Tag Archives: Medicare

How Republicans can hobble Obamacare even without repeal

People march in a "Save Obamacare" rally in Los Angeles.

By Julie Steenhuysen

CHICAGO (Reuters) – Republicans may have failed to overthrow Obamacare this week, but there are plenty of ways they can chip away at it.

The Trump administration has already begun using its regulatory authority to water down less prominent aspects of the 2010 healthcare law.

Earlier this week, newly confirmed Health and Human Services Secretary Tom Price stalled the rollout of mandatory Medicare payment reform programs for heart attack treatment, bypass surgery and joint replacements finalized by the Obama administration in December.

The delays offer a glimpse at how President Donald Trump can use his administrative power to undercut aspects of the Affordable Care Act (ACA), including the insurance exchanges and Medicaid expansion that Republicans had sought to overturn.

The Republicans’ failure to repeal Obamacare, at least for now, means it remains federal law. Price’s power resides in how to interpret that law, and which programs to emphasize and fund.

Hospitals and physician groups have been counting on support from Medicare – the federal insurance program for the elderly and disabled – to continue driving payment reform policies built into Obamacare that reward doctors and hospitals for providing high quality care at a lower cost.

The Obama Administration had committed to shifting half of all Medicare payments to these alternative payment models by 2018. Although he has voiced general support for innovative payment programs, Price has been a loud critic of mandatory federal programs that dictate how doctors should deliver healthcare.

Providers such as Dr. Richard Gilfillan, chief executive of Trinity Healthcare, a $15.9 billion Catholic health system, say they will press on with these alternative payment plans with or without the government’s blessing. But they have been actively lobbying Trump officials for support, according to interviews with more than a dozen hospital executives, physicians and policy experts.

Without the backing of Medicare, the biggest payer in the U.S. healthcare system which Price now oversees, the nascent payment reform movement could lose momentum, sidelining a transformation many experts believe is vital to reining in runaway U.S. healthcare spending.

Price “can’t change the legislation, but of course he’s supposed to implement it. He could impact it,” said John Rother, chief executive of the National Coalition on Health Care, a broad alliance of healthcare stakeholders that has been lobbying the new administration for support of value-based care.

The move Friday to pull the Republican bill only reinforces the risk to the existing law, which Trump said on Friday “will soon explode.”

“It seems that the Trump Administration now faces a choice whether to actively undermine the ACA or reshape it administratively,” Larry Levitt, senior vice president at Kaiser Family Foundation, wrote on Twitter.

“The ACA marketplaces weren’t collapsing, but they could be made to collapse through administrative actions,” he added.

NEW PAYMENT PLANS AT RISK

The United States spends $3 trillion a year on healthcare – more by far than 10 other wealthy countries – yet has the lowest life expectancy and the highest infant mortality rate, according to a 2013 Commonwealth Fund report.

Health costs have soared thanks in part to the traditional way doctors and hospitals get paid, namely by receiving a fee for each service they provide. So the more advanced imaging tests a doctor orders or pricey procedures they perform, the more money he or she makes, regardless of whether the patient’s health improves.

“We have a completely broken economy in healthcare,” said Blair Childs, senior vice president at hospital purchasing group Premier Inc. “Literally, all of the incentives in fee-for-service are for higher cost.”

Alternative payment models are designed to remove incentives that reward overtreatment of patients. Private insurers are on board, with Aetna Inc, Anthem Inc, UnitedHealth Group and most Blue Cross insurers announcing plans to shift half of their reimbursement to alternative payment models to control costs.

To promote the shift to alternative payments, the ACA created an incubator program at the Centers for Medicare Medicaid Services (CMS). The CMS innovation center is funded by $10 billion over 10 years to test payment schemes aimed at improving quality and cutting the cost of care.

The Obama administration’s decision to make some of these payment programs mandatory has drawn the ire of Price, a former U.S. senator and orthopedic surgeon. In response to a mandatory payment program for joint replacements last September, for example, Price charged that the CMS innovation center was “experimenting with Americans’ health.”

In his January 17 confirmation, Price said he was a “strong supporter of innovation,” but said he believed the CMS innovation center “has gotten a bit off track.”

TRUMP SETS WHEELS IN MOTION ON DAY 1

President Trump has already signed an executive order directing the HHS to begin unraveling Obamacare. In the early hours of his presidency, Trump directed government agencies to freeze regulations and take steps to weaken the healthcare law.

