“If we bear in mind that medical care consists of decisions and choices made in the face of uncertainty, then the quality of a decision can only be determined in real time, in a specific context, in light of all its alternatives. A third-party payer—public or private, single or multiple—cannot possibly obtain the needed knowledge to make that determination. For an outsider, the quality chasm is metaphysically impossible to cross. Measuring quality is grasping at straws.”
A “sleeper” provision when Congress created Medicare in 1965 to cover health care for seniors, Medicaid now provides coverage to nearly 1 in 4 Americans, at an annual cost of more than $500 billion. Today, it is the workhorse of the U.S. health system, covering nearly half of all births, one-third of children and two-thirds of people in nursing homes.
Enrollment has soared to more than 70 million people since 2014 when the Affordable Care Act began providing billions to states that chose to expand eligibility to low-income adults under age 65. Previously, the program mainly covered children, pregnant women and the disabled.
Unlike Medicare, which is mostly funded by the federal government (with beneficiaries paying some costs), Medicaid is a state-federal hybrid. States share in the cost, and within broad federal parameters, have flexibility to set benefits and eligibility rules.
Though it provides a vital safety net, Medicaid faces five big challenges to providing good care and control costs into the future:
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A few days ago, we wrote an editorial for US News and World Reports on the scant or dubious evidence used to support some healthcare policies (the editorial is reproduced in full below).In that case, we focused on studies and CMS statements about a select group of Accountable Care Organizations and their cost savings. Our larger point however is about the need to reconsider the evidence we use for all healthcare-related decisions and policies. We argue that an understanding of research design and the realities of measurement in complex settings should make us both skeptical and humbled.Let’s focus on two consistent distortions.
Evidence-based Medicine (EBM). Few are opposed to evidence-based medicine.What’s the alternative? Ignorance-based medicine? Hunches?However, the real world applicability of evidence-based medicine (EBM) is frequently overstated. Our ideal research model is the randomized controlled trial, where studies are conducted with carefully selected samples of patients to observe the effects of the medicine or treatment without additional interference from other conditions. Unfortunately, this model differs from actual medical practice because hospitals and doctors’ waiting rooms are full of elderly patients suffering from several co-morbidities and taking about12 to 14 medications, (some unknown to us). It is often a great leap to apply findings from a study under “ideal conditions” to the fragile patient. So wise physicians balance the “scientific findings” with the several vulnerabilities and other factors of real patients.Clinicians are obliged to constantly deal with these messy tradeoffs, and the utility of evidence-based findings is mitigated by the complex challenges of the sick patients, multiple medications taken, and massive unknowns. This mix of research with the messy reality of medical and hospital practice means that evidence, even if available, is often not fully applicable.
Relative vs. Absolute Drug Efficacy:
Let’s talk a tiny bit about arithmetic. Say we have a medication (calledX) that works satisfactorily for 16 out of a hundred cases, i.e., 16% of the time.Not great, but not atypical of many medications.Say then that another drug company has another medication (called “Newbe”) that works satisfactorily 19% of the time. Not a dramatic improvement, but a tad more helpful (ignoring how well it works, how much it costs, and if there are worse side effects).But what does the advertisement for drug “Newbe” say? That “Newbe” is almost 20% better than drug “X.” Honest. And it’s not a total lie.Three percent (the difference between 16% and 19%) is 18.75%, close enough to 20% to make the claim legit. Now, if “Newbe” were advertised as 3% better (but a lot more expensive) sales would probably not skyrocket. But at close to 20% better, who could resist?
Policy:So what does this have to do with healthcare policy?We also want evidence of efficacy with healthcare policies but it turns out that evaluation of these interventions and policies is often harder to do well than are studies of drugs. Interventions and policies are introduced into messy pluralistic systems, with imprecise measures of quality and costs, with sick and not-so-sick patients, with differing resources and populations, with a range of payment systems, and so on and so on. Sometimes, randomized controlled trials are impossible.But sometimes they are possible but difficult to effect. Nevertheless, we argue they are usually worth the effort. Considering the billions or trillions of dollars involved in some policies (e.g., Medicare changes, insurance rules) the cost is comparatively trivial.
But there’s another question: What if a decent research design is used to measure the effects of a large policy in a select population but all you get is a tiny “effect?”What do we know? What should policymakers do? Here’s what we wrote in our recent editorial in the US News and World Report….
Information about the quality and performance of health care facilities can be confusing to consumers. Dozens of government organizations, trade groups and websites rate doctors, hospitals and long-term care facilities on all kinds of scales, from patient satisfaction to medical outcomes.
In 2008, the Centers for Medicare and Medicaid Services (CMS) attempted to simplify some of this data by creating a five-star rating system for nursing homes. The idea was that public reporting would drive improvement in care, helping nursing home residents and their families choose higher quality facilities, in turn encouraging nursing homes to improve quality to retain residents.
This data can be of limited use, however, for people whose decisions are constrained by insurance networks, cost and geography. People who are enrolled in both Medicare and Medicaid, often called “dual eligibles,” are particularly limited in their choices for long-term care. They are much more likely to have lower incomes, disabilities or cognitive impairment, and to receive low-quality health care in poor neighborhoods than other Medicare beneficiaries.
A new study in the May issue of Health Affairs by public health researchers from the University of Chicago, Harvard, and Penn confirms that despite best intentions, the new rating system exacerbated health disparities between this dual eligible group and non-dual eligible nursing home residents, i.e. those with better financial support. By 2010, two years after the system began, both groups lived in higher quality nursing homes overall, but non-dual eligible residents were more likely to actively choose a higher-rated nursing home. The gap between the two groups also increased: dual eligibles were still more likely to live in a one-star home, and less likely than non-dual eligibles to live in a top-rated home.
The Agency for Healthcare Research and Quality (AHRQ), through its EPCs, sponsors the development of various reports to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. These reports provide comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies. The EPCs review all relevant scientific literature on a wide spectrum of clinical and health services topics. EPCs also produce technical reports on methodological topics and other types of evidence synthesis-related reports.
Where do Technology Assessments come from?
The Technology Assessment (TA) Program at the Agency for Healthcare Research and Quality (AHRQ) provides technology assessments for the Centers for Medicare & Medicaid Services (CMS). These technology assessments are used by CMS to inform its national coverage decisions for the Medicare program as well as provide information to Medicare carriers.
Fact sheets and reports can be found through The Technology Assessment (TA) Program
How can I order Evidence Reports/Technology Assessments (ERTAs) or Comparative Effectiveness Reviews? [From http://www.ncbi.nlm.nih.gov/books/NBK45610/ (accessed 3 March 2015)]
The Evidence Reports/Technology Assessments (ERTAs) and Comparative Effectiveness Reviews (CERs) are provided to Bookshelf by the Agency for Healthcare Research and Quality (AHRQ). AHRQ has a publications clearinghouse, which can be accessed through this link: http://ahrqpubs.ahrq.gov/OA_HTML/ibeCZzpHome.jsp
1Patricia Neuman (tneuman@kff.org) is senior vice president and director of the Program on Medicare Policy at the Henry J. Kaiser Family Foundation, in Washington, D.C.
2Juliette Cubanski is associate director of the Program on Medicare Policy at the Henry J. Kaiser Family Foundation.
3Anthony Damico is an independent consultant in Bethesda, Maryland.
Abstract
Medicare per capita spending for beneficiaries with traditional Medicare over age 65 peaks among beneficiaries in their mid-90s and then declines, and it varies by type of service with advancing age. Between 2000 and 2011 the peak age for Medicare per capita spending increased from 92 to 96. In contrast, among decedents, Medicare per capita spending declines with age.
As the US population ages and more people on Medicare live into their 80s, 90s, and beyond, analysts and policy makers are examining the impact of these trends on the federal budget and the Medicare program. At the same time, geriatricians and other providers who care for older patients are paying greater attention to the question of how best to meet the needs of an aging population. By 2050 the number of people on Medicare ages 80 and older will nearly triple; the number of people in their 90s and 100s will quadruple.1⇓–3
To inform discussions about Medicare’s role in providing coverage for an aging population and to assess the relationship between Medicare spending and advancing age, this article presents findings from an analysis of Medicare per capita spending among beneficiaries over age 65 in traditional Medicare, by age and type of service.4Our main findings are shown in Exhibit 1 and discussed in detail below.
Exhibit 1
Medicare Per Capita Spending For Traditional Medicare Beneficiaries Over Age 65, By Age And Survival Status, 2011
SOURCE Authors’ analysis of a 5 percent sample of Medicare claims for 2011 from the Chronic Conditions Data Warehouse of the Centers for Medicare and Medicaid Services. NOTES Average per capita spending in 2011 for all traditional Medicare beneficiaries over age 65 (“all beneficiaries”) was $9,839; for the subset of those beneficiaries who were still alive at the end of 2011 (“full-year survivors”), it was $8,647. The analysis excluded beneficiaries with Medicare Advantage. The analysis also excluded traditional Medicare beneficiaries age 65 because some of these beneficiaries are enrolled for less than a full year; therefore, a full year of Medicare spending data is not available for all people at this age.
Previous studies have reported an increase by age in Medicare per capita spending,5,6beneficiaries’ out-of-pocket spending,7 and Medicaid spending.8 However, they have not examined Medicare per capita spending in depth, categorizing it by beneficiaries’ age and type of service and including trends over time.
We examine the following questions: What is the trajectory of Medicare per capita spending by age, at what age does spending peak, and has the peak age changed over time? How does Medicare per capita spending by age vary for specific Medicare-covered services? What is the pattern of per capita spending by age among decedents?
This is a preliminary scan of publicly available online health care datasets, transparency websites and tools, gathered from expert recommendations and intensive review. Though this list is not exhaustive, we have attempted to include the most relevant sources for the purposes of this study. Each health data source is assigned an icon representing (1) who the source is useful to i.e. consumers or researchers; (2) what information the source includes i.e. data pertaining to quality of care or cost of care; and (3) who the source provides information on i.e. providers or payers.
Excerpt from the commentary by M. Christopher Roebuck, PhD, MBA
SUMMARY
This brief commentary extends earlier work on the value of adherence to derive medical cost offset estimates from prescription drug utilization. Among seniors with chronic vascular disease, 1% increases in condition-specific medication use were associated with significant (P<0.001) reductions in gross nonpharmacy medical costs in the amounts of 0.63% fordyslipidemia, 0.77% for congestive heart failure, 0.83% for diabetes, and1.17% for hypertension.
