Health Policy

Seniors need to re-evaluate health needs

By Judith Graham

www.kaiserhealthnews.org, Feb. 21, 2012

This story was produced in collaboration with The Washington Posst

　

Nortin Hadler, a professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, has been warning for years about the lack of evidence supporting many popular medical treatments and tests. 

His work is controversial. In books such as “Stabbed in the Back: Confronting Back Pain in an Overtreated Society” and “Worried Sick: A Prescription for Health in an Overtreated America,” Hadler argues for holding medical interventions to a high standard: Do they reduce mortality or substantially lessen the burden of illness? Do potential benefits significantly outweigh potential harms? Unless research proves this, the interventions should be avoided, Hadler insists.

In his newest book, “Rethinking Aging: Growing Old and Living Well in an Overtreated Society,” the 69-year-old Hadler turns his attention to older Americans and the challenging medical decisions they face

Hadler’s conversation with Judith Graham has been edited for clarity and length.

Q: You’ve called your book “Rethinking Aging.” What do you want readers to understand about aging?

A: This book is a celebration of the fact that the baby boomers and the traditionalists — the generation that came before the boomers — are the first in the history of the world to hit age 60 and to be able to say, rationally, “What do I want to do with the next 25 years of my life?”

We shouldn’t worry so much about what will kill us; instead, we should be focusing on making it to age 85 and having a pleasing journey along the way.Q: You’re concerned about the medicalization of aging. Explain why.

A: You can be healthy well beyond 60, but you’ll be different than you were when you were 20. You’ll have different posture, wrinkles and a lot of other changes that are less obvious but age appropriate. We have to be very, very careful about calling any difference from when we were younger an illness or a disease. And we have to be even more careful about telling people that we have things we can do to “fix” these differences, but this happens all the time. That’s the medicalization of aging.Q: What’s the alternative?

A: Helping people understand what’s normal for their age and how to accept and adjust to those normal changes.

Q: You talk a lot about the importance of older people making informed medical decisions.

A: For the first time in the history of medicine, we have a tremendous amount of information about efficacy: what makes sense to do medically and what doesn’t.

What I want to teach people is that it’s perfectly appropriate for patients to ask their doctors, “How certain are you that what you are offering me will produce meaningful benefits? What does the evidence show about the possibility of harm?”Q: Can you suggest some other questions people might ask?

A: People should want to know the likelihood that death will be postponed by doing something. What is the likelihood of the same outcome, or close to the same, if one doesn’t have the treatment? Out of every 100 people, how many are helped by this intervention?Q: What about people who face really serious, life threatening illnesses?

A: You want to know whether a proposed intervention will be effective given your context: your age, your degree of frailty, other illnesses that you have. How much benefit will you get: an extra three months, an extra year? If it’s a year, what kind of year will it be? Will I feel absolutely awful? What will the quality of my life be?

I once took care of a very, very famous physician. He was an octogenarian with heart disease, but he was very active and sharp as a tack. Well, he found out that in his belly was an expanding aortic aneurism – a surgically treatable potential killer. He and I had multiple conversations about what to do and each time he would say, “I’ll be damned if I let them do surgery on me.” He knew there was a high risk of surgical mortality because of his age and his frailty. He knew that urological complications were almost guaranteed and cardiac complications were probable. He didn’t want to try to live through that. And he didn’t have to because he died of a stroke, unrelated to the aneurism, several years later.Q: What about common problems like lower back pain? You say surgical treatments aren’t effective. But what are older people supposed to do?

A: I’m not belittling the pain. In many cases, however, it will resolve over time without medical interventions. The job of the doctor, once the doctor does an exam and realizes there isn’t something extraordinary going on, is to help people deal with the discomfort to minimize suffering. The most effective way to do that is not with surgical violence or even with powerful pills. The doctor helps the patient adapt and address the contextual issues in their life that might interfere with coping while they wait for healing.

Take an older woman who comes in complaining of knee pain. There are no surprises on examination. She’s been your patient for a long time; you know her husband died recently. In our culture, we are primed to assume that the knee pain is interfering with coping with her loss. Science suggests the opposite: the grieving makes the knee pain seem more intense.

With time and trust, a physician can help a patient see this clearly and discover coping skills in the process. Pills, arthroscopy and surgery are missing the forest for the trees.Q: You have very strong and controversial opinions about medical procedures commonly performed on older adults — without adequate justification, you say. Which would you put at the top of the list?

The first would be interventional cardiology and cardiovascular surgery for coronary artery disease. This includes coronary artery bypass surgery, angioplasties and stents. These were designed to spare one from fatal and nonfatal heart attacks. I think these procedures should not be done. We have multiple trials comparing doing them versus taking care of people conservatively, and these studies show that essentially no patient is advantaged by these interventions.

The second would be arthroscopic surgery for knee pain. Again, studies show that patients gain no advantage from arthroscopic surgery. They do as well, even better, with appropriate exercise, a little Tylenol, a supportive community and patience. But going the nonsurgical route calls for coping skills, which many physicians don’t even talk about with older patients.Q: One of your chapters is called “decrepitude.” How do you define that?

I think of it as gray hair of the musculoskeletal system and other parts of the body. There are many age-dependent changes that increase the challenge of doing things physically.

My question is: Do we want to call gray hair a disease or do we want to reframe this period as an essential time of life? I want to reframe it by talking about what we can do to circumvent limitations and how to cope when we can’t.

We’re taught and marketed that all changes in appearance and in function in older people are forms of disease that demand treatment. But often, that isn’t true. Much that is termed a disease is a normal aspect of this time of life and needs to be viewed as such. Sure, there are challenges, but we’re less inclined to label life challenges as diseases in other phases — puberty for example. We need to examine our preconceptions in open dialogue with our physicians and others in our community.Q: In the next chapter, “frailty,” you say this chapter of life has joyful features. What do you mean by this?

A: Frailty is a challenging time, but in caring for the frail, we can be enlightened about what it means to be human. There’s an awful lot that you can learn from frail people. Children feel it more quickly than we do because we’re too busy to really pay attention.

Of course, there are elements of frailty that can take away humanity. Dementia is an example of that. But generally, there is no reason to warehouse the frail, not to talk to the frail, not to be loved by the frail. They may not be the people they once were, but they are human beings and there is great value to be found in them.

Mass. residents like health reform

By Martha Bebiinger, WBUP

From www.kaiserhealthnews.org with WBUP and NPR

Former Mass. Gov. Mitt Romney signs his state’s health care reform bill into law in April 2006. (Photo by Joe Raedle/Getty Images)

“Romneycare has driven the cost of small business insurance premiums up by 14 percent over the national average in Massachusetts.” And from former Senator Rick Santorum last month we heard, “it (Romneycare) was the basis of Obamacare and it was an abject failure.”

So you might think this drubbing would rub off on Massachusetts residents, about two-thirds of whom have consistently endorsed the state’s coverage plan since it passed in 2006. Not so.

In the latest WBUR poll, 62 percent support the law and 33 percent oppose it. Steve Koczela is president of the Mass, Inc. polling group, which conducted the poll.

“Even with all the attention the Massachusetts law has gotten nationally,” said Koczela, “it really hasn’t driven down support among voters here in Massachusetts.”

Related story:

The difference between national and local opinions about the law is part politics, part misinformation, and partly a difference of experience, says Robert Blendon, a professor at Harvard Kennedy School. Massachusetts residents are living with the law. Opinions outside the state are based on speculation.

“A substantial share of Americans believe that the national law will fail and they assume that the Massachusetts law, which in their minds is related to this, is not working well either,” Blendon said.

That’s the case, said Blendon, even when he presents evidence to audiences outside Massachusetts that a strong majority of residents in the Commonwealth are happy with the state law.

“People are convinced,” laughed Blendon, that “[the poll] can’t be right.”

In Massachusetts, most residents in the WBUR poll (68 percent), see former Governor Mitt Romney’s opposition to the national law as an effort to win votes in his presidential campaign. Only 25% see his opposition as a disagreement based on principle.

“Taking that, in concert with the level of influence people thought the state law had on the national law, at least suggests there’s some difficulty distancing yourself from what happened nationally to what happened here at home,” says pollster Koczela.

That dynamic may translate into problems for Republican Sen. Scott Brown, who, like Romney, supports the state law but hopes to repeal the national law.

Robert D’Ambrosio is one of the WBUR poll respondents who said he likes the state health care law and is not sure whom he supports in the Senate race. D’Ambrosio finds Brown’s position confusing.

“I don’t understand why he doesn’t bother the same with the national as he does with the state,” says D’Ambrosio, who lives in Malden, a suburb just north of Boston. “If you like one, how can you not like the other?”

Many residents polled say they want to know how Brown and the leading Democratic contender Elizabeth Warren would control health care costs. Paula Zindler from Cummington in western Massachusetts, is another undecided voter. She says the state law, which both Brown and Warren support, has forced up the cost of her health coverage.

“We had to switch to a different carrier, because my insurance, I was told, was inadequate,” explains Zindler. “So I either had to change my insurance or pay a fine, and I’m not happy with that.”

While health care is expected to be a key issue in the U.S. Senate race in Massachusetts, there are at least two major, yet to be determined, factors that will shape this debate. One is whether the US Supreme Court will let all or part of the federal Affordable Care Act stand. Two is who the Republican presidential nominee will be. But health care will also play into the standard practice of US political races, says Professor Blendon.

“Even though they (Brown and Warren) have a truce on how each side will describe each other, there will be an effort to put one far on the left and one far on the right and health care examples will be very prominent in that effort,” explains Blendon.

By “truce,” Blendon refers to the agreement Warren and Brown reached a few weeks ago to donate half the cost of any political ad funded by an outside organization to charity. Several residents in the WBUR poll praise this deal and say watching whether it holds will be one of the most interesting parts of this year’s Senate race.

 

 

Candidates court seniors on Medicare

Having a peek at your doc’s notes

By Michelle Andrews, KHN Staff Writer, Jan. 17, 2012

www.kaiserhealthnews.org

If you saw that your doctor had written “SOB” in the notes he took during your latest office visit, you might be offended and wonder what you’d done to give him such a negative impression. But “SOB,” in physicians’ shorthand, simply means “shortness of breath.”

Concern about such misunderstandings is one of several reasons doctors are reluctant to share their notes with patients, according to a study published in December in the Annals of Internal Medicine.

The study surveyed 173 doctors and nearly 38,000 patients at primary-care practices about sharing information with patients. After the survey, the practices joined a project called OpenNotes, in which patients were give electronic access to their files.

Although federal law guarantees patients the right to examine and get copies of their medical records, providers haven’t always made it easy to do so. But the movement to give patients direct access to their health information has picked up steam, and policymakers have encouraged it as a way to empower patients to help manage their health and their medical care.

Patients don’t share clinicians’ ambivalence about getting direct, easy access to their health information. No matter their age, education or health status, more than 90 percent of participants in the OpenNotes survey said they thought being able to see doctors’ notes was a good idea.

“In a way, that was the biggest surprise of the study,” says Jan Walker, the study’s lead author. Walker is a nurse at Beth Israel Deaconess Medical Center in Boston, whose practice participated in the study along with those at Geisinger Health System in rural Pennsylvania and Harborview Medical Center in Seattle. “It reflects consumers’ universal interest in their own care.”

In 2010, Quest Diagnostics, a large lab services company, introduced a free smartphone application called Gazelle that lets consumers in 33 states and the District download their lab test results directly. Since then, 125,000 patients have used the service, the company says. “[Gazelle] will help you have an educated conversation with your physician,” says Jon Cohen, chief medical officer for Quest.

John Hadley downloaded the Gazelle app to his iPhone after he developed deep vein thrombosis and was prescribed a blood thinner to help prevent another blood clot. At first, Hadley had to get a blood test every few days so his physician could adjust the medication dose if necessary; now he’s tested every few weeks.

Gazelle let Hadley, 53, track his results and make adjustments to his diet if they started to drift. (Foods high in Vitamin K can affect the ability of blood to clot.)

“It’s my health and my results, I should be able to get them as easily as possible,” says Hadley, IT manager who lives in Parsippany, N.J.

Giving patients direct access to their medical information may also help catch physician errors and omissions, say experts.

Walker says she has heard of patients in the OpenNotes project who have reviewed their doctor’s notes and realized that a test the physician called for hadn’t been ordered. Even more troubling, studies have indicated that as many as a quarter of abnormal test results don’t receive timely follow-up. If patients can look up their results online, that figure might decline.

On the other hand, increased patient access “has the potential to diffuse responsibility” for following up on test results if patients and their doctors both expect the other to check on the results, says Hardeep Singh, chief of the health policy and quality program at the Houston Veteran Affairs Health Services Research and Development Center of Excellence.

Many clinicians are troubled by the prospect that patients may get bad or confusing news without a physician or other health-care provider on hand to help put the information in context.

Patients who use the Gazelle app can’t get direct results on HIV, cancer or genetic diagnostic tests, says Cohen. There’s a 48-hour delay on releasing all other test results, to give physicians a chance to contact the patient and discuss the findings first.

Likewise, patients who participated in the OpenNotes project can’t access the visit notes until their physician has signed off on their release.

“No one wants to see their diagnosis of cancer on their own without a medical professional,” says Jonathan Darer, chief innovation officer for Geisinger Health System, which makes most patient information available online. “We try to manage that.”

At the same time, however, it’s important to ensure that patients get information promptly. “Not knowing is incredibly anxiety-provoking,” says Darer.

 

What boomers need to know about Medicare

By Caroline E. Mayer, Staff Writer, Dec. 5, 2011

www.kaiserhealthnews.org

Throughout Robert Joseph’s career, the Alvin, Texas, electrician always understood his health insurance policies. “I’ve never had a problem,” Joseph says, “until I tried to sign up for Medicare.”

The chief reason: Joseph didn’t sign up when he turned 65. He was still working, receiving health insurance from his employer. And when his company went bankrupt at the end of 2009 — Joseph was then 67 — he received 18 months of severance pay.

“On my last day of work, I went to the Social Security office, asking for some guidance,” recalls Joseph. He never spoke to an expert; instead, he says, he was handed a couple of forms to complete. He researched his Medicare handbook, which noted that “current” employees didn’t need to apply for Medicare. Since he continued to get monthly severance checks that deducted Medicare taxes and he was allowed to continue buying health insurance through the same carrier for the 18 months, he thought he could wait to join Medicare. He was wrong.

Medicare no longer considered him a “current” employee and said he should have enrolled within eight months of his layoff, not 18 months later. As a result, for the rest of his life, Joseph may have to pay extra on his monthly Medicare premium (10 percent for each year he delayed enrollment after his job ended). Even worse, Joseph will be without any insurance for a year. Under Medicare rules, he has to wait until the next open enrollment period, beginning in January, to sign up, and coverage won’t begin until July.

Joseph is not alone. “We’re seeing various people who delayed enrollment into Medicare for various reasons,” says Frederic Riccardi, director of programs and outreach at the Medicare Rights Center, a nonprofit group that helps people with Medicare disputes.

Part of the problem is due to the absence of what most Americans used to see as a simple dividing line: On or about their 65th birthdays, they were expected to stop working, become eligible for full Social Security benefits and sign up for Medicare. Now that a growing number of people work past 65, and the age threshold for collecting full Social Security benefits is 66 and climbing, the transition period is less clear.

To avoid mistakes, here are five tips to help you navigate Medicare.

 

The only exceptions are for people already receiving Social Security benefits — in which case you’ll be automatically enrolled — or are employed (or whose spouse is) and getting health insurance through work. There is a caveat, though, if you are still getting employer-coverage: If you (or your spouse) are working for a firm that has fewer than 20 employees, you must sign up for Medicare because, under insurance rules, Medicare is considered the primary insurer for seniors working at these small businesses.

“We will not be knocking on people’s doors to come in to file,” says Steve Richardson, deputy regional communications director for the Social Security’s office in Boston.

You can start signing up — online, via a toll-free telephone number or in person at a local Social Security office (make an appointment first) — three months before your 65th birthday. You have an additional three months after your birthday month to apply before penalties kick in.

If you hold off because you (or your spouse) are employed and covered by a company plan, you have eight months to enroll after the employment ceases.

And remember, Medicare isn’t family coverage, like you might have had from work. You may be eligible, but that doesn’t cover your spouse or dependent children. They will need to buy insurance from a private company.

 

With all the talk about the high federal budget costs of Medicare, some may erroneously think the government pays for all Medicare services. Far from it. Beneficiaries have to pay monthly premiums, deductibles and co-payments or coinsurance. Figuring out your coverage and costs can be challenging, especially given Medicare’s different alphabetic parts: A (for inpatient hospital care), B (for outpatient services and doctor visits) and D (an optional drug benefit). There’s also a Part C, usually known as Medicare Advantage. This is an alternative to traditional Medicare and is offered by private insurance companies.

“Make sure to choose wisely,” advises Riccardi. For example, if you opt for a Medicare Advantage plan, you may get benefits not offered in traditional Medicare — such as eyeglasses — but the plans may restrict doctors or hospitals and require advance permission for certain services. Some Medicare Advantage plans may also limit coverage geographically, so you may be forced to pay out-of-network fees if you visit grandchildren in another state or if you spend the winter in Florida.

Private insurers also offer Medigap policies that supplement parts A, B and D and help cover deductibles, coinsurance costs and services that may be exempt from Medicare coverage. Military retirees can choose supplemental plans from Tricare.

 

“A good rule of thumb is ‘Medicare doesn’t cover most things above the neck,’ ” says Helen Mulligan, a health insurance specialist in Medicare’s Boston office. For example, Medicare doesn’t cover hearing aids, dentures (or most dental procedures) or eyeglasses, although it does cover cataract surgery.

Basic Medicare also doesn’t cover extended stays in nursing homes or treatment overseas, although some of the more expensive Medigap plans do cover overseas travel.

But the 2010 health-care overhaul law made a number of preventive care services free for beneficiaries, including annual mammograms, flu shots and periodic colonoscopies, as well as screening tests for cervical cancer, prostate cancer and high cholesterol. Also covered is an annual wellness visit.

 

According to some estimates, one in seven claims filed with Medicare are rejected. The reason can be as simple as insufficient or inaccurate information filed by a doctor; often, it’s just an erroneous procedure code that can be quickly corrected.

“It doesn’t hurt to appeal, and it doesn’t cost anything,” says Mulligan. “You don’t need to hire a professional.” Instructions and forms are easy to find and use on the Medicare.gov Web site. (Scroll down to the “Need help?” box and click on “Appeal a claim.”)

But, Riccardi adds, you should not hesitate to enlist the help of your doctor or medical facility, especially if they need to write a letter to explain the medical necessity of a treatment or particular drug.

This article was updated 12/8/2011 to add information about seniors working at businesses of fewer than 20 people.

 

 

 

 

If you have been getting disability benefits from Social Security for 24 months, you can receive Medicare at any age. Medicare also has no age requirements for people with Lou Gehrig’s disease or kidney failure. 

 

Can retail medicine reduce costs?

By Julie Appleby, KHN Staff Writer, Nov. 17, 2011

Just as Walmart and other retailers shook up the prescription drug business by offering $4 generic drugs, the industry now aims to apply its negotiating and marketing clout to tackle problems that vex consumers and the health sector: unpredictable costs, a lack of primary care doctors and inefficient management of chronic illnesses, whose costs drive the majority of health care spending.

“It’s sad that the existing health care establishment has not figured out a way to make primary care affordable and accessible,” says Jerry Avorn, a professor of medicine at Harvard. “We should not be surprised if someone outside of our world comes in and does it for us.”

Last week, Walmart’s ambition to become the nation’s largest provider of primary health care services became known when a confidential document the giant retailer sent to some of its strategic partners leaked out. The request for information sought partners who could help Walmart in a variety of areas, including monitoring patients with diabetes, asthma, high blood pressure, heart disease, obesity and other conditions.

Walmart backed away from parts of its own document, saying it did not intend to build a “nationally integrated, low cost primary care platform.” Indeed, it is hard to imagine what a national platform would look like given the wide variation of state laws governing health care delivery.

But clearly, Walmart and other retailers are looking for ways to expand services at their in-store clinics.

Already, CVS Caremark, the largest operator of in-store clinics with nearly 550, and Walgreens have set up programs aimed at helping diabetics monitor and control their condition, which includes counseling chats with pharmacists. Weight loss programs and counseling are on tap at some retail clinics. Truck drivers can pull their 18-wheelers into the parking lots of more than 600 such in-store centers nationwide to get their mandatory federal health exams.

“There are real savings to containing the cost of the chronically ill in this country,” says Helena Foulkes of CVS/Caremark, which offers in-person and telephone conversations with pharmacists to diabetic patients enrolled in its “Pharmacy Advisor” program. Some employers also send workers to the firm’s MinuteClinics for blood tests and other health screenings. “More and more of clients are actively looking for wellness programs and they see retail clinics as one element.”

In part, the clinics see a pure business opportunity based on consumer convenience and cost savings, which they can market to the public, employers, insurers and hospitals. Costs are roughly 30 percent to 40 percent less than similar care at a doctor’s office and 80 percent cheaper than at an emergency room, according to a study in published this year in the American Journal of Managed Care.

That’s attractive to insurers. Use of retail clinics among patients with insurance rose tenfold from 2007 to 2009, the study found, with clinic visits representing about 7 percent of all medical visits for 11 common acute conditions: “If these trends continue, health plans will see a dramatic increase in retail clinic utilization … particularly among, young, healthy and higher income patients living close to retail clinics,” the study concluded.

Still, while less expensive than going to an emergency room or doctor’s office on a per-visit basis, “if more people seek care, that could increase health care spending,” says one of the co-authors of the study, RAND researcher and medical professor Ateev Mehrotra of the University of Pittsburgh School of Medicine.

The California Healthcare Foundation found the No. 1 thing consumers liked about the in-store clinics was predictability: the cost of the service was clear ahead of time.

“That contrasts with most people’s experience of health care, where if you walk into a doctor’s office or an urgent care clinic, you have no idea what the charge will be,” says Mark Smith, president and CEO of the foundation.

Interest in clinics is also spurred by the federal health law, which, among other things, will create incentives for small businesses to offer wellness programs for workers.

“An employer with 50 to 250 employees can’t afford to bring in a company to do corporate wellness,” but it could partner with a retail clinic and send employees there for blood tests, nutrition counseling or diabetes management, says Stewart Levy, president of Health Promotion Solutions in Newtown, Pa., a consulting firm that is working with the retail clinic industry.

The growth of retail clinics – both in sheer numbers and the scope of services they offer – is one of several avenues being pursued to revamp primary care, which is facing a shortage of physicians. The Association of American Medical Colleges estimates a shortfall of 21,000 primary care doctors by 2015.

Done right, supporters say, expanding services through retail clinics could provide better access for many patients and lower costs, and provide an outlet for an expected jump in demand for care in 2014, when millions more Americans get insurance through the federal health law.

But obstacles remain. Will retail clinics be able to translate their success with simple acute problems to a more long-range and intensive monitoring of complex conditions? Will employers and consumers embrace the idea? Will clinics become components of new, integrated collaborations between doctors, hospitals and insurers?

“Asthma and diabetes are not something you get one time and get fixed,” says health care consultant Ian Morrison, who follows trends in the industry. “How effective will they be in managing that over the long term?”

While studies have shown that retail clinics provide similar – or even better – quality care for simple conditions such as sore throats, researchers haven’t yet looked at their ability to do more complex monitoring of patients, often called disease management. Data is mixed on the success of such programs and some have been shown not to save money. Recently, a study of eight disease management firms that used nurse-based call centers failed to save Medicare money.

Another challenge is the wide variety of laws governing medical centers. Some states, including New York and California, prevent clinics (or hospitals) from directly employing physicians, nurse practitioners or physician assistants. Other states cap the number of nurses each doctor can oversee. Efforts to expand nurses’ ability to practice autonomously are often fought by state medical associations.

“It’s interesting that I can go from Washington D.C., where I can be certified to take care of patients autonomously, to Georgia, where I can do very little because I have to have a supervisor who is a physician overseeing what I do,” says Ken Miller, an associate dean in the school of nursing at Catholic University and a past president of the American College of Nurse Practitioners.

While a few centers operated by retailers have doctors on site, the vast majority of staff are nurse practitioners or physician assistants. According to the Convenient Care Association, the industry’s trade group,there are more than 5,000 nurse practitioners working in the clinics, making up 95 percent of the clinicians.

If more patients with chronic illnesses can be seen in settings like retail clinics, where they can stop by on the way home from work or on the weekends, Miller and others say they may be more likely to take their medications, monitor their blood sugars and take other actions to prevent a worsening of their disease.

“If you have a stable diabetic, why should that person be going in to see a physician when a nurse practitioner can manage care of that patient?” he asks.

Primary care doctors fear retail clinics will skim off the healthiest patients, leaving them with more complex or older patients, with no corresponding increase in reimbursement from insurers or the government. They also worry that the expansion of retail clinics into caring for patients with chronic illnesses will further fragment the care such patients receive.

In a statement, the American Academy of Family Physicians says a better answer for such patients is “the development of a health care system based on strong, team-based . . . care.”

For their part, the clinic industry says it can be an ally for overworked doctors. In the future, clinics could use nurse practitioners and physician assistants to do triage, particularly on the least complex patients, so doctors could “use their training and skill to focus on patients with long term needs,” says Caroline Ridgway, policy and communications director at the retail clinic industry’s trade group.

But unless payment incentives are changed to reward quality over volume – and laws changed so nurse practitioners and physician assistants can provide more direct care in all states, there will be an increasing burden on primary care doctors as more Americans become insured, she says.

“Insuring 30 million more people isn’t going to matter if they don’t have anywhere to go,” says Ridgway.

The majority of retail clinics are in the South and Midwest, according to a 2010 RAND study. They’re more likely to be in areas with lower overall poverty and only 12.5 percent were in medically underserved areas, the RAND report said, although 21 percent of the U.S. population lives in such areas.

“The research did not support the claim by some champions.. that these clinics are improving access to care for the medically underserved: retail clinics are more likely to be located in relatively affluent sections of large urban areas,” the report concluded.

Still, about 35 percent of clinic patients are either uninsured or have high deductible insurance plans that put them on the hook for hundreds, if not thousands, in out-of-pocket costs, says Tine Hansen-Turton, executive director of the Convenient Care Association.

“We are seeing people who are vulnerable,” she says.

For much of their brief history, retail clinics have focused their services on a narrow menu, mainly treatments for acute conditions, such as strep throat or ear infections, vaccinations, and physical exams needed for summer camp or other programs.

But retail clinics are moving beyond just a simple menu of services in part because “it wasn’t a financially sustainable model to be restricted to those things,” says Smith at the California HealthCare Foundation.

Now, the medical community is seeing what other industries have experienced: an interloper gaining a foothold in a market niche, then expanding. “Think about Toyota, they didn’t start off by competing with Cadillac and BMW. They started with cheap little cars but got better and better over time,” Smith says.

