Regulator OKs healthcare deal

Below is an article from the Associated Press which appears in the Business Briefing Section of the Los Angeles Times dated June 21, 2016.  It discusses the acquisition of Humana by Aetna.

I believe that this limits consumer choice and will be harmful in the long run.

ASSOCIATED PRESS

A California regulator is approving Aetna Inc.’s proposed acquisition of rival health insurer Humana Inc.

Shelley Rouillard, director of the California Department of Managed Health Care, announced her decision Monday.

As a condition of the approval, Aetna agreed to limit premium increases in the small group market and to allow greater state oversight of its rates. The company will also have to keep certain decision-making functions in California and must invest in various health initiatives.

The proposed $35-billion cash-and-stock deal would make Hartford, Conn.-based Aetna a sizable player in the rapidly growing Medicare Advantage business, which offers privately run versions of the federally funded healthcare program for the elderly and some people with disabilities.

The merger still requires approval by the U.S. Department of Justice.

Aetna shares rose $1.24, or 1%, to close at $122.34 on Monday. Shares of Louisville, Ky.-based Humana climbed $2.75, or 1.5%, to $189.90.

Blue Shield Will Cancel All Grandfathered Plans On January 1, 2017

Your Blue Shield of California Grandfathered Individual and Family Medical Insurance Plan will no longer be available after December 31, 2016. You will be automatically enrolled in what Blue Shield considers to be an Affordable Care Act (aka Obamacare) plan that is similar to your current plan.

Starting January 1, 2017 you will qualify for a Special Enrollment Period which will allow you to switch to another company with an effective date of no later than March 1, 2017. Using the Special Enrollment Period may not necessarily be in your best interest, for example, if you use part of a Blue Shield deductible between January 1, 2017 and March 1, 2017, this amount may not carry over to another company. A similar situation may exist with the Maximum Out of Pocket limit.

We should discuss your plan change within Blue Shield or to another company during Open Enrollment which begins on November 1, 2016 for an effective date of January 1, 2017. I will be sending an e mail in the middle of October to set up phone appointments to discuss all your options.

Blue Shield will be notifying you beginning this month.

 

 

Costs top healthcare concerns

This article from the Los Angeles Times, dated June 11, 2016 indicates that the cost of healthcare is a primary concern for our country. It also indicates that there is much confusion regarding Obamacare.

In my opinion the cost of healthcare will decrease significantly when physicians understand nutrition, exercise and psychological well being and will be able to effectively communicate this to patients. Everyone must be responsible for incorporating this in their lives.

USC DORNSIFE/LOS ANGELES TIMES POLL
Costs top healthcare concerns
A poll finds state residents more worried about rising prices than access.
BY DAVID LAUTER
WASHINGTON — Six years after President Obama signed the Affordable Care Act, the health reform law has gained acceptance from a majority of California voters, but the cost of getting healthcare remains a major concern, eclipsing worries about having insurance, according to a new USC Dornsife/Los Angeles Times poll.

The widespread worry about costs indicates a potential shift in the debate over healthcare, at least in this heavily Democratic state.

Nationally, the political debate has been stuck for most of the last six years on Republican efforts to block Obamacare, but that gridlock could lessen after the election.

In both parties, lawmakers increasingly have been hearing complaints from their constituents about the cost of care, and polls have found that prescription drug prices, surprise medical bills and other pocketbook issues concern voters more than the future of the health law.

Echoing that national trend, almost two-thirds of voters in the USC/Times survey say they worry “very much” about rising health costs, with only 10% saying that is not something they worry about.

Just slightly more than half say that lack of insurance is something they worry about a lot, and roughly three in 10 say they were not worried about it.

Latinos, however, were an exception, reporting equal levels of unease about cost and having insurance — three-quarters said they were very worried about each.

Cost concerns were most widespread among those in their 50s and early 60s. Indeed, that age group consistently showed the highest levels of anxiety on a series of healthcare concerns.

By contrast, those over age 65, most of whom are covered by Medicare, were the least likely to express worry about healthcare issues.

For a significant number of voters, the healthcare law itself takes blame for rising costs. Just over half of those surveyed said they believed that costs for average Americans have “gone up a lot” because of the law, compared with roughly one-third who said that the law had not caused that to happen.

As with many aspects of the healthcare debate, partisanship plays a big role in shaping beliefs about rising costs: Republicans by overwhelming margins blame the law, while Democrats were split closely on whether it’s responsible.

Most Americans have been forced to confront increased costs for health coverage for years — a trend that began long before the passage of the reform law.

Employers have continued to shift costs to their workers, mostly in the form of higher deductibles and co-payments. Although those higher costs may not have been caused by the new law, many blame it.

The law clearly has raised costs for one relatively small slice of Americans — mostly healthy, self-employed people with middle-class or higher incomes who were previously able to buy low-cost policies on the private market.

The new law requires those people to buy more comprehensive policies, which provide greater coverage, but at a higher price. Covering sicker customers who used to be denied insurance has also led insurers to raise some premiums.