J Manag Care Pharm.
2014;20(10):994-95
Excerpts:
With about half of patients not taking their medications as directed, avoidable adverse health events and use of medical services are estimated to add up to $290 billion in U.S.health care expenditures annually. Improvements in clinical and economic outcomes from medication adherence have been demonstrated across a variety of conditions and patientcohorts. As an example, in 2011 my colleagues and I (Roebuck et al.) determined that adherence to medication for chronic vascular disease was associated with fewer inpatient hospital days and emergency department visits and lower overal health care costs. Specifically, annual net savings in healtcare expenditures for an adherent (compared to nonadherent) elderly beneficiary were estimated to be $7,893 for congestive
heart failure, $5,824 for hypertension, $5,170 for diabetes, and $1,847 for dyslipidemia—or approximately 9% to 28% of total
health care costs. This research employed a rigorous observational study design that addressed a key concern and limitation
ofprior analyses—the potentialendogeneity (confounding) of adherence. More plainly, results reported in earlier publications mayhave been biased if patients who took medications as directed also engaged in other unmeasured healthy behaviors
(i.e., the “healthy adherer effect”)
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Figure 1 presents the new findings and includes the CBO estimate for reference. Specifically, 1% increases in condition-specific prescription drug utilization were significantly (P<0.001) associated with reductions in seniors’ gross nonpharmacy medical costs in the amounts of 0.63% for dyslipidemia, 0.77% for congestive heart failure, 0.83% for diabetes, and 1.17% for hypertension. These results demonstrate that medical cost offsets from prescription drug utilization likely vary bychronic condition and that impacts for therapeutic classes used to treat these 4 conditions—which represent 40% of Medicare Part D utilization—may be between 3 and 6 times greater than the CBO’s assumption. In dollar terms, these relative impacts are not trivial. For example, 53% of Medicare (fee-for-service) beneficiaries have the comorbidity combination of hyperten sion plus high cholesterol—with average annual medical costs of $13,825. The current findings suggest that a 5% increase in the use of antihypertensive medication by patients with those conditions may prompt reductions in medical (Parts A and B) costs of more than $800 annually per beneficiary.
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The present analysis examined retirees with employer-sponsored insurance in addition to Medicare. To the extent that these individuals differed from the broader Medicare population, the generalizability of study findings may be limited.
First, the good news: A new National Center for Health Statistics data brief shows that Americans are living longer. Overall life expectancy rose by 0.1 percent from 2011 to 2012, to 78.8 years, and was highest for non-Hispanic whites and non-Hispanic blacks. Women can expect to live an average of 81.2 years, and men an average of 76.4 years, based on the new analysis.
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Now the bad news – a new report released by the Office of the Inspector General in the Department of Health and Human Services found increased costs associated with critical access hospitals. Medicare beneficiaries paid nearly half of the costs for outpatient services at critical access hospitals – a higher percentage of the costs of coinsurance for services received at these facilities than they would have paid at hospitals using Outpatient Prospective Payment System rates.
Critical access hospitals (CAHs) ensure that rural Medicare beneficiaries have access to hospital services. Reimbursement is at 101 percent of their “reasonable costs,” rather than at the predetermined rates set by the Outpatient Prospective Payment System. Medicare beneficiaries who receive services at CAHs pay coinsurance amounts based on CAH charges; beneficiaries who receive services at acute care hospitals pay coinsurance amounts based on OPPS rates.
Just when you think that you have settled the most significant adult child-aging parent issues — when you and your parents have spoken about medical care support, finances, and the range of their end-of-life wishes — along comes another concern to worry about, and it’s one that may be completely out of our control.
We now need to be concerned about the possibility of a parent entering a hospital and assigned to observation status for several days. Observation means that, rather than being officially admitted as a patient, the person is there to be watched, sort of like an out-patient, but not really an out-patient. The problem is, it’s difficult to discover what status a hospital assigns a patient — the two look almost alike with nurses, doctors, hospital rooms, blood pressure checks, etc. Admission and observation do not look that different to the patient and family, and apparently many hospitals…
(Editor’s note: This is a revision of the original post, which is available on Ornstein’s Tumblr site.)
The Centers for Medicare and Medicaid Services (CMS) said yesterday that it will soon begin releasing data on payments to individual physicians in the Medicare program.
Why is this such a big deal?
Because it overturns a longstanding agency policy that for more than three decades had barred the release of this very information. And, it follows advocacy for greater transparency by numerous news organizations, including the Association of Health Care Journalists.
AHCJ’s board of directors last September sent a letter of comment to CMS asserting the public’s interest in release of this information. “As long as patient confidentiality is protected, we see no reason why taxpayers should not know how individual physicians are spending public dollars,” said the letter, signed by AHCJ executive director Len Bruzzese.
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As this fight has played out, CMS released data to ProPublica on which drugs physicians prescribe in Medicare’s drug program, known as Part D. You can now look up your doctor’s prescribing patterns online.
A novel strategy that has saved Minnesota millions of dollars in unnecessary medical-imaging scans — and probably prevented dozens of patient deaths — might soon go national.
Leaders from Minnesota’s medical and insurance communities met Monday morning to celebrate the project — which has leveled off the skyrocketing growth of MRI and CT scans for back pain, headaches and other problems — and to promote legislation by Rep. Erik Paulsen that would bring it to bear on the federal government’s vast Medicare program.
Minnesota’s “decision support” strategy, enacted in 2006, created a single set of standards for doctors to follow in deciding when patients need the costly scans. It also created a green-yellow-red coding system to show patients when scans were recommended and when they weren’t. The use of such scans, which had been growing at a 7 percent annual clip, grew just 1 percent from 2007 to 2012.
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….officials in other states often view Minnesota as “quite peculiar” because of its small, cooperative community of insurers and physician groups, and don’t believe its innovations can be repeated elsewhere, said Dr. Pat Courneya, medical director of HealthPartners, the Bloomington-based health plan.
Getting this type of approach to succeed in Medicare, on the other hand, would cause it to spread to other states, he said.
More than 80 percent of imaging scans in Minnesota are now ordered only after doctors seek out decision-support guidance to make sure they are recommended based on their patients’ conditions and medical histories.
Courneya said the initial guidelines were based on the clinical expertise and recommendations of Minnesota doctors. They have since been revised as studies refine when imaging scans should be used. Research, for example, has identified the types of patients who are suitable for scans to screen for breast or lung cancers.
The two drugs have been declared equivalently miraculous. Tested side by side in six major trials, both prevent blindness in a common old-age affliction. Biologically, they are cousins. They’re even made by the same company.
But one holds a clear price advantage.
Avastin costs about $50 per injection.
Lucentis costs about $2,000 per injection.
Doctors choose the more expensive drug more than half a million times every year, a choice that costs the Medicare program, the largest single customer, an extra $1 billion or more annually.
Spending that much may make little sense for a country burdened by ever-
rising health bills, but as is often the case in American health care, there is a certain economic logic: Doctors and drugmakers profit when more-costly treatments are adopted.
Genentech, a division of the Roche Group, makes both products but reaps far more profit when it sells the more expensive drug. Although Lucentis is about 40 times as expensive as Avastin to buy, the cost of producing the two drugs is similar, according to scientists familiar with the drugs and the industry.
Doctors, meanwhile, may benefit when they choose the more expensive drug. Under Medicare repayment rules for drugs given by physicians, they are reimbursed for the average price of the drug plus 6 percent. That means a drug with a higher price may be easier to sell to doctors than a cheaper one. In addition, Genentech offers rebates to doctors who use large volumes of the more expensive drug.
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The rising cost of U.S. entitlement programs such as Medicare has prompted outrage in Congress, but it is Congress that has made it difficult in this case and others for Medicare to limit such expenses.
To begin with, the Medicare agency is blocked from seeking better drug prices by negotiating directly with the drug companies, as health agencies in other countries do. Authorities in Britain, for example, have negotiated a price of about $1,100 per dose of Lucentis, and in the Netherlands a dose sells for about $1,300.
Moreover, in cases in which two equivalent options are available, such as Lucentis and Avastin, Medicare is forbidden from restricting payment to the amount of the less costly alternative. After it sought to do so in 2009, a federal appeals court said it lacked that authority.
It’s often difficult, of course, to know when two drugs are equivalent. When the debate over the two drugs and their pricing erupted more than six years ago, Genentech asserted that its more expensive new drug was superior. At the time, it was hard to show otherwise. No one had tested them in side-by-side comparisons.
Since then, the six randomized clinical trials involving more than 3,000 patients have found the drugs to be largely equivalent.
Yet in 2012, the Medicare program and its beneficiaries spent $1.2 billion on Lucentis, according to The Post’s analysis of Medicare data.
Medicare officials said they have no choice but to pay the bill when a doctor prefers to use Lucentis.
As a volunteer Area Office on Aging counselor, I help folks apply for Extra Help with their prescription drugs and a state program for Medicare Part B financial assistance. In the past year I have been astounded at the prescription drug costs for quite a few clients, as well as saddened by those who are falling through the cracks. Have heard folks tell me how they are choosing between eating well and buying prescribed drugs.
This blog item covers what I have heard first hand, and more
Among the sacrifices Congressional representatives placed on the altar of deficit negotiations is an “inflation adjustment” that will shave “only” a few hundred dollars from an average, newly retired Social Security beneficiary’s income each year. But the cruel hoax is that the reduction will amount to as much as $1600 when the beneficiary is older, poorer, and sicker. Many seniors already have a tough time paying for food, rent, and medical care.
Even worse, reductions in beneficiaries’ incomes may well cost government more for potentially preventable hospital and long-term care. Senator Elizabeth Warren and other New England lawmakers should be lauded for splitting from Democratic representatives and the Administration regarding this ill-conceived proposal.
Many senior citizens are already vulnerable to economic hardship. A recent US Census analysis that counts rising medical expenses found that over 1 in 6 elderly people live in poverty, unable to meet basic living expenses, and almost 20% more are living just above the poverty line. Social Security is the only or largest source of income for about 70% of seniors; the average monthly check is only about $1200.
