insured under the law. The answer is clouded by the fact that the White House and others have changed some rules of math for making these assessments.

For example, several years ago, the Obama administration fiddled with the Census Bureau’s definition of what it means to be “uninsured.” The new parameters, which were looser than the old factors, make it hard to construct comparisons between today’s figures for the total number of uninsured and the historical trends.

The Obama team also abruptly started to exclude uninsured illegal immigrants from the national tally on total number of uninsured Americans. Before Obamacare, these individuals were counted in that reporting, inflating the numbers. After Obamacare, these individuals didn’t get insurance, but suddenly didn’t get counted any more.

Now, a new analysis from the highly regarded managed care analyst at Goldman Sachs, Matthew Borsch, and his team, cast uncertainty on some of the recent data releases from the White House, and its network of academicians. In particular, the Goldman breakdown conflicts in some key ways with a recent analysis from RAND that was published in the journal Health Affairs and widely cited by the media.

Goldman Sachs estimates that total coverage under the ACA increased by 13 to 14 million last year and may have increased by another 4 million during the first five months of 2015, for a total coverage increase of 17 to 18 million combined. At a top line, this coincides with the figure from RAND, which estimated that there were 22.8 million newly insured people since the launch of the ACA. At the same time, 5.9 million people lost coverage. This comes out to a net gain of 16.9 million lives.

But how the two reports arrived at their numbers differ in important ways. The Goldman analysis relied on multiple data streams, including information released by insurers. The RAND study used a survey instrument sent to 1,589 people.

There are two critical questions embedded in all of these analyses. First, how many of the newly insured people would have gotten health coverage anyway, through some other mechanism (like their workplace)? In other words, is the law simply crowding out other forms of private coverage? Second, how many of the newly insured simply ended up on an expanded (and decaying) Medicaid program? The answers to these questions are an important measure of the ACA’s “success.”

On the latter question, according to the Goldman analysis, about two-thirds of the 2014 coverage increase was from the expansion in Medicaid. For 2014, their figures for net new coverage includes 9 million more people obligated to Medicaid, and about 2 million aging into Medicare. Only about 3 million got commercial coverage.

Moreover, Goldman estimates that employer sponsored coverage declined by about 2 million lives last year, which is at odds with other estimates. The widely cited study by RAND, for example, estimated that 9.6 million people who became newly insured since the fall of 2013 gained their coverage by enrolling in employer sponsored insurance. At the same time, the Goldman analysis estimates that total individual, commercial coverage increased by about 5 million. People migrating out of employer-sponsored insurance, and onto the Obamacare exchanges, explain a large measure of the relative change, under the Goldman analysis. The biggest change, according to their data, was for small employers, where the number of covered lives declined by 2.2 million people, a reduction of 13% year-over-year.

This is in sharp contrast to other analyses, and particularly the RAND study published in Health Affairs, which found that an increase in employer-sponsored insurance was the biggest driver of the total rise in coverage. Moreover, RAND estimates that 43% of the people newly insured by workplace coverage had the insurance available to them in 2013, but opted not to take it. This would suggest that the new tax penalty compelled them to seek the coverage. The RAND authors noted that there were possible methodological challenges with their survey; including confusion people might have had about their own source of coverage. This could potentially explain the wide discrepancies between the two analyses.

Obamacare’s supporters have argued that the public exchanges have not crowded out private insurance coverage that was previously offered at work. The Goldman analysis suggests that the law has indeed crowded out some employer coverage.

Unanswered in all this is also the question of how many employers might have offered insurance for the first time, or expanded their coverage, but for Obamacare and the ability to move their workers onto the exchanges. In an expanding economy, the total share of employer-sponsored coverage should have similarly grown, if historical trends are any guide. Yet the number of people insured through work was flat by many other estimates, and according to the Goldman analysis, actually declined. This strongly suggests the ACA is displacing private coverage.

It could be that most of what Obamacare does to address the “uninsured” problem is obligate a whole lot more people to Medicaid, a program that already suffers from severe access problems owing to years of underfunding relative to its expanding mission, and the chronic health needs of its mostly indigent population. Obamacare only adds to the program’s strains. At the same time, on the commercial side, Obamacare may be mostly creating churn — by displacing people from their employer-sponsored coverage and moving them onto the exchanges.

It’s hard to know for certain, since the current figures – at least those released by Washington – can’t be compared to historical trends. The Census Bureau made a significant change in how it estimates the number of people who lack insurance, starting with its assessment for 2013. That means that after 2013, the results can’t be compared to those for prior years. The government’s new method conveniently results in a lower estimate of the total number of people without insurance.

So far, even if you accept the most optimistic math, Obamacare is hardly the unmitigated success that its many apostles proclaim. Whatever minimal gains in the level of commercial coverage that’s been achieved has come at a huge fiscal expense. This is not to mention the massive growth in costly and restrictive regulation.

These numbers will continue to be the subject of fierce scrutiny, dispute, and fiddling. The proclamations of those who worship the ACA as a new religion are carved out of these numerals. Their scripture is open to a lot of interpretation.

No comment yet.!

Will Obamacare Ever Be as Popular as Medicare?

Will Obamacare Ever Be as Popular as Medicare? | Healthcare and Technology news |

With a pen stroke, the president signed into law a health insurance expansion that had previously been deemed "socialized medicine" and had drawn fierce criticism from conservatives.

No, the president wasn't Barack Obama, and the legislation wasn't the Affordable Care Act. Nearly 50 years ago, President Lyndon B. Johnson enacted Medicare and Medicaid amidst passionate opposition to the program that has since become widely ingrained in the fabric of society.

But as liberals celebrate the anniversary of Medicare, it's Obamacare that comes to mind. The hope for liberals: that the shift in perspective on Medicare foreshadows a shift to eventual popularity for Obamacare.

"Before Medicare came into law, one Republican warned that 'one of these days, you and I are going to spend our sunset years telling our children and our children's children what it once was like in America when men were free.' That was Ronald Reagan. And eventually, Ronald Reagan came around to Medicare and thought it was pretty good, and actually helped make it better," Obama said in a 2013 speech in Maryland. "So that's what's going to happen with the Affordable Care Act."

But the differences between the passage and beginning stages of the two laws may be more indicative of Obamacare's future popularity than the similarities, said Jonathan Oberlander, a professor in the Department of Social Medicine at the University of North Carolina at Chapel Hill.

"This is not 1965. American politics are extraordinary polarized by party right now. Congress is more polarized in politics and in ideology than at any point since the 1870s," Oberlander said. "This is a political environment where it's very difficult for a program like the Affordable Care Act that was adopted along partisan lines to gain traction."

Timothy Jost, a Washington and Lee law professor, thinks "there may be some fixes," but believes the law will eventually become entrenched within society.

"I think it already is," he said. "In fact, when people talk about repealing the Affordable Care Act, I think they really don't know what they're talking about."

On that, both agreed: "I think it's past repeal," Oberlander said.

Both the Social Security Amendments—creating Medicare and Medicaid—and the Affordable Care Act created political controversy, and both were passed by large majorities of Democrats in Congress after landslide elections, Jost said. And both took a long time to fully implement—Arizona was the final state to begin its Medicaid program in 1982.

Both were even debated along party lines, although many Republicans ended up voting in favor of the final Medicare bill, viewing it as a lost cause, Oberlander said.