Low- and middle-income Americans get subsidies under the law that lower their monthly premiums, but higher-income Americans do not.

More than three-quarters of California voters acknowledge the biggest effect the law has had — reducing the number of Americans who lack health coverage. By 77% to 15%, voters said that the law had achieved that goal.

Since the new law’s coverage expansion began in 2014, some 20 million previously uninsured Americans have gained coverage, and the share of American adults under age 65 who are uninsured has dropped from one in five to about one in eight, according to numerous private and government surveys.

But on that point, too, partisanship colors perceptions. Among Republicans, 28% in the current survey said that the new law had not led to more people having insurance. Among Republicans who identify with the tea party, 48% took that view, compared with 31% who said the law had reduced the number of uninsured.

The public’s view remains split on another of the law’s major accomplishments, as well — ending the ability of insurers to deny health coverage because of preexisting health conditions. The poll found 59% of voters saying that coverage could no longer be denied, while 21% said that had not happened.

On that question, the division did not appear primarily partisan. Instead, some of the groups whom the new law was designed to help most appeared least aware of one of its central elements.

Latinos, those younger than 30 and people with incomes under $30,000 were all less aware of the change regarding preexisting health conditions than whites and those who were older or more affluent. Among Latinos, for example, though 48% said the law had accomplished that goal, 30% said it had not.

That lack of awareness of one of the law’s main achievements marks a “messaging failure” by the law’s supporters, said Anna Greenberg, the Democratic pollster whose firm forms half of the bipartisan team that produced the survey for USC and The Times.

The White House and its allies have struggled at times to convey a message about the law, in part because for many Americans, it remains an abstraction.

Just over half of those surveyed said the law had no effect on themselves or their families. That’s by design: The law was written to cover the uninsured while minimizing the effect on people who get coverage through their jobs, as most working-age Americans do.

That has cost Obama politically. The views that most Americans have of the law have been shaped less by direct experience than by partisanship, according to Drew Altman, the president of the Kaiser Family Foundation, which has carefully tracked opinion about the health law.

Only about four in 10 of those who supported the law in the poll also said it had made their own families’ healthcare better.

Overall, 53% of the state’s voters favor the law, with 31% favoring it strongly. An additional 12% said they opposed it because it did not go far enough, while 27% said they opposed it because it went too far.

Those who said the law did not go far enough do not consistently back liberal views on how to replace it.

Only 40%, for example, supported a single-payer system — the sort of healthcare solution advocated by Sen. Bernie Sanders in his campaign for president.

By contrast, those who support the law backed the single-payer idea 69% to10%. Overall, just over half of the state’s voters supported it, with about one-quarter opposed.

The state’s voters divided evenly on the question of whether to repeal the law’s requirement that people have insurance.

Opinion on that question split along predictable partisan lines with one significant exception — Latinos, who generally back the law, also supported repeal of the mandate, by 57%-37%.

Most California voters have a positive view of their own healthcare and a somewhat positive view of healthcare in the state, the poll found. Seven in 10 rated their own healthcare as “excellent” or “good” while just under three in 10 called their care “fair” or “poor.”

Ratings were highest among those earning more than $100,000 a year and among those aged 65 and older, which reflects the generally positive view that Americans have of Medicare.

Asked about the state of healthcare in California, 44% called it excellent or good, while 34% said fair and 14% poor.

Ratings were gloomier about healthcare nationwide, with only 30% calling it either excellent or good, 39% fair and 25% poor.

The poll for the USC Dornsife College of Letters, Arts and Sciences and the Los Angeles Times was conducted jointly by the Democratic firm Greenberg Quinlan Rosner Research and the Republican firm American Viewpoint. It questioned 1,500 registered California voters from May 19-31. The margin of sampling error is 2.9 points in either direction for the full sample. david.lauter

@ latimes.com  .
DAVID BUTOW For The Times

 

Strengthening the Marketplace – Actions to Improve the Risk Pool

Below are recommendations from the Centers for Medicare and Medicaid Services. The goal is to improve the risk pool and therefore rates and benefits for Affordable Care Act Plans.

It is noteworthy to read the information on Short Term Medical Plans below which might cause discontinuation of these plans.

Date

2016-06-08

Title

Strengthening the Marketplace – Actions to Improve the Risk Pool

Contact

press@cms.hhs.gov

Strengthening the Marketplace – Actions to Improve the Risk Pool

With millions of Americans insured through the Health Insurance Marketplaces, it’s clear that Marketplace coverage is a product consumers want and need and an important business for insurers, with several major issuers expanding their Marketplace presence.  At the Department of Health and Human Services (HHS), we are constantly monitoring the health of the Marketplace and are always looking to make improvements that benefit both consumers and issuers. Over the past several months, HHS has taken a series of actions to strengthen the Marketplace risk pool, limit upward pressure on rates, and ensure a strong Marketplace for the long term. We believe those actions are bringing positive results. As part of our continued commitment to the long-term strength of the Marketplace, we are announcing new measures to ensure that the Marketplace continues to provide affordable coverage for millions of Americans.