Wealthier seniors may pay more for Medicare

By Mary Agnes Carey and Marilyn Werber Serafini, KHN staff writers

www.kaiserhealthnews.org

Nov. 13, 2011

In the scramble to come up with a deficit-reduction deal by Thanksgiving, members of Capitol Hill’s super committee appear to have one group squarely in their cross hairs: high-income Medicare beneficiaries. 

Some fiscal conservatives argue that the federal government shouldn’t help finance health care benefits for the rich. “Frankly, if you’re a wealthy person the taxpayers should not subsidize your [Medicare],” said Robert Moffit, senior fellow at the Heritage Foundation. “You’re retired. You own your own home . . . You’re making $165,000 a year. No, faced with a $37 trillion unfunded liability in Medicare, the answer is no, we’re not going to pay for you.”

House Minority Leader Nancy Pelosi, D-Calif., has left the door open to asking wealthy seniors to pay more, and public opinion polls show support for the idea.

But some seniors’ advocates see attempts to pry more from upper-income seniors as risky today, and a threat to the middle class tomorrow. “When you’re talking about seniors, the definition of wealthy seems to be a whole lot lower than when you’re talking about younger people,” said Maria Freese, director of government relations and policy at the National Committee to Preserve Social Security and Medicare. “Just because they’re retired, it doesn’t mean their expenses are much lower.”

Current law already requires seniors with annual incomes of $85,000 and above ($170,000 for couples) to pay more than others for Medicare Part B, which covers doctor bills and other outpatient costs. In 2012, the standard premium will be $99.90 per month. Premiums for wealthier seniors will range from $139,000 to $319.70 per month.

About fivepercent of seniors fall into the higher-premium group now. President Barack Obama wants the share of beneficiaries paying more for their coverage to grow over time to one quarter of all beneficiaries. If that were the case today, people with incomes as low as $40,000 a year would be paying higher Medicare premiums, according to Tricia Neuman, senior vice president of the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Under Obama’s proposal, more people will fall into the higher-paying category over time because the trigger levels wouldn’t be adjusted for inflation until that one-quarter target is reached. While the threshold would still be $85,000 for an individual, that would buy a lot less in the future than it does today, and tomorrow’s seniors would likely have higher nominal incomes than today’s retirees when they first go onto the Medicare rolls.

Obama’s proposal also would boost the premiums paid by everyone in the higher-income group by 15 percent, with no one paying more than 90 percent of the cost of their coverage. The White House estimates that Obama’s proposal would save approximately $20 billion over 10 years.

Other proposals by various commissions or lawmakers would lower the income threshold or make higher-income beneficiaries pay a higher share of their coverage costs.

Super committee members appear ready to ask high-income seniors to kick in more, perhaps bolstered by favorable public opinion. In a Bloomberg News National Poll conducted in June, 67 percent of respondents said they backed the idea of “wealthy Americans” paying more, although Bloomberg did not define “wealthy” when it asked the question.

Income-relating Medicare is something that both sides could settle on, said James Capretta, a fellow at the Ethics and Public Policy Center, a conservative think tank. “It’s a way of reducing costs on the entitlement side of programs, and it’s done in a way that doesn’t hurt middle-and low-income seniors. It only hurts higher-income people. There’s very little policy opposition to it. Why be against it?”

Republicans on the Senate Finance Committee have urged the super committee to consider it, and Pelosi said in an October 28 CNBC interview: “There may be some seniors, wealthier seniors on Medicare, who can pay more. I have said no cuts in benefits, but I haven’t said no cuts in programs.”

Democrats have warmed to the idea because they don’t want to cut benefits for more typical Medicare beneficiaries, which includes seniors and disabled younger people, said Robert Blendon, professor of health policy and political analysis at the Harvard School of Public Health. “I think they are so worried about cutting benefits for the mainstream people, in their mind it’s much more important to have the upper-income pay more to keep the program going as it is than it is to start cutting benefits and having more and more people feel that Medicare is not adequate for them.”

For decades after it was created in 1965, Medicare cost the same for everyone, regardless of income. Only in 2007 did the government start collecting extra premiums from wealthier beneficiaries. The 2010 health law extended this income relating to Medicare Part D, which covers prescription drugs, effective in January 2011.

The new health law also froze through 2019 the income thresholds that determine which seniors must pay the additional costs, meaning inflation will gradually push more seniors into this group.

Freese said that her group’s biggest concern about asking high-income seniors to pay even more for their coverage is fairness: They already gave at the office.

Unlike Social Security, there is no cap on the annual income that is subject to the Medicare portion of payroll taxes paid by working Americans. The more they earn, the more they pay.

Walmart makes bid to be health care center

By Julie Appleby and Aarah Varney, KHN writers

www.kaiserhealthnews.org and NPR

Walmart – the nation’s largest retailer and biggest private employer – now wants to dominate a growing part of the health care market, offering a range of traditional services from basic prevention to management of chronic conditions like diabete and heart disease, according to a document obtained by NPR and Kaiser Health News.

In the same week in late October that Walmart announced it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for information seeking partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”

On Tuesday, Walmart spokeswoman Tara Raddohl confirmed the proposal but declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”

But by midafternoon Wednesday, the retailer issued a statement saying its own request for information was “overwritten and incorrect.” The firm is “not building a national, integrated low-cost primary health care platform,” says the statement by Dr. John Agwunobi, a senior vice president.

The information request begins with the exact wording that Agwunobi says is incorrect, saying Walmart “intends to build a national, integrated, low-cost primary care healthcare platform.” The request goes on to ask firms to spell out their expertise in a wide variety of areas, including managing and monitoring patients with chronic, costly health conditions. The goal it says is for Walmart to become “the largest provider of primary healthcare services in the nation.”

The document spells out a tight timeline. It was issued to an unknown number of “strategic partners” on October 21 and final vendor selection is set to take place on January 13.

Analysts said Walmart is likely positioning itself to boost store traffic — possibly by expanding the number of, and services offered by, its in-store medical clinics. The move would also capitalize on growing demand for primary care in 2014, when the federal health law fully kicks in and millions more Americans are expected to have government or private health insurance.

“We have a massive primary care problem that will be made worse by health reform,” says Ian Morrison, a Menlo Park, Calif-based health-care consultant. “Anyone who has a plausible idea on how to solve this should be allowed to play.”

In-store medical clinics, such as those offered by Walmart and other retailers, could also be players in another effort in the health law: encouraging collaborations of doctors and hospitals who want to win financial rewards for streamlining care and lowering costs. Such collaborations, known as “accountable care organizations,” might contract with in-store medical clinics, says Paul Howard, a senior fellow with the Manhattan Institute for Policy Research. He has studied retail clinics, some of which have recently expanded to offer services beyond simple tests and vaccinations, such as helping monitor patients with diabetes or high blood pressure.

Walmart’s request goes even further, asking possible partners to provide information on how they would oversee patients with complicated chronic conditions, including asthma, HIV, arthritis, depression and sleep apnea.

While Walmart’s efforts to partner with others on health care could help lower costs for some patients and increase access to primary care services, health policy experts also say it raises questions.

Will expansion of in-store clinics, for example, further fragment care in the U.S. by drawing patients away from their established primary care doctors? Would patients who need specialists fall through the cracks? Will patients seen by nurses or physician assistants at in-store clinics have just as good outcomes as those seen by doctors in more traditional practices?

“Maybe Walmart can deliver a lot of this stuff more cheaply because it is an expert at doing this with other types of widgets, but health care is not a widget and managing individual human beings is not nearly as simple as selling commercial products to consumers,” says Ann O’Malley, a physician and senior health researcher at the Center for Studying Health System Change, a nonpartisan Washington think tank.

And will it save money? Because primary care services are not the main driver of health care costs in this country, “I would be surprised if this were a model that could truly attack cost problems,” says O’Malley.

Whatever it does to health costs, it may also be a way to boost foot traffic and sales in Walmart stores, says Colin McGranahan, a retail analyst for Sanford C. Bernstein & Co.

“Their traffic has been declining for over two years and they’ve been losing market share,” McGranahan says. “If you get someone in the door, you can also sell them milk and a shotgun.”

CVS/Caremark, Walgreen’s, Kroger, Target and others have recently reinvigorated efforts to open in-store medical clinics. The first such in-store clinics opened in 2000, but growthtook off later in the decade.

Until recently, Walmart was the nation’s leader in opening such clinics, but has dropped to third place with about 140 such clinics, well behind industry leader CVS Caremark’s nearly 550 Minute Clinics and Walgreen’s 355 Take Care clinics, according to data tracked by Tom Charland, CEO of Merchant Medicine, a Minnesota-based research and consulting firm. About 1,300 store-based clinics are open nationwide, he says.

They have different business models. Walmart leases space to independent vendors, for example, while CVS owns and staffs its Minute Clinics. While a few centers operated by retailers have doctors on site, most hire nurse practitioners or physician assistants to provide the care. In 2007, Walmart CEO Lee Scott announced the firm would open 400 clinics by 2010 by 2010.

But early efforts backed by venture capital money faltered and the firm failed to reach that number, says Charland. Walmart then switched strategies and began leasing to hospital systems primarily and it began to grow again. Still, last month, the firm appeared to be struggling: Walmart opened three in-store clinics, but closed 10, says Charland.

“This is an industry where people haven’t figured out how to make money,” he says. Hiring nurses isn’t cheap – and business can be seasonal: more people come in during the cold winter months and business can slow to a crawl in the summer. “My guess is the whole purpose of [Walmart's] request for information is to find someone to help them because they’ve not been able to pull it off.”

CVS, which has run Minute Clinics since 2006, expects to break even for the first time this year, says Helena Foulkes, a CVS executive vice president in charge of strategy and marketing. It plans to keep opening clinics and is doing so at a clip of about 10 a month.

“We think the market will evolve so this will become a more important model,” says Foulkes.

 

Romney favors premium support

By Mary Agnes Carey and Marilyn Werber Serafini, KHN Staff Writers

Nov. 9, 2011

www.kaiserhealthnews.org

Mitt Romney’s plan to overhaul Medicare follows a familiar Republican prescription: Use the power of the marketplace to bring down costs and improve care. Yet, such a move would fundamentally change the nature of the popular program, and treads close to a proposal that Republicans were heavily criticized for earlier this year. 
The GOP presidential candidate’s “premium support” plan would provide a set amount of money to beneficiaries, allowing them to shop around for health coverage.

Romney has promised that beneficiaries who like the current fee-for-service Medicare plan can opt for that instead of purchasing private insurance. He also says that all plans must offer coverage at least comparable to what Medicare provides today. But by giving beneficiaries the premium support, it is clear that Romney’s plan would move Medicare’s traditional program from one that pays a share of all medical bills a senior incurs to one that offers a fixed amount to buy insurance.

Keeping a traditional Medicare option helps differentiate Romney’s proposal from a plan advanced earlier this year by Rep. Paul Ryan, R-Wis. By doing so, Romney counters critics who charged that Ryan’s plan would destroy a popular program that has protected millions of seniors from ever-growing health care costs.

“When the president says you’re trying to get rid of Medicare he’s going to say, ‘No I’m not,’” said Robert Blendon, a professor at the Harvard School of Public Health.

Polls have shown that the public in general is split about a “premium support” model, and seniors, an important voting bloc, strongly oppose it.  Noting the negative public reaction to Ryan’s plan, even some Republicans have distanced themselves from it.

Romney has given few specifics about his plan, which he announced at a meeting of a conservative group Friday, but analysts said that’s not surprising.  “Every time we’ve seen a Romney plan, it’s an appetizer that hedges the details,” said Tom Miller, a resident fellow at the conservative-leaning American Enterprise Institute. 

Romney, a former Massachusetts governor, has said that plans would compete on a combination of premium prices and benefits, and seniors could choose either a private health insurance policy or the government-run traditional Medicare plan. Enrollees could use their own money to obtain more generous benefits than the level supported by the government’s premium contribution. Romney’s plan would give lower-income and sicker seniors more money to purchase coverage, while wealthier seniors would receive less support.

A Familiar Concept

The idea of limiting government spending on Medicare and offering private plans isn’t exactly new. Seniors already can choose to obtain their health coverage through private Medicare Advantage plans, most of which are managed care plans and cover some benefits that traditional Medicare does not, including eyeglasses and hearing aids.

Medicare Advantage plans have seen growing enrollment in recent years, thanks in large part to their more generous benefit packages, but they still serve only about a quarter of Medicare’s 48 million beneficiaries.

The lack of details in Romney’s plan leaves an array of possible scenarios for what it might mean to seniors in the future. It does not specify how much money the federal government would contribute to cover their premium costs, whether that support would rise enough each year to keep up with health care costs.

“He is exploring different options for ensuring that future seniors receive the premium support they need while also ensuring that competitive pressures encourage  providers to improve quality and control cost,” according to an outline of Romney’s proposal.

To make traditional Medicare and private plans compete on equal footing, Medicare fee-for-service plans would have to change from the current standard premiums for Part B coverage for doctor bills and other outpatient services to premiums that vary from one region of the country to another, as private insurance premiums do, said James Capretta, a fellow at the Ethics and Public Policy Center, a conservative think tank. “You’ve got to break it a little bit more into more of a region-by-region competition,” he said.

Miller agreed that fee-for-service can only be competitive with private plans if it is broken into smaller, regional units.  “Lump together some of the smaller states and allow them to have some operating authority,” he said. If they can’t operate within their budget, he said, allow them to adjust cost-sharing and establish more restrictive networks of doctors, hospitals and other medical providers.

Who Benefits?

Ron Pollack, executive director of the consumer group Families USA, predicted that Medicare’s oldest and sickest beneficiaries would be worse off under Romney’s plan. With limits on the government’s contributions for premiums, seniors could end up with fewer benefits for the same or higher costs, he said.

While younger, healthier seniors would move to private plans, some of which would have lower premiums than traditional Medicare plans, older and sicker people would remain with fee-for-service because it is what they are used to and they want the guarantee of comprehensive benefits, even if they have to pay more for it, Pollack predicted.

“A defined contribution system provides little guarantee about what benefits are covered,” he said. “You can’t reduce spending in Medicare unless the benefits are somewhat less, or the contribution provided by the government, as a percent of total costs, diminishes over time.”  If the government’s share goes down, the beneficiary’s will go up.

Joe Baker, president of the Medicare Rights Center, a N.Y.-based consumer advocacy group, discounts Romney’s claims that having more seniors in private plans will save Medicare money. The Medicare Advantage program, he said, “has not brought down costs, so to think that there’s a new version that willy nilly by itself will bring down costs is a fantasy . . . It’s really cover for the real goal, and that is to end Medicare as we know it and by doing that, have more money come out of the pockets of consumers and save the federal government money.”

A Congressional Budget Office analysis projected that under Ryan’s Medicare plan, by 2030 a typical 65-year old would be required to pay 68 percent of the total cost of his or her Medicare-covered services. That compares with the 25 percent they would pay under current law.

How much beneficiaries would have to pay under the Romney plan would depend on its details.

In addition to transforming Medicare into a premium support program, Romney would raise the program’s eligibility age to reflect the fact that Americans are living longer. But he has premised all of his changes on first repealing the 2010 health law.

That could leave some retirees without health coverage, because older people are more likely than younger ones to have chronic, pre-existing medical conditions. Without the health law’s requirement that insurers cover most people, many could not obtain affordable coverage.

“If you eliminate the Affordable Care Act, it means that 65 and 66 year olds won’t have that resource. The result will be a substantial number of people joining the ranks of the uninsured. Many of these folks are retired and have moderate incomes, so this is going to be a huge setback for a large number of 65 and 66 year olds who would lose coverage,” Pollack said.

U.S. side of accident in Canada

By Michelle Andrews

www.kaiserhealthnews.org

Nov 07, 2011

A few months ago, I wrote about my experience at a Canadian hospital emergency department following my disastrous encounter with a patch of gravel while cycling in Quebec in July. My impression of emergency care across the border: mostly positive, despite a conspicuous lack of high-tech diagnostic equipment or physician specialists.

When I wrote that story, though, I had just returned home to New York and hadn’t yet organized follow-up care for a broken right thumb, broken left shoulder and very painful pelvis/left hip. I thought a few weeks of bed rest would get me back to some semblance of normal, but the reality was more complicated. What follows is the second and (I hope) final chapter in my tale of two health-care systems.

When I arrived at the Canadian emergency department, they took a series of X-rays that picked up the breaks in thumb and shoulder but showed nothing in my pelvis or hip. The explanation for my pain and inability to walk: strained tendons and ligaments. The prescription: Get some exercise, walk around.

But walking wasn’t helping, and after I got home a U.S. orthopedist ordered an MRI scan to see what might have been missed. That’s when I learned that I had three breaks in my pelvis and a hairline fracture of the left femur, or thighbone.

To Scan Or Not To Scan

In a U.S. emergency department, staff would probably have done head-to-toe CT scans, experts have told me, to identify any bone breaks that didn’t show up on the X-rays. (My earlier story noted a study that found that Americans were almost twice as likely to get CT scans as Canadians when visiting the ED.)

The MRI gave me an explanation for my continuing, disabling pelvic pain. But getting it earlier might not have made a difference in treatment or in the healing process, says Andrew Pollak, chief of the Division of Orthopaedic Traumatology at the University of Maryland School of Medicine.

With minimally displaced pelvic fractures — meaning the broken bone ends are very slightly separated — such as mine, many doctors would suggest exactly what the Canadian ED staff recommended for what they thought were soft tissue injuries: rest and exercise.

Other orthopedists would recommend surgery. There’s no data that show which approach is right long-term, says Pollak.

The hip specialist I saw didn’t recommend surgery, and I decided to leave well enough alone.

As I began to follow up on my other injuries I learned a lot about medicine’s increasing specialization: No single orthopedist would treat my myriad injuries, and I eventually acquired three specialists.

I also learned that lack of clarity about treatment was the rule rather than the exception. Take my thumb. The break had knocked it out of alignment by 50 degrees. In Canada, the specialist told me surgery wasn’t necessary. He explained that this advice was based in part on the fact that my left shoulder and hand were in a sling: If he operated on my right thumb, I’d have no hands to use.

But emergency department care, no matter where you get it, is intended to assess your injuries and stabilize you. It’s not necessarily the final word on treatment. Back in the States, the rule of thumb, literally, is that a misalignment of 35 degrees or more should be fixed, says Douglas Hanel, a professor of orthopedic surgery at the University of Washington who specializes in hand and microvascular surgery. But that’s based on the collective wisdom of orthopedists, not on data, says Hanel.

My hand specialist painted a much less ambiguous picture, explaining that I’d have difficulty grasping things if I didn’t get my thumb fixed. Who knows, he may be right. In any case, I agreed to the surgery.

As for my shoulder, it turned out that I had a cyst in the upper arm bone, the humerus, that made it more susceptible to breaking on impact, which it did. Another judgment call: Could my shoulder heal on its own, or had the fluid-filled cyst taken up so much space that there wasn’t enough bone left for it to mend itself? No one could tell me. My shoulder specialist wanted to operate. He’s a surgeon, after all. I agreed to that surgery, too.

No Way To Know

As I bounced from one orthopedist to the next, there was one constant presence in my medical life: my primary care doctor. While I can’t say that he actively coordinated my care -and his small, messy Greenwich Village office is more medical apartment than medical home – he did keep track of me. He did all the standard stuff: He explained how to care for the nasty, oozing cuts and abrasions I had running up and down my left arm and leg, and replaced the morphine pills I’d been given in Canada with less potent painkillers.

But he also made sure I had the medical clearances I needed for surgery and provided a referral to another orthopedist for a second opinion on my shoulder when I needed it. When I couldn’t get through to that doctor’s office, he called and nagged them until they made an appointment with me. A few days after my shoulder surgery, he called to check in. I was surprised and pleased to be on his radar.

Advocates of consumer-driven health care argue that patients make smarter decisions if they have more financial skin in the game. For my part, I don’t think having to satisfy a $1,500 deductible and then 20 percent of the charges for most subsequent care made me a wiser consumer. Lacking evidence-based data, I had no way of judging whether I needed the surgeries, or the MRIs and the CT scan. I was just worried about being able to function again, and I opted for the more aggressive treatments.

I do know that all this care will make me poorer, for sure, to the tune of several thousand dollars. I’m grateful that I could make my decisions based on what I thought made sense medically rather than on what I could afford. Many people are not as fortunate.

As for my Canadian emergency department visit, a few weeks ago I finally got an itemized bill. The total charge was about $1,120 in U.S. dollars.

That charge probably would have been higher if I’d had the accident in the United States. In 2009, there were 944 ED trauma center visits for bicycle injuries that resulted in one or more fractures in which the patients were treated and released (as opposed to being admitted), according to the federal Agency for Healthcare Research and Quality. That’s pretty close to my profile. The estimated hospital charges for that type of patient: $6,941.77.

To be honest, I’m not entirely sure what the bill for my Canadian care covers, because it’s all in French. The insert instructing me how to make a payment, however, has been helpfully translated into English.

Class Act gets ax

By Julie Appleby and Mary Agnes Carey, KHN staff writers

Oct. 14, 2011

www.kaiserhealthnews.org

Federal officials on Friday effectively shut down part of the health care law that would have helped consumers cover some long-term-care costs, saying they could not find a way to make it work financially.

After looking at a variety of options, the Obama administration determined the CLASS Act program could not simultaneously meet three important criteria: be self-sustaining, financially sound for 75 years and affordable to consumers.

The move does not affect the rest of the health care law, although it does remove more than $70 billion in expected federal budgetary savings over 10 years. The savings would have come having policyholders pay premiums for the first few years, but not receive benefits until 2017.

The program – championed by the late Sen. Edward Kennedy – would have allowed working adults to apply for insurance that would provide up to $50 a day in cash benefits if they became disabled. The money could be used to help with in-home assistance or nursing home care.

While acknowledging the need for such long-term-care assistance, the program’s administrator, Kathy Greenlee, said Friday that the numbers just didn’t add up.

Under one scenario shown in a report to Congress Friday, administration analysts said a basic CLASS insurance plan with a $50 a day benefit might have cost $235 to $391 month. That might have been more than consumers would have been willing to pay based on the benefit. If enough people did not voluntarily enroll, the program would not have been self-sustaining.

“The overall program could not run if it had a highly priced solvent product no one would buy,” said Greenlee, administrator of the Community Living Assistance Services and Supports (CLASS) program.

Sen. Mike Enzi of Wyoming, the ranking Republican on the Senate Health, Education, Labor and Pensions (HELP) Committee, praised Sebelius’ decision to pull the CLASS program. He also said it may indicate more problems ahead for other provisions of the health law.

“After seeing the many unintended consequences that surround the President’s new health care law, this is more evidence that casts suspicion and doubt on the remaining portions of law. Rather than increasing premiums and eliminating coverage, maybe now Congress can take a stand and work to make health care more affordable,” Enzi said in a statement.

But an administration official said the decision did not endanger other parts of the law. “The CLASS program is a unique, stand-alone program,” he said. “Long term care is important and it’s something we are committed to addressing, but drawing conclusions between this and other parts of the law simply doesn’t make sense.”

Congressman Frank Pallone, Jr., D-N.J., a co-author of CLASS, also disagreed with Enzi.

“While we are fighting so hard against Republican attempts to cut Medicaid, which is currently the only available option for long-term care for seniors and the disabled, abandoning the CLASS Act is the wrong decision,” he said in a statement. “Soon enough, those in need will have nowhere to go for long term care.”

The seniors group AARP also said it was disappointed by the decision and urged the administration to look for ways to make the program viable. “Medicare does not cover long-term care, and 70 percent of people age 65 and over will need long-term care services at some point in their lifetime,” said Joyce A. Rogers, senior vice president for government affairs at AARP.

Tests for seniors questioned

By Sandra G. Boodman

KHN, Sep 12, 2011

www.kaiserhealthnews.org

This story was produced in collaboration with The Washington Post

　

Every year like clockwork, Anna Peterson has a mammogram. Peterson, who will turn 80 next year, undergoes screening colonoscopies at three- or five-year intervals as recommended by her doctor, although she has never had cancerous polyps that would warrant such frequent testing. Her 83-year-old husband faithfully gets regular PSA tests to check for prostate cancer.

“I just think it’s a good idea,” says Peterson, who considers the frequent tests essential to maintaining the couple’s mostly good health. The Fairfax County resident brushes aside concerns about the downside of their screenings, which exceed what many experts recommend. “Most older people do what their doctors tell them. People our age tend to be fairly unquestioning.”

But increasingly, questions are being raised about the overtesting of older patients, part of a growing skepticism about the widespread practice of routine screening for cancer and other ailments of people in their 70s, 80s and even 90s. Critics say there is little evidence of benefit — and considerable risk — from common tests for colon, breast and prostate cancer, particularly for those with serious problems such as heart disease or dementia that are more likely to kill them.

Too often these tests, some doctors and researchers say, trigger a cascade of expensive, anxiety-producing diagnostic procedures and invasive treatments for slow-growing diseases that may never cause problems, leaving patients worse off than if they had never been tested. In other cases, they say, treatment, rather than extending or improving life, actually reduces its quality in the final months.

“An ounce of prevention can be a ton of trouble,” observed geriatrician Robert Jayes, an associate professor of medicine at George Washington University School of Medicine. “Screening can label someone with a disease they were blissfully unaware of.”

Dartmouth physician Lisa M. Schwartz cites one such case: a healthy 78-year-old man who was left incontinent and impotent by radiation treatments for prostate cancer, a disease that typically grows so slowly that many men die with — but not of — it.

TheU.S. Preventive Services Task Force, an independent panel of experts that evaluates the risks and benefits of screening tests, does not endorse PSA testing or routine colon screening after age 75. The panel, whose recommendations will guide some coverage decisions under the 2010 federal health law that expands access to screening, says there is no evidence for or against mammography after age 74 and recommends that most women stop getting Pap smears to detect cervical cancer after 65.

So far the task force’s guidelines appear to have had limited impact. Researchers in June reported in the journal “Cancer” that nearly half of primary-care doctors would advise a woman with terminal lung cancer to get a routine mammogram — even if she was 80 years old. A 2010 study in the Journal of the American Medical Association of more than 87,000 Medicare patients found that a “sizeable proportion” with advanced cancers continued to be screened for other malignancies. Last May, Texas researchers reported in the Archives of Internal Medicine that 46 percent of 24,000 Medicare recipients with a previous normal test underwent a repeat colonoscopy in less than seven years and sometimes as few as three — compared with the 10 years recommended by the task force. In nearly a quarter of cases, the repeat test was performed for no discernible reason. (Medicare is supposed to cover the screening test, which can cost about $2,000, only once a decade if no cancer or polyps have been found, but the program paid for all but 2 percent of the procedures reviewed by the Texas researchers.)

“More is not always better, and that becomes particularly true in older Americans where the dangers of medical care grow,”said Michael LeFevre, a professor of family medicine at the University of Missouri School of Medicine who is co-vice chair of the task force. “The older you get, the more likely it is that something else is going to make you sick or die.” Colon polyps take 10 to 20 years to become cancerous, while the risks from colonoscopy, including intestinal perforation and heart attack, substantially increase after age 80.