On the other hand, perhaps because they were vastly outnumbered, Republicans never seriously talked about repealing Medicare. The program also had a very identifiable group of beneficiaries, while Obamacare targets diffuse populations, Oberlander said. And there were no significant court cases brought against Medicare, whereas five years after Obamacare's passage it awaits yet another Supreme Court decision on the legality of key aspects of the law.
Don't Miss Today's Top Stories

" Informative and help[s] me stay on track. "

Director of Scientific Affairs, Non-profit medicial society
Sign up form for the newsletter

Although the gap has narrowed in the past two years, more Americans—43 percent—still viewed Obamacare unfavorably in March than the 41 percent who viewed it favorably, according to a Kaiser Family Foundation poll.

At an event hosted by the Aspen Institute Wednesday to commemorate Medicare and Medicaid's 50th anniversary, several speakers referenced today's partisan gridlock in contrast to the compromises achieved in 1965, although several also brought up the "doc fix" bill—easily passed in the Senate the day before—as a source of hope for increased bipartisanship.

"There are a lot of people who would say this is the most polarized Congress. It doesn't look anything like '64, '65," said former Health and Human Services Secretary Kathleen Sebelius. "I think this is a changed Congress."

Jackie Judd, a special correspondent with the PBS Newshour who served as a moderator at the Aspen Institute event, said the doc fixed served as a reminder that "passions run high around these programs, even today, 50 years later."

But at the end of the day, a bipartisan bill was overwhelmingly passed, a reflection of the way things used to be.

"Medicare and Medicaid were adopted, to some extent, in a bipartisan way, because the parties were much less aligned along the ideological spectrum the way they are now," Jost said.

That meant the programs' flaws could be fixed legislatively. Today, there's little chance of that happening, and solutions instead must come administratively or from the courts, he said.

The question of whether or not subsidies are available on federal exchanges, the largest current threat to the law, "could have easily been fixed by Congress" in 1965, he said.

King v. Burwell, which the Supreme Court is expected to decide this summer, will heavily influence the future of Obamacare. But so will the upcoming presidential election.

"There's a huge difference whether it's Hillary Clinton, Marco Rubio, Scott Walker, or Jeb Bush in the White House," Oberlander said. "The Court case matters greatly here, but I think regardless of what happens in the Court case, the question in 2016 will be: How will the law change?"

No comment yet.!

ACA's Mandate To Buy Coverage May Be GOP-Friendly

ACA's Mandate To Buy Coverage May Be GOP-Friendly | Healthcare and Technology news |

Whether it’s a penalty to pick a drug plan under Medicare or the new Republican proposal to replace the Affordable Care Act or the President’s health law alone, penalties abound for being uninsured.

A new analysis by the Urban Institute said “individual responsibility” requirements akin to the controversial individual mandate included in the Affordable Care Act requiring individuals to buy coverage or face a tax penalty also exist in other health reform proposals and existing health insurance programs.

Some, like the Medicare Part D drug coverage for seniors and Medicare Part B’s physician services for the elderly, have been in place for years. Another, a new Republican proposal to replace the ACA, also has its penalties.

The so-called “Patient Choice, Affordability, Responsibility, and Empowerment Act” or PCARE, proposed by Republican Rep. Fred Upton of Michigan and GOP Sens. Orrin Hatch of Utah and Richard Burr of North Carolina would “impose strong penalties on the uninsured,” Urban Institute health policy researchers Linda Blumberg and John Holahan wrote in their analysis out this week called, “the New Bipartisan Consensus for an Individual Mandate.”

“Specifically, if individuals fail to maintain continuous coverage, they can be medically underwritten or effectively denied insurance in the nongroup market,” the Urban Institute’s authors wrote of the Hatch-Burr-Upton legislation. “Medicare Parts B and D also have provisions that penalize individuals for failing to promptly enroll in coverage for the same reason, yet this approach to an individual mandate has not been controversial.”

All of the proposals share the common thread that health insurance, particularly coverage that involves the private insurance market, need an individual responsibility component to ensure healthy people are in the insurance risk pool. Without healthy people buying coverage and paying premiums, claims submitted largely by sick policyholders would lead to soaring health care costs.

The individual responsibility provision has long been the stance of health care interests like the American Medical Association and the health insurance lobby, America’s Health Insurance Plans, which represents Aetna (AET), Cigna (CI), Humana (HUM), UnitedHealth Group (UNH) and most Blue Cross and Blue Shield plans.

“If you want to keep a private market-centered approach and prevent discrimination in insurance against those with health problems, you have to have a mechanism that brings in and holds in the healthy,” Blumberg, seniors fellow at the Urban Institute’s health policy center told Forbes in an interview. “You have to have an individual mandate to hold the healthy into the insurance risk pools.”

The GOP’s Obamacare replacement requires individuals to have insurance “continuously for 18 months to be guaranteed access to a private nongroup insurance policy,” the Institute said in a statement accompanying their analysis. Meanwhile, the ACA imposes tax penalties for those individuals who go without insurance for more than three months in any given year. And Medicare Parts B and D have penalties that are much steeper than the ACA’s for those who delay enrolling after they become eligible.

“Under both programs, penalties are assessed on those who enroll, disenroll and then enroll again,” the institute fellows wrote.

No comment yet.!

Supreme Court Rules that Providers Cannot Sue States Over Medicaid Payment

Supreme Court Rules that Providers Cannot Sue States Over Medicaid Payment | Healthcare and Technology news |

On Tuesday morning, March 31, the U.S. Supreme Court ruled in Armstrong et al v. Exceptional Child Center, Inc., et al, that private healthcare providers cannot sue states over low Medicaid reimbursement rates, in a 5-4 ruling, reversing a lower court’s ruling. Providers had argued that suing over low rates is sometimes the only way to enforce federal payment requirements.  But their opponents asserted that a ruling in favor of providers could lead to unending litigation that would slow the system.

The Supreme Court took up the case after Idaho residential providers for disabled patients sued state officials over that state’s failure to implement higher reimbursement rates, after the Idaho Legislature failed to sufficiently fund such reimbursement. A federal district court ruled that Idaho’s rates did not align with requirements in federal law requiring adequate reimbursement, and the distrct court was upheld by the 9th U.S. Circuit Court of Appeals.

A report in the online news service NewsMax reported that  “State officials recommended increases in reimbursement rates in the late 2000s but they were never implemented because the Idaho legislature declined to appropriate funds, according to court papers.Writing on behalf of the majority,” the NewsMax report said, “Justice Antonin Scalia said that the providers have no right to sue the state under the so-called Supremacy Clause of the U.S. Constitution, which holds that federal law generally trumps state law. The clause ‘instructs courts what to do when state and federal law clash, but is silent regarding who may enforce federal laws in court,’ Scalia wrote.”

The report further said that “Scalia noted that the providers have another option: they can ask the federal government to intervene on their behalf. In a dissenting opinion, Justice Sonia Sotomayor said there was nothing in the Medicaid law to suggest that Congress intended to prevent private lawsuits.”

No comment yet.!

Uninsured drop by 11M since passage of Obama's law

Uninsured drop by 11M since passage of Obama's law | Healthcare and Technology news |

The number of uninsured U.S. residents fell by more than 11 million since President Barack Obama signed the health care overhaul five years ago, according to a pair of reports Tuesday from the federal Centers for Disease Control and Prevention.