During the month of June, HHS will make three announcements regarding our ongoing efforts to: strengthen the risk pool by spreading the costs of care over a diverse mix of enrollees, work with issuers and state Departments of Insurance to improve coverage options, and step up Marketplace outreach, especially to young adults and uninsured families in advance of Open Enrollment 4.

Today, HHS is announcing a series of actions to strengthen the Marketplace risk pool. These actions include:

·         Curbing abuses of short-term plans that exploit gaps in current rules to use medical underwriting to keep some of the healthiest consumers out of the Affordable Care Act’s single risk pool.

·         Improving the risk adjustment program to more accurately reflect the cost of partial-year enrollees and to incorporate prescription drug utilization data that provide a more complete picture of enrollees’ health status. These improvements will ensure that the program continues to work as intended to compensate issuers with higher-risk enrollees and thereby help issuers sustainably serve all types of consumers.

·         Helping consumers who turn 65 make the transition to Medicare, so that older consumers are served by the program designed for them and their health needs.

·         Beginning full implementation of the Special Enrollment Confirmation Process, which ensures that eligible individuals continue to have access to coverage through Special Enrollment Periods (SEPs), but prevents people from misusing the system to enroll in coverage only if they get sick.

·         Continuing our efforts to reduce data-matching issues (DMIs). CMS outreach, education, and operational improvements have contributed to a sharp reduction in total data matching issues generated and an almost 40 percent year-over-year increase in documents submitted to help resolve income and citizenship and immigration data matching issues. Improving the resolution of DMIs benefits the risk pool because it keeps eligible consumers, often younger and healthier consumers less motivated to overcome obstacles such as extra paperwork, from losing coverage mid-year.

Risk Pool Actions

Curbing Abuse of Short-Term Limited Duration Plans
Short-term limited duration coverage is health care coverage issued for a short period of time.  Because short-term limited duration plans are designed to fill only very short coverage gaps, this coverage is not subject to any of the key rules governing the ACA’s single risk pool: they can be priced based on health status (medically underwritten), can discriminate against consumers with pre-existing conditions, and do not have to cover essential health benefits.  Some issuers are now offering short-term limited duration plans to consumers as their primary form of health coverage for periods that last nearly 12 months, allowing them to target only the healthiest consumers while avoiding consumer protections. As highlighted in recent press accounts, by keeping these consumers out of the ACA single risk pool, such abuses of limited duration coverage increase costs for everyone else, and they could have a greater impact over time if allowed to become more widespread.

Today, the Department of Labor, Department of Treasury, and Department of Health and Human Services (HHS) issued a proposed rule to revise the definition of short-term, limited duration coverage.  Under the new rules, short-term policies may be offered only for less than three months, and coverage cannot be renewed at the end of the three month period. The proposed rule also improves transparency for consumers by requiring issuers to provide notice to consumers that the coverage is not minimum essential coverage, does not satisfy the health coverage requirement of the ACA, and will not prevent the consumer from owing a tax penalty. The proposed changes will help strengthen the risk pool by ensuring that short term limited duration plans are used only as intended, to fill truly temporary gaps in coverage.

Maturing the Risk Adjustment Program
By reducing incentives for issuers to try to design products that attract a disproportionately healthy risk pool, risk adjustment lets them design products that meet the needs of all consumers, protecting consumers’ access to a range of robust options.  Updating risk adjustment to more accurately assess every enrollee’s risk makes it more effective in achieving this goal. Earlier this year, CMS made a number of changes to improve the stability, predictability, and accuracy of the risk adjustment program for issuers. These changes include better modeling of costs for preventive services, changes to the data update schedule, and earlier reporting of preliminary risk adjustment data where available.  We also published a Risk Adjustment White Paper and hosted a conference on March 31, 2016 to solicit feedback from issuers, consumers, and other stakeholders on additional areas for improvement.

Building off the Risk Adjustment White Paper and stakeholder feedback, today we are announcing two additional important changes to risk adjustment that we intend to propose in future rulemaking. First, we intend to propose that, beginning for the 2017 benefit year, the risk adjustment model include an adjustment factor for partial-year enrollees.  By more accurately accounting for the costs of short term enrollees in ACA-compliant risk pool, this change will support the Marketplace’s important role as a source of coverage for people who are between jobs, experiencing life transitions, or otherwise need coverage for part of the year.  Second, we intend to propose that, beginning for the 2018 benefit year, prescription drug utilization data be incorporated in risk adjustment, as a source of information about individuals’ health status and the severity of their conditions.  We are also considering proposing additional changes to the model for 2018 and beyond.

Transitioning Consumers to Medicare
The Marketplace serves as an essential backstop for consumers as they transition between different types of coverage over their lifetime.  For example, many early retirees access Marketplace coverage until they become eligible for Medicare when they turn 65.  But once individuals turn 65, most people should end their Marketplace coverage and switch to Medicare.  In fact, if consumers do not enroll in Medicare Part B when they turn 65, they could face financial consequences for years into the future, because they could owe higher Medicare premiums.  Meanwhile, the Marketplace is intended to serve consumers who are not Medicare eligible, and continued enrollment by individuals who are eligible for Medicare can raise costs for other consumers.