Experts point to several reasons for the persistence of overscreening: habit; incentives that pay doctors and hospitals for individual procedures; quality assessments that rely on how many patients receive such tests; physicians’ fears of missing something important or of upsetting elderly patients — or their children — by suggesting that screening is unnecessary because a patient is too old or too sick to benefit.

In an era where discussions about end-of-life care are branded as “death panels” and curtailing unnecessary and expensive testing is regarded by some as rationing, experts say it is not surprising that overtesting endures. Many doctors say it’s easier to simply order a test than to discuss its risks and benefits with patients.

But some doctors believe it’s time to resist. “I think we need to say we can’t do everything for everybody, and it doesn’t make sense,” said Washington radiologist Mark Klein, who recently performed a virtual colonoscopy on a 99-year-old woman. Klein said he considered not doing the procedure but decided to go ahead because he didn’t learn how old the patient was until she was lying on the table, having undergone the prep.

“The most important thing on any referral is the date of birth,” said Klein, who said he tries to talk some older patients and their doctors out of pursuing tests and treatments he considers overly aggressive. “The game is not finding things, it’s can you improve mortality? And if you do find something, it’s very hard for a doctor to say, ‘Don’t do anything.’ ”

While cancer screenings are most common, other tests are overused among the elderly, Klein and others say. They include cholesterol testing, which can lead to the prescription of statin drugs that require regular blood tests to check liver function; typically, cholesterol plaque takes years to accumulate, and statins confer only a modest benefit in the elderly. Likewise, CT scans of the heart or whole body can unearth suspicious findings, such as lung nodules, which trigger a painful and risky lung biopsy, but often turn out to be benign.

First Mammogram – At 100 Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice and an author of the 2011 book “Overdiagnosed,” said that overtesting may reflect in part the use of screening tests as a barometer of quality. “Unfortunately that’s how we’ve measured quality: Did they get tests? And doctors are being judged and paid accordingly. So all these crazy things get done that don’t help people.”

Patients feel the pressure, too, Schwartz maintains. Screening has become a mantra, she said, trumpeted by advocacy groups. “The message is that you’re a good person if you get screened.”

The American Cancer Society doesn’t support an upper age limit for colonoscopy or mammography, although the group does not endorse PSA testing. The society’s director of cancer screening, Robert C. Smith, said he thinks underscreening is a bigger problem than overtesting. “As long as a patient is in good health and a candidate for treatment, they are a candidate for screening indefinitely,” he said.

But Smith says there are limits. He recalls the loud cheer at a medical meeting after it was announced that a 100-year-old woman had just undergone her first mammogram. “Several of us were just shaking our heads in disbelief because it makes absolutely no sense whatsoever to put a 100-year-old woman through a mammogram,” he said.

Telling someone that screening is no longer necessary can be dicey, as California family physician Pamela Davis discovered when she advised her robust 86-year-old mother to stop getting mammograms and routine colon tests.

Her mother was incensed, Davis recounted in a recent Los Angeles Times article, accusing her of wanting to “save money to spend on the young people and just let us old folks die.” Davis was even more taken aback by the wave of hate mail she received after the article was published, some of it from doctors, accusing her of essentially the same thing.

“I have many, many patients who are like my mother,” said Davis, who directs the family medicine residency program at Northridge Hospital Medical Center. “It’s not about shortchanging them” but about putting screening in context. “Part of keeping people healthy and elderly is keeping them away from the hospital. Sometimes I’ll say, ‘Well, if we do this heart test and then find something then you’ll need a procedure.’ And they’ll say, ‘Oh, I don’t want heart surgery.’ And I’ll say, ‘Why do the test?’”

Baltimore internist Mary Newman said she largely hews to the task force recommendations, and she jokes to patients that “after 85, everything’s optional.” She considers Medicare’s new annual wellness exam, part of the health law, a good time to raise the subject of screening. Newman said she focuses on concerns that geriatrics specialists say matter most in old age: maintaining hearing and vision, stabilizing blood pressure and addressing problems related to dementia and mobility.

In some cases doctors counsel against testing — but patients demand it. Alan Pocinki, an internist who practices in the District, said he tried to persuade an 80-year-old patient, a survivor of several heart attacks, to stop PSA testing. The man’s son, a Boston oncologist, agreed with Pocinki, but the patient insisted.

The elevated reading led to a biopsy, which found cancer. Pocinki said the patient contracted a serious infection from the biopsy, his cancer is being monitored through “watchful waiting,” and he has repeatedly said he wishes he’d never had the test. “He always tells me, ‘I know you told me not to do it.’ ”

Screening The DyingWhy do doctors continue to screen terminally ill patients? Smith, of the American Cancer Society, thinks a primary reason is that they avoid difficult conversations that would involve telling patients they won’t live long enough to benefit.

“Just because it’s hard for doctors doesn’t mean it’s not a conversation worth having,” said Camelia Sima, a biostatistician at Memorial Sloan-Kettering Cancer Center in New York and lead author of the 2010 JAMA study. Doctors may regard additional tests as relatively inconsequential, but Sima notes that they can cause additional pain and suffering in the form of biopsies, surgery and chemotherapy.

To Dartmouth’s Schwartz, the message for older patients, regardless of the state of their health, is essentially the same: “It’s not always in your best interest to do more or to keep looking. But we never seem to talk about the downside of testing.”

New Medgap rules meet resistance

By Susan Jaffe

Aug 30, 2011

KHN (www.kaiserhealthnews.org)

A provision of the 2010 federal health law seeking to increase Medicare beneficiaries’ share of health care costs is meeting resistance from an unlikely group of 33 state insurance regulators, health insurers and consumer advocates charged with revising Medigap insurance policies that cover most out-of-pocket expenses.

The National Association of Insurance Commissioners assembled the group to come up with ways to raise the beneficiaries’ cost for the most popular and generous Medigap policies, a task Congress assigned to the association in the health law. Since then, the idea of shifting some costs to beneficiaries in Medigap policies has emerged as one of several proposals to reduce the federal deficit.

The proposals suggest that if Medigap policies cover less of beneficiaries’ costs, some seniors will be less likely to overuse Medicare-covered health care services. The Congressional Budget Office estimated in March that such changes could save the government $53 billion in Medicare spending over a decade by strengthening incentives “for more prudent use of medical services.”

In a conference call later this morning, the group will discuss their congressional assignment as well as the broader proposals limiting Medigap policies, which help more than 7 million Medicare beneficiaries – about one sixth of those in traditional Medicare – pay for their out-of-pocket costs. Those costs include monthly premiums, 20 percent of allowed charges for out-patient services such as doctor’s visits and other costs Medicare doesn’t cover. The most comprehensive — and expensive — plans pick up nearly all the costs.

Many of the Medigap group’s members have raised questions about their task, including the effects it could have on seniors’ health and whether changing the plans is legal. Such consensus is something the group’s chairman, Guenther Ruch, an administrator at Wisconsin’s insurance department, doesn’t see very often.

“This is a unique situation where such diverse interests have the same concerns about the potential changes to the Medigap insurance market,” he said.

“Some of those proposals are fairly dramatic in the cost shifting effect onto seniors,” said Mary Beth Senkewicz, Florida’s deputy insurance commissioner, who chairs the NAIC’s senior issues committee, which includes the Medigap group. “This has been a product that has worked very well for a number of years, helping to maintain seniors’ peace of mind, knowing that they have coverage for the gaps in Medicare.”

Bonnie Burns, a policy specialist at California Health Advocates and another member of the Medigap group, questioned whether patients need incentives to reduce their use of medical services.

“Beneficiaries don’t order services, providers do,” she said. “To suggest that Medicare beneficiaries overutilize services on a whim because they don’t have ‘skin in the game,’ is pretty disturbing.”

Although some studies have found that seniors with Medigap policies use more Medicare services, Burns said they may be sicker than the average Medicare beneficiary, which is why they bought Medigap coverage.

Senkewicz said members of the group have also questioned the legality of making changes that apply to policies seniors have already purchased. The policies are contracts between the insurer and the beneficiary which contain certain promises of coverage. When state regulators require changes in insurance, those typically apply only to future policies, she said.

Several members have suggested that Medigap policies aren’t responsible for Medicare’s growing costs.

“These carriers only pay for what Medicare has already determined to be medically necessary,” said Senkewicz. “Those determinations are not made by the insurance company.”

William Schiffbauer, a member of the group and an independent health care attorney who has represented insurers, said the health law requires the group to suggest raising beneficiary cost-sharing in Medigap plans in order to encourage more appropriate use of physicians services, based on evidence published in medical journals. Schiffbauer said that the medical literature reviewed so far does not identify which services are inappropriate and should be discouraged by making them more expensive for patients.

The group is being asked to decide what’s medically necessary — an impossible task, he said.

A review of proposed Medigap changes by the Kaiser Family Foundation in July found that one in five Medigap beneficiaries would face higher out-of-pocket expenses, primarily those with health problems and low incomes. The study also noted that the savings to the Medicare program and Medigap members depend on patients seeking less medical care, including treatment they may really need. (KHN is an editorially independent project of the Kaiser Family Foundation.)

Reducing Medicare spending for the wrong reason – by making it inaccessible — also worries members of the Medigap group, including Ruch.

“There may be seniors who would forego medically necessary care because they can’t afford it — even though they have a Medigap policy,” he said.

Gov. Perry’s health care stance

www.kaiserhealthnews.org

KHN with The Texas Tribune

By Emily Ramshaw, The Texas Tribune, and Marilyn Werber Serafini

Gov. Rick Perry routinely attacks federal health care reform, calling it a massive overreach that intrudes into the lives of every American. But in the presidential contender’s early days on the campaign trail, he’s revealed little about what his own “Perrycare” could look like — or how much changing American health care will figure into his candidacy.

Political strategists say don’t hold your breath: Republican candidates talk very little about health care in primary campaigns because the issue isn’t a top priority for their voters, and because anything beyond hammering “Obamacare” could become a target for critics. They don’t expect Perry to roll out the specifics in stump speeches unless he makes it to the general election, where Democrats could try to hit him on Texas’ low spending on mental health and Medicaid, and the state’s poor rate of insurance coverage.

On Wednesday night, the governor’s camp released an early sketch of what his health care plan could entail. Perry spokesman Mark Miner said the first thing the governor would do as president is work with Congress to repeal “Obamacare.” Then he would “start over,” first by working to stabilize the country’s economy for employers, then by trying to “free states from federal mandates and empower them to develop innovative solutions.” Finally, he would attempt to lower skyrocketing health care costs “through the proven, market-based strategies of transparency, choice and competition.” Perry wants states to be given flexibility and incentives to foster competition in the insurance market, to design solutions for patients with pre-existing conditions, to lower costs for small businesses and to implement Texas-style tort reform, Miner said.

Candidates on both sides of the aisle have a history of getting into trouble with voters when they unveil too much too soon. When it looked like Arizona Sen. John McCain’s presidential bid might fold in 2007, the candidate produced highly detailed positions on policy issues, said Douglas Holtz-Eakin, president of the American Action Forum and one of McCain’s top advisers in 2008. The result? “Barack Obama spent a lot of time shooting at our health care plan while saying nothing specific himself,” Holtz-Eakin said.

Still, a look at Perry’s legislative history provides surefire clues as to what some of his specifics could be. Policy experts expect a President Perry would seek to allow more state control over the Food and Drug Administration to blast through what he sees as road blocks that prevent medical industries from taking off. And they think he’d shift far more responsibility for running Medicaid — the joint state-federal health insurer that predominantly covers long-term care and poor children — to the states, as evidenced by his requests for more flexibility (and control of the purse strings) from Washington.

At least on the campaign trail, Medicare would probably be excluded from that conversation, because talk of changing the federal health insurance program for the disabled and elderly could frighten seniors — a key voting group, particularly in primaries.

“He’s going to have to use the bully pulpit to really explain how states have to take the leadership role and how people have to assume responsibility for themselves,” said Arlene Wohlgemuth, executive director of the conservative Texas Public Policy Foundation, which has guided many of Perry’s key legislative initiatives. “That’s not going to be easy.”

Perry will also have to avoid getting hit too hard by Tea Party loyalists on one of his highest profile health care stumbles: his failed effort in 2007 to make vaccines for the human papillomavirus mandatory for school age girls. Perry has acknowledged that his effort, which he argues was firmly rooted in preventing cervical cancer in a generation of young women, was misguided because he didn’t seek more public input on it. Because the virus can be transmitted sexually, conservatives insist that the vaccine might encourage promiscuity. Health care experts suggest Perry might be able to make up for it with the Tea Party by redoubling efforts to protect patient privacy and requiring consent for virtually everything in the electronic records age.

But state Rep. John Zerwas, R-Simonton, who is an anesthesiologist, said Perry’s best bet will simply be to stay on high alert for any health care policies that could bleed into an individual’s private domain. “You have to be very, very respectful all of the time not to step into the living room of every family out there,” Zerwas said.

Strategists say the fact that Perry doesn’t have an extensive health care record as governor can only help him. Candidates are much more likely to get in trouble for what they’ve done than what they haven’t.

“Talk to [Massachusetts] Gov. [Mitt] Romney,” said Gail Wilensky, a senior fellow at Project Hope, a global health care organization, who advised McCain in 2008. Indeed, Wilensky and others say Perry’s best approach in the primary is to continue attacking the federal health law, not only because polls show that GOP voters overwhelmingly oppose it but because many associate it with his Republican foe, who instituted a similar health insurance mandate in Massachusetts as governor.

“Candidates are trying to distance themselves from Romney,” said Kavita Patel, a fellow at the Brookings Institution who was a health care adviser to Obama during the health reform debate. “Perry has a leg up because he has no Perrycare.”

But if Perry makes it to the general election, he’ll have to show his health care hand. “Usually,” Wilensky said, “Democrats want to talk about it.”

Democrats say if the time comes, they’ve got ammunition. Of all 50 states, Texas has the worst rate of health insurance coverage and mental health spending, and the second worst rate of low-income people covered by Medicaid and per capita spending on Medicaid. It has the lowest percentage of pregnant women receiving prenatal care. It ranks 44^{th in health care expenditures per capita.}

Miner suggested Perry’s got his own success stories to offer. Texas has a strong health care industry, he said; Houston’s Texas Medical Center is the largest in the world, and MD Anderson is the no. 1 cancer center in the world. And he argued that the Texas health insurance market is healthy: 133 companies provide coverage, he said, and Texas premiums are lower than the national average.

“Texas continues to pursue measures that will increase access and availability of health care coverage,” he said.

Seniors take advantage of health law

www.kaiserhealthnews.org

Kaiser Health News, Aug. 2

The number of Medicare beneficiaries being helped by the 2010 health care overhaul continues to pile up, Obama administration boasted today.

Polls have shown seniors, who are an important voting bloc, to be more skeptical of the law than other age groups.

Administration officials have sought to allay those concerns and to draw attention to new benefits seniors will receive under the law, including more than a dozen tests and screening procedures that Medicare will fully pay for. Today they announced that so far this year:

•About 17 million seniors in the traditional fee-for service Medicare program have had one of those preventive tests without paying a co-payment or deductible.
•More than 1 million seniors have used the new Medicare wellness visit.
•Nearly 900,000 seniors have benefited from the 50 percent discount on brand name drugs while they are in the so called Medicare prescription drug “doughnut hole,” or the gap in prescription drug coverage.
“This is very good news and shows the law is making Medicare stronger and more effective,” said Medicare Administrator Don Berwick.

Whether Medicare beneficiaries actually realize these benefits are the result of the health law is unclear.

Also in the announcement today, Health and Human Services Secretary Kathleen Sebelius said that in 2012 the average monthly Medicare prescription drug coverage premium will fall by 76 cents to $30. The falling price of the premium has nothing to do with the health law, but more to do with market competition between plans and increasing use of cheaper, generic drugs.
August 4th, 2011, 3:34 PM by Phil Galewitz

Comparing treatments part of health law

By Guy Gugliotta

www.kaiserhealthnews.org

Kaiser Health News, Aug. 2, 2011

This story was produced in collaboration with “The Philadelphia Inquirer

Suppose you have prostate cancer, and you want to know what to do. Surgery, your doctor warns, can be physically debilitating, but is generally effective and low risk. Radiation is not as taxing, but its effectiveness is uncertain. Or you could just wait and see, the doctor says. Many people live for years with prostate cancer and die of other causes. It’s up to you. 

The same is true for parents wondering if they should use drugs to treat their son’s attention deficit hyperactivity disorder or a woman weighing whether to have a lumpectomy or mastectomy to treat DCIS, an early breast cancer. They, too, are often told that it’s their call.

In an era when many patients are eager to look up their latest diagnosis on the Internet and talk to three specialists before committing to a medical procedure, this is not an unusual conversation. Patients want to be partners with their doctors in determining the course of their care. But for many conditions, there are no good guideposts.

The authors of the 2010 federal health law wanted to help. The law established an independent nonprofit organization called the Patient-Centered Outcomes Research Institute (PCORI). Its mission is to compare treatments to determine which options make the most sense for particular people.

Although European countries have long used such comparisons to help set care standards, “comparative effectiveness research” is a relatively new concept in the United States. In fact, the U.S. health system, which largely follows a model that pays doctors and hospitals for any service provided, generally has not embraced comparative effective research.

PCORI faces several major challenges:

– Identifying research priorities for patients based on the study of hundreds of medical conditions and the questions they pose.

– Avoiding political criticism from opponents who argue that PCORI will ration care, some even calling it a “death panel.”

– Maintaining support from medical device makers and drug companies that are concerned the institute will be simply a cost control mechanism.

– Devising strategies for conducting studies to provide meaningful results.

“Making research relevant is a very fundamental issue,” said Dr. Harlan Krumholz, a Yale University cardiologist and a member of the PCORI board. “We want to design and carry out studies that take into account the heterogeneity of patient populations.” It is key, he said, “to connect with the patients, to provide new knowledge for individual patients.”

Options For Conducting Research
There are three basic ways to do the research, and each has both strengths and weaknesses.

Systematic reviews examine all the research that has been done on a particular question. Although this can produce generally unbiased results, it does not offer new evidence.
Observational research compares two treatments for the same disease or condition by examining medical records. Problems arise, however, because of what’s missing. If a doctor decides that a patient cannot have prostate surgery because he is too weak from other illnesses, he recommends radiation, but may not write down his reasons for the decision. If only robust patients get surgery, the study will be biased against radiation.
Randomized trials are the gold standard for research. A researcher sets up a study with the stated purpose of comparing two or more treatments. The drawbacks of randomized studies are that they are expensive, take a long time and may be too specific.
“The heart of the matter,” Helfand said, is to “design and carry out studies that individualize the results. Often a question isn’t answered by just a randomized study or observational research. We have to make the research more applicable.”

–Guy Gugliotta
The institute has not fully outlined its plans, but it is reviewing past comparative effectiveness research. By the end of the year it expects to make a number of grants to identify what they need to find out from patients, for example, should they use social media to ask people what kind of information they want to have before making decisions.

Arthur Levin, director of the Center for Medical Consumers, an advocacy group, noted that in addition to enhancing the quality of the research, reaching out to patients can help the institute shed concerns about rationing that were raised by opponents in the health care debate: “You have to build public support,” Levin said, “because it’s so easy for the opposition to latch on to this.”

The law attempted to wall off PCORI from much of that fury.  Although established by the federal law, the institute operates as an independent nonprofit using a trust fund that will provide an estimated $860 million between 2010 and 2014, and about $500 million per year from 2015 to 2019.

By law, the institute is forbidden to consider the cost of different treatments either in setting its research agenda or in drawing its conclusions. That provision has helped tamp down concerns of medical device manufacturers and drug companies. They want PCORI to “focus on clinical research and not cost effectiveness,” said David Nexon, senior executive vice president for AdvaMed, the medical technology manufacturers’ trade organization.

“For us, the biggest thing is that all stakeholders participate, that the process is transparent and that there are ample opportunities for comment along the way,” Nexon said. “The final version (of the legislation) does that. Everybody has a voice.”

Also, 19 of the institute’s 21 board members were chosen by the nonpartisan Government Accountability Office, and the directors of the National Institutes of Health and the Agency for Healthcare Research and Quality chose the other two. The board chairman is Eugene Washington, vice chancellor for health services at UCLA and dean of the medical school there.

If done well, PCORI’s research could empower patients to make informed choices about treatments and help them steer clear of unnecessary and perhaps expensive options, something that both sides of the political spectrum should endorse, said Dr. Harold C. Sox, former editor of Annals of Internal Medicine and emeritus professor at Dartmouth Medical School. “The basic mission is to insure that patients are well-informed and can have informed conversations with doctors,” he noted. “Shared decision-making is not a blue-red issue.”

In 2009, Sox led an Institute of Medicine (IOM) study on setting priorities in comparative effectiveness research. The study lasted only four months, but it provides a glimpse of what PCORI’s agenda might eventually look like. Both Washington and Dr. Joe V. Selby, the institute’s executive director, were part of the IOM’s 23-member study panel.

Besides participation from doctors, researchers, insurance companies, industry and consumer advocates, the IOM committee also received information and queries from patients both on the Internet and at public meetings. As part of its report, the IOM produced a list of 100 research priorities.

Some of these simply asked for comparisons of different medical treatments. What was the best way to deal with prostate cancer? Was surgery, catheter ablation or medication recommended in treating atrial fibrillation?

Others were almost entirely behavioral: compare school-based interventions, like vending machines, meal programs and exercise at various levels of intensity, in treating childhood obesity. And others were clinical:  how effective are interventions such as prenatal care, nutritional counseling, smoking cessation and substance abuse treatment in reducing infant mortality?

Dr. Mark Helfand, a staff physician at the Veterans Affairs Medical Center in Portland, Ore.and a member of the IOM committee, said that unlike the IOM panel, PCORI is “an ongoing” organization that will need “broader and more intense ways of involving the public.”

“There is a real advantage in going back and looking at a longer term frame,” Helfand said. “As people participate in this process they become involved and knowledgeable in different ways.”

An unreasonable expectation

Kaiser Health News, Aug. 2, 2011

www.kaiserhealthnews.org

By Gail Wilensky

. . . getting politicians and the public to engage seriously in discussing Medicare reform won’t be easy.

As important as entitlements may be to ultimately resolving the debt and deficit challenges, it’s critical to remember that the need to put Medicare on a fiscally sustainable path predates the current fiscal environment. The biggest problem in Medicare is the same as it is for all of health care – spending that has been growing two to two-and-a-half percentage points faster than the economy. The retirement of the baby boomers, which officially started last January, will increase the number of people on Medicare from the current 44 million to around 78 million and will produce added stress.

To be sure, figuring out a way to slow spending on Medicare has been a part of the Medicare program almost from its very beginning. The general strategy has been to place all of the pressure on providers, primarily by controlling their payments. But through the program’s history, this emphasis has not provided a sustained ability to control costs. Nonetheless, it appears that, as part of the debt deal, payments to providers will again likely be among the principal sources of savings.
To a lesser extent, Medicare has also tried to slow spending by changing the incentives embedded in its reimbursement structure.

The Affordable Care Act, for instance, seemed to follow this model. The health law makes some limited attempts to change provider incentives such as the provisions for value-based purchasing, accountable care organizations and other yet-to-be developed projects that will be funded by the Center for Medicare and Medicaid Innovation.

But the measure also introduced a “fail-safe” mechanism to enforce spending reductions – the Independent Payment Advisory Board. This panel will be responsible for making recommendations to the Congress for reductions needed to produce the spending rates established for Medicare. In keeping with the past exclusive focus on providers, the IPAB’s recommendations are limited to changes in provider reimbursement and cannot consider changes in benefits or eligibility.

The question of whether to involve Medicare beneficiaries more directly in strategies that slow spending is being discussed more explicitly than it has been in the past. This is the rationale underlying the premium support proposal included in the Dominici-Rivlin Debt Reduction Task Force recommendations, where a variety of private plans would be offered to seniors along with traditional Medicare, with a fixed subsidy from the government to purchase a plan. It was included in the more controversial proposal by House Budget Committee Chairman Paul Ryan, R-Wis., that would limit the choices to private plans. It is also the motivation that underlies proposals to limit or ban first dollar wrap-around insurance to traditional Medicare.

Congress has previously shied away from encouraging seniors to be concerned about the cost of Medicare-covered services — especially the vast majority with supplementary insurance. Whether the continuing need to slow spending or the failure to achieve desired spending rates by only focusing on providers will encourage the Congress to move in this direction is not yet clear.

Slowing spending is not the only issue that will need to be considered to ensure Medicare solvency. Increasing the eligibility age, as was being considered early in the debt reduction talks, reducing benefits for higher income beneficiaries or modifying Medicare’s funding sources are all likely to be up for discussion. All of these decisions will be challenging for the country and the Congress to consider.

Gail Wilensky, Ph.D., is a senior fellow at Project HOPE. She was the administrator of the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) during the George H.W. Bush Administration and the chair of MedPAC.

First dollar coverage debated

By Bruce Vladeck, Ph.D

www.kaiserhealthnews.org, Aug 2, 2011

Kaiser Health News

While it appears that major policy changes to Medicare are absent from the first stage of the debt-ceiling deal approved by Congress this week , it’s inevitable that Medicare “restructuring” will surface, if not in the second stage of the deficit reduction process this year, then sometime soon thereafter.

Vladeck
The usual laundry lists of proposals for Medicare savings are already being circulated throughout official Washington. Most of these ideas have been around for years, and have never gotten past the talking stages because of political opposition or because they are simply bad ideas. But one especially pernicious proposal appears to have increasing traction among both politicians and policy analysts: the prohibition of first-dollar coverage in Medicare supplemental insurance, whether purchased in the individual markets or provided as a retiree benefit.

This proposal is based on a simple and seemingly self-evident syllogism. Medicare beneficiaries with supplemental insurance that provides them with first-dollar coverage by paying their deductibles and co-payments use more services than the small minority of beneficiaries without such coverage. Hence, forbidding such coverage would reduce use, thereby saving Medicare a pile of money.

Sometimes this poison pill is sugar-coated, as in the recent proposal from Sen. Joe Lieberman, I-Conn., and Sen. Tom Coburn, R-Okla. In their plan, the structure of Medicare out-of-pocket liabilities would be altered to create protection against catastrophic out-of-pocket expenses for some, in exchange for higher out-of-pocket liabilities for most beneficiaries. But whatever form the proposals take, they would have seriously adverse consequences for the sickest and most needy Medicare beneficiaries.

American policymakers, and the health economists who enable them, are obsessed with issues of consumer demand, and the notion that health care is so expensive because Americans are so eager to consume it. In fact, insured Americans already have the highest out-of-pocket liabilities in the developed world, and use fewer services initiated by consumers. In the absence of supplemental coverage Medicare beneficiaries would have still higher out-of-pocket liabilities than other insured Americans, which is why essentially every beneficiary who can afford it seeks extra coverage. But while overuse of some services in some communities is inarguably a part of the Medicare cost problem, there is no compelling evidence that consumer-generated demand is a significant part of the problem. Whatever the political rhetoric, Medicare beneficiaries simply aren’t banging down the doors of physicians’ offices demanding extra MRIs and surgical procedures.