The typical retirement savings of seniors is a paltry $50,000 — barely enough to get through several years’ living expenses, let alone 20-30 years of retirement. This is not the result of cavalier actions by the older generation; these are the Americans whose home values have plummeted, whose defined-benefit pension plans have been decimated or disappeared, and whose retirement accounts were eviscerated by the Wall Street meltdown of the last decade. Yet the current proposal punishes these Americans as if they were at fault for their poverty.
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What are the consequences of having to rely on Social Security alone? High out-of-pocket health care costs can be “catastrophic” because they cause people to go without essential medical care. Our studies published in the New England Journal of Medicine show that a 50% reduction in drug benefits in New Hampshire for low income, chronically ill seniors backfired.
The NH policy reduced the use of essential medicines (e.g., for diabetes and heart disease), worsened chronic illness, increased acute care, and doubled the rate of permanent institutionalization in expensive nursing homes. These increased admissions raised government costs several times more than the drug “savings,” not even counting increased pain and suffering of patients and their families.
Dr. Nicole Lurie, the current US Assistant Secretary for Preparedness and Response, showed that about 15% of people (many seniors) who are admitted to hospital emergency departments experience significant hunger before admission. Frequently, seniors skimp on medicines to pay for food, and this leads to illness and further hospital care.
Similarly, our studies show that almost 30% of disabled Medicare recipients in poor health skip or split pills to make them last longer because they can’t afford their prescription drugs, even in the era of the Part D drug benefit. One study indicates that splitting pills increases hospitalization of heart disease patients by 21%.
The current debate in Washington encapsulates the growing political and ideological divide as to how the costs of deficit reduction should be allocated across various parts of the population. No single proposal more starkly embodies that issue than efforts to trim and chip away from recipients of an earned, contributory entitlement at precisely that time in their lives when they can least afford reduced incomes, and have the least capacity to compensate for them.
Anyone who has spent time with an elder parent in the hospital knows just how easy it is for one problem to be solved only to have the person discharged with different problems. This is not necessarily the fault of the medical caregivers or the hospital itself — it’s a result of a system that puts older people into beds and keeps them there. Add in bed alarms, the inability to move much, and that hospitals isolate elder patients from their routines and support communities, and you have a recipe for unsuccessful care, a result of age associated hospital complications.
So I recommend reading The Hospital is No Place for the Elderly, a November 20, 2013 article that appeared in the The Atlantic. This piece aptly illustrates the conundrum of frail elderly patients with chronic health issues admitted to hospitals where medical care focuses primarily on fixing acute health problems. The difficulty is that most of frail elders’ medical issues cannot be fixed — but the quality of their lives can improve. Author Jonathan Rauch also describes several programs in the United States — teams of physicians, nurses, and other health professionals — that collaborate to keep patients as healthy as possible and out of the hospital. The teams even save money.
Many team-based support programs for frail elders run deficits, despite that they are so successful, but Rauch reports that the climate is changing, as Medicare and some insurance companies develop a more welcoming attitude toward innovative health care programs. The Affordable Care Acthas designated money to support innovative and new models of care delivery. (To learn more about other innovative programs you might also want to read Atul Gwande’s 2011 New Yorker article about changing models of medical care.)
One of the most interesting parts of The Atlantic article was the description of the team meetings where participants collaborate and coordinate patients’ medical care in order to help elders stay as healthy as possible.
Best Atlantic Article Quotes
The idea is simple: rather than wait until people get sick and need hospitalization, you build a multidisciplinary team that visits them at home, coordinates health-related services, and tries to nip problems in the bud.
These people aren’t on death’s doorstep, but neither will they recover. Physically (and sometimes cognitively), they are frail…
Patients were presented not as bundles of syndromes—as medical charts—but as having personal goals, such as making a trip or getting back on their feet. The team tries to think about meeting patients’ goals rather than performing procedures.
This is worrisome. Granted UHC may not be doing anything illegal, but are their actions ethical?
Disclaimer…at the local Area Office on Aging I assist folks with Medicare Advantage Plan comparisons. A very satisfying volunteer position. Well worth the 20 hours or so of training through the State of Ohio Department of Insurance.
In mid-October UHC began terminating physicians in their Medicare Advantage plan. We immediately reached out to UHC when it appeared that the terminations were not isolated, but rather part of a broad initiative. This week, UHC responded to some of our questions. We are disappointed that there was no warning of this termination initiative which appears to be a significant redesign of the UHC Medicare Advantage network, nationwide, and that information is sparse. For example, UHC would not tell us how many physicians in New Jersey were terminated or whether any specialties were immune to the termination initiative. Yet, UHC assured us that the network had been “tested and retested” for network adequacy and that there would not be a specialty access issue.
Network Adequacy: Obviously, MSNJ has no way of evaluating the impact on the network without more information. Therefore, we are asking all physicians who received termination letters, to provide us with information so that we can better evaluate network adequacy concerns. CMS has agreed to help us with that assessment.
Lack of Transparency: In addition to our network adequacy concerns, we are troubled that patients may be enrolling or re-enrolling in the UHC Medicare Advantage plan now, because seniors are in the middle of open enrollment, believing that they will be able to continue to be treated by physicians who are currently in the plan. UHC agreed to consider our complaint on lack of transparency on the 2014 network, given that seniors are enrolling now based on the current network. It is important to note that patients may change their network selection. CMS will honor the last selection made by the patient by December 7 when open enrollment ends.
Continuity of Care: We expressed our concerns about continuity of care and a disruption of established physician-patient relationships. We urged UHC to carve out an exception for patients who wish to continue to see their current physician. UHC agreed to consider this request. We believe that patients should have the right to choose their physicians and must know their network status to make those choices.
Discussions with CMS: With a reopening of the federal government, we have contacted CMS about our network adequacy and continuity of care concerns. Our Region 2 office has been facilitating communication with the Region 9 office which is responsible for the UHC Medicare Advantage network. CMS Region 9 is charged with ensuring network adequacy and transparency for Medicare beneficiaries in their selection of a Medicare product. CMS has offered to test areas for network adequacy. Pleaseprovide us with information so that we can identify geographical and specialty areas of concern.
What to do: Last week we urged physicians who wished to stay in the Medicare Advantage network to appeal and provided suggestions for those appeals. We will continue to update our advice to members as more information becomes available to us. Visit our web site for a list of Do’s and Don’ts, Appeal Suggestions, a template letter to inform patients of your imperiled status in the UHC Medicare Advantage Network.
Save the date for MSNJ’s UHC Termination Update webinar on Tuesday, October 29 at 7:00PM. Details to follow on www.msnj.org.
aker said the State Medical Association plans to complain to the Centers for Medicare and Medicaid Services, which has contracts with all Medicare Advantage plans. He said the cuts will leave UnitedHealthcare with an inadequate provider network for Medicare enrollees.
UnitedHealthcare’s parent, UnitedHealth Group, the largest provider of Medicare Advantage plans nationwide, signaled several months ago that it might shrink its business of managing care for seniors, according to Kaiser Health News. This month, UnitedHealth Group said funding cuts in Medicare Advantage plans had put a drag on its earnings.
Shermach offered this prepared explanation for why the insurer is dropping doctors from its Ohio network: “With the many changes happening in the health-care industry, we are building a network of health-care providers that we can collaborate with more closely to have the most positive impact on the quality of care for our members. This will encourage better health outcomes and ultimately lower costs.
“Additionally, more focused provider networks help deal with the financial pressures created by severe cutbacks in funding of Medicare Advantage and other government-sponsored programs.”
The State Medical Association said UnitedHealthcare also has dropped doctors in other states, citing media reports in Florida and Connecticut.
AARP Ohio spokeswoman Kathy Keller said the organization hasn’t heard concerns about the change from its members.
Medicare Advantage plans are private insurance plans that cover hospital, medical and often prescription-drug expenses. About 36 percent of Ohio’s 2 million Medicare enrollees are in Medicare Advantage plans.”
Flashback— About 20 years ago I was in an urgent care center around 11 pm with a severe migraine. The doctor was getting ready to give me a shot with appropriate medication. At the time I was unemployed with little money. So I asked him if I could get a prescription for capsules/tablets instead, and how much the shot would be. He looked a bit startled, but looked up the information for me. I opted for the capsules/ tablets. My mother, bless her, drove me to a nearby hospital so I could get the prescription filled. Was very grateful the medication kicked in within 10 minutes or so. Will never forget the compassionate professionalism of that physician.
Flashback II – About 25 years ago I had rather painful wrists (not carpal tunnel) and went to a doctor. (From a temp job, basically keyboarding for hours at end.) Again, I was uninsured with little money.. Went to the doctor with a book from the library with exercises to relieve pain in the wrists. Asked the doctor what he thought about them. Told him I was uninsured and didn’t have much money. The doctor didn’t say much. Just directed me down the hall to a physical (occupational?) therapist. The therapist gave me several pages of exercises and went over them with me. I asked her what the additional charge for her services was. She said nothing. Again, the doctor showed compassionate professionalism. Such a “business” where the staff communicated well and worked with each other for the customer’s benefit! Oh, and the exercises worked, and I keyboarded with better ergonomics as outlined in the handouts given.
by David Pittman, Washington Correspondent, MedPage Today
Oct 16, 2013 – Physicians need to broach discussions about out-of-pocket costs with patients the same way they discuss a treatment’s side effects, public policy professors wrote.
“Admittedly, out-of-pocket costs are difficult to predict, but so are many medical outcomes that are nevertheless included in clinical discussions,” Peter Ubel, MD, of Duke University’s School of Public Policy, and colleagues wrote.
They noted in a New England Journal of Medicine perspective published Wednesday that patients can experience considerable financial strain from out-of-pocket costs, with little or no discussion beforehand about potentially avoidable health-related bills.
“Because treatments can be ‘financially toxic,’ imposing out-of-pocket costs that may impair patients’ well-being, we contend that physicians need to disclose the financial consequences of treatment alternatives just as they inform patients about treatments’ side effects,” the authors wrote.
They gave the example of a colon cancer patient who receives bevacizumab (Avastin), which can help prolong life by 5 months over chemotherapy alone.