To make sure consumers understand the steps they need to take to move to Medicare, this summer the Marketplace will start contacting enrollees as they near their 65th birthday. This outreach will provide consumers with the information they need to enroll in Medicare if they are eligible and end their Marketplace coverage if they choose to.   This builds off the changes we made to the HealthCare.gov application this year which included new pop ups with reminders for consumers who are about to turn 65 that they may be eligible for Medicare.

Implementing the Special Enrollment Confirmation Process
Over the last several months, the Marketplace has taken a number of steps to ensure that Special Enrollment Periods (SEPs) are there for consumers when they need them while avoiding misuse or abuse.  We’ve strengthened our rulesand clarified our processes for SEPs, so that the people who need to can still easily get coverage, while making it hard for anyone thinking about taking advantage. We also eliminated 7 SEPs, including the SEP for individuals who paid the tax penalty for not having health insurance, contributing to an almost 30 percent year-over-year drop in the number of SEP enrollments during the three months after Open Enrollment.

Continuing that work, today we are announcing that, consistent with the process we announced in February, starting June 17 individuals enrolling in coverage through Special Enrollment Periods will be asked to provide certain documents. We are also providing models of the eligibility notices that consumers will receive with the list of documents that people enrolling through a Special Enrollment Period will need to prove their eligibility for their SEP. Consumers should provide the appropriate documents by the deadline listed in their notice to confirm eligibility for a Special Enrollment Period to avoid any disruptions to their coverage.

Reducing the Impact of Data Matching Issues
CMS takes very seriously its obligation to ensure that access to coverage and financial assistance are limited to those individuals who are indeed eligible.  The Marketplace verifies eligibility for most consumers through electronic trusted data sources, but if consumers’ data cannot be matched electronically we generate a data matching issue to request additional information from enrollees.  Consumers who do not provide the necessary information will have their coverage or financial assistance ended or modified.

Unfortunately, eligible individuals sometimes lose coverage or financial assistance through the Marketplace during the year because they have trouble finding documents or navigating the data matching process. In addition to the direct impact on consumers, avoidable terminations due to data-matching issues also negatively impact the risk pool, since younger, healthier individuals appear to be less likely to persevere through the data matching process. In fact, in 2015, younger open enrollment consumers who experienced a data matching issue were about a quarter less likely to resolve their problem than older consumers.

This year, CMS made a range of improvements to the data matching process to help consumers avoid generating data matching issues in the first place and to help them resolve these issues once generated.  More recently, we have also intensified our outreach, and partnered with issuers so that they are reaching out to consumers about data-matching issues as well. These efforts are beginning to pay off, with a sharp reduction in total data-matching issues generated and an almost 40 percent year-over-year increase in the number of documents consumers have submitted to resolve these issues. Continued progress in this area should benefit both directly affected consumers and other consumers who will benefit from a stronger risk pool.

 

Healthcare part of retirement planning

This article appears in the Los Angeles Times Personal Finance Section dated May 29, 2016.

The discussion is about saving for healthcare, both Medicare and Long Term Care during retirement.

Dear Liz: You’ve been writing about how much to save for retirement, including how much of our incomes we should aim to replace with our savings. Two more reasons to shoot for a higher replacement rate are the possibilities that medical needs will be higher the older one becomes (even with Medicare and a supplemental plan) and that long term care will take a huge bite out of savings if one self-insures for this. My wife and I took these into account when we saved as much as we could afford during our working years.

Answer: Many people erroneously believe that Medicare will take care of their healthcare costs in retirement. In reality, Medicare generally pays for about 60% of typical healthcare services, according to the Employee Benefit Research Institute. Fidelity Investments estimates that the typical couple at age 65 can expect to spend $245,000 on healthcare throughout retirement. That figure doesn’t include the costs of nursing homes or long-term care, which also aren’t typically covered by Medicare. Saving for these expenses was a smart move.

Firm Accused of Bilking Medicare

From the Los Angeles Times Business Section, dated May 26, 2016

Firm bilked Medicare, U.S. says
Justice Department joins whistle-blower case accusing Prime Healthcare of overbilling.
BY PAUL SISSON
The U.S. Justice Department has joined a whistle-blower case against Prime Healthcare Services, adding significant weight to allegations of widespread Medicare overbilling at 14 of the company’s hospitals in California.

A Los Angeles magistrate judge granted the agency’s request to intervene in the case Tuesday, one day after the government declared in a court filing that its investigation of the Ontario- hospital operator has “yielded sufficient evidence” that the facilities “submitted or caused the submission of claims to Medicare for unnecessary inpatient stays.”

Prime finds itself under federal scrutiny because of a whistle-blower complaint submitted in 2011 by Karin Berntsen, a registered nurse and director of quality and risk management at Alvarado Hospital in San Diego. Berntsen’s lawsuit accuses Prime of routinely making Medicare patients’ illnesses seem more severe than they really were in order to justify billing for additional services and increasing hospital admissions.