Quite the contrary: during the past decade, Congress has eliminated cost-sharing for most Medicare preventive services in response to concerns about the underuse of such services, and because of evidence that out-of-pocket costs were a significant deterrent, especially for less affluent and minority beneficiaries. More generally, while the evidence has been clear since the RAND experiments of the early 1970s that out-of-pocket costs reduce health care use, it’s also been clear that their effect is inversely related to disposable income: the less income a person has, the greater the effect of copayments and deductibles, not to mention the greater likelihood of poor health.

That’s why Medicaid historically forbade deductibles, and now permits them at only nominal levels. More importantly, the growth in out-of-pocket costs for health care consumers during the last decade or so has provided an abundance of illustrations of the basic fact that consumers deterred from seeking health care for economic reasons are just as likely to forego needed services as “discretionary” ones, and that that phenomenon is further correlated with income. Faced with higher out-of-pocket expenses, consumers may get fewer Botox treatments or buy fewer laxatives, but they also skip visits for management of their heart disease and diabetes, and don’t fill their prescriptions for hypertension medication.

The reason health insurance exists in the first place, after all, is to relieve individuals who are not medical experts of the need to figure out whether they can afford any particular medical service. In a rational world, policymakers worried about unnecessary or inappropriate use of specific services would just refuse to pay for those services. But in the contemporary American political environment, they might be accused of “rationing” or “death panels,” so they stay away. Instead, they appear to be willing, once again, to impose the consequences of their inability to control costs on those least able to bear them.

Bruce Vladeck, PhD, is senior advisor to Nexera, Inc. He was administrator of the Health Care Financing Administration (now Centers for Medicare and Medicaid Services) from 1993-1997, and was subsequently appointed by President Clinton to the National Bipartisan Commission on the Future of Medicare.

Emergency treatment – Canadian style

By Michelle Andrews, Aug. 2, 2011

www.kaiserhealthnews.com

As a health care writer, I talk with people all the time about their experiences navigating the system, whether in the United States or elsewhere. Writing about health care is different from writing about the arts, say, or sports, in one crucial way: When you write about health care, you’re often left feeling profoundly grateful that you didn’t have to experience firsthand the event that you’re describing. But now my luck had turned, and I was about to get up close and personal with emergency care, Canadian style.

The ambulance arrived within 15 minutes, and I had a bumpy but uneventful ride to the hospital, a regional trauma center at one of the local universities. On arrival, we showed them my passport and American insurance card. Because I was a trauma patient, I was wheeled right in, just as would happen in a U.S. hospital. A nurse removed my clothes, cutting off my shirt since I couldn’t move my arm. Another nurse drew blood.

At the request of a very young-looking resident, I moved various body parts on command and answered questions about what hurt. The resident, who was my main contact throughout the visit, also looked over my injuries, including checking my ears and eyes. She was friendly and kind, and kept up a running commentary in mostly fluent English explaining what she and others were doing.

(One of my friends, a French-speaking Montreal resident, stayed with me and interpreted when the medical staff’s questions or my answers were complicated.)

One of the most striking things about the exam was how little high-technology equipment they employed. Until I had X-rays made of my hand, hip, shoulder and knee, a blood-pressure cuff was the most advanced equipment I encountered.

Emergency department technology use varies, of course, in Canada and elsewhere. Still, clinicians at a trauma center in the United States treating someone with injuries similar to mine would probably wheel a portable ultrasound machine to the bedside in the trauma bay to scan for internal injuries, says Sandra Schneider, president of the American College of Emergency Physicians. They would also probably do CT scans, perhaps of my neck, pelvis and back, to make sure there were no bone breaks that didn’t show up on the X-rays. Some of the tests might not be absolutely necessary, but “a lot of what [U.S. emergency physicians] do is because we are very frightened of getting sued, because we get sued so often,” says Schneider.

In an analysis of data from 2003 to 2008, researchers at Yale and in Canada found that Americans were nearly twice as likely to get a CT scan during an emergency department visit as were Canadians living in Quebec.

In Canada, residents who go to the emergency department pay nothing for the visit, not even for X-rays or other imaging tests or for lab work, says Michael Schull, an emergency physician who co-authored the study on CT use. Patients would be charged for specialist visits and if they were admitted to the hospital, however.

“Hospitals aren’t making any money off these tests,” Schull says. “There’s no incentive to do them, because they’re not going to get paid for them.”

After the X-rays were taken and I was wheeled back into the trauma bay (No. 13, but I figured I’d already had my bad luck for the day), the resident came to my bedside with a big smile on her face and said, “You really are in pain! You have three fractures!”

Validation is nice, but I wished the news were different.

I had two fractures at the top of the humerus, the long arm bone that attaches to the shoulder, and another break in a bone at the base of my thumb. The shoulder breaks could be expected to heal cleanly, she said, but the thumb was slightly out of alignment and might require surgery. There were no broken bones in my pelvis or hip; the pain and difficulty walking I was experiencing there was probably caused by torn or otherwise damaged muscles, tendons and ligaments.

The trauma team referred me to an orthopedist to examine my shoulder and a plastic surgeon with expertise in hands to look at my thumb. Unfortunately, an orthopedist wouldn’t be able to see me until two days later. (The chief orthopedic resident, however, stopped by that night and reassured me that it would be okay to wait.) I did get examined by a plastic surgeon that evening, but my friends had to drive me to a sister hospital several miles away to see him. Specialists, it seemed, were pretty thin on the ground.

According to a 2010 Commonwealth Fund survey of health care in 11 countries, 33 percent of Canadians waited six days or more to see a specialist when they were sick, compared with 19 percent of Americans.

My pelvis apparently did not warrant special attention. Since the injury seemed to be muscular rather than skeletal, the hospital staff would do nothing further to diagnose what was wrong, the resident said. Her recommendation for me — rest and exercise — would probably be the same no matter what I’d done to any tissue.

I couldn’t argue with her reasoning, and if she was right, it was the sensible course. But what a difference in approach from what I would be likely to experience in the United States, Schneider says, where clinicians would probably have worked hard to nail down a definite diagnosis. I left with prescriptions for morphine, naproxen (an anti-inflammatory) and Tylenol.

Puzzled by my U.S. private insurance card, the billing person estimated that my care that night would cost 700 Canadian dollars (about $740) and charged my credit card. If it turned out I had been overcharged, she said, they would send me a refund. Yes, you read that right: overcharged.

Although comparing costs and bills is tricky, by any measure my evening in the Canadian emergency department was a good deal.

Default would be devastating to health care

By Jordan Rau, Christopher Weaver and Jessica Marcy

KHN Staff Writers

Jul 29, 2011

www.kiserhealthnews.org

Hospitals, nursing homes, doctors and state health programs could survive a brief pinch if the Washington debt ceiling deadlock leads the government to stop paying Medicare and Medicaid bills. But if an impasse were to drag on for more than a few weeks, health care providers could be unable to pay their staffs or even face insolvency, according to health care experts and former government officials.

Even as the Tuesday deadline for a deal between President Barack Obama and Congress approaches, the implications of a worst-case scenario remains speculative. The Treasury Department hasn’t signaled how it would prioritize which government bills to pay. Few health care providers have made any doomsday plans, but the uncertainty is making many edgy.

On The Capsules Blog
What Will States Do If Federal Dollars Stop Flowing?
“It’s not a matter of planning right now because there’s too much unknown,” says Cheryl Phillips, senior vice president for advocacy for LeadingAge, an association of 5,600 not-for-profit home health agencies, nursing homes and other organizations that work with seniors. She says that many of their members have very limited operating margins, so a stop in payment could quickly be destructive.

There’s no precedent for this kind of fiscal crisis, although Medicare providers have experienced short-term delays in the past when Congress made last-minute changes to Medicare reimbursement rates, says Gail Wilensky, who ran Medicare, the federal health program for the elderly and disabled, under President George H.W. Bush.

“I’m sure it irritated the providers, but it didn’t affect the beneficiaries,” Wilensky says, noting that despite delays that sometimes stretched for several weeks, business continued as usual. “In the short term, there should be little to no effect.”

Others believe financial pain could come rapidly for some. John Reiss, a Philadelphia lawyer who advises hospitals, doctors and medical device makers for the firm Saul Ewing, says his clients are “dumbfounded” by the ongoing deadlock but still assume that there’ll be a deal before it’s too late. 

If not, he says some facilities have enough cash on hand to last for several months, but “there are some hospitals surviving on six or seven days cash on hand and those places are going to be in trouble.”

Stan Rosenstein, a health care consultant and the former director of California’s Medicaid program, known as Medi-Cal, says a prolonged impasse could be “devastating.” Nursing homes in particular rely on Medicare and Medicaid, the joint state-federal program for the poor, for most of their payments and could rapidly be unable to finance their daily operations, he says.

“California has had a lot of experience in this with its late budgets and it only takes a couple or three weeks for it have a major impact,” says Rosenstein, referring to when the state legislature deadlocked over budgets and the state stopped paying its bills, including for Medi-Cal.

But the worst case scenario here would be more apocalyptic, he says. That’s because health care providers would lose revenues from Medicare and Medicaid at the same time. Plus, a debt default could also unnerve the capital markets, making it difficult or impossible for providers to borrow money to stay afloat. And states are having so many financial problems that they’re not in a position to fill in the gaps.

Matt Salo, executive director of the National Association of Medicaid Directors, says that in the “worst-case scenario, Aug. 2 comes around with no deal, Medicaid is not going to shut down.” But if the bond markets melt down, states could face higher interest rates on money they’ve already borrowed from investors, making it even harder for states to pay their share of Medicaid, which is generally about half, he says. The federal government on average pays about 56 percent of Medicaid costs.

How quickly states feel the pain depends on the schedule Medicaid pays them. Rhode Island receives payments every two weeks, and it was just paid yesterday, says Fred Sneesby, a spokesman for the state’s Department of Human Services. The next scheduled payday is Aug. 12. California, though, is paid every week, Rosenstein says.

“I don’t think there’s any state that has the wherewithal to advance the money,” says Rosenstein, who advises states, insurers and providers for the consulting firm Health Management Associates.

Thomas Scully, who was the administrator for Medicare under President George W. Bush, says if there is a default, the Obama administration’s political decisions will determine how quickly health care payments are shut off. “They’re either going to shut down Medicare and Social Security first or last,” he says. “If they want to provoke a crisis they would quit paying hospitals and doctors and quit sending out Social Security checks.”

Donna Shalala, who was health and human services secretary under President Bill Clinton, says Medicare pays its claims within two weeks, which is faster than many private insurers. “The health care system is very dependent on Medicare payments, because they come very quickly,” she says. “If they’re not reimbursing, that would create problems for the entire industry – hospitals, doctors, everyone. It is not a happy scene.”

Doug Myers, chief financial officer for Children’s National Medical Center in Washington, D.C., says 55 percent of the hospital’s patients are on Medicaid. He said the hospital would “start feeling the impact” within 30 days of a halt in federal funding.

“Whatever happens to Medicaid, happens to Children’s National,” he says.

Martha Roherty, executive director of the National Association of States United for Aging and Disabilities, says she’s been advising state agencies that advocate for services for the elderly to immediately claim any money they’re entitled to from federal grants. Usually, she says, they do it just once a month or quarterly.

“We have been telling them” to “take it now,” she says. Roherty added that basic services that rely on federal money, such as senior centers and nutrition meals that are delivered to people’s homes, could quickly shutter if the federal government stops paying those bills.

Paul Ginsburg, president of the Center for Studying Health System Change, a Washington think tank, says the health care system is actually in a better position to handle a halt in government payments than many other sectors of the economy. “Medicare and Medicaid beneficiaries are going to be able to get care for a while, while if a store is selling something and people don’t have money to buy it, that will hit immediately,” he says.

Salo agrees that by the time health providers are in serious trouble, everyone else will be too. “If we go into default for a really long time,” he says, “I’m guessing cash flow in Medicaid is not going to be the biggest of our concerns.”

Kaiser Health News staff writers Julie Appleby, Mary Agnes Carey, Juan E. Gastelum,  Peggy Girshman, Shefali S. Kulkarni and Bara Vaida contributed to this story.

Beware “free” placement help

By David Spiegel, attorney, FTC

www.kaiserhealthnews.org, July 28, 2011

They have enticing names that communicate understanding in regard to finding a home for an aging parent — names that use words like “mom,” “help” and “care.” They advertise expertise in the field of elder care, promising the assistance of “senior care specialists” or “personal family consultants.” Best of all, they promise “FREE” advice in selecting appropriate long-term care arrangements, particularly for people whose needs are less than those of nursing home residents.

These companies, which fall under the catch-all category of long-term care referral services, are the cyberspace era’s quick fix solution for the growing number of Americans seeking non-nursing home institutional care for their aging parents, relatives and significant others. Unfortunately, this purported expert assistance in navigating this bewildering world of assisted living is, at best, a hit-or-miss proposition.

Unlike nursing, social work and psychology, there are no formal education, training, regulatory or professional ethics standards for people hired as “long term care specialists” by Internet placement services. Granted, a small number of universities — the University of Southern California’s Davis School of Gerontology and the University of Florida’s College of Public Health are two examples — offer certification programs in geriatric care management. However, even this impressive title is not yet subject to formal state licensing or regulation. As a result, referral services are free to hire whomever they choose, irrespective of training and prior job experience. The primary job requirement — to use industry lingo — may simply be the marketing skill of “putting a head in the bed.”

Meanwhile, the services these Internet agencies provide may not be violating any laws, but their advice should be viewed with caution. Beyond the questionable expertise of the employees, their financial allegiances also can raise issues for consumers. For example, a company’s assistance often may be free to the consumer, but the placement agency typically receives a handsome payment from assisted living facilities for each successful referral. This amount can be 50 percent or more of the resident’s first monthly rent payment. According to the most recent MetLife Market Survey of Long-Term Care Costs, the 2010 national average monthly base rate for assisted living facilities was $3,293. High-end facilities charged upwards $6,000. Thus, the commission for a single referral to one of these facilities may be $3,000 or more. Since the salary of placement service employees often consists of a percentage of the employer’s compensation, there is an obvious incentive to steer consumers to the highest bidder. Or, at the very least, to refer only to those facilities with which the placement service has reimbursement contracts.

Because it is unlikely that the free placement agency’s employees will be a nurse or social worker — a professional who has ethical and regulatory strictures requiring the disclosure of third party fees — they will be under no obligation to reveal this fee structure. Some placement services do in fact disclose in their Internet advertising how they are paid. However, a casual Web search shows that many do not, preferring instead to use the word “free” as a lure.

The alternative to free referral services is to hire a brick-and-mortar geriatric care management agency. These agencies typically employ licensed professionals with training in geriatric issues who typically meet with both the prospective resident and his or her caregivers as part of a comprehensive multi-hour evaluation process. A listing of these agencies, arranged by region, agency name or zip code, can be found on the website of the National Association of Professional Geriatric Care Managers.

According to Kaaren Boothroyd, the NAPGCM’s executive director, costs of this type of assessment will vary between $300 and $800. Unfortunately, many consumers may find the free and quick Internet fix more attractive than this more traditional approach.

“My advice about Internet placement services is ‘buyer beware,’” says Eric Carlson, the director of the Long Term Care Project of the Senior Citizens Law Center and the author of a legal treatise on institutional care issues. “Even though it’s tempting to delegate a decision to such a service, you can’t assume there’s quality control behind their recommendations. You have to understand that the service will have a motive to refer based on its agreements with facilities.”

In the end, hype notwithstanding, the services of free long-term care referral agencies are not unlike those of a real estate broker or an apartment locator service. Like these businesses, the referral agency provides choices to consumers. However, the existence of choices is only the first step in a long process. It is not an end in itself.

David R. Spiegel is a Federal Trade Commission attorney who focuses on consumer protection issues affecting seniors. The views expressed in the article are solely those of the author and do not in any way represent the views of the FTC or its individual commissioners.

IPAB is essential

By Jonathan Cohn, senior editor, “The New Republic”

www.kaiserhealthnews.org, July 29, 2011

This column is a collaboration between KHN and  The New Republic. 

A little over two weeks ago, while most of you were paying attention to the debate about how to raise the debt ceiling, those of us who study health care policy were following hearings before the House Budget Committee. The purpose of the hearings was to scrutinize the Independent Payment Advisory Board, a commission that the Affordable Care Act created as part of its apparatus to control health care costs. And the hearings produced some genuinely interesting testimony on everything from the scope of the board’s authority to the limits of its legal power. If we were in the middle of a dialogue about how to improve the board’s structure and function, that testimony would be extremely useful.

But we’re not having a discussion about whether to reform the IPAB. We’re having a discussion about whether to repeal it. Opponents of the Affordable Care Act see the IPAB as an instrument of, and metaphor for, everything that is wrong with the new health care law. The problem with this law, they keep saying, is that it tries to solve the health care cost problem through “central planning.” At best, they say, this strategy will misallocate resources in ways that stifle innovation and make access to care more difficult. And at worst? It will ration care in ways that deny life-saving treatment to people who need it. As one Republican lawmaker put it recently, “It will destroy the very core of what has made our medical system the best in the world.”

Yes, these arguments should sound familiar. They are the same ones critics began making in the summer of 2009, when enactment of the law first seemed imminent. And since neither the argument nor the people making it are going away, maybe it’s a good time to take a step back and remind everybody what the IPAB is; how it will work; and why it (or something very much like it) is essential to making health care accessible to all seniors and, eventually, all Americans.

Despite the fanciful attacks from some conservatives, the IPAB will not be a modern-day Politburo that brings Soviet-style management to American health care. It will be, instead, a board comprised of 15 experts on health care policy, including consumer representatives. The president will appoint the members, subject to Senate confirmation, and they will serve six-year staggered terms. Their job will be to issue recommendations on how Medicare can spend its money more wisely.

A similar commission already exists. It’s called the Medicare Payment Advisory Commission, or MedPAC. But its recommendations, however intelligent, usually end up collecting dust on the bookshelves of policy wonks like me. IPAB’s proposals shouldn’t meet the same fate. Whenever the cost of Medicare grows faster than the targets set by the law, IPAB will make proposals that would reduce the program’s spending by as much as to 1.5 percentage points, depending on the circumstances. At that point, Congress would have three choices: Allow the recommendations to take effect, come up with alternatives that would achieve the same savings or opt to let Medicare costs grow up faster than planned. The one key caveat is that the final course of action, allowing Medicare to grow without further restraint, would require a three-fifths vote in the Senate.

The thinking behind this structure reflects a long-standing consensus among health care experts that Medicare needs better, smarter management. Relative to private insurance, the program has actually done a pretty good job of managing costs overall, thanks to the natural efficiencies of such a massive program and the lack of investors to satisfy with profits. But Medicare is still getting too expensive, too quickly — and there’s a ton of data to suggest it doesn’t do a very effective job of fostering good quality. Probably the best known evidence along these lines are the Dartmouth Atlas studies, which show that Medicare spends far more in regions like Miami than in regions like Minneapolis, but without achieving better results.

If we want to keep providing seniors with comprehensive coverage, while still getting the program’s costs under control, the obvious way to do it is to operate the program more carefully. One way to do this is to adopt payment models that reward quality and efficiency. And that’s not something Congress is likely to do on its own, particularly with lobbyists for every health care special interest, from device makers to local hospitals, crawling all over Capitol Hill. The hope is that an independent commission of experts, insulated from politics but still accountable to the president and Congress, can succeed where our lawmakers have failed.

The more extreme critics of IPAB claim it will abuse its power — that it will issue treatment edicts that keep the sick and elderly from getting cancer drugs, expensive surgeries and the like. But the new health law explicitly prohibits IPAB from changing the program’s benefits or imposing anything that would amount to “rationing.” Besides, all insurance plans, public and private, must choose what to cover and what not to cover. That includes Medicare, which already exercises this power routinely. At most, IPAB would increase the influence of scientists and reduce the influence of lobbyists over these decisions. Would critics really prefer it the other way around? (Actualy, maybe some would. Many IPAB critics, including Democrats, have benefitted from large health industry donations.)

The less extreme, more honest criticism of IPAB is that it will encourage payment schemes that lead to indirect rationing, by restricting access to the people who provide care. According to this argument, doctors are already turning away patients because of low reimbursements. Once IPAB ratchets down payments further, they’ll turn away even more patients. But the stories about doctors turning away Medicare patients turn out to be mostly anecdotal, at least at this point. The best data available, from MedPAC among others, suggests most doctors still see Medicare patients — and are more open to them than they are to privately insured patients. Particularly given the Affordable Care Act’s other reforms, which provide financial incentives that reward efficient styles of care, providers should be able to offer care as good if not better than what they offer now — while charging less money per patient.

But what if the critics are right? What if IPAB changes really did make it more difficult for seniors to see providers? That would be a problem, obviously. But the alternative is to cut spending on Medicare in ways that will affect beneficiaries more directly and more severely. The House Republican budget, which most of these critics support, is a prime example. Instead of introducing a commission to manage Medicare more efficiently, it eliminates the government program and hands seniors a voucher that, according to every reliable estimate, would provide far less financial protection. Even if competition among plans reduced the cost of care, seniors would still have a far tougher time getting care — with large numbers forced to choose between health care and other necessities, much as they were in the days before Medicare came into existence. Somehow I think that’s not a reality most seniors would like.

 

Rebate will come back to seniors

By Grace-Marie Turner, President of the Galen Institute

Kaiser Health News, July 27, 2011

www.kaiserhealthnews.org

Leading congressional Democrats appear ready to impose a new tax on prescription drugs for seniors — a tax that would increase Medicare drug plan premiums for some seniors by as much as 40 percent.

Those lawmakers wouldn’t describe their plan that way, of course, but that would be the effect of their proposal to require drug companies to pay Medicaid-style rebates to Medicare.

Pharmaceutical companies already are required to pay rebates to states for the right to sell their products to Medicaid patients. A proposal by Rep. Henry Waxman, D-Calif., and Sen. Jay Rockefeller, D-W.V., would require drug companies to pay a rebate to the federal government for prescription drugs sold through Medicare Part D for those low-income seniors who also qualify for Medicaid or who are eligible for subsidies. This proposal, which is now in play as part of the negotiations to increase the government’s debt ceiling, would collect up to $112 billion over the next 10 years.

Supporters of the rebate proposal say the money would come from the pharmaceutical companies, but the logic is flawed. Experience with the Medicaid rebate programs already has been shown to increase costs for prescription drugs sold in the private sector. And ultimately, the rebate costs are shifted to consumers.

If the new Medicare rebate tax were imposed, more than 17 million seniors who don’t qualify for low-income subsidies would face drug benefit premiums that would be 20 to 40 percent higher than they are paying now, and they would face an average of $200 a year in higher out-of-pocket costs.

These are the findings of a study conducted by Douglas Holtz-Eakin, former director of the Congressional Budget Office who is now president of the American Action Forum, and his associate, Michael Ramlet, the forum’s director of healthcare policy.

Holtz-Eakin and Ramlet studied government data to determine the impact that the rebate plan would have on prescription drug costs. While lower income seniors are protected by government subsidies from paying higher premium costs, they find that millions of other seniors would be forced to pay higher premiums for their drug coverage as a result of the rebate tax.

“This proposal would be a bad deal for Medicare and a raw deal for millions of seniors,” Holtz-Eakin said. “This is a price-fixing scheme that will take money out of the pockets of senior citizens and greatly reduce customer choice.”

The proposed rebate tax also would undermine the most successful health program the government operates — the Medicare prescription drug program.

The prescription drug program, which began in 2006, requires private companies to compete on benefit design and price in offering drug coverage to seniors.

The program is popular because it gives seniors a wide range of choices of prescription drug plans, with different cost points and drug offerings. And it is has the remarkable distinction of costing taxpayers much less than expected. The Medicare Part D program is coming in at 46 percent below projected costs, according to the CBO.

And Part D’s competitive model is saving seniors money as well. The average monthly beneficiary premium for Part D coverage will be $30 in 2011, far below the $53 forecast originally.

But the proposed rebate tax, which also has been endorsed by President Barack Obama, would undermine the gains that competition and consumer choice have brought to the Part D drug benefit program by forcing higher costs on seniors.

“The Medicare prescription drug benefit is one of the only bright spots on the entitlement landscape, costing less than projected and delivering real value for seniors. The last thing the president and Congress should do is turn it into a Medicaid-style program,” Ramlet said.

The rebate plan is not a way to cut government spending but is simply a ploy to shift higher costs to seniors. Congress should look elsewhere for real savings rather than resorting to gimmicks that will trick seniors into paying the bill.

Grace-Marie Turner is president of the Galen Institute, a non-profit research organization that focuses on market-based health policy solutions. She is a co-author of  “Why ObamaCare Is Wrong for America” (Broadside/HarperColllins, 2011).

It’s not just the money

By Harold Pollack, KHN, July 17, 2011

www.kaiserhealthnews.org

Health reform raises central ideological questions about the size and scope of government, about progressive taxation, about the individual mandate and more. It’s easy to forget that cost control will be a huge challenge, no matter how these ideological matters are resolved, indeed under any health system. Finding the right combination of humanity and restraint will be particularly hard in addressing life-threatening or life-ending illness. Economic incentives, American culture, a changing doctor-patient relationship and fundamental uncertainties at the boundaries of clinical care conspire against our efforts to provide more humane, more financially prudent care.

The necessity and the difficulty of these tasks were underscored by a beautiful New England Journal of Medicine essay, Bending the Cost Curve in Cancer Care, by Thomas Smith and Bruce Hillner. Their essay received favorable attention from health policy journalists. Yet because it didn’t push the usual partisan buttons, it didn’t receive much wider attention. That’s too bad, because Smith and Hillner raise many issues that apply beyond the realm of advanced cancer care. For instance, they offer a brave model of skilled providers identifying specific opportunities to reduce costs within their own specialties. They also present suggestions to address the burdens imposed by cancer overtreatment and undertreatment on patients and society as a whole.

Their first, deceptively simple recommendation is to target cancer testing and imaging to situations of proven benefit. Measured at the population level, the survival benefits of such imaging — routine mammography screening for asymptomatic young women or early lung cancer screening, for example — are often minimal or unproven. Such imaging is also quite costly. The annual direct costs run into the billions of dollars. Indirect costs include patient anxiety and follow-up treatments that can be expensive and intrusive. And, at the other end of the life spectrum, physicians are performing annual mammograms in patients who have quite limited life expectancy. Providers also implement follow-up scans searching for relapse, such as frequent PET-CT scans, that are not supported by guidelines or by clinical trial evidence.

In part, these problems reflect powerful incentives on providers, device manufacturers, and others which promote aggressive care. The problems go deeper, too.

Dr. Vivek Murthy, president of Doctors for America, e-mails that physicians spend less time with patients (not always for reasons of their own choosing) and are less likely to have important discussions with patients and families about priorities or tradeoffs in care. It takes less time to consent to an intervention or to prescribe a medication than it does to persuade a patient that an intervention or procedure is unwise. Murthy notes that one cumulative effective of millions of missed conversations is to reinforce the intervention mindset among patients. So, alongside efforts to alter physician incentives, medical schools and health care settings must equip physicians with the knowledge, the interpersonal skills and other supports to conduct these important conversations well.