Many providers don’t mention that the drug can cost $44,000 for 10 months of therapy, Ubel and others wrote. A Medicare patient responsible for 20% of the cost can expect $8,800 in out-of-pocket costs on top of other treatment costs, doctor’s fees, and diagnostic tests. The out-of-pocket costs can be even higher for patients with high-deductible insurance plans.
“Most physicians insist on discussing the 2% risk of adverse cardiovascular effects associated with bevacizumab, but few would mention the drug’s potential financial toxicity,” the authors noted.
More than one in five patients covered only by Medicare (20.9%) reported some kind of financial burden, according to the National Center for Health Statistics data the authors cited. Even 30.4% of privately insured patients under age 65 reported some financial burden from medical care.
The authors suggested that taking the time to discuss what can be an uncomfortable topic may:
Enable patients to choose lower-cost treatments when available
Help patients who are willing to trade medical benefit for financial distress
Enable patients to seek financial assistance earlier and avoid duress
In addition, evidence suggests that considering costs as part of clinical decision-making might reduce long-term costs to society, the authors noted. For example, some physicians feel it’s their responsibility to provide the best care regardless of costs, and patients worry that inquiring about prices will pit them against doctor’s orders and open them to subpar treatment.
Physicians lack training in this area, and may feel uncomfortable or may not know what a patient’s costs will be since it depends on what health insurance plan they have. “It is often difficult to determine a patient’s out-of-pocket costs for any given intervention,” Ubel and colleagues wrote.
But insurance companies are developing ways to better estimate patients’ costs, the perspective stated. Furthermore, policymakers need to push for greater price transparency, especially when it comes to prices borne by patients.
“We can no longer afford to divorce costs from our discussion of patients’ treatment alternatives,” they wrote.
A new report from the Dartmouth Atlas Project shows that the use of both effective and risky drug therapies by Medicare patients varies widely across U.S. regions, offering further evidence that location is a key determinant in the quality and cost of the medical care that patients receive.
In their first look at prescription drug use, Dartmouth researchers also find that the health status of a region’s Medicare population accounts for less than a third of the variation in total prescription drug use, and that higher spending is not related to higher use of proven drug therapies. The study raises questions about whether regional practice culture explains differences in the quality and quantity of prescription drug use.
“There is no good reason why heart attack victims living in Ogden, Utah, are twice as likely to receive medicine to lower their cholesterol and their risk of another heart attack than those in Abilene, Texas, but this inconsistency reflects the current practice of medicine in the United States,” said Jeffrey C. Munson, M.D., M.S.C.E., lead author and assistant professor at The Dartmouth Institute for Health Policy & Clinical Practice.
“This report demonstrates how far we still have to go as a nation to make sure people get the care they need when they need it,” said Katherine Hempstead, Ph.D., M.A., senior program officer at the Robert Wood Johnson Foundation, a longtime funder of the Dartmouth Atlas Project. “Instead of varying widely, patterns of care should be nearly uniform across the country for non- controversial drug therapies with a strong evidence for their use.”
The new report offers an in-depth look at how prescription drugs are used by Medicare beneficiaries in the program’s Part D drug benefit, which had 37 million enrollees in 2012. The report separates the country into 306 regional health care markets and examines variations among them in the quantity and quality of prescription drug use, spending, and use of brand name drugs. To examine the quality of care, the report looks at prescription use in three categories:
Drug therapies proven to be effective for patients who have suffered heart attacks, have diabetes, or have broken a bone;
Discretionary medications, which have less clear benefits, but may be effective for some patients who take them; and
Potentially harmful medications, for which risks generally outweigh benefits. 1
The federal agency in charge of Medicare announced that for the next three months it will relax enforcement of its controversial “two-midnight rule,” but will not eliminate it per the desires of healthcare providers and now members of Congress.
Earlier this year the Centers for Medicare and Medicaid Services (CMS) announced a new standard for determining whether a patient is admitted to a hospital or there for observation, the two-midnight rule. Medicare patients must spend at least two continuous midnights in a hospital to be classified as inpatient, a status which comes with the highest reimbursement rates. Patients who spend less than two midnights will be automatically considered outpatient or under observation status.
As with any rule there will be exceptions:…
…
For patients, the advice we offered a few weeks ago still stands: If you are admitted to a hospital, ask and ask often about your status. For more information about how to manage hospital visits, download this pamphlet from the United Hospital Fund, “Hospital Admission: How to Plan and What to Expect During the Stay.” The section pertaining to inpatient versus observation status begins on page 9.***
Just because your family member is in a hospital bed, on a hospital unit, eating hospital food, and undergoing hospital tests does not automatically mean that he or she has been admitted to a hospital. Sometimes doctors want to watch a patient for a few hours or a day to see whether there is really a need to be admitted to the hospital. This is called “observation.” More patients are now in hospitals being observed rather than admitted. This is largely because of Medicare’s efforts to reduce expensive hospital admissions and possible readmissions.
Does it matter if your family member is admitted to the hospital or is just being observed? Yes, because Medicare pays for hospital admissions and observation differently. As a result, your family member’s part of the bill is likely to be higher if he or she is only being observed than if he or she were actually admitted.
Admission vs. Observation
Hospital admissions are covered under Medicare Part A. Under Medicare Part A, after a one-time deductible fee, all hospital costs are covered when a person is admitted as an inpatient.
Observation status and emergency room care (without admission) are considered outpatient care, and are covered only by Medicare Part B. Medicare Part B treats each lab test, X-ray, and other service as individual items, each with a copay. Prescription drugs are not covered and may be a separate charge.
There’s more. To be eligible for Medicare-covered skilled nursing facility services, your family member must have been a hospital inpatient for at least three days. The observation days do not
The result? After 72 hours of observation, your family member will have a higher hospital bill and will not be eligible for Medicare- paid rehabilitation services in a skilled nursing facility. Note that these rules apply to regular (that is, fee-for-service) Medicare; if your family member belongs to a Medicare Advantage (HMO) plan, check with the plan for its requirements.
What can you do?
In addition to all your other questions, ask repeatedly, “Has my family member been officially admitted to the hospital, or is he or she under observation status?” Your family member’s primary care doctor will probably not be involved in this decision.
Make a note of each staff person’s response, including the name and date.
The hospital can retroactively (after the fact) change the patient’s status from inpatient to outpatient. This change is supposed to be made while the patient is still in the hospital, with a written notification to the patient.
If you do not receive this notification, or if you want to appeal the decision, you can contact your state Quality Improvement Office at http://www.qualitynet.org/dcs/ContentServer?c=Page&page name=QnetPublic%2FPage%2FQnetTier2&cid=11447678747 93
The Department of Health & Human Services has created a database that for the first time gives consumers information on what hospitals charge. The data, on the charges for services that are provided during the 100 most common Medicare inpatient stays and 30 common outpatient services, show significant variation across the country and within communities.
For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif. Even within the same geographic area, hospital charges for similar services can vary significantly. For example, average inpatient hospital charges for services that may be provided to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, Colo., and from a low of $9,000 to a high of $51,000 in Jackson, Miss.
My volunteer position at the NW Ohio Area Office on Aging brings me in contact with many older Americans with health issues.
The past few months I’ve been making follow up phone calls to screen folks for eligibility for the Extra Help Medicare Prescription Drug program **through the Social Security Office. Quite a few screenings went beyond the rote answering of about 15 questions related to income, resources and current prescription drug coverage. At times I got quite an earful of their present medical conditions, financial conditions, and inability to fully take care of themselves and others. Was usually able to refer folks to in-house and area resources.
This morning I came across a training class for librarians on how to assist older Americans on how to locate health information.
While information doesn’t cure or assist on it’s own, it does empower people. At the Area Office on Aging, we do not advise, but present information so they can make their own best possible decisions.
The class material is online and free. I’ll be going through the materials on my own. Partly so I can be a better volunteer.
Also, I’ll be adding some of the material to my Google site, Health Resources for All.
Some interesting factoids from the online class, Healthy Aging at Your Library, specifically the Power Point presentation
The number of Americans aged 65 years or older during the next 25 years will double to about 72 million.
By 2030, older adults will account for roughly 20% of the U.S. population.
2 out of 3 older Americans have multiple chronic conditions, and treatment for this population accounts for 66% of the country’s health care budget ***
Heart Disease – #1 cause of death adults over age 65
Cancer – #2 cause of death adults over age 65
Patients with low literacy skills were observed to have a 50% increased risk of hospitalization
Only 3% of older adults surveyed had proficient health literacy skills
**Medicare beneficiaries can qualify for Extra Help with their Medicare prescription drug plan costs. The Extra Help is estimated to be worth about $4,000 per year. To qualify for the Extra Help, a person must be receiving Medicare, have limited resources and income, and reside in one of the 50 States or the District of Columbia.
To see if you qualify, and apply… do one of the following
Call the US Social Security Office 1-800-772-1213 (somtimes one can bypass menu options by saying “Customer Service”_
Contact your nearest Area Office on Aging, United Way, or similar agency
*** Right now at the Area Office, I am doing Medicare Advantage Plans and Part D (Prescription Drug) plan comparisons. Part of the comparison includes entering all prescription drugs used. This can get quite lengthy. Averages around 8 drugs, the record for me was 27 prescription drugs entered for one person.
I encourage folks to compare Medicare Advantage Plans/Part D plans every year. Even if one is happy with one’s plan, it does not hurt to look at others. Medicare.gov (the official government site) has a tool where one can compare plans for free. The results are in an easy to read chart, which includes prices, coverage, co-pays, and more.
Need assistance in doing the online comparisons? Contact your local Area Office on Aging, United Way, or other related social service agency.
Earlier this week I attended a workshop for Ohio Benefit Bank volunteers. All sessions I attended addressed different aspects of the Health Insurance Exchange. The take home message was that while there are challenges, there is hope that overall ObamaCare will do more good than bad.
It is very important to go to reliable resources for unbiased and timely information about ObamaCare
I strongly recommend the resources** listed below
There will be glitches when the major provisions of the Affordable Care Act are implemented starting Oct. 1. Huge glitches. Many glitches. Bet on it.
That is a prediction not only from those resolutely opposed to the ACA. Even those quite excited about President Barack Obama’s federal health law have the same expectation: The rollout of the biggest new social program in nearly 50 years is not going to be pretty.