Berntsen alleged that this practice occurred not only at Alvarado but also at 13 other Prime properties. Most of these hospitals are in Southern California, including Centinela Hospital Medical Center in Inglewood, Encino Hospital Medical Center, Sherman Oaks Hospital and Huntington Beach Hospital.

Berntsen’s litigation estimates the total amount of overbilling at $50 million, an amount that now could result in a significant financial payoff for her — and potentially large damages against the company.

Anti-fraud statutes allow fines of $5,500 to $11,000 — plus triple damages under certain circumstances — for each false or inaccurate bill submitted by hospitals and other healthcare companies . Whistle-blowers are entitled to 15% to 25% of the money recovered in cases involving the Justice Department.

In 2012, for example, pharmaceutical giant GlaxoSmithKline agreed to pay $2 billion to the federal government to resolve accusations that it overbilled for the prescription drugs Paxil, Wellbutrin and Avandia. In 2006, Tenet Healthcare was crippled after paying $900 million in a case involving alleged Medicare bill-padding, kickbacks and changing of billing codes to obtain higher reimbursements.    Prime has denied Berntsen’s allegations, calling them “speculative nonsense” after her complaint was unsealed in 2013.

In a new statement issued after the federal government’s intervention, the company was a bit more subdued. It said Medicare billing is complex and that there is a “lack of clarity between what federal regulators and physicians believe is necessary to adequately document medical necessity for hospital admissions.”

Prime also said its hospitals have successfully undergone Medicare billing audits conducted by an array of organizations, including the Joint Commission, the Healthcare Facilities Accreditation Program, the California Department of Public Health and government “recovery audit” contractors who are rewarded for spotting billing irregularities. The company currently owns 43 hospitals across14 states.

“Over 600 medical records that were appealed to the Administrative Law Judges and Medicare Appeals Council, all had rulings in Prime Healthcare’s favor, with no exception,” Prime’s statement said. “Given this precedence of successful appeals on thousands of claims, Prime Healthcare is confident it will prevail and ultimately be exonerated.”

But the Justice Department in a wide-ranging investigation referenced in its court filing this week cited “multiple witnesses who have worked at different Prime hospitals” who told the government that Dr. Prem Reddy, Prime’s chairman, president and chief executive, criticized emergency department physicians and demanded “their termination if he decided they were passing up opportunities to cause the admission of Medicare beneficiaries.”

The agency said those witnesses also accused Reddy of requesting “increased work schedules for [emergency department] doctors whose patients had a relatively high rate of admission,” of decreasing or discontinuing such shifts for physicians with low rates and of telling emergency department doctors “to find a way to admit all patients over 65 because they all have insurance.”

In contrast, the government said, Reddy allegedly worked to minimize hospital stays for uninsured patients — instructing that they should stay in the emergency department for only six to eight hours to get test results and then be discharged.

The Justice Department also cited the results of a Medicare contractor’s review of the company’s hospital admissions that “put Prime on notice of the same pattern of seemingly unnecessary inpatient admissions.”

Kathleen Clark, a Washington attorney who is an expert on the False Claims Act that governs whistle-blower cases, said the government’s involvement raises the stakes, given that federal regulators participate in only about one-quarter of such cases.

“It is actually quite significant when the government decides to intervene in one of these cases. The government brings to bear significant investigatory resources and leverage,” Clark said. “Intervention is seen not as a guarantee of a win, but it’s a very good sign for the whistle-blower and [his or her] lawyers.”

Marlan Wilbanks, an Atlanta attorney who is one of several lawyers representing Berntsen, said the government’s involvement could turn up additional evidence in the case disproving Prime’s assertion that previous audits proved the company’s billing practices are sound.

“Those entities were not designated to look for fraud,” he said. “Prime was given the benefit of the doubt. However, those entities did not have the evidence and the documents that the government and [Berntsen’s party] now possess.”

It’s unclear how long the legal discovery phase might take, especially because the Justice Department’s intervention will likely spur a series of procedural adjustments in the case. paul.sisson

@ sduniontribune.com

Medicare for More

The following article from the Atlantic states that lowering of the Medicare age from 65 to a younger age might infuse needed money into the Medicare system. Additionally, rates for those who are younger and not Medicare eligible might benefit if older sicker people enroll in Medicare. All will depend on the healthcare needs of those who are shifted around.

Hillary Clinton’s new proposal to expand coverage for middle-aged adults provides a glimpse at how she would make Obamacare her own.

VANN R. NEWKIRK II

MAY 23, 2016

What’s the next step for Obamacare? Much of the 2016 presidential race functions as a referendum on just what to do with the the six-year-old Affordable Care Act. Despite some mixed returns on costs and the stability of insurance markets, the health-reform law has brought the uninsured rate to its lowest point in American history. Reflecting that mixed legacy, most Americans now favor modifications to the ACA over continuing to implement it as it is or repealing it.