Another problem may be even more challenging. We, the public, display a strong bias toward the most aggressive and costly care, often at the expense of other things. The proliferation of $100 million proton beam cancer facilities, even as basic cancer prevention efforts go unfunded, exemplify the imbalance in urgency and priorities. Continued Medicare reimbursements for costly yet dubious medications such as Avastin for breast cancer raise inevitable questions of cost-effectiveness. Whatever your ideological perspective, Medicare should not and cannot provide a blank check to the supply-side of the medical economy, especially in a political and regulatory context in which private payers are under strong pressure to follow suit.

Smith and Hillner’s essay also raises sensitive issues regarding overly aggressive chemotherapy for patients who face fatal metastatic cancers. Given anxieties captured in the crystalline phrase “death panel,” I would not commence a national cost-control discussion within the frightening and divisive arena of end-of-life care. On the merits, though, Smith and Hillner cite much evidence that both patients and American society would benefit from less toxic and less aggressive care. When further chemotherapy is unlikely to be successful, they suggest that symptom-directed palliative care provides a better treatment course. 

Ironically, the inclusion of palliative care elements within standard care may also prolong life. As Atul Gawande noted in the New Yorker, a randomized trial found that metastatic non-small-cell lung cancer patients assigned to early palliative care lived almost three months longer, on average, than their counterparts receiving usual care. The earlier palliative care group experienced higher quality of life, was less likely to display depressive symptoms and was more likely to be spared toxic side-effects of futile therapies. Some imperfectly understood combination of these benefits prolonged survival through provision of more cost-effective, less-punishing care.

Here again, we, the general public, must alter our own mindset to improve the quality of care. Metastatic lung cancer may be the most straightforward case. The majority of patients with this condition die within one year. Inclusion of palliative care and the turn away from further futile therapy are thus most compelling. Even here, though, many families hesitate to embrace palliative care because they regard loss of hope as the entry ticket. A definitive bleak diagnosis should not be required to receive services commonly associated with palliative care. All patients require effective pain management. All patients require open communication about prognosis and, often, advance care directives.

Such discussions aren’t easy, especially when families don’t fully trust the care team. Years ago, my father-in-law was diagnosed with advanced lung cancer. At one point, his doctors discussed the possibility of a punishing thoracic surgery. They were unenthusiastic. Yet our family wasn’t really ready to give up on the prospect of substantially life-prolonging care. Moreover, we weren’t very confident in his doctors. They had done a pretty poor job in the early stages of his care. They lacked the authority to say: “There’s nothing more we can do.”

Fortunately, one of my own physician colleagues mapped the options with me. He explained that surgery was unlikely to prolong my father-in-law’s life and the most likely outcome was that he would spend his few remaining months in recovery from a painful and failed surgery. A different path was chosen. He died soon after, at home, under dignified and humane circumstances in the care of his family and a local hospice.

We all must face these issues to control costs, and for other reasons, too. We can treat our loved ones, and ultimately ourselves, more effectively, more efficiently, and more decently than we often do.

Changes to Medicare supplementals could cost seniors more

By Julie Appleby, KHN Staff Writer

Jul 15, 2011

www.kaiserhealthnews.org 

As debt limit talks drag on, lawmakers are eying possible changes in Medicare supplemental plans – moves that could increase seniors’ out-of-pocket costs.

Traditional Medicare, the federal health program for the elderly and disabled, requires beneficiaries to pay hospital deductibles and a portion of the cost of tests and doctor visits.  To protect themselves from those out-of-pocket costs, about 17 percent of beneficiaries buy Medigap plans.   Another 34 percent get such coverage through a former employer.

But some health policy experts say such “first-dollar protection” drives up demand for Medicare services, costing the government money for what may be unnecessary care. One proposal would bar supplemental insurance from completely eliminating out-of-pocket costs – or charge enrollees a $530 a year extra if they want to keep such protection. That change could save up to $53 billion over 10 years, according to a chart used during the bipartisan talks led by Vice President Joe Biden.

What is Medigap and why do people buy it?

Unlike most job-based health insurance, traditional Medicare does not include “catastrophic” coverage, an annual maximum upper limit on the amount beneficiaries could pay. So enrollees can be liable for thousands of dollars each year, including: $1,132 per-episode deductible for hospital admissions; hundreds of dollars in daily charges for hospital stays of longer than 60 days; a $162-a-year deductible for doctor care, plus 20 percent of charges for office visits or equipment like wheelchairs.

Ten standardized types of supplemental plans offered by private insurers – including AARP’s UnitedHealthcare policies  – cover all or most of such deductibles and copayments.  Some employers also pay all or part of such costs for their retirees.

What changes are under consideration?

It is not clear exactly what’s on the table in the negotiations between congressional leaders and the White House.  But the charts  released show that one such proposal under consideration would bar insurers from offering supplemental policies unless the policies came with an annual deductible. People who didn’t want a deductible could pay $530 a year in additional premium to ensure that they won’t be hit with costs before their coverage kicks in.

Is this a new idea?

No.  It is a subset of a larger discussion about spending on Medicare and other entitlements. In recent years, the National Commission on Fiscal Responsibility and Reform (The Bowles-Simpson Commission), the Debt Reduction Task Force, the Medicare Payment Advisory Commission and lawmakers, including Sen. Joe Lieberman, a Connecticut independent, and Sen. Tom Coburn, an Oklahoma Republican, have all suggested changing traditional Medicare.

Most of the ideas would create a single annual deductible – generally around $550 – after which beneficiaries would pay about 20 percent of medical costs up to a maximum annual cap, ranging from around $5,000 to more than $7,500.

Would changing supplemental coverage save money?

Some economists and policy experts say that supplemental coverage insulates beneficiaries from medical costs, driving up demand for unnecessary care. A study done for MedPAC in 2009 found that beneficiaries with supplemental insurance used more care and cost the program more money. The increased spending wasn’t for emergency hospitalizations, but for other services such as elective hospital admissions, preventive care, doctor office visits and some types of tests.

Supporters of the insurance say it shields seniors from unpredictable costs and reduces big-ticket expenses by encouraging them to seek help for medical problems before they become severe.

What else do people say about the idea?

Advocacy groups like the Medicare Rights Center oppose restricting Medigap plans, saying it would simply shift more costs from the government to elderly and low-income people who can least afford it. “Some in government feel people in Medicare don’t have enough ‘skin in the game,’” says Ilene Stein, federal policy director for the center. In fact, she says, people on Medicare already pay 15 percent of their incomes for health care, well above the level paid by non-Medicare households. While the proposals would cap maximum annual spending per enrollee to $5,500 or $7,500, “that’s a lot of money for someone making $22,000,” the median household income for those on Medicare, she says. 

Still, Joe Antos of the conservative American Enterprise Institute says many of those people already pay large premiums for Medigap coverage – and would likely see those premiums decline if “first-dollar” protections are barred. Antos and Jonathan Gruber, an economist at MIT and consultant to Democrats, both think that if Congress were to change supplemental coverage – or the traditional program itself – that lawmakers would create exemptions for lower-income beneficiaries.

How would the proposal affect a Medigap policy I already own?

Congress would have to decide whether to impose restrictions only on new policies or include existing coverage.

What about people who don’t have a Medigap plan?

Only about 10 percent of seniors don’t have some sort of supplemental coverage. Some people have military/VA benefits, others are in Medicaid, and some have coverage through Medicare Advantage plans, which are insurance policies offered by private insurers as an alternative to traditional Medicare.

What are the chances that these ideas will be adopted by lawmakers?

Because making any change that could be seen as a cut in Medicare benefits carries huge political risk, previous calls for changing the traditional Medicare program or limiting first-dollar coverage through supplemental insurance have not picked up support. But now, when failure to lift the debt ceiling could result in widespread economic problems, a middle-of-the night compromise between warring factions in Congress could put it back on the table.

“Normally, this would be dead on arrival. But this is such a dicey environment that these guys are going to cut some kind of deal at midnight either before or after Aug. 2 in such a hurry that they won’t be worried about the kinds of things people normally worry about when they cut senior benefits,” says Robert Laszewski, an Alexandria-Virginia-based consultant to the health care industry.

Antos is less sure. He says the potential savings of $53 billion over 10 years would be just a tiny slice of any deficit-reduction deal and might not be worth the political hit Congress would take from seniors.

“You can’t sugar coat it,” says Antos. “It would be much easier to do what lawmakers have always done in Medicare, which is lower payment rates (to doctors and hospitals) or restrict services in ways that are subtle and complicated. But to do something that looks like changing benefits, I don’t see it this time.”

Shifting home health payments won’t work

By Mary Agnes Carey

www.kaiserhealthnews.org, July 13, 2011

Former House Energy and Commerce Committee Chairman Billy Tauzin has some advice for Republicans who want Medicare beneficiaries to pick up part of the tab for home health services:  It won’t work.

“[Home health] is not an elective thing. You get assigned to it by your doctor. You have to have it or otherwise you’re in the hospital or a nursing home,” says Tauzin, former head of Pharmaceutical  Research and Manufacturers of America who is now a senior adviser to the Partnership for Quality Home Healthcare, a coalition of home health care providers.

While Medicare imposed a co-pay for home health in 1965, Congress repealed it in 1972 because “it was counter-productive,” he said.  Seniors who couldn’t afford the co-pay didn’t get home health care, became sicker and cost Medicare more, he said.

A list of potential Medicare and Medicaid payment changes discussed as part of the ongoing debt ceiling talks included instituting cost sharing for home health services in Medicare.  The Medicare Payment Advisory Commission also has recommended a home health co-pay and the Congressional Budget Office said that taking that step would raise $47 billion over a decade.

Tauzin says that 60 percent of those payments would fall on the nation’s poorest and sickest seniors. “You’re going to put a sick tax on them that’s going to encourage them not to use the cheapest, most efficient health care available to them,” Tauzin said in an interview. “They end up in emergency rooms. … Rehospitalizations go up, you end up with a lot more nursing home care.”

Tauzin doesn’t buy the argument that beneficiaries must share in the cost of Medicare services to keep the program solvent for future generations. “You go ask a senior veteran whether he’s already put skin in the game. You go ask grandmas and grandpas who build this country … whether they have skin in this game already. They’ve been paying into this system all of their lives. You’ve got a debt so you want to tax the oldest and the sickest in our country?”  A better approach, the home health alliance says, would be to pursue waste, fraud and abuse in the program.

Tauzin also has some advice for his former colleagues as they debate ways to raise the federal debt ceiling.

“We all went to college right? When did you do your term paper? We all started a week out but we really didn’t do it until the night before. And you probably had to be real careful about staying sober that night. That’s where they are right now,” he said. “They’re bouncing around and they’re posturing and the bottom line is they’re going to get something done.”

Cash for health

By Michael F. Cannon, Cato Institute

www.kaiserhealthnews.org June 19

Democrats and Republicans may not be able to agree on whether to increase taxes as part of a deal to raise the federal debt ceiling. But they can at least agree on this much: Congress must restrain Medicare spending. The trick is how to do it without sacrificing access to necessary care?

As luck would have it, we have a home-grown model for Medicare reform that would contain spending and improve the quality of care. This model appeals to both Republican and Democratic ideals: it satisfies the Republican desire for individual ownership and control, but emulates a social insurance program revered by Democrats. The key to improving health care for seniors is . . .  to make Medicare look more like Social Security.

Consider: Medicare subsidizes the elderly and disabled by giving them a health plan designed and typically administered by government. Social Security does a better job of meeting seniors’ individual preferences because it gives them cash and lets them decide how to spend it. They can spend more on housing and less on food, or vice versa.

Medicare enrollees have little incentive to avoid wasteful spending, because the savings revert to the government. Seniors spend their Social Security subsidy more carefully, because they themselves keep the savings.

Medicare issues endless regulations that dictate prices and other terms for 1.2 billion health care transactions each year. It’s tempting to think this micromanagement is necessary because health care is special. Yet a steady stream of research shows this command-and-control approach leads to mispricing, rampant medical errors, unnecessary hospital readmissions, uncoordinated care and massive waste. It also blocks innovations, such as accountable care organizations, that would solve these problems.

If Social Security subsidized food the way Medicare subsidizes health care, seniors would dine out every night; they would go to a separate restaurant for each course; portions and waistlines would be enormous; everything would be overcooked; the bills would make your jaw drop; and tipping more than 9.25 percent would be illegal.

“Medicare gives very good health care very inefficiently,” says Sen. Chuck Schumer, D-NY. At least he’s half right.

Suppose that rather than send $574 billion to providers and insurers, Congress divvied it among Medicare’s 48.9 million enrollees and send each of them a check. The average enrollee would get $11,700 — more if they’re sick, poor or disabled.  Call it a “bundled payment to enrollees.”

Enrollees could use that cash to purchase medical care or any health insurance plan licensed by any state. Whatever they saved by being prudent shoppers, they could keep and pass to their kids and grandkids.

If 50 million high-end health care consumers suddenly started caring about every dime they spent, they would wring unnecessary services and administrative costs out of the health care sector.

One concern would be that these Social Security-like subsidies would not be large enough for enrollees to purchase decent coverage. The evidence shows they would.

First, they would come with a built-in margin of safety. The Dartmouth Atlas of Health Care estimates that 30 percent or more of Medicare spending is pure waste, meaning that enrollees Medicare checks would include what Medicare currently spends on worthwhile medical care, plus an additional 40-50 percent. That cushion would also protect against inadequate risk- and income-adjustments.

Second, 77 percent of enrollees have Medicare supplemental coverage that they purchase directly or through an employer.  That often amounts to thousands of dollars that they could use to supplement their Medicare check.

Third, these 50 million Medicare enrollees would demand cost-saving innovations — in the immortal words of George Costanza – “like an old man trying to send back soup at a deli.”

There’s a lot more to be said about why Congress should reform Medicare in the image of Social Security. But the most important reason may be that it is the only way to restrain Medicare spending while meeting the Democratic goal of preserving Medicare benefits. Again, Sen. Schumer: “there are savings to be wrought out of Medicare … [but] actual cuts in the benefits, are not something we would want to entertain.”

Cutting Medicare spending through a command-and-control approach, such as by reducing provider payments, may inadvertently eliminate access to services that enrollees really want.

If Congress wants to preserve what matters most to Medicare enrollees — you know, the people the program is supposed to serve — then there’s no better way than to give them the money and let them decide which benefits are most important.  Who better to judge what benefits seniors than seniors themselves? 

That’s how FDR subsidized them, anyway. 

Michael F. Cannon ( @mfcannon ) is director of health policy studies at the Cato Institute and coauthor of Healthy Competition: What’s Holding Back Health Care and How to Free It.

Health plan brings drug savings

www.kaiserhealthnews.org, June 29

CQ Healthbeat- HHS says nearly one-half million people have gotten doughnut hole relief, thanks to the automatic 50 percent discount on brand name medicines that kicked in when enrollees reach(ed) the coverage gap, officials at the Centers for Medicare and Medicare Service (has said). The 478,272 Medicare beneficiaries who would have had to pay the full cost of their prescription drugs after they and their insurance companies paid $2,810 for their medicines instead saved $260.5 million, or an average of $545 per beneficiary, in the first five months of 2011. (Bunis 6/29)

Hard to tell a difference

www.kaiserhealthnews.org

and The Washington Post

June 21, 2011

Unless you’re trained as a lawyer or Talmudic scholar it’s hard to see a practical, moral or constitutional distinction between Obamacare, requiring every American to buy health insurance, and Ryancare, requiring every American to pay a Medicare payroll tax, so they can buy health insurance from a regulated exchange at age 65. Both are individual mandates.  

Health policy reality check

By John E. McDonough, professor

Harvard School of Public Health

www.kaiserhealthnews.org, June 12, 2011

Let’s face it, this is a strange time in U.S. health policy. Over the past two years, beliefs and policies that united liberals and conservatives have been blown apart. Repair work is needed, and one place to start is by exploring blown assumptions. From a liberal perspective I offer these.

First, Medicare: Before the health reform debate, broad bipartisan agreement prevailed that the health system in general and Medicare in particular were loaded with waste and inefficiency, and that eliminating waste could help finance universal coverage. Then, during and after the brawl leading to passage of the Affordable Care Act, Republicans relentlessly attacked Democrats for cutting Medicare by $450 billion between 2010 and 2019 to help pay for the health overhaul. Never were these attacks more pitched than during the 2010 congressional campaigns.

Democrats’ defense was that most reductions had been negotiated with affected industries – $155 billion in hospital reductions as Exhibit A – to finance coverage expansions. The defense did not stick with the public, and the effectiveness of the Republican assault is credited as a key driver that helped them score huge gains in last November’s House and Senate elections.

Now, the budget plan advanced by Rep. Paul Ryan, R-Wis., and supported by all but nine Senate and House Republicans, proposes complete repeal of the health law with one exception, the $450 billion in Medicare savings. Ryan’s plan even maintains the measure’s cuts to their beloved Medicare Advantage private plans. It now seems Republicans did not mind cutting Medicare. They just objected to how the saved funds would be used – to cover the uninsured. This key element of the Ryan blueprint has been obscured by the raucous debate over his proposal for Medicare vouchers/premium support, though it demands explanation.

How do Republicans explain their current support for Medicare cuts to which they so strenuously and publicly objected in last fall’s elections and before?

Second, the individual mandate: Since its conception in the 1980s by conservative Wharton School economist Mark Pauly, the individual mandate has been associated with Republicans and conservatives, including the Heritage Foundation, Newt Gingrich and Republican former and current senators including Bob Dole from Kansas. John Chafee of Rhode Island, Iowa’s Chuck Grassley and Utah’s Orrin Hatch. Heck, even Sen. Jim DeMint, R-S.C., embraced it in 2007 when he backed former Massachusetts Gov. Mitt Romney’s presidential bid. The mandate has a long pedigree in Republican circles, and a very limited constituency among Democrats.

No wonder Romney thought he was on solid ground advancing it in Massachusetts in 2006. Well into 2009, there was little indication the mandate would be a divisive part of the health reform debate. The breaking point came during the town meetings held in August of that year as angry Tea Partiers transformed the political landscape. If there were an emblematic moment then, it was DeMint’s comment that defeat of health reform would be President Barack Obama’s “Waterloo.”

It prompts another question: What happened in conservative circles to the concept of individual responsibility? Third, health insurahce exchanges. Recently, speaking with state legislators, I took them to the website of the Massachusetts Health Insurance Connector Authority, and walked them through the process of signing up online for individual health insurance in about seven and a half minutes – about the time it takes to fill a car with gas. I suggested.

And that is the point worth noting, because I remember when it was illegal for me to gas up my car (still, is by the way, in New Jersey and Oregon). That is the essence of the exchange – to allow individuals and small businesses to pump their own insurance.

The exchange is a conservative, free-market idea – Stuart Butler from Heritage deserves most credit. Heritage gave the idea to Romney who loved it, as did Massachusetts Democrats, who changed the name to “Connector” to deny Romney naming rights. In the federal health reform process, Republicans insisted on state-based exchanges. House Democrats and the White House wanted one big federal exchange. The Senate sided with Republicans and, under the health law, states have right of first refusal with feds as back-up.

Now Republicans criticize exchanges as a federal take-over. Yet the real federal take-over happens only if a state refuses to act – precisely what some conservative governors, such as Louisiana’s Gov. Bobby Jindal, and some right-leaning legislatures want.

Why is this conservative, free-market idea now so anathema to Republicans?

Fourth, comparative effectiveness research and end-of-life counseling. I first read about the idea to establish a national CER entity in a Health Affairsarticle in 2005 by widely-respected Republican health policy thinker Gail Wilensky. In the June 2008 heath reform summit organized by Sens. Max Baucus, D-Mont., and Chuck Grassley, Grassley highlighted areas where he already saw consensus. CER was among them. When Republicans later demanded that CER efforts not examine costs, they got their wish.

During the Senate HELP Committee’s health reform mark-up in June and July 2009, Sen. Johnny Isaakson, R-Ga., first proposed adding end-of-life counseling to the legislation by proposing that people shouldn’t be able to enroll in Medicare without an advance directive. Sen. Barbara Mikulski, D-Me., convinced him to just pay physicians to counsel enrollees. Both issues morphed into the accusation that health reform would create “death panels” to decide, as Grassley later put it, “whether to pull the plug on granny.”

Where does the Republican/conservative health policy stand on comparative effectiveness research (now led by the Patient Centered Outcomes Research Institute) and voluntary end-of-life counseling? What happened to delivery system improvement?

Finally, universal coverage: Sen. Kay Bailey Hutchinson, R-Texas, often remarked: “Of course we all want universal health care . . . we all want everyone to have health insurance.” And, “We all agree, doing nothing is not an option.” Having been part of this strange health policy world since 1985, I always believed most Republicans wanted to improve the system and expand coverage, just along other pathways.

Part of the after-shock on the liberal/Democratic side is that this idea is no longer easy to believe. When the Republican House voted earlier this year to repeal the health law, their slogan was “repeal and replace.” Last month, House Ways and Means Chairman Dave Camp,R-Mich., admitted the House would offer no replacement.

To final questions: Do Republicans still believe in the goal of universal coverage? What is the basis for moving forward together from here? 

Political expediency and health care reform

By James C. Capretta, Fellow, Ethics and Public Policy Center

www.kaiserhealthnews.org, June 12, 2011

Once upon a time, President Barack Obama and many others who championed his health care plan actually professed faith in the power of a functioning health care marketplace. That now seems like a distant memory, given the demonization campaign that the president and his allies have launched against House Budget Committee Chairman Paul Ryan’s plan to inject consumer choice and competition into Medicare. But there’s no doubt that while the health law was under consideration in Congress, the president and his team wanted to leave the impression with voters that the plan they were pushing would rely mainly on market signals, not heavy-handed government control.

Recall the basics of the Obama reform, “Premium credits” (vouchers) are given to participants in the new state-based health care exchanges. These credits are set based on a reference plan offered in the exchanges, and they don’t vary based on the plans selected by participants (but do vary based on the household incomes of the participants). Does all this sound familiar?

Ironically, after a tortuous debate, Congress decided that the Obama premium credits could only be used by exchange participants to enroll in private health insurance plans (privatization). There’s no “public option” available (at least not officially). Moreover, the law imposes a requirement on citizens and legal residents to enroll in qualified coverage of some sort. So, without an explicit public option, the new law has effectively created a guaranteed pool of captive customers for profit-hungry, investor-owned and patient-abusing private plans.

Finally, the credits that are given to exchange participants won’t keep up in future years with the expected increases in premium costs. That’s right. The Obama “vouchers” are indexed in a way that will gradually push more premium costs onto the income exchange enrollees. For some reason, in all of the heat and fury over the Ryan Medicare blueprint, this feature of the Obama plan has been almost entirely overlooked by the media, with the notable exception of Jed Graham at Investor’s Business Daily.

It doesn’t help that the Obama indexing provision was written extremely carelessly, which has led the Congressional Budget Office and Health and Human Services actuaries to different interpretations. But no matter the interpretation, it’s clear that, if health care costs don’t moderate, the new law will end up pushing higher premium costs onto low-income exchange participants. CBO recently issued a report on this subject that shows that the premium increases for low-income households could easily reach 10 to 12 percent every year.

Meanwhile, now that their plan is law, the tune has changed. The enthusiasm for premium credits, consumer choice of private health plans and decoupling of credits from health costs seems to have waned. Indeed, it’s waned to such an extent that these are now not just bad ideas but ideas that would destroy America as we know it.

Moreover, those who previously stressed that the new health law would have a strong component of consumer choice and competition are now saying that a functioning marketplace will never work.

For instance, Peter Orszag, who played a key role in the law’s passage as Obama’s first budget director, now says consumer choice – a fundamental component of the Ryan Medicare reform plan – won’t control costs at all. He mischaracterizes the Ryan plan as nothing more than a scheme to increase copayments and deductibles on seniors, which will actually add to overall costs.

What’s going on here?

First, it should be clear that the attacks on the Ryan plan have taken Washington political hypocrisy to a new level, which is saying something.

Second, it’s clear that the Obama administration and its congressional allies – despite what they said during the debate over the health law – actually don’t believe in a functioning marketplace. What they do believe in is the capacity of the federal government to impose cost control.

And that brings us to the fundamental disagreement at the heart of the Medicare debate.

Both sides agree that the key to slowing the pace of rising costs is continuous improvement in the productivity and efficiency of the health care delivery system. But what will bring that about?

Orszag argues that the new health law can improve health care delivery, by using the levers of Medicare to push concepts like bundled payments, accountable care organizations and medical homes. But what evidence does he have that this will work? Medicare’s administrators have been trying for 40 years to build a higher value, lower cost network of care (remember “Centers of Excellence”?), without any success.

When push comes to shove, the program has been completely incapable of making real distinctions among providers of care based on quality and cost metrics. To hit budget targets, the solution has always been indiscriminate across-the-board payment-rate reductions that hit everyone equally, regardless of how well or badly they treat their patients. And the predictable consequence is a reduction in the willing suppliers of services.

Orszag says the Ryan plan won’t work because higher cost-sharing doesn’t change the delivery system. But that’s not an accurate description of the Ryan plan. Medicare beneficiaries will have strong financial incentives to sign up with plans that charge low premiums even as they deliver high value, and that means real delivery system reform. The fastest, surest way to get hospitals, physicians and clinics to reorganize their processes and achieve savings is by having engaged consumers in a position to reward market leaders who are the first to find ways to deliver more for less. That’s the Ryan plan.

When Ryan and his colleagues unveiled their budget plan in April, the president had a choice. He could work with his adversaries to find common ground on budget and health poslicy matters, or he could eschew bipartisan compromise and attempt to defeat them politically. He made his choice, and so the battle is on.

Medicaid stops paying for hospital mistakes

By Phil Galewitz, KHN Staff Writer, June 1, 2011

www.kaiserhealthnews.org

Medicaid will stop paying for about two dozen “never events” in hospitals, such as operations on the wrong body part and certain surgical-site infections, federal officials have said.

Currently, about 21 states have such a nonpayment policy. The 2010 federal health law, in effect, expands the ban nationwide. The rule gives states until July 2012 to implement it.

Medicaid is a joint state-federal program for the poor and disabled. Under the rule, Medicaid funds can’t be used to pay doctors and hospitals for services that “result from certain preventable health care-acquired illnesses or injuries,” the officials said.

A similar regulation has been in place for Medicare, the federal health program for the elderly, since 2008.

“These steps will encourage health professionals and hospitals to reduce preventable infections and eliminate medical errors,” said Donald Berwick, administrator of the Centers for Medicare and Medicaid Services. “As we reduce the frequency of these conditions, we will improve care for patients and bring down costs at the same time.”

Some physician groups have concerns about the new policy. “Simply not paying for complications or conditions, that, while extremely regrettable, are not entirely preventable, is a blunt approach that is not effective or wise for patients of the Medicare of Medicaid program,” Dr. Michael Maves, CEO of the American Medical Association, said in written comments to CMS in March.