Although that still would leave about 37 million people uninsured, it's the lowest level measured in more than 15 years.

The most dramatic change took place in comparing 2013 with the first nine months of 2014. As the health care law's major coverage expansion was taking effect, the number of uninsured people fell by 7.6 million over that time.

That's "much bigger than can possibly be explained by the economy," said Larry Levitt of the nonpartisan Kaiser Family Foundation. "The vast majority has to be due to the Affordable Care Act."

Monday was the law's fifth anniversary, and supporters and detractors again clashed over its impact.

Obama says the law in many ways is "working even better than anticipated."

House Speaker John Boehner says it amounts to a "legacy of broken promises."

The health care law offers subsidized private coverage to people who don't have access to it on the job, as well as an expanded version of Medicaid geared to low-income adults, in states accepting it.

The White House says 16 million people have gained health insurance, a considerably higher estimate than Tuesday's findings from CDC's National Center for Health Statistics.

The figures cited by the White House cover a longer period of time, through the beginning of this month. That includes the law's second sign-up season. The estimate was produced by the principal policy adviser to Health and Human Services Sylvia M. Burwell.

The CDC reports compared the first nine months of 2014 with annual statistics going back as far as 1997, from the National Health Interview Survey. Among the highlights:

— The number of uninsured dropped from 48.6 million in 2010 to 37.2 million for the period from Jan.-Sept. last year. That amounted to 11.4 million fewer uninsured since the signing of the health care law.

— In 2014, about 27 million people said they had been without coverage for more than a year.

— Some 6.8 million people were covered through the health care law's new insurance markets during July-Sept. of 2014.

— The most significant coverage gains last year came among adults ages 18-64. Nearly 40 million were uninsured in 2013. But that dropped to 32.6 million in the first nine months of 2014.

— States that moved forward with the law's Medicaid expansion saw a bigger decline in the share of their residents uninsured.

The main question hanging over the law now is a Supreme Court case in which opponents argue that its subsidies are illegal in most states. They contend that the exact wording of the law only allows subsidized coverage in states that have set up their own insurance markets. Most have not done so, relying instead on the federal

The administration counters that the context of the law makes it clear the purpose was to expand coverage in every state. A decision is expected to be announced by late June.

No comment yet.!

Obamacare Cut The Ranks Of The Uninsured By A Third

Obamacare Cut The Ranks Of The Uninsured By A Third | Healthcare and Technology news |

A total of 16.4 million non-elderly adults have gained health insurance coverage since the Affordable Care Act became law five years ago this month. It's a reduction in the ranks of the uninsured the the Department of Health and Human Services called historic.

Those gaining insurance since 2010 include 2.3 million young adults aged 18 to 26 who were able to remain on their parents' health insurance plus another 14.1 million adults who obtained coverage through expansions of the Medicaid program, new marketplace coverage and other sources, according to the report from the department released Monday.

Officials say the percentage of people without coverage has dropped about a third since 2012: from 20.3 percent to 13.2 percent in the first quarter of 2015.

"The Affordable Care Act is working to drive down the number of uninsured and the uninsured rate," Richard Frank, assistant secretary for planning and evaluation at HHS, told reporters. "Nothing since the implementation of Medicare and Medicaid has seen this kind of change."

Latinos, who traditionally have been least likely to have health coverage, have seen the largest drop in their uninsured rate, according to the report. The Latino uninsured rate fell 12.3 percentage points, from 41.8 percent to 29.5 percent. The uninsured rate for African Americans fell by nearly half, from 22.4 percent to 13.2 percent. The rate for non-Latino whites fell by just over 5 percentage points.

States that expanded the Medicaid program to 138 percent of the poverty line also saw large reductions in their low-income uninsured populations – an average of 13 percent among people with incomes under the new Medicaid threshold. States that haven't expanded the program still saw a decline, though not as large, of about 7 percent.

HHS officials said they expect to have better state-by-state breakdowns and estimates of the number of children covered later this year. The ACA turns five on March 23.

No comment yet.! isn't perfect, but it's a whole lot better isn't perfect, but it's a whole lot better | Healthcare and Technology news |

Management of isn't perfect, but it's far better off than it was a year-and-half ago.

Much of a new report from the Government Accountability Office rehashed all the problems that caused the initial rollout of to be a mess. But it also pointed to the current state of the website as much improved.

How so? In the immediate aftermath of the debacle, the Centers for Medicare and Medicaid Services doubled the number of servers for systems supporting, added virtual machines for the Enterprise Identity Management and Federally-Facilitated Marketplace, and replaced a virtual database with a high-capacity physical database, the GAO reported. All of that allowed more efficient system processing — going from 25 to 400 terabytes of monthly capacity.

The CMS also directed its development contractors at the time to, among other things, modify system software to increase the efficiency in system interactions and implement software fixes to address issues with users logging into their accounts. It documented data quality plans for the Enterprise Identity Management system in March 2014 and the FFM system in June 2014 that outline an approach for improving the quality of the systems' code.

And then, of course, it awarded a new contract in January 2014 to Accenture Federal Services in Arlington that "represents almost exclusively new development and major fixes to software already developed," the GAO reported.

Indeed, as I reported in October, a lot was involved with getting the website in working order — and it's come a long way since then. While some FFM system development activities are still in progress, the GAO noted the Centers for Medicare and Medicaid Services made progress in developing and implementing services related to eligibility and enrollment and plan management. Users can now "window shop" for plans, for example, and the CMS can validate plan application information and route the validated information to the appropriate system.

But there are still areas the Centers for Medicare and Medicaid Services, with Accenture (NYSE: ACN), could stand to improve to ensure they don't again land in hot water, the GAO noted. Even with its new requirements approval process, for example, the CMS has not consistently and appropriately approved requirements. And whether all requirements are properly approved before they're implemented is unclear. Also, the Centers for Medicare and Medicaid Services does not have the proper processes in place to ensure stakeholders fully understand system-wide effects as a result of changes to requirements.

"With the issuance of a new development contract … CMS has taken the opportunity to make improvements," the GAO reported. "However, until it ensures that it is fully implementing best practices for managing the development of and its supporting systems, it increases the risk that future development will experience additional problems."

No comment yet.!

No Medicaid Expansion?

No Medicaid Expansion? | Healthcare and Technology news |
Hospitals that treat many poor and uninsured patients were expected to face tough financial times in states that did not expand Medicaid under the federal law known as Obamacare.

That’s because they would get less Medicare and Medicaid funding under the Affordable Care Act, while still having to provide high levels of charity care.

But in some of the largest states that did not expand Medicaid, many safety-net hospitals fared pretty well last year — even better than in 2013 in many cases, according to their financial documents. KHN looked at the performance of about a dozen such hospitals in Florida, Texas, Georgia, Tennessee, South Carolina, Virginia and Kansas, which released their 2014 financial results.

An improving economy was the single, biggest reason shared by all of the strongly performing hospitals because it helped reduce the number of patients who couldn’t pay their bills and increased local property and sales tax revenues earmarked for publicly supported hospitals.

Another factor for some hospitals was the increase in insured patients who bought coverage through the health law’s insurance exchanges. For instance, Fort Lauderdale, Fla.-based Broward Health saw a 30 percent drop in charity care, which officials attributed to seeing more insured patients.