LATEST FROM POLITICS
That puts most Americans on the opposite side of whatever Donald Trump’s health care plan might be. But both Hillary Clinton and Bernie Sanders have plans to modify and expand Obamacare. Sanders’s plan of “Medicare for All,” a radical overhaul of the current system based on a single-payer system, has received most of the attention. Clinton’s more modest proposals to expand tax credits and allow undocumented immigrants access to health-insurance marketplaces have garnered less press. But recently, Clinton has made waves with a new idea to allow people over 50 or 55—the specifics have not yet been announced—to purchase Medicare plans.  At present, only those over 65 and a select few of their dependents are eligible for Medicare. This “Medicare for More” concept is a significant addition to the Clinton health plan, but what does it mean for the future of Obamacare?

A new report from Avalere extrapolates what it might mean for the future of 50-somethings. There are about 13 million people between the ages of 50 and 65 who are either uninsured or have purchased private insurance on the Obamacare marketplaces. This population represents most people in the age range without affordable employer- or group-insurance coverage and who don’t qualify for Medicaid. Assuming that this is the population that would be eligible for Clinton’s Medicare for More, Avalere reports that it is “unclear” if Medicare would automatically be a good deal for them.

With no knowledge of premiums or subsidies yet, a Medicare buy-in might just be too costly for those uninsured adults above 50 who have low incomes but are ineligible for Medicaid because of state rules. For those in private plans, Medicare has a distinct number of cost disadvantages, including a 20 percent cost-sharing requirement, no lifetime cap on out-of-pocket expenditures, and drug benefits that are generally less generous. Also, it is unclear if people under 65 could qualify for the Medicare Advantage plans that help fill in gaps in coverage. Sicker elderly adults regularly run up against the limits of Medicare, and it is hard to envision cases in which Medicare would make more financial sense for near-elderly adults with serious chronic illnesses than medium-cost marketplace plans.

Medicare for More is a step away from Clinton’s position as a defender of President Obama’s legacy and towards her central policy identity as an architect of American health policy.

But Medicare has always been a good deal for those who don’t use many health-care services, and it might beat out low-cost marketplace plans for healthy adults between 50 and 65 with few health problems. Medicare provides access to one of the broadest networks of physicians, providers, and benefits possible, and consumers value continuity. A buy-in at 50 could allow people to remain on the same insurance coverage with the same providers for the rest of their lives. Also, while Medicare has not been shown to have a serious effect on health trajectories for uninsured adults who become enrollees at age 65, at age 50 it might provide services early enough to change outcomes. Medicare also provides protection against medical debts, and if premiums could be made affordable to uninsured adults over 50, it could have serious value as health issues mount with age.

Medicare for More might have more value to the Medicare program than to any individual beneficiary. People between 50 and 65 are healthier than those over 65, and many of the costs that penalize high utilization can be seen as offsets for having to cover the most expensive population in the country. Even for Medicare, which has broad power to affect prices and policy, covering services, visits, drugs, surgery, and hospital stays costs money, and as patients near costly end-of-life holding patterns, the cost curve skyrockets. Adding healthier, younger people to the risk pool might bring down the per-person costs of the program. If the subsidies are equivalent to marketplace subsidies, premiums and savings from the over-50 crowd could actually cut back net costs for the Medicare albatross. Removing more middle-aged adults from marketplace risk pools might actually make insurance cheaper for young adults as well.

The results of a Medicare buy-in for potential beneficiaries and the program will likely depend on specifics as detailed by the Clinton campaign, but its rhetorical value is much more readily assessed. Allowing private purchase of one of America’s two big public-insurance programs is an addition to Obamacare’s willingness to blur the lines between public and private insurance, risk, and public-health responsibility. The proposal gives Clinton ammunition both against Sanders in the primary and, should she win, Trump in the general.

But above all, Medicare for More is a step away from Clinton’s position as a defender of President Obama’s legacy and towards her central policy identity as an architect of American health policy. Obamacare could very well be a platform for Clinton to achieve some of the goals that remain unfulfilled from the 1993 health plan that she spearheaded. Combined with some recent support from Clinton for the idea of a public option, a Medicare buy-in can be seen as a very Clinton-esque way of using the market to provide universal care. The free market solution to coverage, along with the major expansion of Medicare as a coverage pathway for non-elderly adults, is reminiscent of the ‘93 plan, and the population that it impacts is massive. Medicare for More would also cement Obamacare as the foundational law of all of American health policy, and establish a regime of incrementalism not unlike the coverage shifts seen in the decades between Medicare and Obamacare. The proposal might open the door for other shifts, such as allowing even younger people or government employees Medicare buy-ins.

For those further to Clinton’s left, however, Medicare for More might close the door for hopes of more radical overhauls while the figurative iron is still hot and while the ACA is still a hotly debated law. Sanders’s plan rests on frustrations about the compromising nature of the Affordable Care Act, which whittled down some of the more ambitious coverage plans in favor of  a market-based solution that still leaves millions uninsured. The current Obama-Clinton doctrine of health-care views zero uninsurance as a lofty and likely unreachable goal more than a first-order cause. Much of Sanders’s momentum with Medicare for All comes from the fact that the liberal benchmark––a universal public option supported by high, progressive taxes––has still not been reached. Clinton’s incrementalism would in all likelihood reset the clock on that dream.