He said the medical association has “grave concerns” about states extending the nonpayment policy beyond the conditions considered by Medicare. The American Hospital Association expressed similar reservations.

Responding to complaints from hospitals, CMS gave states additional time – until July 2012 – to implement the new policy.

Cindy Mann, deputy director of CMS and director of Medicaid, said the rule gives states the option to expand the nonpayment policy to health care settings besides hospitals and to add other types of “never events.”

She said the policy would help improve patient care and drive down costs in the $364 billion program. “All (health care) payers are looking to gain better value for the dollars they spend and Medicaid is no different,” she said.

But the cost savings from the change is relatively modest. According to the proposed rule, Medicaid would save about $35 million over the next five years from stopping pay for such medical mistakes. Medicare has saved about $20 million a year under its policy.

“It’s a welcome first step into the national debate on quality,” said Matt Salo, executive director of the National Association of Medical Directors. “Clearly many states have already moved ahead, although that should never be taken as rationale for forcing the rest of them to do . . . well, anything. But improving quality in a coordinated fashion between Medicare and Medicaid is important.”

This is a list of preventable conditions that Medicaid will no longer pay for:

* Foreign object removal after surgery

* Air embolism

* Blood incompatibility

* Stage III and IV pressure ulcers

* Falls and trauma: fractures, dislocations, intracranial injuries, crushing injuries, burns, electric shock

* Catheter-associated urinary tract infection (UTI)

* Vascular-associated UTI

* Vascular catheter-associated infection

* Manifestations of poor glycemic control; diabetic keratosis, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, secondary diabetes with hyperosmolarity

*Surgical infection following: coronary artery bypass graft -mediastiritius, bariatric surgery, laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrict surgery

* Orthopedic procedures: spine, neck, shoulder, elbow

* Deep vein thrombosis following total knee or hip replacement – with pediatric and obstetric exceptions

* Surgery on the wrong patient, wrong surgery on a patient and wrong site surgery. (Source: CMS)

 

Medicare forecast is gloomy

By Phil Galewitz and Mary Agnes Cary,

KHN Staff Writers, May 13, 2011

Medicare will start running out of money in 2024 – five years earlier than projected last year – as a result of the sluggish economic recovery, the program’s trustees (have reported).

The outlook for the federal health insurance program that covers 47.5 million elderly and disabled Americans is a dramatic shift from last summer. That’s when the trustees, including Treasury Secretary Timothy Geithner and HHS Secretary Kathleen Sebelius, proudly projected that the new health law had extended the solvency of the program by 12 years, from 2017 to 2029.

Medicare faces serious financial challenges over the next few decades as the aging population and rising costs push expenses higher while the employer and employee tax revenues that fund the health insurance program struggle to keep pace. Last year, the total cost of the program was $523 billion.

Swings in the predictions about the financial health of Medicare are common year-to-year. But the latest scorecard puts renewed pressure on the administration to find ways to improve the economy and make sure its experiments in the health law to lower health costs can actually work, said Deborah Chollet, a senior fellow with Mathematica, a nonpartisan research firm. “The general health of the economy is crucial” to the future of the Medicare fund, she said.

Even Geithner acknowledged that the health law won’t do enough on its own to control rising health costs – a commoon complaint of Republicans who have been pushing for repeal of the health overhaul. “We must go beyond the Affordable Care Act and identify additional reforms,” he said.

Sebelius said the new patient safety initiative, announced recently by administration officials, could save Medicare $10 billion over the next 10 years.

The trust fund covers Part A of the Medicare program, which pays for hospital costs. In 2010, payroll taxes that support the fund took in $182 billion, about $2.5 billion less than expected, and have fallen short each year since 2008.

Another factor hurting Medicare’s future solvency: The trustees estimate people who are 65 now will live 2.4 months longer than projected a year ago. While that’s good news for beneficiaries, it means higher costs for the program.

Social Security, which faces some of the same pressure, will remain solvent until 2036 – one year earlier than projected last year, program trustees said.

AARP Executive Vice President John Rother said lawmakers must look at more than just Medicare to find ways to reduce health care spending. “While provisions of the Affordable Care Act are helping to control spending in Medicare, far more must be done to reduce costs throughout the health care system and extend the Medicare trust fund for [hospitals] for the long term,” he said.

Some Republicans said that five fewer years of solvency for the Medicare trust fund demands that Congress take steps now to control spending. “Today’s report makes it clearer than ever that doing nothing is not an option,” House Ways and Means Chairman Dave Camp, R-Mich., and other panel subcommittee chairmen said in a statement. “The failure to act means current, as well as future beneficiaries, will face significant cuts even sooner than previously estimated.”

But Senate Finance Committee Chairman Max Baucus, D-Mont., had a different interpretation, saying the report shows that the health law’s provisions governing Medicare are necessary. “Health reform strengthened Medicare by cutting wasteful subsidies to private insurance companies and helping doctors save money by increasing coordination, and these improvements extended the life of the program by more than a decade,” Baucus said.

The report’s finding come as the parties are debating what role Medicare spending should play in reducing the federal deficit.

In last fall’s campaigns, Republicans accused Democrats of stripping hundreds of billions of dollars from the program to fund the health law’s subsidies for insurance coverage and Medicaid expansion. president Barack Obama and Democrats returned the favor last month when House Budget committee Chairman Paul Ryan, R-Wis., unveiled his plan to reduce the federal deficit, in part by converting Medicare to a “premium support” program where the government would pay a set amount per beneficiary.

Obama and Democrats, citing an analysis from the nonpartisan Congressional Budget Office, said the Ryan plan would force seniors to pay more for their medical care. Last week, House Republican leaders backed away, suggesting sweeping changes like the Ryan proposal won’t become law this year. This week the message shifted again, with House Speaker John Boehner, R-Ohio, and Senate Minority Leader Mitch McConnell, R-Ky., insisting that Medicare changes must be part of the negotiations over raising the federal debt ceiling.

Separately, the administration has also released a state-by-state analysis about how the health law is benefiting Medicare recipients. Health care providers who took payment cuts in the law in exchange for new customers are sure to rebel against further reductions.

And with the 2012 elections just 18 months away, Democrats and Republicans may be reluctant to strike a deal on Medicare, preferring instead to make each party’s plans for the program a central focus of campaigns where control of the White House and congress are at stake, pointing to 2013 as the year for a deficit deal.

Medicare to pay hospitals for patient satisfaction

By Jordan Rau, KHN Staff  Writer, April 28, 2011

In collaboration with The Washington Post

Thought your hospital room was dirty? Did your nurse sometimes ignore you? If so, the hospital has a new reason to worry: Patient gripes will soon affect how much hospitals get paid by Medicare.

The Centers for Medicare & Medicaid Services is finalizing details for the new reimbursement method, required by last year’s health care law. Consumer advocates say tying patient opinions to payments will result in better care. But many hospital officials are wary, arguing the scores don’t necessarily reflect the quality of the care and are influenced by factors beyond their control.

Medicare has been publishing patient satisfaction scores on its Hospital Compare website since 2008, but hasn’t used them to adjust payments. Under CMS’s “value-based purchasing” proposal, Medicare will begin withholding one percent of its payments to hospitals starting in October 2012. That money – $850 million in the first year – will go into a pool to be doled out as bonuses to hospitals that score above average on several measures. The agency’s final rule is due out soon.

Partly linking payments to patient satisfaction may hurt hospitals in regions where patients tend to render less-than-glowing judgments, including the District of Columbia, Maryland, New Jersey and Hawaii. The District and New York state rank at the bottom, 59 percent of patients in both places give their hospital experiences a top rating, lower than anywhere else except the Virgin Islands. Nationally, an average of 67 percent of patients give their hospitals a top rating.

CMS says more than 3,000 hospitals will be affected. Under the proposal, patient scores would determine 30 percent of the bonuses, while clinical measures for basic quality care would set the rest. Hospitals argue the scores should have less weight, but nevertheless are trying to fiture out how to improve their rankings.

“These are hard scores to imrpove, and I think that’s why hospitals get frustrated,” says Dale Shailer, a Minnesota health care researcher who oversees the national patients survey database for the federal government.

No one is sure why hospitals in some regions fare more poorly than those in other parts. One theory: Hospitals in these regions treat lots of patients with multiple ailments, which is associated with worse reviews. CMS says it adjusts its ratings to take that into account. Teaching hospitals and other large hospitals also get worse patient evaluations than do small community hospitals, somc research shows, but CMS doesn’t factor it in.

Hard-to-measure cultural factors also may play a role. Northeasterners, for example, may be harder to please than Midwesterners and Southerners. Hospitals in South Dakota, Nebraska, Louisiana and Iowa are at the top of hospital patient reviews, according to Patient Compare.

“Someone said, “Well, people from the East Coast are just grumpier,’” says Edward Goodman, an executive at VHA Inc., a national alliance of nonprofit hospitals. “In some cultures praise is not as predominant.”

Hospitals conduct the surveys of recently discharged people, including those too young to be on Medicare. Questions include whether nurses and doctors always communicated well, whether the patients always received help as soon as they wanted, whether their pain was always well-controlled, whether their rooms and bathrooms were clean, whether they got explanations about medications and whether they got directions on what to do after leaving the hospital.

The District of Columbia’s hospitals lag on many of the specific questions. For instance, about two-thirds of recently discharged patients at George Washington University Hospital reported nurses always communicated well. That was 10 percentage points above the national average. At United Medical Center in Southeast, 64 percent of patients said they were given instructions on what to do after leaving the hospital, 18 points below average.

Chris Jordan, director of quality management at George Washington Hospital, says his hospital has been improving its patient ratings this year. “I can guarantee you that we’ll get better,” he says.

Some Maryland hospitals also have some lower-than-average scores. At Shady Grove Adventist Hospital in Rockville, 39 percent of patients said they always received help as soon as they wanted; 25 points below average. At Laurel Regional Hospital, 55 percent of patients said their rooms and bathrooms were always clean, 16 points below average.

“We’re not where we ought to be,” says Dennis Hansen, Shady Gorve’s president. To improve satisfaction, nurses now check in with patients every hour.

Academic medical centers often fall short of perfection because their patients need multiple medications and see lots of specialists, leaving more room for oversights, says Paul Cleary, dean of the Yale School of Public Health. In New York City, three nationally-known teaching hospitals – Beth Israel Medical Center,NYU Lagone Medical Center and Mount Sinai Medical Center – scored below average. Even New York-Presbyterian Hospital, which did better than average on its overall rating, still scored below average on specific questions.

“Because we have such cultural diversity, such literacy variability and such large and very complex hospitals, for us to always hit it out of the park is very difficult,” says Jaclyn Mucaria, a senior vice president at New York-Presbyterian. “There’s another theory, that we New Yorkers are very hard to please, whether it’s in a hotel or a restaurant or a hospital. For somebody to really rave about something is an anomaly.”

While many hospitals have been uneasy with the surveys, they’re stepping up on the scrutiny about their visibility. Dr. James Merlino, chief experience officer of the Cleveland Clinic, which scores below average on seven of nine key patient-satisfaction questions, says doctors and nurses have done their own studies and concluded that very sick and depressed patients give skewed views. For instance, severely ill patients are less likely to report that nurses check in on them every hour – even when logs prove they did, he says.

“Focusing on patient satisfaction is the right thing to do, but it’s also necessary we pick the right metrics and we hold hospitals accountable for things within their control,” Merlino says. “I don’t think we should hold hospitals accountable for patient perceptions.”

But low patient ratings often spring from real shortcomings, says Jodie Cunningham, director of public reporting at Pines Ganey, an Indiana-based company that administers the surveys for more than half the nation’s hospitals. She says poor ratings can be caused by bad employee morale or bed shortages that force patients to remain in emergency rooms for hours before being admitted.

“If your nurses are not getting along well with the physicians, it definitely shows in lower scores,” says Cunningham.

Consumer advocates, who want CMS to give even greater weight to the patient views, say the payment changes, even if imperfect, will spur improvement.

“There’s always resistance to change,” says Debra Ness, president of the National Partnership for Women & Families, a Washington nonprofit. “If we go at the rate many providers would like us to go, we’ll be having the same conversation in 10 years.” 

 

Few seniors support new plan

By Phil Galewitz, KHN Staff Writer, April 27, 2011

www.kaiserhealthnews.org

Senior citizens, whose fierce opposition to the 2010 health overhaul law helped propel Republicans’ midtern election gains, have little appetite for the House GOP’s plans to turn Medicare into a voucher-type program that sends beneficiaries to private plans but limits the amount of federal funding, according to a poll recently released.

The survey this month by the Kaiser Family Foundation found that just 30 percent of seniors supported the idea of restructuring Medicare into a system where seniors are given government subsidies to shop for private coverage. In contrast, 62 percent of seniors said they wanted Medicare to be left alone with the program continuing to guarantee the same benefits to all enrollees.

Overall, the poll found Americans evenly divided on dramatically changing Medicare, part of a Republican plan to reduce the federal deficit. Fifty percent of respondents say they wanted Medicare to remain as it is while 46 percent said it should be changed.

Respondents were split along party lines with 63 percent of Democrats in favor of maintaining the current Medicare system compared to 41 percent of Republicans. Independents were evenly split.

Among Republicans, about 55 percent favored the Medicare overhaul proposed by House Budget Chairman Paul Ryan, R-Wis., compared to 34 percent among Democrats.

Democrats have been pounding Republicans’ plan to change Medicare since Ryan released his pan earlier this month. Democrats say the plan would lead to seniors paying more for their health coverage, and President Barack Obama has said he opposed turning Medicare into a voucher program and instead, favors strengthening a provision in the health law to slow the increase in Medicare costs.

Republicans have said any changes would be phased in gradually so they would not affect people who today are 55 and over.

The nationwide (Kaiser Foundation) telephone survey of 1,207 adults was conducted between April 7 and April 12, shortly after Ryan released his plan but before Obama’s April 13 speech about his deficit proposal. (KHN is a program of Kaiser Foundation.) 

The Kaiser poll, which is the latest survey to find most Americans divided on the Medicare revamp, found most respondents don’t understand the terms “voucher” or “premium support” that are at the heart of the Republicans’ plan. The survey also suggested their opinions could be easily swayed.

For example, when the survey told those initially opposed to changing Medicare that a voucher system would help reduce the deficit and let seniors choose plans based on cost and quality, support rose from 46 percent to 54 percent. Conversely, when initial supporters of a voucher system were told changing Medicare would put private insurers in charge of their benefits and cause seniors to pay more or get fewer benefits, preference for keeping Medicare rose from 50 percent to 68 percent.

Results from other polls have varied widely on the public’s support for Ryan’s Medicare proposal, with findings suggesting that support for keeping the traditional Medicare ranges from 39 to 84 percent of the country. Those differences appear to reflect both the timing of the surveys and the wording of the questions.

In addition to the Kaiser survey, a Gallup/USA Today poll released recently found seniors were the age group most receptive to Ryan’s plan. In that poll, 48 percent of seniors support Ryan’s plan over Obama’s plan, while 42 percent back the president. Overall, the poll found 43 percent of adults favor the Ryan plan.

The Gallup poll asked respondents if they favored the Ryan plan or the Democratic plan. The Kaiser poll asked if Medicare should be left alone or changed to a system in which people choose their insurance from a list of private health plans that may offer different benefits and the government pays a fixed amount toward the cost.

The monthly Kaiser survey again showed Americans evenly divided over the health law, although there was a slight decline in people who opposed it and an uptick in people who don’t have an opinion. It also found the seniors’ views remained steady with 31 percent favoring the health law, compared with 41 percent support among all adults.

The margin of error on the Kaiser survey was +/- 3 percentage points. 

Church groups cover medical costs

By Michelle Andrews

KHN, April 25

www.kaiserhealthnews.org

When Jase and Jennie Stefanski needed to pay a midwife her $5,000 fee for delivering their sixth child 10 months ago, the money came from an unlikely source: people who are members, like them, of a Christian nonprofit group called Samaritan Ministries. In dribs and drabs, the checks arrived, most between $135 and $320, many with personal notes attached congratulating the family.

The Stefanskis don’t have health insurance. Instead, they belong to a “health-care sharing ministry” whose members follow Biblical teachings that they share each other’s burdens – in this case, their medical costs. Each member pays a monthly fee that varies with family size. Single members generally pay $135, couples $270, single-parent families $200 and two-parent families $320. Members pay the first $300 for any medical expense they incur; when they  have bills – or “needs,” as they call them – above that amount, they send them to the ministry’s Peoria, Ill. offices.

The ministry keeps track of the needs, informing other members where to send their monthly check, and letting those who have made requests know what checks to expect.

If there’s a shortfall one month – the last one at Samaritan was a little over a year ago – every household seeking help gets a prorated portion of its needs covered, and the ministry asks members for voluntary contributions to make up the difference. If the shortfall continues, members vote on raising the share amount.

With 56,000 members, Samaritan is the largest such ministry in the country. Two other major ministries operate slightly differently – pooling members’ money and sending checks out from the ministry – bringing the total number of people who are sharing their medical costs to roughly 120,000.

Health-care sharing ministries aren’t for everyone. In general, members must be practicing Christians – attested to by their pastor in some cases – and abstain from tobacco and illegal drug use. They must agree not to have sex outside marriage – and typically cannot seek help for any medical expenses that arise  from such sexual activity.

Rules vary about when or if the ministries cover pre-existing medical conditions.

Although the ministries say that they’re not providing health insurance and are therefore exempt from state insurance regulations, states sometimes beg to differ. Concerned that members may believe such ministries guarantee coverage of their medical bills, regulators have at times tried to shut them down.

“They’ve made a commitment to what is effectively health insurance, that when you need to have your medical bills paid they’ll help or will pay those costs for you,” said Mike Kreidler, Washington state’s insurance commissioner.

Earlier this month, Kreidler’s department issued a cease-and-desist order to Samaritan. Nonetheless, Kreidler says he believes Samaritan is an “upfront group” and notes that no complaints have been filed with his office against them.

But within days of Kreidler’s order, the legislature passed an amendment to an existing bill exempting health-care sharing ministries from state insurance regulations. The bill is on the governor’s desk.

This month’s action was the first against Samaritan Ministries, which operates in all 50 states, as does Christian Healthcare Ministries, which reports having 25,000 to 30,000 members in Illinois, according to the Pew Charitable Trust’s Center on the States. The group says it has 40,000 members.

Washington state’s Kreidler says he is concerned that the legislature’s action may encourage groups that aren’t legitimate to take consumers’ money and scam them. “What I’m afraid of . . . is that you open the door to a Ponzi-type scheme and illegal activity from which we have no authority to step in and protect consumers,” he says.

One of the most important responsibilities of an insurance regulator is to make sure insurers have enough money to pay claims, says Sandy Praeger, the Kansas state insurance commissioner. “We monitor their solvency,” she says. “And as a company builds up its book of business, they have to build up their reserves.”

Such concerns don’t trouble Jase Stefanski, whose family lives near Vancouver, Wash. “It’s not insurance, I know,,” he says. “It’s on my risk.”

Stefanski says he likes the connection with other Christians that Samaritan offers. In addition, it’s a much more affordable option than the $1,050 a month he was paying for private insurance.

Eleven states have laws that specifically exempt health-care sharing ministries from state insurance regulation.

The federal health-care overhaul adopted by Congress last year also recognizes ministries that share health care expenses as part of their religious practice. The law exempts members of such ministries from the penalty that will be levied against individuals who don’t purchase health insurance starting in 2014, a fact which all three of the major ministries highlight to varying degrees on their Web sites.

James Lansberry, Samaritan executive vice president, says membership growth stalled while health care reform was being debated, and people were uncertain how health care sharing ministries would be affected. “We’re seeing a little higher growth now,” he says, although he doesn’t expect a huge influx of new members.

Only long-standing ministries are affected by the new law’s exemption clause because it limits recognition to organizations that have 501(c)(3) tax-exempt status and have shared medical expenses continuously since at least Dec. 31, 1999. They must also be audited annually by an outside accounting firm.

But these criteria won’t necessarily stop scammers from creating fake ministries and soliciting members, said Praeger. “You have to look at the fine print to see whether it’s truly one of these [religious] programs or is it someone tryng to take advantage of that,” she says. “I think we’ll see more of that because of the exemption in the Affordable Care Act.”

Generic drug prescriptions increase

KHN, April 21 (www.kaiserhealthnews.org)

NPR’s Shots Blog – The brand-name pharmaceutical industry has a drug problem. All 10 of the most prescribed medicines in the United States last year were generics, led by the defending champion generic equivalents of Vicodin (hydrocodone plus acetaminophen) . . . Big Pharma’s losses have meant savings for consumers, insurers and employers that pay for health coverage. The average copayment fell 20 cents to $10.73 last year compared with 2009. The biggest factor in the decline was greater use of generics, which typically require the lowest copayment from consumers. (Hensley, 4/20)

Fix the CLASS Act, don’t repeal it

By Howard Gleckman, senior research associate, Urban Institute

KHN, April 6

www.kaiserhealthnews.org

If it survives, the Community Living Assistance Services and Supports (CLASS) Act would, for the first time, create a national, voluntary long-term care insurance program to help pay for personal care for the frail elderly and younger adults with disabilities. It is a modest first step toward turning long-term care from an unsustainable and inappropriate welfare program into an insurance-based system.

But congressional critics want to kill CLASS long before the first policy is ever sold. Rep. Phil Gingery, R-Ga., who has sponsored legislation to repeal the program, calls it “a Bernie Madoff fraudulent investment scheme run by the Secretary of Health and Human Services.” And the House GOP leadership’s 2012 budget proposal released April 5, would eliminate CLASS, along with much of the rest of the 2010 health law.

Overheated rhetoric aside, critics have two substantive objections to their obscure health law measure. They are offended that, under the conventions of budget accounting, CLASS premiums are counted as revenues that help “pay for” health reform. And they fear that if the program fails as self-funded insurance, it eventually will be bailed out with general tax revenues.

Their concerns are important, and there is no doubt the program needs to be significantly revised if it is to have any chance of success. But without CLASS, or something like it, millions of disabled adults, frail seniors and their families will be left with only Medicaid’s tattered safety net to support their personal care needs.

That’s why CLASS should be revamped, not repealed.

If CLASS is murdered in its crib, many families will have no resources to pay for long-term care services. Fewer than half of us will have sufficient savings. Most retirement nest eggs will fall far short of what we’ll need for nursing home care that costs more than $200 a day or home health aids who cost $20 per hour. Even fewer of us – about 7 million Americans – have private long-term care insurance.

As a result, many of the 10 million Americans who need long-term care will go broke paying out-of-pocket and then turn to Medicaid, a woefully underfunded entitlement program that pays for nearly half of all long-term services. The joint federal-state program spends one-third of its funds – more than $110 billion annually – on both home-based and nursing facility personal care.

But Medicaid is busting both the federal and state budgets, and many states are slashing already-skimpy benefits.

CLASS could be an alternative. It would provide an average minimum benefit of $50 per day for life – in cash. This feature would let families decide how to structure care, a vast improvement over Medicaid that too often forces the frail elderly into nursing homes.

Unfortunately, as designed, CLASS will be unaffordable for the vast majority of potential buyers, with average monthly premiums well in excess of $100. HHS Secretary Kathleen Sebellius vows to fix the program’s many flaws. And while the repairs she has suggested don’t go nearly far enough, she is on the right track.

Here are a few ways to make CLASS more attractive to buyers:

- Narrow the focus. Today CLASS attempts to achieve two goals at once. It tries to provide a personal care benefit for working people with disabilities and, at the same time, sell insurance to healthy people looking to hedge against the risk of needing assistance sometime in the future. The result: those who buy insurance will end up subsidizing those with disabilities. That will drive up premiums and discourage healthy people from participating. CLASS needs to be an insurance program only. Congress should make personal assistance benefits available to working people with disabilities – but not through CLASS.

- Second, encourage employers to include this insurance in their employee benefit plans. CLASS will succeed only with robust enrollment, but people must be nudged to participate. That will only happen if employers offer policies to their workers.

- Third, start premiums low, but gradually increase them as people age. This structure will make policies far more attractive to younger buyers.

- Finally, Congress should create an independent insurance fund to collect and invest CLASS premiums. This would assure participants that they are buying real insurance and not just exchanging their premium dollars for Government IOUs.

Someday, perhaps, the U.S. will join nearly every other major developed nation in the world and create a universal long-term care insurance system funded by some mix of taxes and premiums. Coverage could be provided by private insurers – just as the Medicare Part D drug benefit is today – or it could be run by the government. Monthly premiums for a universal CLASS-like program could average as little as $40. And such a program could cut Medicaid long-term care costs in half – by as much as $60 billion.

Given our current anti-government, anti-tax climate. Congress won’t pass a unversal long-term care insurance program any time soon. But as 7 million baby boomers age, the nation’s care needs will only grow. Two out of three seniors and many younger people with disabilities will need some personal assistance before they die. They won’t be able to count on a crumbling Medicaid program, and they have not saved. Insuring against this risk makes perfect sense. And CLASS, for all its flaws, is a step in that direction. It deserves a chance.

By Howard Gleckman

Proposals could shift costs to beneficiaries

By Mary Agnes Carey, KHN Staff Writer, April 3

www.kaiserhealthnews.org

Amid the buzz about a possible government shutdown over this year’s budget looms a more difficult question: What to do about entitlement programs, especially Medicare?

Politicians of all stripes have been decrying the nation’s soaring debt and say that taming entitlements is crucial to curbing spending. So far, President Barack Obama hasn’t proposed big changes. But some Republican leaders have called for a major overhaul of Medicare, a $520 billion program that covers nearly 47 million older and disabled Americans. Given the political peril involved in tampering with Medicare, the question is: How serious are the Republicans?

The answer: Pretty serious.

This week, House Budget Committee Chairman Paul Ryan of Wisconsin unveils his proposed budget for 2012. In an appearance on Fox News Sunday, Ryan refused to give the final details of his proposal but said he would dramatically slow the growth rate of Medicare by adopting a fundamental change called “premium support.” Ryan also said he would propose turning Medicaid, the state-federal program for the poor, into a block grant program. Altogether, he said, his budget would save more than $4 billion over 10 years.

House Majority Leader Eric Cantor, R-Va., said last week: “Most of us, 54 and younger, are not going to be able to enjoy the same type of programs that are in existence now.”

With a presidential election coming up next year, some observers say it’s unlikely anything big will happen involving entitlements before 2013, at the earliest, but that won’t stop the debate. Here is a guide to some of the ideas being discussed, especially in Republican circles, on changing Medicare.

Raising the Eligibility Age: The age for full Social Security benefits is now 66 and will reach 67 in 2027. Some analysts – including Ryan and Alice Rivlin, who was budget director for President Bill Clinton – argue that it makes sense to slowly raise the Medicare eligibility age from 65 to 67. People are living longer and retiring later so they don’t need Medicare as early as their parents did, they say.

How Much Would It Save? According to an analysis by the Congressional Budget Office, gradually increasing the Medicare eligibility age would save the federal government $125 billion over the next decade.