“When you’re dealing with tens of millions of new clients, mistakes are inevitable,” said Henry Aaron, a health economist at the Brookings Institution. “You’re going to have thousands of mistakes.”
…
“People can make comparisons to Medicare Part D and to Medicare itself, but nothing this big has ever been tried.”
In the simplest terms, the task at hand is to enroll 16 million currently uninsured Americans into health insurance plans or an expanded Medicaid. That process begins Oct. 1 with coverage starting Jan. 1.
…
Although Americans have until the end of March to sign up for health insurance, a crush of demand at the very start could overwhelm exchange call-in centers, websites and personnel. No one will say this out loud, but administrators are hoping for a steady trickle rather than a flood, at least in the early going.
All of the eligibility determinations and subsidy calculations will require a seamless transfer of information. The exchanges will have to interact with the U.S. Treasury for income information. They will have to communicate with the Department of Homeland Security to verify citizenship. And all this information must be handled without violating the privacy of consumers.
“CMS (the Centers for Medicare and Medicaid Services) has designed and tested a system that they think is going to work, and they know where the risks and vulnerabilities are,” said Charlene Frizzera, president of her consulting firm, CF Health Advisors, and a former acting administrator of CMS. “The question is, how will they deal with those vulnerabilities they anticipated and those they haven’t anticipated?
….
Dennis G. Smith, also a former head of what is now CMS, believes one weak point will be in the calculation of Medicaid eligibility. He believes it is likely that the exchanges and state Medicaid offices will use different formulas or time frames for determining eligibility, leading to frustration and confusion for many consumers.
“Exchanges will send a whole bunch of people to Medicaid and Medicaid will say ‘Nope, they don’t qualify,’ and send them back to the exchanges,…
…
states with federal exchanges are doing no outreach at all, which raises the possibility that residents of those states will remain uninformed and do nothing.
….
Even people who get the message may arrive at the exchanges having never before purchased health insurance and unfamiliar with the way premiums, co-pays and deductibles work. Others may lack documentation proving citizenship, residency and income.
…
Perhaps the question that causes the most trepidation in the Obama administration is whether healthy young people will sign up for health insurance as the ACA requires. Because young people tend to be healthy and file relatively few insurance claims, their premiums are supposed to help pay for claims of older, sicker people. If the only people buying insurance are old and the sick, insurance premiums will be prohibitively expensive…
Health Reform: Seven Things You Need to Know (Consumer Reports) [2012]- 15 pages with topics as newly enacted protections and benefits,what to expect in 2014, essential benefits defined, and how it will affect you
Health Insurance Marketplace – a great FAQ page with links to state information. Also answers to some specific questions as dental coverage, how to estimate costs, how to protect from fraud, and unemployed options
BenefitsCheckUp, a service of the National Council on Aging, can help you find public and private programs that may be able to help pay for your prescription drugs.
Non-profit information resource devoted to helping people in need find assistance programs to help them afford their medications and costs related to health care. Includes coverage gap programs.
A way to receive discounts on prescription drugs at participting pharmacies.
Printable coupon at Web site
Contact by email or phone (1-888-412-0869). FAQ page here.
How it Works
Use FreeRxPlus® Bin and Group numbers for FREE access to savings on prescriptions, lab tests, and imaging services.
For access to Lab Test savings: Locate a lab or order your test call toll-free 1-888-412-0869
For access to Imaging Savings: Locate an imaging center or order your service call toll-free 1-888-412-0869
For access to Prescription Savings: Click HERE and locate a participating pharmacy or search for medication pricing. Then simply present your FreeRxPlus® card to the pharmacist for immediate saving
PatientAssistance.com is a free resource designed to help connect patients who can’t afford their prescription medications with patient assistance programs. Generally for the uninsured and underinsured.
The PAF helps to solve health insurance and access problems. The website has information on resources, programs, and provides personal help. PAF offers assistance to patients with specific issues they are facing with their insurer, employer and/or creditor regarding insurance, job retention and/or debt crisis matters relative to their diagnosis of life threatening or debilitating diseases.
CINV (chemotherapy-induced nausea and vomiting) CareLine is a patient hotline designed to provide case management assistance to patients diagnosed with cancer and experiencing chemotherapy-induced nausea and vomiting who are seeking education and access to care.
The Co-Pay Relief Program currently provides direct financial support to insured patients, including Medicare Part D beneficiaries, who must financially and medically qualify to access pharmaceutical co-payment assistance. The program offers personal service to all patients through the use of call counselors; personally guiding patients through the enrollment process
RxAssist is a website with information, news, and a database that are all designed to help you find out about ways to get affordable, or free, medications. The database includes information on the pharmaceutical companies’ patient assistance programs, or programs that provide free medication to low-income patients. RxAssist was created by Volunteers in Health Care, a national, nonprofit resource center for health care programs working with the uninsured.
The main entrance to the east campus of the Beth Israel Deaconess Medical Center, on Brookline Avenue in Boston. (Photo credit: Wikipedia)
“At the very least, Paulson said, patients should receive immediate written notice of observation status and the chance to appeal while they are still in the hospital. For now, she and Edelman recommend that patients and families always ask — and push back if needed.”
Harold Engler recently spent 10 days in a Boston teaching hospital, trying to snap back from complications after urgent hernia surgery. Nurses provided around-the-clock treatment, changing the 91-year-old’s catheter, for example, and pumping him with intravenous drugs for suspected pneumonia.
It all seemed like textbook hospital care to his wife, Sylvia. So she was shocked to learn that Beth Israel Deaconess Medical Center had never “admitted” her husband at all.
“Mrs. Engler, we have bad news for you. This was marked ‘medical observation,’ ” said a nurse at the nursing home where her husband was sent for rehabilitation. The hospital had decided Harold Engler was not sick enough to qualify as an official “inpatient.”
The difference in terminology was not a mere technicality: the observation classification left the Englers with a huge bill. It triggered a mystifying Medicare rule that required the Framingham couple to pay the entire $7,859 cost of his rehabilitation care and the medications he needed while at the nursing facility. If Harold Engler, a retired sales executive, had been admitted to the hospital, they would have likely paid nothing.
It is a striking example of just how impenetrable the US health care system can be for those who use it. Thousands of Medicare enrollees in Massachusetts and across the country are finding themselves caught in the same perplexing bind: Despite long hospital stays, they have been deemed observation patients or outpatients whose follow-up care is not covered. They also can face higher costs for the hospital stay itself when they are not officially admitted.
Medicare Observation Status: Update (eldercenter.wordpress.com)
“a patient who is admitted to the hospital under observation status and then discharged for rehabilitation will find himself responsible for the full cost of skilled nursing expenses.”
“A lawsuit, Bagnall v. Sebelius, is currently working its way through the courts. The plaintiffs are seeking the elimination of hospital observation stays, or at least requiring hospitals to inform Medicare patients that their stay is classified as observation status.
On the legislative front, the “Improving Access to Medicare Coverage Act” was introduced on March 13 of this year (Senate Bill 569 and House Bill 1179). If passed, the law will amend Title XVIII of the Social Security Act, and permit a 3 day inpatient hospital stay to meet the 3-day hospital requirement for coverage of skilled nursing facility services under Medicare.
The judicial and legislative wheels turn very slowly, so here are some steps you can take to protect yourself and your pocketbook if you are admitted to the hospital:
You or your family member should find out how the hospital has classified your stay. Is it inpatient or observation status? Ask each day, because it may change from day to day.
If you have been admitted under observation status, contact your primary care doctor or the hospital doctor treating you. Ask that you be admitted an an inpatient. This has to be done promptly, since under Medicare rules, reclassification from observation status to inpatient status cannot be done after you are discharged.
If you go to a skilled nursing facility for rehabilitation following your hospital stay and then discover Medicare is not covering the costs because you were under observation status, you may appeal. When you receive your Medicare Summary notice, highlight the disputed charges and follow the directions on the form regarding where to send your appeal. Needless to say, the wheels of this process also turn slowly, and there is no guarantee that your appeal will be successful, but keep at it. Note that you have only 120 days to appeal.
Check back to my blog for updates on this issue of great importance to seniors and their loved ones.”
Great 7 minute overview, published by KaiserHealthCare. Really liked how the graphics (including Playschool like cartoon figures) outlined the major points without making me feel like a dummy!
Do you have a good sense of what the new health care options are starting 2014? The HR folks at work just shared this cute 7minute video that does a good job of clarifying what the options are and the advantages and disadvantages of each. I found it really useful and thought I’d pass it along.
” Individual exchanges in 34 states will be created via the federal government – but on July 5, it quietly granted another concession. The Department of Health and Human Services relaxed a requirement for the 16 other states and the District of Columbia to verify the income and health coverage status of applicants to those individual exchanges. These 17 exchanges will only check the income eligibility of applicants at random next year, and they will wait until 2015 to check if applicants are getting employer-sponsored health benefits.5″
“Where do things stand state-by-state with the Medicaid expansion? Just 23 states and the District of Columbia have signed up for it. (You’ll recall that the Supreme Court allowed states to opt out of it when it ruled that the ACA was constitutional in 2012.) In these states and in Washington D.C., those with earnings of up to 138% of the federal poverty level may qualify for Medicaid (that works out to earnings of $15,856 for an individual and $32,499 for a family of four). The expansion of Medicaid in these states doesn’t require the federal government to recreate the wheel, but delays could happen in other ways. In Michigan, for example, state legislators have passed their own version of a Medicaid expansion requiring a 90-day federal review process, which will put Michigan weeks behind in enrolling participants in expanded Medicaid coverage.6,”
North Carolina Gov. Pat McCrory (R) has signed abill that will require the state’s hospitals and ambulatory surgical centers to publicly disclose how much they charge — and how much insurers pay them — for 140 common medical procedures. The information will be posted to the Tar Heel State’s Department of Health and Human Services website and provide consumers a way of knowing which hospitals are giving them the most bang for their buck.
….
The federal government took a small step towards addressing this lack of transparency by releasing charge records for the most common inpatient procedures at more than 3,300 hospitals across 306 locales in May. The numbers confirmed health care experts’ suspicions: the cost of U.S. medical care is essentially arbitrary, with even hospitals in the same county charging anywhere from $7,000 to $99,700 for the same procedure. And the hospitals charging the most money don’t even offer much better services. Reform advocates say these staggering fluctuations are a direct result of price opacity.