Still, the biggest fiscal challenges lie just ahead — with significant Medicaid funding cuts starting late next year under the Affordable Care Act. The health law’s drafters anticipated the number of uninsured Americans to decrease dramatically, in part because they expected a nationwide expansion of Medicaid. Therefore, beginning in October, 2016, the law calls for cuts to special Medicaid funding for hospitals that typically see a disproportionate share of the poor. In addition, other Medicaid funding that supports indigent care in certain states (and that predates the 2010 health law) is slated to expire in Florida in June and in Texas, next year.

“We are still very early in the Affordable Care Act, and one year does not make a trend,” cautioned Daniel Steingart, an analyst with Moody’s Investors Service. “Just because they got though this period, does not mean they do not have more financial pain to come.”
So-Called Safety-Net Hospitals Record Profits in 2014

So-called safety-net hospitals, many of which are supported by local or county taxpayers, often struggle financially because they see a high proportion of patients that are either uninsured or enrolled in Medicaid, the state-federal program that pays less money than Medicare or private insurers. The hospitals face added pressure from providing high-cost and traditionally money-losing services such as trauma and burn care. They also have the expense of training doctors.

Nonprofit hospitals need to make enough money to buy new equipment, expand programs and meet rising labor costs. The average nonprofit hospital makes about a 3 percent profit margin, Steingart said.

In the past decade, two of the nation’s largest public safety-net hospitals — Grady Memorial Hospital in Atlanta and Jackson Memorial Health System in Miami — were on the verge of financial collapse but recovered after major management changes and increased public support.

Last year, the county-owned Jackson finished its second consecutive year with about a $51 million surplus on about $1 billion in revenue, in part as a result of increased county sales-tax revenue going to the health system and tighter expense management. Jackson’s operations are supported by a sales tax in Miami-Dade County.

Grady’s profit increased to nearly $30 million through November last year, up from $17 million for the same period in 2013.

Several other safety net facilities in states that did not expand Medicaid had profits in 2014, according to financial reports, including:

— Broward Health, which runs four hospitals, saw $69 million in profit in the 2014 fiscal year that ended June 30, compared to $59 million a year earlier, on about $1 billion in revenue. That included support from local taxpayers.

— Orlando Health, a six-hospital system in central Florida, saw its profit grow to $161 million in the fiscal year that ended in September, up from $32 million the year before, on about $2 billion in revenue. Its vice president of finance, Paul Goldstein, cited the improving economy, an increase in the number of privately insured patients and the financial performance of recently purchased doctors’ groups.

— Tampa General posted a $49 million profit last year, up from $31 million the year before, on $1 billion in operating revenue. Its operating margin was 4.5 percent.

— Chattanooga, Tenn.-based Erlanger Health posted a $20 million profit for the six months that ended Dec. 31, on revenue of $336 million, after factoring in local tax support, compared to losing $1.5 million in the same period a year earlier.

— Greenville Health System in South Carolina made a $63 million profit in the fiscal year that ended Sept. 30, down slightly from $80 million the prior year. The system had about $1.8 billion in revenues.

Twenty-eight states have expanded Medicaid under the health law since the Supreme Court ruled the provision optional in 2012. Medicaid enrollment has increased nationally by almost 11 million since October 2013. Most of the drop in uninsured nationally is attributed to people gaining Medicaid coverage.

Safety-net hospitals in Florida fear what will happen after June 30 when $2 billion in federal funding expires under an agreement between the state and the federal government. Under such agreements, the federal government supplies billions of dollars in special Medicaid dollars to certain states including Florida, Texas and California to support hospitals with large number of Medicaid and uninsured patients.

“Without those dollars we have an unsound system,” said Tony Carvalho, president of the The Safety Net Hospital Alliance Of Florida.

While Miami-based Jackson Health is financially healthy now, Chief Financial Officer Mark Knight worries about the end of that federal waiver funding in June, which contributed $160 million to his budget this year. “We could not continue to serve and maintain current capacity … without that money,” he said.

In 2014, Florida safety-net hospitals also benefited from a strong tourist season and lower unemployment rates, Carvalho said.

The improved economy also helped many safety-net hospitals that are supported through local property and sales taxes, such as Broward Health and Jackson Memorial, said David Gruber, managing director of research at Alvarez & Marsal consulting firm.

A recent report by the firm predicted the nonprofits would face major financial threats as a result of health law funding cuts, particularly in states that do not expand Medicaid. “Safety-net hospitals are now operating in the untenable crosshairs of economic distress and health care reform,” the report said.

Greenville Health has kept in the black partly by finding ways to trim charity care costs, said Chief Financial Officer Terri Newsom. The South Carolina hospital has hired case managers to oversee care to some of the uninsured patients who show up regularly at its emergency department. It also launched a program to divert ambulances with patients who do not have medical emergencies to urgent care centers.

Though the hospital worked to get people signed up for Obamacare plans, it only saw a 1 percent drop in uninsured numbers last year. Nonetheless, administrators say the health system is in good shape. “We are in stable health and making the right investments,” Newsom said.
No comment yet.!

3 Medicare Enrollment Myths

3 Medicare Enrollment Myths | Healthcare and Technology news |

Medicare can be deeply confusing, and there are a lot of myths out there about how it works and what works best for a particular situation. Here are three myths that you need to watch out for to ensure that you don't lose out on important coverage or get hit with big penalties. 

Myth #1: I'm automatically enrolled
Unless you're already getting Social Security or Railroad Retirement Board benefits when you turn 65, you will not be automatically enrolled in Medicare. You need to apply directly with Social Security to get on the books.

You can enroll anytime from three months before your 65th birthday month to three months after, meaning that you have a seven month period in which to choose the right plan for you. Part A is free, so it makes sense to sign up right away.

Of course, if you're still working you might think that you don't need Medicare Part B (which isn't free), so there's no point in enrolling. That brings us to myth number two:

Myth #2: I can wait to enroll
One thing you don't want to do when it comes to Medicare is wait. Part A is free, so, again, no matter what your situation it makes sense to enroll right away. 

When it comes to Part B, it generally makes sense to enroll as soon as you're eligible, as making a mistake can be quite costly. Missing your enrollment can mean a permanent 10% annual increase in your Part B premium and a 1% monthly increase in your Part D premiums, which is probably not something you want to deal with.

What if you or your spouse are still working and have health insurance? In this case, check with your current provider to see how they work with Medicare. It might make sense to postpone -- but don't forget about signing up when you do retire. You'll have eight months to do so. 

Also, as a rule of thumb, if you work for a company with fewer than 20 people, it makes sense to sign up when you're first eligible. That's because smaller plans are allowed to drop you once you're eligible for Medicare, and they might even refuse to pay Medicare-eligible claims. 

If you're retired and have health coverage, sign up anyway. This applies even if you have COBRA, a retiree health insurance plan, or veteran's benefits. All of these plans become secondary plans once you're signed up -- and none of them exempt you from the late-enrollment penalties. 

Myth #3: Once I've signed up, I'm done
While Parts A and B cover a fair amount, neither has out-of-pocket limits. That means that the 20% of costs you're responsible for under A and B could add up to a lot of money should you need extensive treatment. This is the main argument for getting Medigap's supplemental coverage or signing up for an Advantage plan.

But even here, it's important to keep an eye out for gaps in coverage. 