The Gain:People who are still worki;ng at 65 and get health insurance at work could stay on their employers’ plans for another two years, thus slowing Medicare spending. Assuming the health law survives, people without job-related insurance would have more alternatives than they do now. They could buy coverage – even if they are sick – on the new exchanges being seet up under the health law and may qualify for subsidies to help purchase insurance. Or, if they are lower income, they might be eligible for Medicaid, the state-federal program for the poor that will be expanded sharply in 2014. A gradual phase-in of the higher age requirement means that current beneficiaries and those near retirement would not be affected. “The impact of that takes a long time to hit,” said Joe Antos of the conservative American Enterprise Institute.

The Pain:Health care costs that are now borne by Medicare for people 65 and 66 would be shifted to individuals, employers and states, according to a new report by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.) If the health care law were repealed, some people without employer insurance might not be able to afford coverage or get insurance at any price, especially if they had pre-existing conditions. These people might delay needed treatments, which could eventually increase Medicare’s cost to treat them.

“More Skin In The Game”: Republicans, and some Democrats, have long thought that spending could be slowed if patients, including Medicare beneficiaries, had “more skin in the game” – in other words, put up more of their own money for health services. Some have suggested raising seniors’ share of the Medicare Part B premium (which covers doctor visits and other outpatient services) from 25 percent to 35 percent and imposing co-payments for home health services or the first 20 days of a skilled nursing facility.

How Much Would It Save? The home health co-payment would save $40 billion over the next decade for the federal government, the skilled nursing co-pay would save $21.3 billion, according to the CBO. Increasing the beneficiary’s share of Part B would save $241 billion over 10 years.

The Gain: Raising beneficiaries’ share of Part B premiums would bring the program closer to its original 50-50 split between the federal government and beneficiaries, proponents say. And greater cost-sharing for services would discourage overuse of care, they add.

The Pain: Opponents say beneficiaries already spend a big chunk of their incomes on medical care. In 2006, one in four spent 30 percent or more of their incomes on health expenses, one in 10 spent more than half, according to the Kaiser Family Foundation.

Requiring seniors to pay more could discourage people from getting needed medical care. “When you think about this population, which is sicker and uses health care more, what does it mean that they have to pay more and are living on a fixed income?” said Vicki Gottlich, senior policy attorney with the nonprofit Center for Medicare Advoacy.

Medicare Vouchers Or Premium Support: Rep. Ryan, in a blueprint for entitlement overhaul he wrote in 2008 and continues to update, calls for a sharp, fundamental change. Transforming Medicare into a voucher program for future beneficiaries, starting with people who are now 54 and younger. Instead of being entitled to a specific package of benefits, beneficiaries would be given a voucher to spend on private insurance.

On Fox, however, he said he would instead propose a “premium support” plan to overhaul the seniors’ program. Ryan says that under that proposal, beneficiaries would choose Medicare coverage they like and the government would pay a specific percentage toward the premium. The beneficiary would be responsible for the rest.

In his comments, Ryan drew a sharp distinction between vouchers and premiums support. There are technical differences. For example, vouchers tend to be a specific dollar amount with growth pegged to an inflation gauge or the growth in the economy plus one percentage point. Under premium support, enrollees would likely get a certain percentage of their premiums covered by the government. But how different the two approaches are depends on how they are designed. They are both geared toward curbing government spending.

How Much Would It Save? Although CBO says Ryan’s earlier Medicare proposal would reduce federal spending, it has not estimated a specific dollar amount.

The Gains:Ryan has said that switching to vouchers would give Medicare financial stability. His goal would be the same with premium support. The voucher idea has also gained the backing of Rivlin, who is now a senior fellow at the Brookings Institution.

The Pain:Critics see danger ahead. Most voucher proposals peg the growth in value of the voucher to general inflation of economic gorwth. But the cost of Medicare benefits is likely to be higher. That raises concerns that costs will slowly be shifted to beneficiaries. Some health analysts say the same could occur under a premium support model, depending on how it’s designed. Ryan says, under his plan, wealthy beneficiaries would pay more for Medicare than less-affluent seniors.

Changing Medicare’s Deductible and Medgap Coverage:Medicare charges beneficiaries separate deductibles for their hospital care (Part A) and for outpatient and physician services (Part B). This year, in Part A, beneficiaries pay $1,132 for each hospital stay, and enrollees also pay daily co-payments for extended hospital and skilled nursing care. For Medicare Part B, the annual deductible this year is $162. Nearly one in five beneficiaries in Medicare’s fee-for-service program have supplemental insurance known known as Medigap coverage to help with those costs.

Some proposals, including one advanced by the president’s deficit panel chaired by former GOP Sen. Alan Simpson, and former Clinton chief of Staff Erskine Bowles, have suggested combining the Part A and B deductibles into one $550 yearly deductible. That could reduce beneficiaries’ costs for hospital care but be more expensive for seniors who mostly use Part B. In addition, some proposals suggest a 10-20 percent co-payment for all services until beneficiaries reach a catastrophic limit. Others argue for making that $550 deductible ineligible for Medigap coverage so that beneficiaries are responsible for covering the cost of those initial services.

How Much Would It Save?Instituting the change in deductibles, co-pays and Medigap rules would save about $93 billion over the next decade, CBO estimates.

The Gain:Medicare would save money, but not just because beneficiaries were putting up more of their own. If Medigap plans were less generous, analysts believe beneficiaries would be more careful about spending and that could help lower Medicare costs.

The Pain: Once again, the proposal would shift costs to individuals.

 

Feel good reasons for health reform

By John E. McDonough, Professor

Harvard School of Public health

www.kaiserhealthnews.org

Supporters of the Affordable Care Act tend to get gloomy about the threats haunting every step along its path to implementation, seeing the negatives more clearly than they perceive the positives. As an antidote, I offer 10 reasons to feel optimistic about health reform’s progress and prospects.

1. A lot of Americans are being helped by reform every day. Who? Four and a half million early retirees, 3.2 million seniors protected from the doughnut hole and 2 million more kids in Medicaid and CHIP, plus the uncounted millions who now have coverage of clinical preventive services. The many families that can keep adult children up to age 26 on their health plans, the consumers now protected by the prohibition of recissions and many, many more. If these benefits are not recognized adequately by those receiving them, just wait until there is a genuine threat to eliminate them.

2. Because of the health law, a wave of innovation is now energizing the U.S. health system – driving the most vibrant reform atmosphere ever. Affordable care organizations, medical homes, disease prevention and wellness initiatives; anti-fraud and abuse effort, insurance exchanges – these are all part of the series of dynamic change processes triggered by the overhaul. Even in terms of health care workforce reform, despite a congressional stalemate that is stalling the launch of the new Workforce Commission, the field is exploding with activity, according to George Thibault, president of the Josiah Macy Foundation, which focuses on workforce innovation. Contrast the dynamics with the funk following the 1994 collapse of the Clinton Health Plan.

3. The Obama adminstration has managed successfully the development of a lengthy list of complex and politicaly-charged regulations to implement the law. Each process faced a chorus of critics predicting negative outcomes. Instead, skilled professionals at the Departments of Health and Human Services, Treasury and Labor, as well as the White House, mastered each controversy, worked through the minefields and established the parameters of the new health care marketplace that puts consumers and patients first.

4. The administration has demonstrated how flexibility can show strength, not weakness. Waiver approvals involving medical loss ratios and annual limits have been dissed by critics. Yet one can easily imagine their opposite complaints of rigidity had the administration denied any waivers. The key date is 2014, not 2011, and the Obama team has kept its eyes on that goal. President Barack Obama’s embrace of state experimentation is another welcome sign that strengthens rather than undermines the measure’s future.

5. As the dust settles, the constitutional challenges seeem a lot less scary. The scorecard of major decisions is 3-2 in favor of the individual mandate. Charles Fried, Ronald Reagan’s solicitor general, told a Senate panel, “The health care law’s enemies have no ally in the Constitution.” Increasingly it is clear that a decision based on the law will uphold the ACA’s most controversial provision, and a ruling based on politics will go the other way. And if the mandate goes down, there are other approaches at hand.

6. All key stakeholders are all sticking with the law. No observable erosion in support has occurred among hospitals, physicians, pharmaceutical/biotech/medical device companies, labor groups or consumers. In January, House Republicans predicted substantial desertions by House Democrats, and wound up with only three Democratic votes for their repeal effort. The only visible chink is on the other side of the debate – the business community’s evident noninterest in hyping repeal. In state after state, the hard work of implementation is moving forward.

7. An improving economy will help. In 1988, Massachusetts passed a major health reform law, which preceded a major economic downturn by months. The ensuing collapse destroyed any chance for implementation. Conversely, had the Clinton health reform plan passed in 1994 while the national economy was still crawling out of a downturn, implementation in the mid-to-late-1990s would have been much easier than that early Massachusetts experience because the nation was experiencing an economic boom. The best time to pass major health reform legislation is near the bottom of an economic downturn, with implementation happening when the economy is back on track. And that is how it will play out this time around for the health law.

8. The federal deficit is a growing advantage. When the overhaul was signed in 2010, the Congressional Budget Office estimated $143 billion in 10-year deficit reduction – from 2010 to 2019 – because of the law. In February, the CBO updated its 10-year deficit reduction estimate – spanning 2012 to 2021 – to $210 billion. That number will grow year-by-year as the measure’s savings and revenues take full effect, making repeal harder and harder.

9. Public opinion is sharply against total repeal, with only 21 percent support, according to the March Kaiser Family Foundation tracking poll. (Kaiser Health News is a program of the foundation.) Overall numbers in public support are still sharply divided – 46 percent unfavorable to 42 percent favorable. Yet on all key elements of reform, except for the mandate, the public supports the law and opposes repeal.

10. The msot devastating blow for implementation would be election of a president who supports the health law’s repeal. Though it is a long way to November 2012, the odds-on favorite now (see Intrade at 64.0 percent – 3/31/11) is the one candidate who supports full and effective implementation of the reform measure.

Can we get through the most challenging implementation of a federal law since the civil rights laws of the 1960s? Yes, we can.

Spending less not always good

By Jonathan Cohn

Senior Editor of The New Republic

March 30

A Collaboration between KHN and The New Republic

www.kaiserhealthnews.org

Conservatives think traditional health insurance provides too much financial protection from medical expenses. They also think that the Affordable Care Act will make this situation worse. That’s one reason they want to repeal it.

The problem, according to the conservatives is that insurance dulls the average person’s consumer instincts. When medical care is cheap or free, people don’t bother to shop around for the best prices – and they don’t think twice before seeing the doctor. In other words, they end up with too much care at too high a price. Insurance and government programs spread that cost around, so that eventually all of us end up paying more in the form of higher premiums or taxes over which we have little individual control.

The solution, as this argument goes, is to redesign insurance so that it forces people to pay more out-of-pocket expenses. And, within reason, it’s not a bad idea. Most economists, even those on the left, would agree that excessive coverage leads to higher health care spending.

But redesigning insurance in a way that actually lowers spending, and, by the way, promotes good health, is a lot more complicated than merely giving people “more skin in the game,” as conservatives like to put it. A new study by researchers affiliated with the Rand Corporation, suggests why.

The study, published in the American Journal of Managed Care, compares trends in medical spending by two groups of people – one group with traditional insurance and one with newly-purchased high-deductible coverage. It appears to be the largest study of its kind, and the three authors did their best to adjust for factors like age, occupation and underlying medical conditions. The result? People with high-deductible plans spent substantially less on their medical care.

That’s good news. Or is it? Giving people more skin in the game has distributional consequences. It shifts the burden of medical expenses onto those people with the most serious medical problems, which is, arguably, what insurance is designed to prevent. In addition, discriminating medical consumers are not always intelligent medical consumers. People may decide to skimp on useful medical care rather than the superfluous kind.

Sure enough, that seems to be what happened in the Rand study. In families with high-deductible plans, kids were less likely to get immunizations and adults were less likely to get cancer screenings. Not only did this seem to jeopardize the beneficiaries’ health, it also called into question the cost savings. After all, as the authors pointed out, it was possible the failure to get preventive care in the first year would lead to bigger, more expensive medical problems down the road.

This was not a surprising finding. The original, gold-standard study on high-deductible insurance, also from Rand, found that people couldn’t discern between useful and unnecessary care. More recent studies have suggested that higher co-payments on prescription drugs discouraged seniors from taking medication to control high blood pressure.

What makes this latest examination particularly arresting is that the high-deductible plans involved in the study actually made special exceptions for preventive care, effectively making it free. So why did patients skimp on that care anyway? One possible explanation is that people with higher cost-sharing plans were confused about what their plans covered. Another is that, because of the associated costs, they avoided regular physician visits, which would have been the impetus for the preventive care they needed. “These services are often initiated when you go to the doctor,” says co-author Neeraj Sood, who is a professor at the University of Southern California’s Schaeffer Center on Health Care Policy and Economics. “It’s possible you didn’t go to the doctor because of the high-deductible policy.”

This doesn’t suggest higher cost-sharing is a bad idea. It does suggest higher cosst-sharing must be imposed delicately – with full coverage of preventive care, extra protection for the chronically ill and better education about what plans actually include. It also suggests that, in the long run, controlling the cost of medical care can’t simply be about changing consumer behavior. It needs to change provider behavior as well. “Doctors and hospitals are better at figuring out where it’s possible to cut down care without sacrificing health,” Sood says. “Patients have a more difficult time figuring out appropriate care.”

And what that tell us about the Affordable Care Act? Contrary to the conservative wisdom, it tells us that the law moves health care in the right direction. The tax on benefits should discourage excessive insurance, while regulations on private benefits and changes to Medicare should promote preventive care. And that’s in addition to the myriad Medicare payment experiments designed to encourage more efficient care by doctors and hospitals.

The health law could do a better job in all of these respects – the benefits tax could be bigger, the payment reforms more aggressive and so on. The law could do (a lot) more to insulate the chronically ill from onerous bills. But, once again, that’s an argument for improving the law, not for repealing it.

The opinions in this column solely reflects those of the author. They aren’t endorsed by KHN, which seeks a broad range of opinion to stimlate discussion.  

States consider eccentric ideas

By Christopher Weaver, KHN Staff Writer, March 30

www.kaiserhealthnews.org

When New York’s Medicaid director asked the public for money-saving ideas, the most popular suggestion - as measured by the sheer volume of e-mails raising the idea – left him a bit red-faced.

End payments for routine circumcisions, e-mailers advised.

Though the idea didn’t make the final list for New York’s cost-cutting plan, it’s just one example of how interest groups, such as www.intaction.org, which opposes circumcision, businesses and other policy proponents are pushing to capitalize on states’ dire Medicaid shortfalls.

“At budget time, you’ve got many organizations coming in talking about how that product could save us millions or billions,” said Cameron Bachrach, who directed New York’s Medicaid program and now works for Menatt, Phelps and Phillips, a law firm. “Sometimes there were good ideas there, other times there weren’t.”

In California for instance, a measure became law last week that would, among other things, pay for automated medication dispensing devices in Medicaid patients’ homes beginning in July. Lawmakers said that could save $140 million a year. The proposal is short on details.

But to reach that $140 million goal, “it would have to be a pretty large progran,” said Stefan Solvell, the founder of e-pill, LLC, a large dispensing-device manufacturer. He said the devices improve medication compliance, reducing the need for hospitalization. (Solvell hadn’t heard of the proposal before Kaiser Health News asked.)

In South Carolina, state Rep. Bill Herbkersman, a Republican, is aggressively pushing a $3 million plan he says will prevent costly emergency room visits by Medicaid patients. The money would pay for “medical monitoring devices” in the homes of 3,000 patients who frequent ERs . Herbkersman told a local paper that only one, Californiai-based company makes such a device.

The monitor would essentially speed-dial nurse-operators who would advice patients and avert an ER visit. But, to break even, the call center would have to prevent around a half dozen emergency room visits per patient each year,” said Myles Riner, a California-based emergency doctor and consultant.

Local health industry lobbyists declined to comment, saying they could not afford to sour relations with a key lawmaker. The American College of Emergency Physicians blasted the plan for unfairly blaming the high cost of health care on emergency patients.

The states are facing collective budget shortfalls of well over $100 million in 2012, according to the Center on Budget and Policy Priorities, a liberal think tank, and Medicaid is a significant driver. But doctors and hospitals have already faced steep cuts, and the federal health law limits states’ authority to cut back Medicaid enrollment. That can make novel ideas – even if they come from left field – appealing to lawmakers and officials.

If you come across any unusual Medicaid savings ideas in your state, please send them our way, cweaver@kff.org.

Playing the Granny Card

By Mary Agnes Carey and Marilyn Werber Serafini

KHN staff writers, March 18

www.kaiserhealthnews.org

To Douglas Holtz-Eakin, one thing is clear: Widening deficits mean that sooner or later both parties will have to take on the politically-sacrosanct Medicare program for the elderly and disabled.

“We’re all going to cut Medicare,” he said in an interview . . . with KHN. “Playing the granny card’s gotta end. The question is, how to do it.”

Holtz-Eakin, former senior member of John McCain’s 2008 presidential campaign, advisor to President George W. Bush and director of the Congressional Budget Office, now is building a conservative think tank, the American Action Forum.

He’s also offering guidance to 2012 prospective GOP presidential candidates and attacking the health care law as unsustainable. Here are edited excerpts from the interview.

What are your concerns about entitlement programs?

I understand the traditional political arithmetic that says this is the third rail, you can’t do it. But I think that argument has to be reversed. You can’t afford not to fix it. At the heart of this is a spending problem, and at the heart of the spending is entitlements.

Doesn’t the health care overhaul law already cut back on future Medicare spending?

If you just cut payments to doctors and hospitals and don’t change the system, that’s an empty promise. That’s my problem with the Affordable Care Act. Those cuts aren’t real. It’s really a spending problem.

If you want to overhaul entitlements, where do you start?

Social Security is easiest. Health is bigger numbers, and we know that, but it’s all intertwined with the [health care law]. The President has put a political firewall on that.

That’s one of the greatest disservices of the act. It paralyzes real entitlement reform for a period, at least until after 2012.

If Republicans win big in the next election, what happens to the health law and entitlement spending?

If Republicans take the Senate in 2012, then here we go. If they take the White House [the health law] is gone.

I think it’s a no-brainer to say we simply have to put [entitlements] on a budget. If nothing else, let’s say we have a budget for Medicare and Medicaid. And a good way to budget in Medicaid is in fact to give a fixed grant, a block grant, to the states. That limits taxpayer exposure.

You [also] favor the idea of “premium support” for Medicare, where beneficiaries receive a fixed amount from the government for their coverage. But there’s more to overhauling entitlements than setting a budget cap, right?

Fundamentally, what we have in all our health programs is the following: We say to beneficiaries, you can have all the highest quality medical science that we can provide. and we say to [medical] providers, “God, that’s expensive! Stop it!” And we cut back their payments or tell them not to do stuff. Then the beneficiary says, ‘But you said,’ and we go back and give it to them. It’s incoherent.

Some proposals would exclude anyone 55 and older from entitlement changes. Do you think that’s a good idea?

I’m 53 . . . if you grandfather me, you grandfather the problem. We don’t have the luxury of time on this anymore.

Should higher-income people pay more for their Medicare?

Making high-income folks pay more in premiums [makes sense]. The idea that we have these things 75 percent subsidized out of general revenue . . . is crazy.

The health care law reduces federal payments to the Medicare Advantage program, which provides private insurance to about a quarter of Medicare beneficiaries. Democrats said the cuts are warranted because these plans cost more than traditional fee-for-service. You disagree.

We want people in managed plans that have all the elements of care in them. We might not like the way current [Medicare Advantage] plans manage people. It may not be your idea of a medical home, or whatever you want to call it, but it is a vehicle for managing these costs in a comprehensive fashion as opposed to the fee-for-service system.

How will the pressure on entitlement spending affect implementation of the health law?

If you look at this from a budgetary [standpoint], I really believe these pressures are going to grow enormously, and I think the Affordable Care Act will come under pressure.

I always believed [the law] was a dead man walking from the beginning. It’s going to fall under its own fiscal weight. It has so many bad internal contradictions.I have employer-sponsored insurance. I get no help. This identical person doesn’t have employer-sponsored insurance, they [get a subsidy]. The law, I don’t think, can hang together over a long period of time. I think [Republicans] should help topple it faster.

 

 this wee  

Nursing home workers have records

KHN, March 3 (www.kaiserhealthnews.org)

More than 90 percent of nursing homes employ one or more people who have been convicted of at least one crime, federal investigators said recently in a news report. In addition, they said, 5 percent of all nursing home employees have at least one criminal conviction. (Pear,3/2)  

Health law targets re-admissions

By Michelle Andrews, Feb. 22, KHN

“Welcome back” are two words you’d really rather not hear at a hospital, especially if you’ve just been discharged. Yet one in five Medicare patients found themselves back in the hospital within 30 days of leaving it in 2003 and 2004, according to a recent study in the New England Journal of Medicine. Even more troubling is the possibility that three-quarters of those readmissions might have been prevented, as estimated in a 2007 report by the Medicare payment Advisory Commission (MedPAC), an independent agency that advises Congress.

What gives? All too often, experts say, the problems that send patients back to the hospital might have been avoided if there had been a better hand-off from the hospital to the people responsible for the next phase in a patient’s recovery, whether it’s the patient himself and his family, a home-health agency, a nursing home or a hospice. “We don’t do a good job of coordinating care,” says Patricia Rutherford, vice president at the Institute for Healthcare Improvement, which is directing a multi-state initiative to reduce rehospitalizations.

Discharged patients may be confused about their new medication regimen, for example, or they may not understand diet restrictions. Maybe they don’t have transportation to a follow-up appointment; worse, they may not have an appointment scheduled at all. In fact, the New England Journal of Medicine study found that half of patients who were readmitted within 30 days hadn’t visited a doctor since their discharge. “For very sick patients being discharged by hospitals, we think that’s way too late,” says Rutherford.

Hospital readmissions aren’t only bad for patients’ health, they’re expensive. MedPAC estimated that in 2005 readmissions cost the Medicare program $15 billion, $12 billion of which could have been avoided.

The health-care overhaul takes aim at the problem by penalizing hospitals with higher-than-expected readmission rates for Medicare patients who had been treated for heart failure, heart attack or pneumonia. Those hospitals could see their Medicare payments reduced by up to 1 percent beginning in October 2012, 2 percent the following year and 3 percent the next. The law expands in later years the list of conditions that can result in penalties.

The Department of Health and Human Services allows consumers to make side-by-side comparisons of hospitals’ readmission rates for heart failure, heart attack and pneumonia at www.hospitalcompare.hhs.gov.

“There’s a very strong case to be made that if you want to change something as important as readmission, you’ve got to look at every lever you’ve got,” says Stephen Jencks, a physician and lead author of the NEJM study. “Payment is a very important one, but by no means the only one.”

A growing number of hospitals and health systems are already working on the readmissions problem with support from nonprofit groups and foundations.

Piedmont Hospital in Atlanta is one. A few years ago, it began participating in Project Boost, a discharge transition-program developed by the Society of Hospital Medicine.

Through Boost, Piedmont proactively targets patients who are at high risk of readmission. Staff members use a checklist to ensure that potential logistical and psychosocial problems are addressed before the patient leaves the hospital. Another priority: scheduling patients before discharge for their first follow-up visit to the doctor.

Patients also receive a form to take home that explains in simple terms why they were in the hospital, what they need to do to continue their recovery, including medications, diet restrictions and warning signs of trouble, and whom to call if they experience problems. Within three days of discharge a nurse calls to check on them.

“It’s more work. It takes more time and there’s more confusion” until the new processes are in place, says Matthew Schreiber, chief medical officer for the 480-bed hospital. But the effort has paid off. Thirty-day readmission rates for patients under age 70 have declined from 13 percent to just under 4 percent since the program began; rates for those 70 and older have dropped from 16 percent to 11 percent.

A Project Boost phone call may have helped Bill Cox avoid a hospital readmission. Among many medical problems, the 58-year-old recently had femoral bypass surgery at Piedmont to reroute blood from the large artery in his leg to avoid a blockage there. After Cox returned home, a nurse practitioner from the hospital called to check on how he was doing. One of the questions she asked his wife, Rhonda, was whether he had had a blood test to see if his dose of Coumadin, a blood thinner, was the correct one. Coumadin can cause fatal bleeding, and patients who are on it must have their blood tested regularly. He hadn’t done so, so the nurse practitioner asked the local home health agency helping the couple to arrange for the test.

As it turned out, the does needed adjustment. “His blood was too thin,” sasys Rhonda Cox. “It was just like water.”    

Slippery slope to defunding health law

By Timothy Jose, Rebert L Willett, Family Professor of Law,

Washington and Lee University School of Law

This is high season for budget blueprints on Capitol Hill.

The week began with the unveiling of the Obama administration’s budget request for the upcoming fiscal year.

Meanwhile, in Congress, lawmakers are in the midst of debating a spending measure to provide current year funding for the federal government. As the action unfolds, the burning question is whether Republicans will try to “defund” health care reform and, if so, what strategy might they employ to do it. In fact, the defunding has already begun.

A key provision of the health law that will provide 19 million consumers with tax credits to help afford their health insurance has been raided once. Now, Republicans are planning to raid it again.

Here’s the background. In late December Congress was looking for money to help pay for a plan to stop dramatic scheduled cuts in doctors’ Medicare reimbursements. As a temporary fix, the lame duck Congress changed a part of the new health law so that some consumers will have to pay back a hefty chunk of their tax credits. That change is expected to save the government $16 billion over 10 years.

Now Congress is again looking for money – this time to offset the funds lost with the repeal an unpopular health law provision that involves 1099 tax reporting requirements. Republicans are proposing another increase in the liability of tax credit recipients to raise the necessary revenue.

To understand why the proposal is worrisome, it is necessary to understand the function of the new tax credits. They are designed to help finance insurance premiums beginning in 2014, and are, perhaps, the most important provision in the new law for making health care affordable to middle-class Americans. They will be available on a sliding scale to families with incomes up to 400 percent of the federal poverty level. This is $88,200 for a family of four, but most of the money will go to families with far less income.

Here’s how they work. The amount of the tax credit for which people are eligible is based on annual income for the year the credits are received. But because people will likely need help paying their insurance premiums during that tax year, the law provides for advance payments of the credits. These payments are made directly to the insurer on a monthly basis. The insurance exchanges, through which individuals will purchase health coverage, will determine eligibility for tax credits based on a taxpayer’s prior year tax return. (Taxpayers can provide more recent information if their income or family circumstances have changed.) At the time taxpayers file their annual tax return, the advance payments will be reconciled against the tax credit for which the taxpayers are eligible using their annual income reported on their return. If the advance payments are greater than the final tax credit the taxpayer will get a bill from the Internal Revenue Service.

Excess advance payments can happen easily and will happen often. The income of hourly-wage lower and middle-income Americans often fluctuates from week to week and is difficult to predict. Dependants may leave or return home. Family members may become elilgible for Meidicaid or CHIP. Taxpayers may be eligible for a premium tax credit in the early months of the year while unemployed but then get a job with coverage and no longer need premium assistance. Or they may lose a job part-way through the year and face dramatically reduced income, even though their full-year reported income remains high.