But North Carolina’s law actually goes further than the federal government did by giving consumers even more relevant information. The top-line charge data released by the government isn’t actually what insurers and patients pay hospitals. The actual payments are negotiated between the hospitals, insurers, and uninsured Americans. To address that, the North Carolina will require hospitals to disclose the actual prices paid by Medicare, Medicaid, and Americans without any health coverage for the procedures in question, as well as the average and range of prices paid by the top five insurers in the state.
Hospitals make mistakes, sometimes deadly mistakes. A patient may get the wrong medication or even undergo surgery intended for another person. When errors like these are reported, state and federal officials inspect the hospital in question and file a detailed report.
Now, for the first time, this vital information on the quality and safety of the nation’s hospitals has been made available to the public online.
A new website, www.hospitalinspections.org, includes detailed reports of hospital violations dating back to January 2011, searchable by city, state, name of the hospital and key word. Previously, these reports were filed with the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid (CMS), and released only through a Freedom of Information Act request, an arduous, time-consuming process. Even then, the reports were provided in paper format only, making them cumbersome to analyze.
Release of this critical electronic information by CMS is the result of years of advocacy by the Association of Health Care Journalists, with funding from the Ethics and Excellence in Journalism Foundation. The new database makes full inspection reports for acute care hospitals and rural critical access hospitals instantly available to journalists and consumers interested in the quality of their local hospitals.
The database also reveals national trends in hospital errors. For example, key word searches yield the incidence of certain violations across all hospitals. A search on the word “abuse,” for example, yields 862 violations at 204 hospitals since 2011. …
o treat observation care as simply a loophole that allows hospitals to avoid the Medicare penalties from readmissions — as Brad Wright, an assistant professor of health management and policy at the University of Iowa did earlier this month — is to take a short-sighted approach to a complex health issue.
Observation care in fact aims to address several of healthcare’s thorniest challenges head on. In the process, a well-run observation unit can not only help reduce hospital readmission rates, but it can reduce crowding and speed throughput in the ER, save patients an extended first hospital admission (let alone a re-admission), and perhaps most importantly, improve patient outcomes.
To see how, and to clear any misconceptions some like Wright could have about observation care, it might be helpful to do some Q&A.
In response to a Freedom of Information Act request by ProPublica, the government has released unredacted write-ups of problems found during nursing home inspections around the country. We’re making them available today for anyone who wants to download the complete versions.
For several months now, ProPublica has made redacted versions of this same information available in an easily searchable format in our Nursing Home Inspect [1]tool. These versions, which reside on the U.S. Centers for Medicare and Medicaid Services website, Nursing Home Compare [2], sometimes blank out patients’ ages, medical conditions, dates and prescribed medications.
The agency has said the redactions are intended to balance patient privacy concerns with the need to inform consumers about the quality of care. ProPublica requested the unredacted reports because they are public records and because the added information can make them more useful.
In response to a Freedom of Information Act request…
…The Dartmouth Atlas Project is an online database which collects Medicare spending and utilization data from around the country. Information gathered from the database has shown immense variation in the way medical resources are utilized by even similar regions, communities, and health care organization. Evidence has repeatedly shown that, from a population perspective, areas that spend more on medical care do not consistently benefit from increased quality of care or patient wellbeing. Variation in the type of care delivered can be attributed to diverse incidence and prevalence of disease severity or the type of care a well- informed patient chooses. Variation in health care delivery is thus omnipresent and expected, because every patient is unique and medical innovation presents a growing number of care options to choose from….
The top ten Republican states have higher Medicare spending than the top ten Democratic states. The rate of hospitalization and surgical procedures are also higher for Republican states. If we investigate a procedure like percutaneous coronary interventions (PCI), the Republican states are performing more PCI procedures with equal mortality benefit compared to Democratic states. The evidence of variation in cost and utilization is a strong indication of inconsistency and inefficiency in the care delivery process. Are the Republican states providing better care by providing more care? We cannot find evidence of for such an assertion. Nor do we find evidence of harm occurring from a lack of utilization to individuals residing in democratic states. Six of the ten Republican states sued the federal government over the individual mandate and Medicaid expansion earlier this year (Utah, Alabama, Louisiana, Texas, Georgia, and Nebraska), compared to only one democratic majority state (Maine). Yet the Republican states have a higher average of uninsured people, thus inhibiting a greater percentage of their citizens from accessing preventive healthcare….
English: Nursing and Residential Care Home, Withington This is Clyde Court, on Lapwing Lane. (Photo credit: Wikipedia)
From a recent USA.gov email
When planning ahead in these uncertain financial times, it’s important to think about long-term care for yourself and your loved ones. Long-term care (LTC) is a range of services and supports you may need to meet your health or personal needs over a long period of time. These services might include emergency response systems, senior centers, assisted living, nursing homes, transportation services, and many more.
Most long-term care assists people with activities of daily living like dressing, bathing and using the bathroom. Other common long-term care services include helping with housework, cooking, shopping, or even managing money. Long-term care can be provided at home, in the community, in assisted living or in nursing homes. And it’s not just for seniors—if you have a significant health challenge, you may need long-term care at any age.
While there are a variety of ways to pay for long-term care, it is important to think ahead about how you will fund the care you may need. Generally, Medicare doesn’t pay for long-term care, but only for a medically necessary skilled nursing facility or home health care. Long-term care insurance may be an option to help you and your family prepare ahead of time for the potential need for long-term care. There are a variety of plans available that vary in cost depending on what services you want covered and the age you begin coverage. Before you choose a plan you should take into account where and what kind of care you might need.
Be sure to take some time this month to check out your options and plan ahead, so you can rest assured that you and your family get the care you need. And if you’re a caregiver now for a family member with health challenges, find more resources and support from USA.gov.
[Flahiff’s note…
If you do not have ready access to a computer or find computers challenging, try these resources for assistance in comparing plans
Local Area Office on Aging (may have a slightly different name in your area)
As a volunteer at our area office, this is our top priority during open enrollment…which ends December 7th
Local United Way for referral to agencies in your area (211 for most localities)
Local public library for referral to agencies in your area (ask for a reference librarian)]
This October 2, 2012 Reuters article by Mark Miller goes into considerable detail about the rising premiums and explains what steps Medicare beneficiaries can take to shop around.
Best Quote from the Article: Premiums for many popular Medicare prescription drug plans will soar next year – but seniors don’t have to take the rate hikes lying down.
Medicare beneficiaries and their adult children can use these two articles, together with the Plan Finder at Medicare.gov. At the top right on the page is a button that takes visitors to an online demonstration of the Plan Finder.
In the context of changing demographics, the increasing cost of health care services, and continuing federal budgetary pressures, Medicare has become one of the most controversial federal programs. To facilitate an informed debate about the future of this important public initiative, this article examines and debunks the following ten myths surrounding Medicare: (1) there is one Medicare program, (2) Medicare is going bankrupt, (3) Medicare is government health care, (4) Medicare covers all medical cost for its beneficiaries, (5) Medicare pays for long-term care expenses, (6) the program is immune to budgetary reduction, (7) it wastes much of its money on futile care, (8) Medicare is less efficient than private health insurance, (9) Medicare is not means-tested, and (10) increased longevity will sink Medicare.
I, like many, read the internet version of my local newspaper. And in doing so, I am provided with an opportunity to view the comments of my fellow residents on topics of importance. My local newspaper is a bit right leaning and as a result, the vox populi is as well.
Many of those who post thoughts on current events do so with great fervor and some with great frequency. The tone and tenor of the “discussions” can vary but were at their most vitriolic when writers could use pseudonyms. Many of the most vocal appear to have departed when a requirement was made to self identify posts to the site. Several continue to provide the rest of us with the fruits of their years and breadth of experience as well as their keen intellect.
Given the right leanings of the newspaper and the most vocal of the vox populi, it is not surprising that the Affordable Care Act (presumably a four letter word for many) is viewed in a somewhat negative fashion. This is somewhat surprising since presumably the writers are either the beneficiaries of then Governor Romney’s surprising insight into healthcare or to the workings of President Johnson’s Great Society and Medicare. Massachusetts has managed to insure just about every citizen in the state and has now enacted legislation to better control health care costs. While there is work to be done to develop an ideal healthcare delivery system in Massachusetts and control costs, near universal access has been accomplished.
Why then do people object so strenuously to Obamacare? Is it their fear of government control? If so, the objectors should rightfully refuse Medicare, a pay as you go, government run insurance program managed by the Centers for Medicare and Medicaid. I suspect that the underlying reason is really rooted in economics. In essence, it is a zero sum game. If you win something, I must lose something.
439,000 more Massachusetts residents have health insurance coverage than did before reform.
Massachusetts has the highest rate of insurance in the country with 98.1 percent of residents insured.
There has been no evidence of subsidized coverage “crowding out” employer-sponsored insurance, and employer offer rates have grown from 70 percent to 77 percent since implementation of reform.
Public support for Massachusetts health reform has remained strong with two out of three adults supporting reform.
Most employers believe health reform has been good for Massachusetts and 88 percent of Massachusetts physicians believe reform improved, or did not affect, care or quality of care.
The cost of health care and the annual rate of increase in health care spending remains a challenge. With no intervention, per capita health care spending in Massachusetts is projected to nearly double by 2020.
Given the intensity of the debate around Obamacare, I would have assumed that more news stories would provide readers with more information about the Massachusetts experience. More often than not however, readers are provided with partisan arguments for and against the Affordable Care Act. While there is a good deal of noise, there often is little in the way of real information.
I, like many, read the internet version of my local newspaper. And in doing so, I am provided with an opportunity to view the comments of my fellow residents on topics of importance. My local newspaper is a bit right leaning and as a result, the vox populi is as well.
Many of those who post thoughts on current events do so with great fervor and some with great frequency. The tone and tenor of the “discussions” can vary but were at their most vitriolic when writers could use pseudonyms. Many of the most vocal appear to have departed when a requirement was made to self identify posts to the site. Several continue to provide the rest of us with the fruits of their years and breadth of experience as well as their keen intellect.