The order directed departments to “waive, defer, grant exemptions from, or delay the implementation” of provisions that imposed fiscal burdens on states, companies or individuals. These moves were meant to minimize the costs and regulatory burdens imposed on states, private entities and individuals.

David Cutler, the Harvard health economist who helped the Obama Administration shape the ACA, said Price could do all sorts of things to undermine the law.

“If he wants to blow it up, he can,” Cutler said in an email. But if they do, he added, “they alone will own the failure.”

(Editing by Edward Tobin)

U.S. healthcare costs to escalate over next decade: government agency

doctor holds hand of patient

WASHINGTON (Reuters) – The cost of medical care in the United States is expected to grow at a faster clip over the next decade and overall health spending growth will outpace that of the gross domestic product, a U.S. government health agency said on Wednesday.

A report by the U.S. Centers for Medicare and Medicaid Services (CMS) cited the aging of the enormous baby boom generation and overall economic inflation as prime contributors to the projected increase in healthcare spending.

Overall healthcare spending will comprise 19.9 percent of the economy in 2025, up from 17.8 percent in 2015, the report forecast. The pace of growth in U.S. spending on health is expected to pick up in 2017, increasing 5.4 percent over 2016. That compares with an estimated 4.8 percent spending uptick in 2016. Spending for 2016 was estimated at $3.4 trillion.

When the final numbers are in, the growth in prescription drug spending for 2016 is expected to have slowed to 5 percent from 9 percent in 2015. However, CMS has forecast growth of 6.4 percent per year between 2017 and 2025, in part because of spending on expensive newer specialty drugs, such as for cancer and multiple sclerosis.

The projections for 2016 to 2025 were made assuming that the Affordable Care Act (ACA), former President Barack Obama’s signature healthcare law widely known as Obamacare, would remain intact. It does not take into account likely changes to the law.

The Republican-led Congress and President Donald Trump have vowed to repeal and replace the ACA, but a viable replacement plan has yet to emerge.

Trump signed an executive order on his first day in office last month to freeze regulations and enable government agencies to take other steps to weaken Obamacare.

The ACA expanded Medicaid, the government health insurance program for the poor, in more than 30 states and set up private healthcare exchanges that enabled previously uninsured people to buy health insurance. After high enrollment between 2014 and 2015, Medicaid and private health insurance spending were expected to have slowed in 2016.

But spending on Medicare, the government health insurance program for the elderly, is expected to grow between 2017 and 2025 as a larger elderly population requires more medical services.

The overall insured rate of the population is expected to reach 91.5 percent in 2025, up from 90.9 percent in 2015, the report said.

(Reporting By Yasmeen Abutaleb; Editing by Tom Brown)

The facts about Social Security, Medicare may surprise you

An elderly lady walks in Copacabana in Rio de Janeiro

y Mark Miller

WASHINGTON (Reuters) – While the era of “alternative facts” dawned in Washington last week, experts from across the ideological spectrum gathered in the capital for a review of real facts about our two most important retirement programs: Social Security and Medicare.

The annual policy research conference of the National Academy of Social Insurance (NASI) focused on the group’s new report to the Donald Trump administration and Congress on the future of all our social insurance programs – those that cover retirement, but also those that protect the disabled, jobless, impoverished poverty and frail.

NASI is a consortium of many of the nation’s top social insurance researchers. The new report includes input from 80 experts in the field with a wide array of ideological and political perspectives. It describes the challenges facing these programs and provides a menu of solutions reflecting a variety of ideological perspectives.

As such, it reflects a set of consensus facts that should inform the looming debates about the future of social insurance at a time when these programs certainly will be under assault from budget cutters.

Here are a few facts on Social Security and Medicare that caught my eye:

FACT: Social Security benefits already have been cut. Raising the retirement program’s full retirement age to 70 is mentioned often as a way to solve the program’s long-term imbalance between costs and revenue. But did you know that Social Security benefits already are scheduled to be cut 24 percent? That is the average cumulative reduction in enrollee benefits by 2050 due to reforms passed by Congress in 1983, driven mainly by a gradual increase in full retirement ages from 65 to 67.

Since Social Security cannot deficit-spend as a matter of law, legislative reform will be needed by 2034 in order to avoid an immediate 21 percent cut in benefits. The reforms could include new revenue to the system, benefit cuts or a combination of both. Raising the retirement age to 70 would effectively cut benefit payouts by raising the bar on the age an enrollee must reach to receive her full benefit.