The Part D donut-hole is a great example. Part D provides for prescription drug coverage, but once you and the insurance company have collectively paid a certain amount on prescription drugs ($2,960 in 2015), you become responsible for significantly more of the cost -- 45% of brand name drugs and 65% of generics. Once your out-of-pocket spending reaches $4,700, the donut-hole closes and you'll pay a small amount on drugs for the rest of the year.

In other words, take the time to do your homework. Don't just stop at Parts A and B, and remember to note the deductibles, premiums, and coverage limits in the plans you're reviewing. Taking the time now can save you a lot of stress down the line.

No comment yet.!

Does the Affordable Care Act Guarantee Healthcare as a Right?

Does the Affordable Care Act Guarantee Healthcare as a Right? | Healthcare and Technology news |

In his recent celebratory remarks after the Supreme Court (SCOTUS) upheld the legality of subsidies/tax credits under the Affordable Care Act (ACA), President Obama had this to say: "Five years ago, after nearly a century of talk, decades of trying, a year of bipartisan debate -- we finally declared that in America, healthcare is not a privilege for a few, but a right for all." (1)

It would be good if this were true, but it is not. Healthcare as a right has been debated over many years, but is still not in place for all Americans as this country remains an outlier among advanced industrial countries around the world. Instead, despite the ACA, we continue to have a patchwork of ever-changing programs assuring access to health care for some people some of the time.

Let's look at what we do have in this respect. In the 1960s, Congress established a broad right to health care under statutory law by enacting Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) for the elderly, disabled, people living in poverty, and children. In the 1980s it passed the Emergency Medical Treatment and Active Labor Act (EMTALA) requiring all Medicare-funded hospitals with emergency departments to provide appropriate emergency and labor care. More recently, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2013, which assures a right to equal access to care for patients with medical and mental health problems. SCOTUS has established a right to health care for prisoners and has protected some limited rights for women's reproductive care (2), but has never interpreted the Constitution as guaranteeing a right to health care for all Americans. In fact, the words "health," "health care," "medical care," and "medicine" do not appear in the Constitution. (3) 

It is disingenuous to claim that health care is a right in the U. S. when we consider these inconvenient facts:

  • 35 million uninsured, plus another similar number underinsured.
  • The first question asked of us in seeking care is "what is your insurance?"
  • 21 states have opted out of Medicaid expansion under the ACA.
  • Medicaid eligibility and coverage varies widely from one state to
  • another, in many cases falling far short of necessary care.
  • As the costs of insurance and health care continue to rise and shift
  • more to patients, a growing part of the population cannot afford either and forgo seeking care.
  • More than 40 million Americans now have an account in collection for medical debt. (4)

This situation stands in sharp contrast to elsewhere in advanced societies. Healthcare has been recognized as a right since 1948 when the General Assembly of the United Nations adopted a Universal Declaration of Human Rights including access to health care. (5) The right to health care was also later adopted by the World Health Organization (WHO) in its Declaration on the Rights of Patients. (6) As a result, most of Western Europe, Scandinavia, the United Kingdom, Canada, Taiwan, and many other countries have one or another form of national health insurance assuring access to care for their populations. Here we spend twice as much and still have no universal access to health care.

Can we ever see this country coming around to universal access to health care based on medical need, not ability to pay? The record shows that we never can, or will, as long as we permit corporate stakeholders in our medical-industrial complex to call the shots, and as long as they succeed in perpetuating our exploitive for-profit system. There is a fix -- single-payer national health insurance, as embodied in H. R. 676, Expanded and Improved Medicare for All.

No comment yet.!

A Promising Medicare Plan, if Only Health Organizations Would Stick Around

A Promising Medicare Plan, if Only Health Organizations Would Stick Around | Healthcare and Technology news |

Two recent studies of Medicare’s new way to pay for health care show that it’s reducing spending and improving quality. The problem is, health care organizations don’t always stick with the program.

Both studies examined Medicare’s 32 Pioneer Accountable Care Organizations. This program, and a related, similar one with a larger number of participants, offers health care organizations the opportunity to earn bonuses in exchange for accepting some financial risk, provided they meet a set of quality targets.

One study, published in the New England Journal of Medicine, found that in their first year, Pioneer A.C.O.s reduced spending 1.2 percent, relative to comparable patients who received care elsewhere. The other study, published in the Journal of the American Medical Association, found a 3.6 percent spending reduction in the first year and considerably less in the second year. (Though the studies reach broadly similar conclusions, their different savings estimates stem from methodological differences.)

Across a variety of measures, the two studies found that Pioneer A.C.O. quality of care held steady or improved.

Even if the overall savings are modest and assessed only in the first year or two of the program, the studies’ findings are good news for Medicare. Inspired by some of the nation’s most revered health care organizations — like Kaiser Permanente and the Mayo Clinic — Medicare’s A.C.O. program is its flagship reform initiative. It’s intended to promote the delivery of more efficient and effective care, paying more for value than for volume. Medicare has announced it intends to accelerate the transition from volume to value in the coming years. The new studies offer some confidence that it can do so while reducing spending and without harming quality.

However, there is still cause for concern. Thirteen A.C.O.s left the Pioneer program after the first year. Even though those A.C.O.s had saved money too, according to the studies, this is a troubling sign. A program that fails to retain its members cannot succeed in the long term. And, as these two studies cover only the first two years, despite the encouraging findings they do not provide information about what happened in the longer term.

Because the program is voluntary, an organization that can earn more by leaving, or one that anticipates it cannot recoup investments necessary to succeed, will not participate. One reason organizations may have dropped out is that payments decrease quickly as organizations become more efficient.

Dr. Michael McWilliams, lead author of the New England Journal of Medicine study, suggested that Medicare may achieve greater success over time with a more gradual approach that better balances the goal of achieving savings with the need to retain participants.

“Building on this early success will require greater rewards for A.C.O.s that generate savings,” Dr. McWilliams said.

Dr. McWilliams’s study also found that organizations that consolidated hospitals with physician practices performed no better than those that did not. This suggests that such consolidation — which has been rampant in the industry and drives up prices paid by commercial insurers — is not necessary to reduce Medicare spending and improve care.

“If financial integration between physicians and hospitals fosters more effective responses to new payment models, those efficiencies have not yet manifested among A.C.O.s,” Dr. McWilliams said.

The voluntary nature of the program also challenges study of it. Self-selection invites the possibility that organizations that opt in could be different from those that don’t, perhaps better able to reduce spending and improve quality. Randomizing organizations into the program — akin to a randomized controlled trial of medical therapies — would offer more certain estimates of the program. But it’s not practical to force such a large change on health care organizations, and possibly dangerous to experiment so directly with factors that could affect patient care.

The two studies’ researchers used a different approach to tease out estimates of the program’s effects. They compared changes in cost and quality experienced by beneficiaries in A.C.O.s with those of comparable beneficiaries served by other organizations. Dr. McWilliams’s study also tested whether those changes corresponded to the timing of A.C.O. participation. Since no changes were detected before program initiation, that provides confidence that the findings are because of the program itself.

The good news is that, at least in the first year or two of participation, A.C.O.s seem to spend less and deliver equivalent or better care than other health care organizations. The bad news is that many organizations drop out of the program, even as they’re succeeding.

No comment yet.!