Medicare for More isn’t Sanders’s Medicare for All, and it certainly isn’t what many Sanders supporters are looking for, but it is a step for Clinton and would be a significant addition to the massive impact of Obamacare. If Clinton does wind up in the White House, it could be the beginning of a piecemeal process to bring the ACA closer and closer to its originally intended ideal of universal coverage, as Obamacare is a perfect platform for incremental increases in coverage. Now, it is another sign that the work of providing coverage and making the health care system more affordable and better is not yet done.

The Cost of Long Term Care

Long Term Care costs are rapidly rising as well as the premiums for Long Term Care Insurance. Delay in purchasing insurance results in higher premiums and decreased benefits.

Below is an article from the Associated Press, appearing the Business Section of the Los Angeles Times dated May 11, 2016.

Long-term care costs climbing
ASSOCIATED PRESS
Long-term care grew more expensive again this year, with the priciest option, a private nursing home room, edging closer to $100,000 annually, according to a survey from Genworth Financial Inc.

Americans also are paying more for home health aides and assisted living communities, but adult day-care costs fell slightly compared with last year, Genworth said in a study released Tuesday.

Private nursing home rooms now come with a median annual bill of $92,378, up1.2% from last year and nearly19% since 2011. That’s roughly twice the rate of overall inflation.

Genworth sells long-term care coverage and did not address that cost in its study, which was based on information from 15,000 long-term care providers.

Such coverage is pricey too. “It’s really becoming more and more difficult for the average family to even purchase long-term care insurance,” said Joe Caldwell of the National Council on Aging.

Medicare doesn’t cover long-term stays, so many people who need that coverage end up spending down their assets until they qualify for Medicaid, the government’s health insurance program for the poor.

Even semi-private nursing home rooms cost $82,125 annually, up nearly 17% over the last five years, according to the survey.

Nursing home costs are rising largely because residents are more likely to arrive with chronic conditions such as diabetes or emphysema that need more medical attention, said Greg Crist, a spokesman for the American Health Care Assn., a trade group for nursing homes.

The survey found that the median annual cost for assisted living communities adds up to $43,539 this year.

Medicare Fraud is a Big Concern

Below is an article from the Los Angeles Times, dated Saturday May 7, 2016 which addresses the conviction of two doctors.

2 doctors found guilty of fraud

The pair tried to steal almost $9 million in hospice scheme, prosecutors say.

BY JASON SONG

Two Southern California doctors were found guilty this week of falsely certifying that their patients were terminally ill as part of a larger scheme to bilk Medicare and Medi-Cal out of $8.8 million in hospice-related services, according to federal prosecutors.

Sri “Dr. J” Wijegoonaratna, 61, of Anaheim was convicted of seven counts of healthcare fraud and Boyao Huang, 43, of Pasadena four counts after a two-week trial.

Prosecutors said the scheme involved Covinabased California Hospice Care, where employees paid so-called marketers to recruit Medicare and Medi-Cal beneficiaries. The patients were assessed by nurses to determine whether they were terminally ill, according to federal prosecutors.

Prosecutors argued that regardless of the assessments, Wijegoonaratna and Huang certified that the patients were dying, even though most were not. The certifications were then used to submit bills for unnecessary hospice-related services, prosecutors said.

“In fact, only a small percentage of patients died — notwithstanding the two doctors declaring they needed hospice care,” said Eileen M. Decker, the U.S. attorney for the Central District of California.

Prosecutors said also that Wijegoonaratna recruited some patients into the scheme and received tens of thousands of dollars in kickbacks. The California Medical Board has revoked his medical license.

The scheme was shut down in June 2013, according to prosecutors.

Wijegoonaratna and Huang will be sentenced Aug. 15 and face a maximum sentence of 10 years in prison for each count. Four other defendants have already pleaded guilty.

Jason.Song@latimes.com   Twitter: @byjsong

Medicare Physician Reimbursement Proposal Could Reduce Number Of Practices.

Many doctors are leaving the Medicare system due to low reimbursements. Will additional costs drive more away?

Below is an article from Modern Health Care

Docs face stark choices under new Medicare pay proposal

By Beth Kutscher  | April 30, 2016

The new draft regulations designed to change how Medicare pays clinicians represent the most sweeping overhaul the CMS has made in a long time to the business of running a physician practice.

The goal is to have the vast majority of CMS funding flow through payment models that reward doctors for the quality of care they deliver, not just how many patients they see.

The changes have the potential to upend the way medicine is practiced today, accelerating the move toward hospital employment and making the small group practice a thing of the past. At the very least, the rule, once finalized, will inspire closer collaboration between doctors and hospitals, since physicians will have more incentives than ever to steer patients away from high-cost medical centers.
The CMS’ 962-page proposed rule is the first major step in hashing out the details of physician payment that Congress outlined in the Medicare Access and CHIP Reauthorization Act, the 2015 legislation that replaced the controversial sustainable growth-rate formula.