Raising the retirement age would whack benefits further, and we have much better options, including lifting the cap on wages subject to property taxes, or raising payroll tax rates very gradually.

FACT: Social Security matters to high-income households. We will hear calls to transform it into a means-tested program for the poor. But Social Security is the largest source of income for a majority of retired workers and their surviving spouses.

Eighty-four percent of all people over 65 and about 90 percent of surviving spouses over 65 receive income from Social Security, and for three-fifths of them, Social Security makes up at least 50 percent of their income. “Many upper middle class people assume that it’s mostly important for poor people, but that’s not the case,” said Benjamin Veghte, NASI’s vice president for Policy.

Proposals to restore solvency by means-testing Social Security would tear at a core design feature – its universality. At a time when a majority of households have not been able to save adequately for retirement, Social Security will remain critical.

MEDICARE: NO CAUSE FOR ALARM

FACT: Medicare is not facing a financial crisis. Politicians pushing Medicare reforms often claim that the program is teetering on the brink, but the NASI researchers conclude otherwise.

Let us start with the basics on how Medicare’s various “parts” are funded. Part A (hospitalization) is funded mainly by a 2.9 percent payroll tax split by employers and workers. For Parts B (outpatient services) and D (prescription drugs), 75 percent of funding comes from general federal revenue, with the remainder funded by enrollee premiums.

The Hospital Insurance trust fund that finances Part A can meet all its obligations through 2028, according to the program’s trustees. At that point, incoming revenue would cover 87 percent of expected costs, so there is a need to close the shortfall with additional revenue, less spending or a combination of the two.

But the NASI experts note that historical trustee projections regarding how soon the trust fund will become insolvent have varied widely – as little as two years, and as much as 28. “There’s no big cause for alarm in the current projection,” said Veghte.

Parts B and D cannot run out of money because they have permanent appropriations to cover whatever premiums do not. The cost of those programs will grow in the years ahead as the population ages, and as healthcare costs rise – especially prescription drugs. But that trend is not driven by Medicare itself, but by the cost of healthcare.

Overall Medicare spending is not out of control – per-enrollee outlays rose at an average annual rate of 5.5 percent, somewhat slower than the 6.3 percent average annual growth rate in private insurance spending per enrollee between 1989 and 2014. In addition, cost containment measures within the Affordable Care Act improved the outlook substantially, pushing the insolvency date out by 11 years.

“The problem really is healthcare cost, and how to control it,” said Veghte.

The 200-page report is exhaustive, thorough and authoritative. I encourage anyone interested in the facts on any of our social insurance programs to download it and read. You can find it here: (http://bit.ly/2kpgtNy)

(Editing by Matthew Lewis)

In-patient or not? Medicare requires hospitals to tell you

An entrance sign to a hospital is seen in Dallas, Texas,

By Mark Miller

CHICAGO (Reuters) – You are in the hospital for tests after experiencing dizziness. You are nervous about what the tests will show, but at least you do not have to worry about hospital bills – you have Medicare, so you can relax about healthcare coverage. Or can you?

Not if you are in the hospital under “observation status” – a Medicare designation applied to patients deemed insufficiently ill for formal admission, but still too sick to be allowed to go home. Observation status can result in thousands of dollars in higher costs – especially if you need post-hospital nursing care.

Medicare covers care in skilled nursing facilities, but only for patients who were first formally admitted to a hospital for three consecutive days.

Federal data shows that the number of Medicare patients classified as under observation has jumped sharply in recent years, and it has stirred a great deal of pushback from Medicare enrollees and advocacy groups. A new law – the Notice Act – requires hospitals to at least notify patients if they stay in the hospital more than 24 hours without being formally admitted. Patients will receive the warnings starting in January, but advocates argue the new protection does not go far enough.

“It does half of what we would like to see,” said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy. “The notice should also allow patients to appeal their status.”

Hospitals have been motivated to use the status to avoid costly penalties from Medicare for improper admissions under a well-intentioned effort by Medicare to control costs through a program that audits hospitals for possible overpayments. The program began during the George W. Bush administration.

The number of patients cared for under observation status doubled to nearly 1.9 million in 2014 compared with 2006, according to figures from the Centers for Medicare & Medicaid Services (CMS). The majority (54 percent) were for observation stays of less than 24 hours; another 38 percent of the stays were 48 hours or less, CMS reports.