New Medicare data available to increase transparency on hospital and physician utilization

New Medicare data available to increase transparency on hospital and physician utilization | Healthcare and Technology news |

As part of the Administration’s efforts to promote better care, smarter spending, and healthier people, today CMS is posting the third annual release of the Medicare hospital utilization and payment data (both inpatient andoutpatient) and the second annual release of the physician and other supplier utilization and payment data. The announcement was made at the annual Health Datapalooza conference in Washington, DC.

“These data releases will give patients, researchers, and providers continued access to information to transform the health care delivery system,” said acting CMS Administrator Andy Slavitt. “It’s important for consumers, their providers, researchers and other stakeholders to understand the delivery of care and spending under the Medicare program.”

The Medicare hospital utilization and payment data consists of information for 2013 about the average amount a hospital bills for services that may be provided in an inpatient stay or outpatient visit. The hospital data includes payment and utilization information for services that may be provided in connection with the 100 most common Medicare inpatient stays and 30 selected outpatient procedures at over 3,000 hospitals in all 50 states and the District of Columbia. The top 100 inpatient stays represented in the hospital inpatient data are associated with approximately $62 billion in Medicare payments and over 7 million hospital discharges.

The Medicare Part B physician, practitioner, and other supplier utilization and payment data consists of information on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals. The data also shows payment and submitted charges, or bills, for those services and procedures by provider. It allows for comparisons by physician, specialty, location, types of medical services and procedures delivered, Medicare payment, and submitted charges. The new 2013 dataset has information for over 950,000 distinct health care providers who collectively received $90 billion in Medicare payments. Hospitals, physicians, and other health care providers determine what they will charge for services and procedures provided to patients and these “charges” are the amount the hospital or provider generally bills for the service or procedure, but the amount paid is determined by Medicare’s physician fee schedule or other payment methodologies. CMS protects beneficiaries’ personal information in all its data releases.

“Data transparency facilitates a vibrant health data ecosystem, promotes innovation, and leads to better informed and more engaged health care consumers,” said Niall Brennan, CMS chief data officer and director of the Office of Enterprise and Data Analytics. “CMS will continue to release the hospital and physician data on an annual basis so we can enable smarter decision making about care that is delivered in the health care system.”

The Administration has set measurable goals and a timeline to move Medicare toward paying providers based on the quality, rather than the quantity, of care they give patients. These data releases are part of a wide set of initiatives to achieve better care, smarter spending, and healthier people through our health care system. Open sharing of data securely, timely, and more broadly supports insight and innovation in health care delivery.

Today’s data release adds to the unprecedented information recently released on Medicare Part D prescription drugs prescribed by physicians and other health care providers.

No comment yet.!

Four Medicare Misconceptions That Cost You Money

Four Medicare Misconceptions That Cost You Money | Healthcare and Technology news |

Conventional wisdom has it that what we "don't know we don't know" can present serious threats to our personal, professional, and corporate well-being and success. True as that may be, I think another subset of total knowledge is even more dangerous. It is that which we erroneously believe to be true. Decisions based upon misconceptions and misperceptions, in the absence of extraordinary good luck, always lead to sub-optimal outcomes.

Here are four examples applicable to physicians and their medical practices:

1. We don't take Medicare. The reimbursements are too low.

When a physician says this to me, I respectfully suggest she check her private payer contracts. (Most of the time, the physician has not read them.) Almost always, the physician learns two things: 1) Private payer reimbursements are tied to the Medicare allowable. 2) The private payer reimbursements are defined as "Medicare minus __ %."

2. We take Medicare, but the work behind meaningful use, PQRS, the value modifier, etc., are not worth the trouble. We come out ahead financially by taking the penalties for not participating.

This may be true, especially for those on the cusp of retirement, but there is no way to know without performing a comprehensive cost/benefit analysis.

An often-overlooked cost for nonparticipation in quality programs is that IPAs with the most favorable reimbursement contracts require participating physicians to report quality data, and to report it in specific media.

It also seems to be fairly certain that the private payers are letting Medicare pave the "pay-for-performance" road, and they will follow as the models mature.

3. My partner refuses to jump through Medicare's hoops, so there's nothing I can do.

Actually, there is. Meaningful use is evaluated at the individual provider level, as is PQRS. There is no systemic requirement that a physician cannot participate individually.

The Value Modifier (VM) actually provides an opportunity for a subset of physicians in a group to benefit the group as a whole. If the practice has not registered as a group for the taxpayer identification number (TIN) and at least half of the physicians billing under that TIN have successfully reported PQRS, the TIN is deemed to have successfully reported PQRS. That keeps the TIN from being automatically assigned the Low Quality/High Cost VM. If no Medicare beneficiaries are assigned to the group, which is at least possible and may be probable for specialty practices, the group is assigned the Average

Quality/Average Cost VM, meaning no payment adjustment for quality.

4. The PQRS measures don't apply to my practice, so I cannot report.

Physicians who say this usually mean that the recommended sets of measures, one for adults and another for children, do not apply to their practice. These sets are merely recommended. There are lots of measures and six different reporting mechanisms.

Sometimes physicians have trouble identifying nine applicable measures across three quality domains, with at least one cross-cutting measure for physicians who have face-to-face encounters with patients. This problem can be addressed by reporting at least one applicable measure within a measures group, as well as a cross-cutting measure. If the physician's Medicare claims history supports his assertion that he cannot report on the other measures in the group, he will be viewed as having successfully reported. (The devil here is in the details. Be sure to fully research this before trying it.)

I am convinced of four things:

• Medicine as a regulated industry is extremely complicated.

• It is only going to get more so.

• Understanding the rules is a bigger challenge than compliance.

What you don't know can hurt you. So can what you think you know that is wrong.

Sound bites and headlines cannot adequately inform you. And it is not likely that you have the time or inclination to dive as deeply as necessary into these topics. The most effective and efficient course of action is to make use of subject matter experts and require them to support their assertions with documentation.

No comment yet.!

Obamacare Penalty May Not Be High Enough For Middle Incomes

Obamacare Penalty May Not Be High Enough For Middle Incomes | Healthcare and Technology news |

Even though penalties under the Affordable Care Act for not having health insurance jumped significantly this year, they still might be too low to attract Americans to signup for subsidized coverage, a new analysis shows.

Avalere Health, a Washington health policy and consulting firm, said some middle income healthy individuals would rather pay the fine when they weigh it against spending a few hundred dollars more on insurance.

The fee increased to $325 per adult or 2% of income for 2015, according to That compares to a fee of $95 per adult or 1% of income for those who went without coverage last year.

“Individuals earning more than double the poverty level may continue to forgo coverage since paying the fine is still much more affordable than purchasing insurance,” Caroline Pearson, senior vice president at Avalere, told journalists during a panel discussion Friday on exchanges at the Association of Health Care Journalists annual meeting in Santa Clara.

Avalere looked at such a person for its analysis, citing a 27-year-old who makes $23,000 a year. Here’s a link to the analysis and cost comparisons to income.

“If he did not buy insurance, he would pay $230 in penalties – $619 less than if he had purchased coverage,” Avalere said in its report. “However, with mandate penalties rising in 2015, if the same individual chose to stay uninsured in 2015, he would spend only $391 more on insurance than if he had paid the penalty.”

With such scenarios likely common, it’s no wonder just 68,000 Americans took advantage of the recent special open enrollment period for those who didn’t enroll in the regular open enrollment period that ended in February and faced a penalty for not signing up for 2014 coverage.