Given the right leanings of the newspaper and the most vocal of the vox populi, it is not surprising that the Affordable Care Act (presumably a four letter word for many) is viewed in a somewhat negative fashion. This is somewhat surprising since presumably the writers are either the beneficiaries of then Governor Romney’s surprising insight into healthcare or to the workings of President Johnson’s Great Society and Medicare. Massachusetts has managed to insure just about every citizen in the state and has now enacted legislation to better control health care costs. While there is work to be done to develop an ideal healthcare delivery system in Massachusetts and control costs, near universal access has been accomplished.
Why then do people object so strenuously to Obamacare? Is it their fear of government control? If so, the objectors should rightfully refuse Medicare, a pay as you go, government run insurance program managed by the Centers for Medicare and Medicaid. I suspect that the underlying reason is really rooted in economics. In essence, it is a zero sum game. If you win something, I must lose something.
439,000 more Massachusetts residents have health insurance coverage than did before reform.
Massachusetts has the highest rate of insurance in the country with 98.1 percent of residents insured.
There has been no evidence of subsidized coverage “crowding out” employer-sponsored insurance, and employer offer rates have grown from 70 percent to 77 percent since implementation of reform.
Public support for Massachusetts health reform has remained strong with two out of three adults supporting reform.
Most employers believe health reform has been good for Massachusetts and 88 percent of Massachusetts physicians believe reform improved, or did not affect, care or quality of care.
The cost of health care and the annual rate of increase in health care spending remains a challenge. With no intervention, per capita health care spending in Massachusetts is projected to nearly double by 2020.
Given the intensity of the debate around Obamacare, I would have assumed that more news stories would provide readers with more information about the Massachusetts experience. More often than not however, readers are provided with partisan arguments for and against the Affordable Care Act. While there is a good deal of noise, there often is little in the way of real information.
Excessive health care spending is overwhelming America’s economy, but the subtler truth is that this excess has been largely facilitated by subjugating primary care. A wealth of evidence shows that empowered primary care results in better outcomes at lower cost. Other developed nations have heeded this truth. But US payment policy has undervalued primary care while favoring specialists. The result has been spotty health quality, with costs that are double those in other industrialized countries. How did this happen, and what can we do about it.
American primary care physicians make about half what the average specialist takes home, so only the most idealistic medical students now choose primary care. Over a 30 year career, the average specialist will earn about $3.5 million more. Orthopedic surgeons will make $10 million more. Despite this pay difference, the volume, complexity and risk of primary care work has increased over time. Primary care office visits have, on average, shrunk from 20 minutes to 10 or less, and the next patient could have any disease, presenting in any way.
By contrast, specialists’ work most often has a narrower, repetitive focus, but with richer financial rewards. Ophthalmologists may line up 25 cataract operations at a time, earning 12.5 times a primary care doctor’s hourly rate for what may be less challenging or risky work.
These differences in physician worth and payment didn’t just happen. Instead, they have been driven by a 31 doctor – 26 specialists and 5 primary care physicians – American Medical Association panel, the Relative Value Scale Update Committee (RUC), which for 20 years has been Medicare’s sole advisor on the value of physician services. The Centers for Medicare and Medicaid Services (CMS), the federal agency overseeing the program, has historically accepted nearly 90 percent of the RUC’s recommendations with no further due diligence. So the RUC has huge financial impact throughout health care, not only for Medicare but for many commercial health plans that follow Medicare’s lead on payment…
…
t is clear that it will be impossible to get American health care under control unless we can recapture regulation and reconfigure it to act in the common rather than the special interest. Until that is accomplished, America’s and our children’s diminishing prospects will be directly tied to our failure to stop the health industry’s rapaciousness.
The Affordable Care Act – the new health care law – helped over 16 million people with original Medicare get at least one preventive service at no cost to them during the first six months of 2012, Health and Human Services (HHS) Secretary Kathleen Sebelius announced today. This includes 1.35 million who have taken advantage of the Annual Wellness Visit provided by the Affordable Care Act. In 2011, 32.5 million people in Medicare received one or more preventive benefits free of charge.
“Millions of Americans are getting cancer screenings, mammograms and other preventive services for free thanks to the health care law,” said Secretary Sebelius. “These new benefits, made possible through the health care law, are helping people stay healthy by giving them the tools they need to prevent health problems before they happen.”
Prior to 2011, people with Medicare faced cost-sharing for many preventive benefits such as cancer screenings. Through the Affordable Care Act, preventive benefits are offered free of charge to beneficiaries, with no deductible or co-pay, so that cost is no longer a barrier for seniors who want to stay healthy and treat problems early.
The law also added an important new service for people with Medicare — an Annual Wellness Visit with the doctor of their choice— at no cost to beneficiaries.
To learn what screenings, vaccinations and other preventive services doctors recommend for you and those you care about, please visit the myhealthfinder tool at www.healthfinder.gov.
Baltimore, MD, June 28, 2012 /PRNewswire/ — Now is an ideal time for caregivers to get organized, manage personal finances and plan for the future. Effective long-term planning can help bring peace of mind and is particularly important for the nation’s growing number of caregivers who must manage their own affairs while attending to the health and well-being of another. Nearly 66 million U.S. residents¹ provide care for a chronically ill, disabled or aging family member or friend. This can involve:
Setting up doctor appointments for the many free, preventive services available to Medicare beneficiaries,
Reviewing drug plan coverage,
Planning for changes in in-home care needs, or
Preparing for a transition from the home to an assisted living or nursing home facility.
The Centers for Medicare and Medicaid Services initiative, Ask Medicare, can help caregivers plan by offering a wealth of consumer-focused information, including personal stories from other caregivers on overcoming common challenges, a free e-newsletter, and decision-making tools addressing a range of health care issues. The “How Can you Plan for the Future?” checklist provides planning ideas.
American Heart Association meeting report – Abstract 12
Differences in regional hospital readmission rates for heart failure are more closely tied to the availability of care and socioeconomics than to hospital performance or patients’ degree of illness, according to research presented at the American Heart Association’s Quality of Care & Outcomes Research Scientific Sessions 2012.
U.S. regional readmission rates for heart failure vary widely ― from 10 percent to 32 percent ― researchers found. Communities with higher rates were likely to have more physicians and hospital beds and their populations were likely to be poor, black and relatively sicker. People 65 and older are also readmitted more frequently.
To cut costs, the Centers for Medicare and Medicaid Services plans to penalize hospitals with higher readmission rates related to heart failure, heart attack and pneumonia. Next year, hospitals with higher-than-average 30-day readmission rates will face reductions in Medicare payments.
But the penalties don’t address the supply and societal influences that can increase readmission rates, said Karen E. Joynt, M.D., lead author of the study and an instructor at Brigham and Women’s Hospital, Harvard Medical School and the Harvard School of Public Health in Boston, Mass….
This dissertation contains three papers on the health and welfare of the elderly population. Overall, these papers provide insights into the costs and challenges of providing health care to the elderly population. These papers help us understand the effects of obesity on longevity and health care, as well as better understand the benefits of social insurance. The first paper uses a micro-simulation model to estimate the longevity effects of poor health trends among younger Americans, and finds that difference in these trends can explain 92% of the difference between US and European longevity. The second paper estimates the welfare effects of Medicare Part-D from gains in market efficiency and dynamic incentives for pharmaceutical companies. It finds that these gains alone nearly cover the welfare cost of funding Medicare Part-D. The last paper presents and estimates a structural model of health, exercise, and restaurant consumption. It provides estimates for future welfare analyses of programs targeting obesity through restaurants and exercise in the elderly population. It also estimates the long run effects of making policies which make restaurant food healthier. It finds only minor effects of restaurant policies on health for the elderly. Overall, these papers further our understanding of the challenging objective of improving senior health while containing costs.
Carol McCall, Chief Strategy Officer at GNS Healthcare shared some sobering figures during her Keynote at the Health & Wellness Hub for Social Media Week this past Monday. Among the data points she mentioned were:
– 8000 people age in to Medicare every day
– if unchanged, healthcare costs and interest on the national debt will take up all US revenue by 2025
– a recent NEW ENGLAND JOURNAL OF MEDICINE study revealed that among determinants of health, only 10% was accounted for by actual healthcare practices ((behavior and genetics accounted for over 70%)
With figures like that, most people would want to get as far away from hard data as possible. But McCall argues that the key to big data is interpretation and with the right communications, these types of figures can be powerful drivers for change. She argues that we need to create new roles for ourselves and one of these should be a role for the pursuit of health (as opposed to traditional nomenclature/roles like “patient”). She also believes that social media can be a critical accelerator for defining these new roles….
Our new study, recently published online in Medical Care (“Factors Predicting Medicare National Coverage: An Empirical Analysis” (1)), highlights factors underlying Medicare decisions on medical technology.
Interventions considered to be particularly controversial or expected to significantly impact the Medicare program in the United States are considered in National Coverage Determinations (NCDs). Medicare coverage for interventions is limited to eligible items and services deemed “reasonable and necessary” for the diagnosis or treatment of an illness or injury. What constitutes reasonable and necessary has not, however, been clearly defined.
This study is the first of its kind to quantitatively evaluate the factors associated with positive NCDs…
…Key findings include:
• CMS favors proven interventions. Compared to interventions with clinical evidence deemed “insufficient”, interventions with good or fair quality supporting evidence were approximately six times more likely to receive a positive decision (p<0.01).
• Interventions with available alternatives are less likely to be covered. Compared with interventions with no available alternative, those for which an alternative was available were approximately eight times less likely to receive a positive decision (p<0.01).
• CMS accounts for value in coverage decisions. Compared with technologies estimated to be dominant, i.e., more effective and less costly than the competing intervention considered, those with no published estimate of cost-effectiveness were approximately five times less likely to receive a positive coverage decision (p<0.05).
• Coverage decisions have become more restrictive over time. Compared with coverage decisions made in the years 1999 to 2001, decisions made from 2002 to 2003 were more than three times less likely to be positive (p<0.05). Decisions made from 2004 to 2005 were also more than three times less likely to be positive (p<0.1), and from 2006 to 2007 decisions were almost ten times less likely to be positive (p<0.01).
This analysis can help the medical community better understand the type of evidence that Medicare considers in NCDs. CMS and other payers may also benefit from this kind of external review of coverage decisions as it can help ensure the consistency of decisions and the integrity and accountability of the coverage process.