FACING HIGHER COSTS

The new notifications will require hospitals to inform patients orally and in writing if they are on observation status for more than 24 hours. The written notification, developed by CMS, is called the Medicare Outpatient Observation Notice (MOON). The MOON also explains the cost implications of receiving hospital services as an outpatient.

The costs of observation status can affect any enrollee on traditional fee-for-service Medicare. (Beneficiaries using Medicare Advantage, which provide all-in-one care, will also receive the MOON, but some Medicare Advantage plans will cover a stay in a skilled nursing facility without first requiring that patients have a three-day inpatient hospital stay.)

Medicare normally covers up to a maximum of 100 days of care in a skilled nursing facility following a hospital admission – it pays 100 percent for the first 20 days, and patients are responsible for a daily $161 co-pay for the next 80 days. But patients leaving the hospital for a nursing facility after an observation pay the full cost out of pocket.

RISING NURSING HOME COSTS

The cost of skilled nursing care is substantial, and rising quickly. This year, the national median monthly cost of a private nursing room is $7,698, according to a Genworth survey, and it runs much higher in states such as New York ($11,330 per month) and California ($9,338).

Medicaid would cover the stay if the patient meets the program’s low-income requirements (a status called “dual-eligible”). A commercial long-term care policy might provide some coverage, although many of these policies have “elimination” features (deductibles) that require patients to pay the first 90 days out of pocket.

Observation status also affects coverage of drug usage in the hospital. Medicare Part B would cover drug usage for the specific problem related to the hospitalization, subject to Part B’s typical 20 percent copay); for routine drugs that you take at home (say, a statin for high cholesterol), practices vary. Some hospitals allow patients to bring their own drugs from home, others do not, and charge much more than you would pay at a typical pharmacy.

Some – but not all – Part D drug plans will cover some of these prescription drug costs.

A broader fix to the observation status has garnered broad support from organizations ranging from AARP to the American Medical Association, elder law groups and Medicare advocacy groups. Legislation that has bipartisan support has been introduced in the U.S. House and Senate that would require that time spent in observation be counted toward meeting the three-day prior inpatient stay that is necessary to qualify for Medicare coverage.

“The bill is simple,” said Edelman of the Center for Medicare Advocacy. “Count the time in hospital, no matter what. If you are in the hospital for three midnights, you have met this requirement.”

(The writer is a Reuters columnist. The opinions expressed are his own.)

(Editing by Matthew Lewis)

U.S. completes ‘takedown’ of Medicare fraud: officials

Attorney General Loretta E. Lynch

By Sarah N. Lynch

WASHINGTON (Reuters) – U.S. law enforcement officials have charged 301 suspects with trying to defraud Medicare and other federal insurance programs in 2016, marking the “largest takedown” involving health care fraud allegations, the Justice Department said on Wednesday.

The national sweep resulted in charges against doctors, nurses, pharmacists and physical therapists accused of fraud that cost the government $900 million, the department said.

The cases involved an array of charges, including conspiracy to commit health care fraud, money laundering and violations of an anti-kickback law.

This year’s sweep exceeded last year’s record in which 243 defendants faced charges in a combined $712 million in government losses. Officials said it was the largest takedown in the nine-year history of the Medicare Fraud Strike Force, a joint initiative between federal, state and local law enforcement.

Attorney General Loretta Lynch said some of the cases reflect new, troublesome trends, including instances of identity theft in order to prepare fake prescriptions and a growing number of cases involving compounding, or the mixing of medications tailored to meet a patient’s needs.

Compounded medications are typically very expensive. From 2012 to 2014, the quarterly Medicare spending on these prescriptions skyrocketed from $28 million to $171 million.

“As this takedown should make clear, health care fraud is not an abstract violation or benign offense,” Lynch said. “It is a serious crime.”

In one case, two owners of a group of outpatient clinics and a patient recruiter stand accused of filing $36 million in fraudulent claims for physical therapy and other services that were not medically necessary.

The Justice Department said that to find patients, the clinic operators and the recruiter targeted poor drug addicts and offered them narcotics so they could bill them for services that were never provided.

Another case was filed against the operator of a marketing business that received referral fees from pharmacies that filled and billed Tricare, the U.S. military’s government insurance program, for compounded medicines.

The prescriptions were submitted via “telemedicine” sites, and doctors were given blank prescription forms to fill out, regardless of medical necessity, according to the complaint.

One doctor told the FBI her identity and medical credentials were used without her permission to fill thousands of dollars worth of prescriptions.

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