“That lackluster uptake of the special enrollment period is driven, in part, because for most people individual mandate penalties are much lower than actual costs of coverage,” Avalere said in a statement accompanying its report.

No comment yet.!

Congress Approves Bill Eliminating 21 Percent Medicare Cut While Senate Delays Decision

Congress Approves Bill Eliminating 21 Percent Medicare Cut While Senate Delays Decision | Healthcare and Technology news |

A 21 percent cut in Medicare physician payments went into effect last week on April 1, 2015. While Congress passed legislation intended to eliminate the automatic cut that resulted from the Medicare Sustainable Growth Rate (SGR) formula, the Senate failed to take action before its current two-week spring recess. In response, last week the American Optometric Association (AOA) released a statement informing optometrists how they can attempt to avoid being impacted by the cut until further action is taken.
On March 26, Congress passed H.R. 2: the Medicare Access and CHIP Reauthorization Act of 2015 to prevent the automatic 21 percent payment cut for doctors who treat Medicare patients. The bipartisan bill would replace Medicare’s SGR formula with a new merit-based incentive payment system. However, while Congress approved the bill, the Senate will not vote on the measure until after it returns from its spring recess on April 13. This means that technically with no stopgap measure that the automatic 21 percent cut to Medicare physician payments took effect on April 1.
However, there is still time for physicians, including optometrists, to prevent having their reimbursements cut. The U.S. Department of Health and Human Services announced that it would hold off processing claims at the lower rate until April 15.
Also, according to the AOA’s statement: “ODs and other Medicare physicians are unlikely to immediately feel the impact of this cut. By law, the Centers for Medicare & Medicaid Services (CMS) may not process and pay claims any sooner than 14 days. CMS does have the option of delaying claims until the Senate acts on the bill. CMS plans to update providers by April 11. In the meantime, AOA has advised members to hold off on submitting April claims for as long as practical, giving Congress time to complete the legislative process on H.R. 2 and Medicare contractors the ability to implement new payment rates. No processing or payment delays should occur for claims submitted to Medicare that are dated March 31 or earlier.”

No comment yet.!

Senate Has New Deadline To Avoid Doctors' Medicare Cuts

Senate Has New Deadline To Avoid Doctors' Medicare Cuts | Healthcare and Technology news |

Congress will get a little extra time to prevent a threatened 21 percent cut in Medicare payments to doctors.

Technically, the cut was to take effect Wednesday.

But the Department of Health and Human Services said it will hold off processing claims at the lower rate until April 15.

The House has overwhelmingly passed a bill to repeal the 1990's budget formula that requires the Medicare cuts. But the Senate left on its spring break before taking action. President Barack Obama says he would sign the House bill.

The Senate goes back into session on April 13, giving it just two days to act.

If Medicare is forced to pay doctors at the lower rate, it would cover the difference later, assuming Congress acts.

But that could raise administrative costs.

No comment yet.!

Obama says he's ready to sign Medicare doctor payment fix

Obama says he's ready to sign Medicare doctor payment fix | Healthcare and Technology news |

President Barack Obama said Wednesday that he's ready to sign good bipartisan legislation to fix Medicare's doctor payment problem, without endorsing any specific legislation.

Without a fix, doctors face a 21 percent cut in Medicare fees, the consequence of a 1990s budget law that Congress has repeatedly waived.

The House is expected to vote Thursday on a bill with rare support from both top leaders in the House that would permanently fix the problem. Obama backed the idea of a fix at a White House event marking this week's five-year anniversary of his signing the Affordable Care Act, while stopping short of backing the House compromise.

"As we speak, Congress is working to fix the Medicare physician payment system. I have my pen ready to sign a good bipartisan bill," he said.

The House bills calls for a period of basically stable reimbursements, followed by gradually shifting a larger share of doctors' pay so that it's keyed to quality, rather than quantity, of service. The Medicare fix is packaged with an extension of children's health insurance, funding for community health centers and dozens of other provisions. The outlook in the Senate is unclear.

Drafted with the unusual support of both top leaders in the House — Speaker John Boehner for the GOP and Democratic leader Nancy Pelosi — the bill is aiming for the political center. That seemed to have collapsed on health care in the battles over President Barack Obama's overhaul.

The legislation is being criticized from the political right and the left. Conservatives don't like that most of the cost will be added to the federal deficit. Liberals object to higher premiums for upper-income beneficiaries, when drug companies are not being asked to share the burden through Medicare rebates.

Obama also announced a cost-cutting effort that the White House calls a Health Care Payment Learning and Action Network. The White House says more than 2,800 health care providers, patients and consumer groups have agreed to take part.

The goal is to tie more payments for health care services to the quality — not quantity — of services rendered. Earlier this year the administration set a goal to tie 30 percent of Medicare payments to quality and value, but Obama wants to go further.

"A central notion in the Affordable Care Act was we had an inefficient system with a lot of waste that didn't also deliver the kind of quality that was needed that often put health care providers in a box where they wanted to do better for their patients, but financial incentives were skewed the other way," Obama said.

"We don't need to reinvent the wheel — you're already figuring out what works to reduce infections in hospitals or help patients with complicated needs," Obama told health care providers gathered in the Eisenhower Executive Office Building next to the West Wing. "What we have to do is to share these best practices, these good ideas, including new ways to pay for care so that we're rewarding quality."

No comment yet.!

Will cuts to Medicare Advantage reduce quality?

The feds are at it again. Medicare is in the cross hairs with an anticipated 0.9 percent cut to Medicare Advantage plan payments in 2016. The final decision is to be made on April 6 of this year.

Medicare Advantage plans are an alternative to traditional Medicare. Traditional Medicare consists of Part A (hospital) and Part B (medical) coverage.  Medicare Advantage plans (Part C) can be chosen in place of the traditional Medicare option, for a price. That price is a monthly premium. The added cost is enticing to many seniors who need eyeglasses, hearing aids, dentures, and other services not covered by traditional Medicare. So enticing, in fact, that nearly 16 million Americans signed up for Medicare Advantage plans in 2014.

It is not hard to see why the government wants to cut back on expenses. They pay more per patient for Medicare Advantage than on traditional Medicare. That extra money goes not to the hospitals or doctors who care for patients, however, but to the insurance companies that sponsor these plans.

With the increasing number of baby boomers reaching Medicare eligibility age, Medicare Advantage has been a profit making venture for insurance companies. Now the government is threatening to cut payments to those insurance companies by 0.9 percent. That may not sound like much but multiply that by millions and the dollars quickly add up. How will the insurance companies respond when they are faced with a cut to their profit margin?

Medicare Advantage plans could decrease the number of services offered. If the intended goal is to offer more services than traditional Medicare, cutting services defeats the purpose of a Medicare Advantage plan. Seniors in the end lose out on necessary coverage.

Medicare Advantage plan premiums could increase. If Medicare Advantage plans become more expensive, fewer seniors will be able to afford the benefit at all. This will leave many seniors without the full breadth of services they need.

Medicare Advantage plans could decrease payments to physicians and health care providers. This could lead to fewer health care providers wanting to participate in Medicare Advantage. It hardly matters if seniors have expanded health care coverage if they cannot find somewhere to use it.