Patients, providers and the public have much to celebrate. This week, the Centers for Medicare and Medicaid Services’ Hospital Compare websiteadded central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.
Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences….
Leapfrog Hospital Ratings – information on this site is derived from hospitals’ voluntary submissions of The Leapfrog Hospital Survey. More about the Leapfrog Group at their About Page
AHRQ (US Agency for Health Care Research and Quality
At The Atlantic, a post by Alex Tabarrok, “The Innovation Nation vs. the Warfare-Welfare State“, has been making its way around the bloggysphere, in part due to the big shout out to science, as embodied by this figure:
Tabarrok:
We like to think of ourselves as an innovation nation, but our government is a warfare/welfare state. To build an economy for the 21st century we need to increase the rate of innovation and to do that we need to put innovation at the center of our national vision.
Innovation, however, is not a priority of our massive federal government. Nearly two-thirds of the U.S. federal budget, $2.2 trillion annually, is spent on the four biggest warfare and welfare programs, Medicaid, Medicare, Defense and Social Security. In contrast, the National Institutes of Health, which funds medical research, spends $31 billion annually, and the National Science Foundation spends just $7 billion.
I’m all for cutting back on the warfare state–that senitment is as old as the biblical prophets. And spending more money on non-military research is a good thing (and while we’re on the subject, go sign this petition). Regular readers will know I agree with that. But I’m not sure what’s wrong with the so-called welfare programs.
I’m all for controlling healthcare costs and figuring out ways of delivering care more effectively (who could possibly be against these things?).
he Academy of Nutrition and Dietetics has prepared a request to submit to the Centers for Medicare and Medicaid Services (CMS) to expand coverage of medical nutritiontherapy (MNT) for specific diseases, including hypertension, obesity, and cancer, as part of the CMS National Coverage Determination (NCD) Process. Most chronic health conditions can be controlled or treated with medical nutrition therapy, yet Medicare will only reimburse nutrition therapy services provided by a registered dietitian for individuals with diabetes and renal disease. “That’s just not enough if we want to improve the health of the nation and rein in escalating healthcare costs,” says Marsha Schofield, MS, RD, LD, the Academy’s Director of Nutrition Services Coverage.
Under the NCD Process, the Secretary of the Department of Health and Human Services can expand Medicare coverage for services that are reasonable and necessary for the prevention of an illness. Ms. Schofield explains, “There are an escalating number of baby boomers turning 65 and entering the Medicare system. The majority of Medicare spending is on individuals with chronic conditions, and almost 70% of Medicare beneficiaries suffer from cardiovascular disease. Chronic conditions can be controlled or treated with medical nutrition therapy, so it just makes sense to try to expand the Medicare beneficiary’s access to these important services.”
The Academy’s NCD request is published in the January 2012 issue of the Journal of the Academy of Nutrition and Dietetics …
…The article is “The Academy of Nutrition and Dietetics National Coverage Determination Formal Request,” by Prashanthi Rao Raman, Esq, MPH, and Erica Gradwell, MS, RD, in the Journal of the Academy of Nutrition and Dietetics, Volume 112, Issue 1 (January 2012) published by Elsevier.
Reflections on the importance of health information literacy awareness and how it impacts the public health of our citizens. Low health literacy affects nearly 50% of the US population.
The following was posted to several listservs by Mary Alice Gillispie, M.D.; Healthy Roads Media. “Healthy Roads Media has several new free patient education resources. There is now a Spanish version of Advance Directives in multiple formats. There is also an English version of A Quick Look at Medicare in multiple formats. The link iswww.healthyroadsmedia.org/topics/personalhealth.htm We hope to have materials on both Medicare and Medicaid in English, Spanish and Russian in the next couple of months.
If you work for one of the hundreds of organizations who uses Healthy Roads Media materials but have not provided any support, please consider making an end of the year tax deductible donation (www.healthyroadsmedia.org/donate.htm). Keeping these materials free and adding new resources is an increasing challenge!
Philadelphia, PA — The Academy of Nutrition and Dietetics has prepared a request to submit to the Centers for Medicare and Medicaid Services (CMS) to expand coverage of medical nutrition therapy (MNT) for specific diseases, including hypertension, obesity, and cancer, as part of the CMS National Coverage Determination (NCD) Process. Most chronic health conditions can be controlled or treated with medical nutrition therapy, yet Medicare will only reimburse nutrition therapy services provided by a registered dietitian for individuals with diabetes and renal disease. “That’s just not enough if we want to improve the health of the nation and rein in escalating healthcare costs,” says Marsha Schofield, MS, RD, LD, the Academy’s Director of Nutrition Services Coverage.
In an accompanying podcast Ms. Schofield, Ms. Blankenship, and Ms. Gradwell discuss the NCD process undertaken by the Academy and share insights about its potential impact on healthcare and the role of the registered dietitian. The podcast is available at http://andjrnl.org/content/podcast.
The major cause of the federal budget crisis, which is still in its early stages, is the relentless growth of Medicare spending. The two biggest causes of Medicare growth are the retirement of the baby boom generation, thus increasing the number of people on the rolls, and the persistent increase in the per person cost of medical care. The retirement of the baby boom generation is just beginning and the per person growth of Medicare, even though it has moderated slightly in recent years, tends to be well above economic growth, the growth of wages, and overall inflation. Unless something is done, Medicare will continue to consume an increasing percentage of the federal budget. According to the Medicare Actuary, Medicare will grow from 3.6 percent of the nation’s GDP in 2010 to 10.4 percent by 2080. Moreover, the interest on the money borrowed to pay for our programs, one of the most rapidly growing of which is Medicare, will greatly exceed even our spending on Medicare. Unchecked, growth in spending on Medicare and interest on the federal debt will bankrupt the country….
…If the reluctance of politicians to incur the wrath of voters can be overcome, and if the internecine fighting between the parties can be quelled, analysts and policymakers have developed two broad choices for constraining the growth of Medicare costs. The first is to call on health professionals and other experts to identify reforms that would contain costs by adopting measures such as reducing the use of redundant or unnecessary tests, reducing the use of treatments that evidence shows are not effective, increasing the use of generic drugs, and increasing the effectiveness and use of preventive care…
…The second way to contain Medicare growth is to adopt policies that harness market forces to control costs. Although controversial, premium support is perhaps the most credible approach of this type developed so far….
Patients who are discharged from the hospital after a heart attack, congestive heart failure, or pneumonia have high rates of short-term readmissions. As per a provision in the Affordable Care Act, a Medicare patient with one of these diagnoses who is readmitted within 30 days for the same will trigger a denial of reimbursement for the subsequent admission. There are many things which need to change to limit these events, though not all readmissions can be prevented, as nothing in medicine is absolute. Identification and intensive interventions (inpatient and post-discharge) with high risk patients, better communication/care coordination, discharge processes, and patient education have been shown to produce results. I would make a case for mHealth to become an integral part of all these components of a multi-faceted solution . here are a few ways that mHealth may be incorporated in the process:
The use of bioinformatics to determine the patient’s low, moderate, or high risk of readmission can be put into a hospital app to be shared among members of a multidisciplinary transitional team, which will formulate a discharge and post-discharge plan based on this data, while rounding on the patient daily….
While legislators talk about “bending the cost curve,” one company serving Medicare patients has discovered how to provide better care at lower cost—with wireless scales, free transportation, regular toenail trimmings, and doctors who put the patient first.
Get Mobilized! An introduction to mobile resources and tools in health sciences libraries (Medical Library Association)
Archived 2011 online class including “lecture notes”, resources, class discussions, and related slides/videos
Health Apps(in Health and Medical News and Resources selected by Janice Flahiff)
a short list of information and tracking apps derived from the above Get Mobilized class
“These tools are new ways CMS is making sure consumers have information about health care quality and important information they need to make the best decisions about where to receive high-quality care,” said Dr. Don Berwick, the CMS Administrator. “These efforts are designed to also encourage providers to deliver safe, patient-centered care that consumers can rely on and will motivate improvement across our health care system.”
The steps announced today include:
· A Quality Care Finder to provide consumers with one online destination to access all of Medicare’s Compare tools — comparison information on hospitals, nursing homes and plans: www.Medicare.gov/QualityCareFinder.
· An updated Hospital Compare website, which now includes data about how well hospitals protect outpatients from surgical infections and whether hospitals care for outpatients who are treated for suspected heart attacks with proven therapies that reduce death: www.hospitalcompare.hhs.gov
Health services researchers who studied controversial aspects of Medicare spending and quality of patient care received a prestigious award yesterday from the nation’s largest health services research professional association….
…The Article of the Year Award recognized two companion studies by Silber and Kaestner: “Aggressive Treatment Style and Surgical Outcomes,”*** published in the December 2010 issue of the journal Health Services Research, and “Evidence on the Efficacy of Inpatient Spending on Medicare Patients,” ***published the same month in The Milbank Quarterly.
As an indicator of aggressive care, Silber and Kaestner used the Dartmouth Index, a prominent set of measures of inpatient spending on elderly patients. In studying over 5 million Medicare admissions for various surgeries between 2000 and 2005, they found that surgical patients in hospitals with a more aggressive treatment style were less likely to die within 30 days of admission compared to patients in less aggressive hospitals. They also found that this benefit was stable, persisting after the 30-day mark. …
This blog presents a sampling of health and medical news and resources for all. Selected articles and resources will hopefully be of general interest but will also encourage further reading through posted references and other links. Currently I am focusing on public health, basic and applied research and very broadly on disease and healthy lifestyle topics.
Several times a month I will post items on international and global health issues. My Peace Corps Liberia experience (1980-81) has formed me as a global citizen in many ways and has challenged me to think of health and other topics in a more holistic manner.
Do you have an informational question in the health/medical area? Email me at jmflahiff@yahoo.com I will reply within 48 hours.
My professional work experience and education includes over 15 years experience as a medical librarian and a Master’s in Library Science. In my most recent position I enjoyed contributing to our library’s blog, performing in depth literature searches, and collaborating with faculty, staff, students, and the general public.
While I will never be be able to keep up with the universe of current health/medical news, I subscribe to the following to glean entries for this blog.
AHCJ’s 
Health and Medical News and Resources 