RELATED STORIESSidebar: Medicare’s new quality program targets measurement fatigue

Sidebar: How Medicare’s new payment overhaul tries to change how docs use tech

In its attempt to move more physician payments through value-based arrangements, the CMS is combining three existing programs into a new Quality Payment Program.

Clinicians will have to choose one of two paths: submit to the Merit-based Incentive Payment System (MIPS), or put a significant portion of their business into a qualifying Alternative Payment Model (APM).

Both carry financial risk for failing to meet program goals. The potential impact on physicians’ Medicare revenue under MIPS—which will apply to the vast majority of clinicians—would be as high as 4% in the first year, rising to 9% in subsequent years. The program goes into effect in 2019, but the first performance period begins on Jan. 1, 2017.

“This really is a defining piece of legislation for how we pay for healthcare in America,” said David Muhlestein, senior director of research and development at consulting firm Leavitt Partners. “It changes the expectation of what practicing medicine is. It’s increasing the scope of responsibility for physicians.”

Even though Medicare spending on inpatient services was nearly double the amount spent on physicians, according to 2014 data, the rule makes it clear that physicians will increasingly be the ones held accountable for keeping hospital expenditures in check.

That contrasts with the old way of paying for medical services, in which the person or entity performing a service also controlled the revenue.

“What’s important is not just what the costs are, but who is responsible for those costs,” Muhlestein said. Clinicians “now have all sorts of incentives to steer people away from the hospital.”

Physicians are likely to respond by fleeing to hospital employment, large independent group practices or joint ventures with hospitals. “This will hasten the demise of the very small physician practice,” Muhlestein said.

Another element of the rule that puts pressure on physicians is the transition from the current incentive program for meeting meaningful use of electronic health records to the CMS’ broader Advancing Care Information program. The new requirements emphasize interoperability, information exchange and data security, creating some concern that doctors will need to invest in sophisticated information technology and analytics systems.

“It’s really an infrastructure question,” explained Eric Zimmerman, a principal at McDermott+Consulting. “What you might find with some of these small groups is sort of a downward spiral.”

The rule also came under criticism from the American Hospital Association for its narrow definition of an alternative payment model. The CMS exempted many of its current value-based payment models from qualifying as advanced APMs for the purposes of their exemption from MIPS. For instance, the rule excludes the Bundled Payments for Care Improvement initiative, as well as Track 1 of the Medicare Shared Savings Program, which delivers bonuses for meeting cost and quality targets but carries no downside risk.
MH TAKEAWAYS Physicians have traded the perennial threat of Medicare pay cuts for a framework that gives them little choice but to adapt their practices to value-based care.

Ninety-five percent of the 433 accountable care organizations in the Shared Savings Program this year are in that track.

APMs, the CMS said, must bear “more than nominal financial risk” in order to qualify.

The incentive payment system, meanwhile, is designed to be budget-neutral, which means there will be winners and losers when it comes time to dole out payments. The CMS is forecasting that there could be $833 million in negative payment adjustments and $1.3 billion in positive payment adjustments, which includes $500 million in “exceptional performance” payments for the highest-scoring physicians.

Under the framework the CMS laid out, it will be harder for physicians to tread the neutral middle ground.

“MIPS is essentially a linear performance score,” said Tom Lee, CEO of SA Ignite, a technology firm helping providers prepare for MIPS. “Every point counts. That’s going to increase the need for people to get educated that the game has changed.”

MIPS consolidates the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier and the EHR meaningful-use program—none of which was particularly popular.

Under those programs, huge numbers of physicians swallowed Medicare pay cuts rather than submit the quality data necessary to avoid the cuts and possibly earn a bonus. For example, about 5,400 out of 13,800 physician groups eligible for the value-based payment modifier in 2016 took a 2% pay reduction because they failed to meet the reporting requirements.

“No one liked PQRS and no one is going to really want to participate in MIPS,” said Sheila Madhani, a director at McDermott+Consulting. “So there’s going to be this push to get into APMs.”

APMs also provide more flexibility for physicians who want to make investments that otherwise would not be covered, such as hiring care coordinators.

But the CMS’ strict eligibility standards for APMs mean that the only way for many practices to avoid MIPS would be through an accountable care organization. “An ACO is basically the approach that most providers are going to end up with,” Muhlestein said.

Yet many of the APM deadlines are fast approaching. Applications for the Shared Savings Program, for instance, are due as soon as May 31. That doesn’t give providers much lead time to prepare, Lee said.

At the same time, a game of musical chairs will play out as physicians rush to find partners, either as a “virtual group”—a mechanism in the statute that allows small, independent groups to spread performance evaluation across a larger number of physicians—or through a more formal relationship.

“If I’m a practice manager, I’m probably getting pitched a lot,” Lee said. “The big underlying question is ‘What is the minimum amount of resources and support you need in order to play the value-based game?’ ”

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