No matter what happens, Medicare beneficiaries are surely the ones who will pay if the cuts go into effect. With decreased breadth of Medicare Advantage plans, some seniors will be left with higher out-of-pocket expenses for uncovered tests and treatments, tests that they need. Some seniors are already so strapped for cash they have to choose between paying for their mortgage or paying for health care. It isn’t fair, not while insurance companies pocket a few bucks at their expense.

How do we solve this coverage problem? The answers are not easy in a capitalist society. The government wants to eliminate their deficit, and money waits to be made by for-profit companies. Perhaps the government could find other areas to cut services or better yet dictate that insurance companies not decrease their Medicare Advantage coverage options if they are to receive federal dollars at all. The risk is that could lead to insurance companies dropping out of Medicare Advantage altogether.

As we age, our medical needs increase. Seniors need access to care that will address those needs. They need quality care at a reasonable cost. Each swipe at Medicare makes it harder for American seniors to get by.  I can only imagine what the government has planned next.

No comment yet.!

Thinking of retiring? Learn about Medicare options

For those who are celebrating their 65th birthday, or have surpassed age 65, and are contemplating retirement, it’s time to think about Medicare and coverage options. Understanding Medicare and transitioning to new medical coverage can be confusing, and even seem overwhelming To help people understand their options, Sharp HealthCare is conducting free Medicare educational meetings.

Medicare expert Alicia Flynn will host the meetings, discuss commonly asked questions, and explain how to avoid financial penalties for delayed enrollment. The meetings will take place once monthly from 6-7:30 p.m. on Wednesdays at the Sharp Corporate Office Auditorium, 8695 Spectrum Center Blvd., San Diego.

Learn about Medicare Parts A and B, special enrollment requirements if you start using Medicare after age 65 and the difference between Medicare Advantage and Medicare Supplement Insurance plans. Experts will guide you step-by-step to enrollment and answer questions.

To register, call (800-827-4277) from 8 a.m.-6 p.m. Monday thru Friday. Free visitor parking is available from the lot entrance on Spectrum Center Boulevard.

For a full schedule of the sessions, go online to

Tips for controlling high blood pressure

High blood pressure or hypertension increases the risk of heart disease and stroke. Following are some tips to control high blood pressure:

• Aim for a healthy weight. Extra weight raises the risk of high blood pressure. Talk to your doctor to find out if you’re at risk.

• Increase your physical activity to at least 30 minutes of moderate activity such as walking on most days.

• Read nutrition labels and reduce sodium intake. Almost all packaged foods contain sodium. Use spices and herbs for seasoning foods at home in place of salt.

• Eat more fruits, vegetables, grains and low-fat dairy products.

• Consume alcohol in moderation.

No comment yet.!

Modernizing Medicare: An important first step

Modernizing Medicare: An important first step | Healthcare and Technology news |

The Medicare program is at a crucial juncture: it is responsible for 25 percent of all federal outstanding debt this century, and the total continues to grow. Every day, 10,000 newly eligible seniors enter a Medicare health insurance program whose budget needs are already escalating out of control. This path is simply unsustainable. 

Just as troubling is the fact that all those Medicare dollars are not delivering the top-quality health care that senior citizens deserve.  A quick look at how Medicare pays for care makes plain why this is so.  Under its antiquated “fee-for-service” approach, Medicare pays for services delivered, rather than for outcomes achieved.  We know that prevention and care coordination are essential, for instance, but the current payment system does little to encourage or reward this.  Since Medicare is the largest payer of medical bills in the United States, the poor incentives embedded in its fee-for-service approach set a subpar standard for care throughout the American health care system.

It’s past time for Medicare to be modernized. A sensible first step toward this objective is with post-acute care bundling – payment based on the treatment of an entire illness or injury, not each individual service provided. 

Over the next 10 years, Medicare is projected to spend nearly $1 trillion on medical treatment for seniors who have been discharged from a hospital. But what are we currently getting for all that money?  A study by the Alliance for Home Health Quality and Innovation showed that primary chronic conditions do not explain variation in Medicare payments across setting or clinical conditions. Many seniors are returning to the hospital while millions of others are receiving treatment that is not coordinated, is not of sufficient quality, and is not being delivered in the most clinically-appropriate and cost-effective settings. The fee-for-service approach costs Medicare money and seniors’ their health.

Research suggests that one way to approach reform would be to replace fee-for-service with condition-specific bundled payments modeled on the DRG system that hospitals have been using with great success for three decades. This would allow patients and their families to choose their own providers and networks to coordinate patient care for a period of time, such as 60 or 90 days following discharge from the hospital at a rate determined based on the patient’s clinical condition. If a patient returns to the hospital during that period, or if the cost of her care exceeded the amount of the bundle, the coordinator would bear the loss. If the patient’s needs were met effectively such that she didn’t need to be re-hospitalized and her costs were less than the bundle amount, the resulting savings would be split among the coordinators, physicians, discharging hospital, and the participating post-acute care providers.

This type of approach was effective in the past was the Department of Veterans Affairs’ Home Based Primary Care demonstration program, which used teams of health care providers to provide coordinated care for participating veterans with chronic and disabling conditions who needed more continuous care. This program was able to reduce days spent in hospitals by 62 percent, and overall care costs for this uniquely expensive population dropped by 24 percent.

Applying this type of program to Medicare would modernize it by rewarding participants for the delivery of high-quality, coordinated care in the most clinically appropriate, cost-effective manner possible. Different approaches to this reform have previously been proposed by Reps. David McKinley (R-W.Va.) and Tom Price (R-Ga.) and by Rep. Diane Black (R-Tenn.). Post-acute care bundling would simultaneously keep costs low while preventing risky hospital readmissions for seniors.

Taxpayers and the Medicare Trust Fund would likewise benefit.  This type of proposal could limit overall spending on post-acute care to a percentage of what those same services would cost in a fee-for-service setting without the need to make cuts to provider reimbursement. 

Modernizing Medicare is no longer an option – it’s an imperative.  Bundling post-acute care services is an important first step.

No comment yet.!

Expanding Medicare for all would be wise

Expanding Medicare for all would be wise | Healthcare and Technology news |

The U.S. Supreme Court is hearing another case attacking Obamacare (“Bad case against Obamacare,” editorial, March 4). This will not be the last.

The complexity of the Affordable Care Act makes it easy to attack. The 19,000 members of Physicians for a National Health Program, of which I am past president, agree it would be tragic, possibly fatal, for those with Obamacare subsidies to lose coverage.

But these attacks confirm that more durable and effective reform is needed. We would prescribe a constitutional remedy that is known to work — improved and expanded Medicare for all.

That would have many advantages over private insurance marketplaces. Medicare’s financing is fair — all contribute and all benefit, versus a marketplace of private insurance that will ration care by ability to pay. Medicare’s benefits are inclusive and generous, versus private insurance, which seems to be exclusionary, greedy, mean-spirited, and arbitrary.

Medicare for all would allow complete choice of providers, with access to services we prefer, versus private insurance with restricted provider networks and other barriers to care.

Medicare for all would focus on long-term improvements in the health of the nation with public accountability based on professional values, versus private insurance, which must focus on short-term profits, trade secrets, and commercial — and sometimes near-criminal — values. Multiple studies confirm that the simplicity of Medicare for all would save $400 billion a year — enough to cover all the uninsured and improve benefits for the rest of us.

We need to move on quickly from Obamacare. Improved and expanded Medicare for all will save money and save lives. It is the right thing to do.

No comment yet.