All these changes will affect the subsidy calculation. It will be difficult for the exchanges to keep up with changes in family circumstances and for families to know what changes they should report and to whom. It is inevitable that there will be some inconsistency between advance payments based on estimated income for the year and the final credit determined at tax time.

Originally, when the health overhaul was signed into law, the amount the government could recover was capped at $400 for families with incomes below 400 percent of poverty. The amendment adopted in December increases the amount families will owe on a sliding-scale basis. Under the December amendment families with incomes at 200 percent of poverty will have to pay back as much as $1,000, families with incomes at 400 percent will have to pay back up to $2,500. It also, however, puts some limits on overpayments for families up to 500 percent of poverty.

The “1099 fix” legislation, which is likely to be considered this week by the House Ways and Means Committee, would require families at 200 percent of poverty to pay $1,500, and families earning a dollar more than 400 percent of poverty to pay back their entire tax credit.

It is important to understand what is at stake here.

Fear of potential end-of-year liability could be a substantial deterrent to participation in the advance premium tax credit program. It was estimated that the December amendment increased the likely number of uninsured after 2014 by about 200,000 people, who would rather be uninsured than face substantial repayments. Millions more consumers will face unanticipated financial burdens. this is likely to create a powerful backlash, as Americans who thought they were receiving a tax credit to help them purchase insurance find out it was in fact only a loan, and that they owe the IRS a substantial debt.

These changes are not needed to deter any potential gaming of the system. The health law provides separately for substantial fines for providing false information, even neglitently. The December-passed amendment simply increased the penalty for failing to accurately make a very difficult projection of future income and family circumstances, and the new proposal would increase the penalty even more.

The December amendment was a compromise, improving some aspects of the legislation while diminishing tax credit protection. But it also set a bad precedent by cutting premium subsidies before they even became available. It can only be hoped that congress does not adopt the proposed amendment, again increasing the risk of Americans who accept premium tax credits, as it attempts to find ways to cut the budget during this session.

Answering Obama budget critics

By Jonathan Cohn, Senior Editor of The New Republic

A collaboration between KHN and The New Republic

Conservatives and Republicans had a lot to say about the budget President Barack Obama released on Monday. None of it was good. The budget doesn’t do enough to stabilize federal finances, they said. And it doesn’t do enough to slow rising health care costs.

Both criticisms have merit. Even if Obama got everything he wanted in his budget request, the federal government would still be committed to spending far more money than it will collect over the next few decades. And the single biggest reason for that discrepancy would be rising health care costs.

But for all of those critics out there, furious that Obama hasn’t proposed a more fiscally responsible budget, I have a question: Do you have an alternative? More specifically, do you have an alternative that would both slow federal health care spending and be politically viable? The answer, I think, is no.

Broadly speaking, conservatives and Republicans have proposed three approaches to health care. The first is the one that’s gotten so much attention lately. Repealing the health law. Intuitively, it sounds appealing. The Affordable Care Act would expand government programs in order to make sure more people have comprehensive health insurance. Getting rid of it is bound to save the taxpayers money, right?

Not exactly. The health law does more than simply create or expand government programs, it custs wasteful spending, such as subsidies to private insurance companies. It also raises some taxes. Put it all together and, according to the Congressional Budgeet Office, the program actually generates more money than it would spend. Repeal it and the government’s bottom line actually gets a little worse.

The usual conservative retort is that the CBO projections are wrong, in part because lawmakers will never implement the spending cuts or new taxes in the face of inevitable political resistance. But even if you accept that claim – more on that in a second – it’s hard to see how getting rid of the Affordable Care Act substantially improves the government’s long term picture.

Remember, the government’s health care costs were out of control before the health reform debate even began. That’s why the overhaul starts up so many initiatives that attempt to improve the efficiency of medical care, making it possible to reduce costs without reducing care. Some will work, some won’t. But the only way to find out is to try them. If lawmakers repeal the measure, those experiements will stop – and we’ll be right back where we started.

Of course, conservatives and Republicans sometimes vow to repeal “and replace” the health law. That’s their second alternative. It generally means enacting a hodge-podge of familiar conservative initiatives, from allowing the purchase of private insurance across state lines to encouraging more use of health savings accounts. (By reducing the cost of care overall, in theory, these measures will also reduce the cost of government health insurance.) Some of these ideas, like malpractice reform, have some merit. But overall, no serious economist believes these steps will, by themselves, substantially slow down health care spending either for the government or for society as a whole. At most, they would make an incremental difference.

That brings us to the third alternative – the one that, if fully implemented, really could slow down government health care spending. It’s the alternative known as “obliterating Medicare.” House Budget Chairman Rep. Paul Ryan, R-Wis. has famously put forward a version of this plan. In it, younger workers would not get government-provided Medicare when they retire. Instead, they would get vouchers for buying private insurance. The catch is that the value of the vouchers would rise really, really slowly – too slowly to keep up with medical costs.

That might very well save the federal government money, largely by forcing seniors to pay for more of their own health care bills. And if seniors react by getting less care, costs will come down even more. But this is where political reality intrudes. You can safely assume seniors would scream about those cuts, as well they should. Such huge reductions in the value of their health insurance would likely leave many seniors unable to afford not just frills but even essential care, producing the kind of widespread hardship that, in the 1960s, spurred lawmakers to create Medicare in the first place.

A far better approach to controlling health care costs, both for the government and for society as a whole, would be to do so very carefully, spreading the pain widely, by enacting cuts that affect providers and consumers, employers and workers, using new benefits to mitigate the impact of cuts and, whenever possible, attempting to re-engineer the actual delivery of medical care so that it’s possible to spend less without providing less. Not only would that be more politically realistic, it would also spare any one group too much suffering. Not coincidentally, that’s basically what the health care law does. Doctors and hospitals lose some revenue but get more paying patients. Seniors lose some Medicare Advantage extras but get extra prescription drug coverage. And so on.

The result, if it works, will be a gradual slowing-down of health care costs. Would I like the change to be less gradual? Would I like to know, with more certainty, the cuts will actually work? Sure. But the conservative alternatives don’t offer better guarantees. In fact, the proomises they make are far more illusory.

Some seniors in for sticker shock on drugs

By Mary Agnes Carey, KHN, Feb. 11, 2011

The Obama administration often touts the health law provision that over the past decade will close the unpopular “doughnut hole” – a gap in Medicare prescription drug coverage.

But officials rarely cite another provision, one that might cause sticker shock among some seniors. Starting this year, more affluent beneficiaries will have to pay higher premiums for their drug benefits.

Since 2007, Medicare beneficiaries with incomes of $85,000 ($170,000 for couples) have had to pay more on a sliding scale than the standared premium for Medicare Part B, which covers physician and outpatient services. The health law extended this “income relating” to Medicare Part D, which covers prescription drugs. The change took effect in January.

In addition, the law froze the income thresholds that determine which seniors pay the additional costs. That means those thresholds won’t be adjusted for inflation through 2019, and more and more seniors will fall into this group.

In 2011, the standard Medicare Part B monthly premium is $115.40; higher income beneficiaries will pay between $161.50 and $369.10. Part D premiums vary widely depending on the specific plan, but the national average is $32.34; higher income seniors will pay between $44 and $101, according to the Kaiser Family Foundation.

Some seniors advocates fear that requiring wealthier seniors to pay higher Medicare premiums will encourage those beneficiaries to leave the program and get private insurance. And, since seniors with higher incomes tend to be healthier, their departure could drive up costs for the sicker seniors left behild.

“Where is that line where it becomes too much and then you have a two-tiered systen?” said Nora Super, director of government relations for health at the seniors’ group AARP.

Others say it makes perfect sense to require seniors with higher incomes to pay more for Medicare. “Given where we are fiscally in this country, I really don’t have a big problem with making that argument that we ought to be asking seniors in that income category to pay a larger share of the value of the benefit they are receiving,” said James Capretta, a fellow at the Ethics and Public Policy Center, a conservative think tank. Capretta also said he doubted that seniors could get a better deal from a private insurer than from Medicare.

The federal health program for the elderly and disabled currently covers about 47 million enrollees, and the number is expected to rise to 60 million by 2019.

According to the Centers for Medicare and Medicaid Services, this year 1.7 million seniors will pay the higher premium for Medicare Part B coverage and 822,000 will pay it for Part D coverage.

The percentage of seniors paying the higher premium for Part B has remained at about 5 percent of beneficiaries since 2007. Now, with inflation adjusting gone, about 5.7 million seniors will be paying the higher Part B premiums by 2019, that’s about 10 percent of the total. Nearly 3.4 million beneficiaries will be paying more for their Part D coverage, according to CMS.

The Kaiser Family Foundation, in a separate analysis, estimated that those figures could be substantially higher. Kaiser projected that by 2019, 7.8 million beneficiaries will be paying the higher Part b premiums, and of that group, 4.2 million also would pay the higher Part D premiums. Kaiser also estimated the combined premium costs in 2011 would range from $206 to $471 per month. By 2019, nearly one-fifth of Part B beneficiaries who enroll in the program for the first time will pay income-related premiums for their physician and outpatient coverage, according to the foundation.

AARP lobbied against increasing premiums for higher-income seniors, but the pleas “sort of fell on deaf ears,” Super says, in part because Democrats need money to finance the health law. The Medicare income -relating provisions will raise about $36 billion through 2019, according to the Congressional Budget Office. AARP continues to oppose the provision and hopes to have it taken out of the law.

Meanwhile, AARP and other seniors groups are concerned that charging wealthier seniors more could encourage insurers to create policies that could encourage insurers to create policies that would be more attractive than Medicare.

“If you’re paying $400 a month, you might be able to find insurance in the private market that would be less than that,” said Marie Freese, government relations and policy director for the National Committee to Preserve Social Security and Medicare. “If you’re healthier we need to keep you in the system in order to keep costs low for everybody else.”

Capretta said the odds are “very low” that wealthier seniors would leave Medicare in droves or that insurers would build new products to cover them.”You take an awful big risk by opting out of Medicare, which is guaranteed issue, community-related insurance. I don’t think a lot of people would do that.”

Jonathan Blum, deputy CMS administrator and director of the agency’s Center for Medicare, said he’s not aware of any seniors who have left the program because they ahd to pay more for their Part B coverage, and he added that CMS is “confident that higher-income beneficiaries will stay in the Part D program based upon the history and the fact that the Part D benefit is more generous.”

He also said that while higher-income seniors would be required to pay more for their drug coverage, the benefit is more generous this year, pointing to the 60 percent discount for brand-name prescription drugs once seniors hit the “doughnut hole.”

Fixing failure at Physician Compare

By Michael L. Millenson, president. Health Quality Advisors, LLC

KHN, Jan. 27

    The launch of Medicare’s Physician Compare website at year-end should have been a watershed event in the long campaign for health care transparency and patient empowerment. Instead – and it pains me to write this – Physician Compare is a case study in how the interests of the average citizen can be shunted aside by indifferent government, lazy journalists and solipsistic special interests. That remains true despite all of those involved being Good People Trying To Do The right Thing.

  By way of background, the Accountable Care Act required the Centers for Medicare & Medicaid Services to make public certain types of provider information by Jan. 1, a deadline the agency (barely ) met. Phase one of the new Physician Compare site is “designed to be consumer-friendly and help all patients – whether on Medicare or not – locate health professionals in their communities,” according to CMS.

  In reality, the site is confusing and unfriendly to consumers, painfully slow and worst of all, factually unreliable. Put bluntly, the agency, whose leader famously called himself a “patient centered . . . extremist” in a 2009 “Health Affairs” article, has produced a consumer tool that practically shouts, “We couldn’t care less whether any consumer ever uses this.”

  Fortunately for CMS, most of the journalists writing about the site apparently did little more than cut and paste the government press release description of it into their own stories. If I were a federal flack, I’d drink a toast to that famous Marx Brothers movie line: “Who are you going to believe, me or your own eyes?”

  The most notable exception was Forbes’ David Whelan. In a biting critique, he wrote that the site ” is little more than a directory of doctors and one that, in my basic testing, is missing many entries and slow to load. You’d be better off using a site like HealthGrades or Vitals.com for research since those sites actually list where the doctors trained and in some cases provide richer information like patient reviews, which hospitals the doctors practice at and how good they are, and even malpractice or disciplinary records.”

  As for the additional quality information the site pledged to provide, Whelan says he had difficulty finding it or even understanding what it meant. Me, too – and both of us are far more sophisticated users than the average patient.

  My experience in getting the site to do the baiscs it promised was even worse than Whelan’s After typing in my suburb’s zip code, I’d sometimes receive a list of internists practicing here and sometimes be told there were none. I’d ask for doctors within a one-mile radius and get back a list of more than 500 providers within 15 miles. The site couldn’t even reliably supply physician addresses on the same page as their names. Sometimes it did. Sometimes it didn’t.

  CMS did not respond to Whelan about site usability and clarity, but the agency did say it will “begin to implement” in 2012 a plan for making available more comprehensive quality and patient experience data. This information will start appearing by Jan. 1, 2013. Both dates are required by statute. I’ll tell my 89-year-old father to mark his calendar.

  Perversely, Physician Compare’s ineffectuality probably protects it from provider ire. Based on past experience in places like the state of New York, a tool that prompts patients to start differentiating among doctors based on clinical criteria could create a political firestorm the Medicare agency is ill-equipped to handle. As it is, physician groups want the government to let doctors correct information. And, in regard to such clinical outcome rankings, these groups also want to ensusre there is “adequaate” adjustment for patients’ medical conditions before treatment (otherwise known as the my-patients-are-sicker factor).

  Meanwhile, future focused consumer advocates seem to be giving CMS a free pass on its current failure to provide a basic, reliable and usable tool. In a “Perspective” piece for the California HealthCare Foundation, David Lansky of the Pacific Business Group on Health and Steven Findlay of Consumers Union gloss over the present in favor of a detailed blueprint showing how Physician Compare could be a “game changer for consumers” only if the government “is bold, decisive and innovative.”

  But are these hopes realistic? The health law notwithstanding, the Physician Compare experience suggests the public might be better served in some instances if government provides data while the private sector analyzes it and presents it electronically. “Private sector” is a term that also includes nonprofits. After all, as the leader of the Foundation for Accountability, Lansky pushed the envelope on tranparency. Findlay has helped do the same at Consumers Union. Depending on the political views of the president appointing the CMS director in 2013, I might prefer a Lansky or Findlay exercising more control over health care information than the U.S. government.

  As government regulators, journalists and consumer advocates are fond of reminding doctors and hospitals in a different context, good intentions don’t excuse bad results. In a recent survey, two-thirds of adults said they’d like access to more comprehensive information about doctors. Medicare should fix Physician Compare today and learn from its mistakes to make systematic improvements for tomorrow.  

What repeal is not about

By Douglas Holz-Eakin

President, DHE Consulting, LLC, Fellow Manhattan Institute

KHN, Jan. 18, 2011

  With the House of Representatives poised to vote on the repeal of the Patient Protection and Affordable Care Act, there has been a flurry of commentary regarding what is at stake. First and foremost, the law itself is not at risk this week. Regardless of the action in the lower chamber, no sane observer believes that a repeal vote will pas the Senate or ever be signed by President Barack Obama.

  Despite, this, defenders of the law have launched a massive disinformation initiative regarding the vote. So, in the interest of dispassionate evaluation, let us step back for one moment and review the situation.

  First this is not about denying coverage to those with pre-existing conditions. Yes, repeal would roll back the specific provision of the health law in this regard. But there is nobody on either side of the debate who favors the inability of those with costly, pre-existing medical ailments to obtain insurance. There are deep disagreements over the best way to reach this goal, but the basic objective is, and always has been, shared on both sides of the aisle.

  Similarly, a repeal vote is not about defending insurance companies. Conservatives have no love of insurers and many of their proposed reforms would have forced insurers to compete much more vigorously for the business of Americans. For this reason, many (if not all) insurers are nervous about the notion of repeal as it puts at risk the easy access to customers engendered by the measure’s individual mandate.

  More generally, repeal is not about being happy with the status quo. It is easily forgotten that at the start of the health care reform debate in January 2009 there was a bipartisan agreement that health care reform was needed. And there was consensus that real reform would provide insurance for more Americans. So assertions like that of New York Times columnist Paul Krugman – who said of the Republican leadership: “They’re against reform because it would cover the uninsured – and that’s something they just want to do” – are just nonsense and shameful.

  This brings us to what a repeal vote is about: real health care reform. In January 2009, all sides agreed that the central tenet of health care reform was to control the growth of health care spending. And it is not well understood that the health law fails this test, as witnessed by the findings of dispassionate experts ranging from the Congressional Budget Office to the Obama administration’s actuary. So, with the overhaul’s framework, the health care cost spiral will continue. Repeal is about moving to reforms that will control costs.

  Worse, the law sets up two new open-ended entitlement programs that will feed at the trough of excess cost growth and fuel the already-explosive growth in federal spending, deficits and debt. Repeal is about caring enough for the next generations to not destroy the foundation of their prosperity and saddle them with our debts.

  Finally, repeal is hopefully about a new era in politics. Many candidates ran for office promising to reverse this measure. They ran in an environment in which the top three issues were jobs, controlling federal spending and accountability. To not hold a vote for repeal would be to deny their accountability to the voters who put them in office. It would be to deny the importance of controlling federal spending. And it would be to deny the importance of pro-growth policies, especially in the one-sixth of the economy most riddled with inefficiency: the health care sector.

  Real health care reform that delivers quality care at lower cost and controlling explosive federal spending and debt – that is what the repeal vote is about.    

Making end-of-life decisions hard on family

By Michelle Andrews, KHN, Jan. 18, 2011

  Most people would agree that when the time comes, they want a “good death.” But what that means is all too often left up in the air until a crisis strikes or the stricken person is no longer able to communicate his wishes or his advance planning documents are not clear. When that happens, spouses, adult children, siblings and others find themselves in the unenviable role of surrogate decision-makers, trying to divine, sometimes with very few facts and under very emotional circumstances, what people they love would have decided to do if they were able to choose.

  The critical role of the surrogate decision-maker deserves more attention and support, say experts. It’s incredibly stressful – on a par psychologically with having your house burn down, says Daniel Sulmasy, a professor of medicine and ethics at the University of Chicago Divinity School and co-author of a commentary on surrogate decision-making in the Nov. 3 issue of the Journal of the American Medical Association. Too often, hospital staff and clinicians want to move into the decision-making phase without taking into account the family members’ need to come to terms with the situation, he says.

  It’s a role that many of us may have to step into. Only about one in four people have signed advance directives that spell out their wishes if they’re unable to make medical decisions on their own, according to a 2008 report published by the Pew Research Center for the People & the Press.

  An advance directive includes two types of documents. A living will describes what sort of life-sustaining and other treatment people want if they’re unable to communicate their wishes; a health-care power of attorney designates someone to make decisions for a person who’s unable to do so. Different states have different names for these documents. The National Hospice and Palliative Care Organization provides links to instructions for completing the documents in every state.

  Unfortunately, advance directives often don’t neatly address the specific medical situations that arise. When Marianne Vakiener’s 80-year-old mother entered the hospital near her home in Winchester, Va. for a hip replacement in 2008, her living will stated that she wanted no extraordinary measures used to keep her alive.

  After the operation, the surgeon joined Vakiener and her father in the waiting room and told them the surgery had gone well.

  A little later, however, a different doctor asked permission to insert a breathing tube because the patient wasn’t coming out of anesthesia as quickly as her doctors had hoped. Husband and daughter agreed.

  Vakiener’s mother never woke up. Eventually, clinicians determined that she had had a stroke, although they couldn’t pinpoint when it happened. During the nine days that she was in the intensive care unit while the family waited to see if she would recover, Vakiener, her three brothers and her father kept her on a respirator and had her connected to an IV line that provided nourishment.

  Were these extraordinary measures? It didn’t seem so at the time. “We thought, “How can we not help her breathe and feed her if there’s a chance she might wake up?’ ” says Vakiener. As time passed, however, it became clear that her mother probably wasn’t going to come out of her coma and that even if she did, she wouldn’t have the quality of life she wanted. So the family decided to remove her breathing and feeding tubes.

  “I had always thought that having a signed document would make things clear,” says Vakiener. “I learned that it didn’t.”

  Vakeiner’s mother had always been clear with her family that she would rather die than live her life hooked up to machines, says Vakiener. Vakiener’s father, who held her mother’s health-care power of attorney, knew this, as did her children. Because it’s hard to anticipate medical decisions that may need to be made decades hence, naming a health-care poser of attorney who knows you and your values intimately may be even more important than a living will in some instances, say experts.

  Clinicians can help guide family members through the decision-making process, and there’s an increasing recognition that doctors who have critically ill patients need good training in this area, says Douglas White, director of the program on ethics and decision-making in critical illness at the University of Pittsburgh Medical Center.

  Physicians may not feel comfortable spelling out the likely consequences of one decision over another, in part because of scientific complexity that makes predicting outcomes difficult, says White. But in his research, he says, he has found that more than 90 percent of family members would like to receive prognostic information in the ICU. “There’s a real hunger for this information even though it’s emotionally difficult to hear,” he says.

  The most effective surrogates are those who aren’t afraid to ask lots of questions, says Kathy Brandt, a senior vice president at the National Hospice and Palliative Care Organization. What are the benefits and burdens of this decision? What are other options? Will it cause a tremendous amount of pain? Here’s what my loved one values more than anything. Given that, what would you do?

  “You don’t want a passive person or someone who’s intimidated by the physician,” she says.  

Medicare beneficiaries missing out

By Phil Galewitz, KHN Staff Writer, Jan. 4, 2011

   More than two million Medicare beneficiaries have failed to sign up for a program that could save them thousands of dollars a year in drug costs despite government mailings, ads and even pitches from rock and roll legend Chubby Checker.

  The subsidy program, called Extra Help, can provide significant savings on the cost of Part D prescription drug coverage for low-income Medicare beneficiaries. The government estimates Medicare recipients can save an average of $3,900 a year. The subsidy, which began in 2006, helps reduce prescription drug premiums, co-pays and deductibles and plugs the “doughnut hole” or gap in coverage that starts when beneficiaries exceed $2,840 in total drug costs. The Department of Health and Human Services and the Social Security Administration jointly oversee the subsidy program.

  Nearly 10 million of the nearly 25 million people enrolled in Part D prescription plans received the low-income subsidy this year. Of those, more than eight million people were automatically enrolled in the subsidy program, mostly because they are on both Medicaid and Medicare or are receiving other federal government support.

  A study released in September by researchers at Georgetown University and the University of Chicago estimated that 2.3 million people were eligible for the program but didn’t apply. The percentage of those not automatically enrolled who do seek the discounts – about 40 percent – has changed little since 2006, the researchers found. The study was commissioned by the Kaiser Family Foundation. (KHN is a program of the foundation.)

  “This is a really hard population to reach,” said Vicki Gottlich, an attorney with the Center for Medicare Advocacy. She said many low-income beneficiaries may not speak English or have stable housing that makes it difficult to get them to enroll.

  Seniors and the disabled ares eligible for the subsidy if their income is less than $16,245 a year for individuals and $21,856 for married couples living together. The value of their stocks, bonds and bank accounts can’t exceed $12,510 for individuals and $25,010 for married couples. The income definition doesn’t include the value of homes or automobiles.

  Over the past five years, both Social Security and the Centers for Medicare and Medicaid Services have run publicity campaigns about the subsidy, including using direct mail and working with faith-based organizations and seniors’ groups.

  In June 2009, CMS gave states $25 million in grants to help get the word out about the program. This initiative includes special efforts targeting seniors in rural areas and native Americans. The grant program continues until June 2011.

  In addition, in January 2010, Social Security launched a new television, radio and internet campaign with Chubby Checker. The theme of the marketing blitz was that Social Security says there is a ”new twist” that makes it easier for senior citizens to qualify for extra help with Medicare prescription drug costs.

  Mark Hinkle, a spokesman for Social Security, said the agency is doing everything it can to get those eligible to enroll.

  Helen Boesch of Perry, Mich., said the subsidy helped her parents, Robert, 76, and Daisy Yenson, 68. Both llive with her and have cancer. She estimates the subsidy will save each of them at least a few thousand dollars every year. “It’s really nice to get some help,” she said.

  The number of people eligible for the subsidy is expected to rise this year because of two recent changes to the rules. The cash value of the insurance policies is no longer counted toward the asset limit, and assistance received from friends and relatives to pay for household expenses such as food or utilities is also no longer counted as income.

  Unlike standard Medicare Part D enrollment – which occurs annually beetween Nov. 15 and Dec. 31 – seniors can apply for Extra Help throughout the year.

  As a result of the HHS campaign, about 120,000 people have applied for the Medicare drug subsidy, according to federal reports. Through the same marketing campaign, about 100,000 people have signed up for the Medicare Savings Plans, which lowers the cost of doctor visits and the Medicare Part B premium.

  Results of the $25 million campaign that provided grants to states varied widely, according to data collected by the National Council on Aging.

  For instance, Pennsylvania, which received a $1.1 million grant, has signed up 5,742 people for the two subsidy programs from June 2009 through September 2010. But Texas, which got a $1.2 million grant, has signed up 2,430 people. Nevada has found the fewest people – 584 – through the grant program while Illinois has signed up the most – more than 30,000.

  States used the grants in different ways to find eligible Medicare beneficiaries. They’ve given grants to nonprofits to go into homeless shelters, work with religious groups and set up enrollment kiosks in public libraries.

  In Wisconsin, the grant money has gone to advocacy groups that have visited senior centers, food pantries and even distributed flyers at trailer parks, said Peg Nugent, a Medicare training counselor at the Greater Wisconsin Area Agncy on Aging Resources. Using its $800,000 grant, the state has helped find 7,600 people for the subsidy programs. “There’s still a lot more people out there,” Nugent said.

  But officials have much to overcome in the recruiting effort. They say that in addition to not knowing about the program, some people don’t sign up because they think they won’t meet the eligibility or are afraid of taking the help. As Elaine Wong Elkin, executive director of California Health Advocates, explained, “It can be a pride issue or the stigma about asking for assistance,” she said.

  To apply for Extra Help, go online to the Social security website or the Extra Help website or call Social Security at 1-800-772-1213.     

Long-term care a tough subject

By Harold Pollack, KHN, Dec. 23, 2010

  Democrats and Republicans may spend the next two years fighting about what to jettison or retain in the Affordable Care Act. In whatever fashion these conflicts are resolved, we’ll be back – at some point soon – to address another looming challenge: long-term care.

  This is a big problem. Less than 4 percent of American adults, and only about 10 percent of seniors, possess LTC insurance coverage. As Michelle Andrews previously noted for Kaiser Health News, such policies are costly. So most Americans do not purchase them. And there’s a reason why these policies are expensive. The average nursing home stay is 2.5 years. The cost of such care would deplete the finances of most senior citizens, at minimum leading them to seek Medicaid assistance.

  The health law includes some valuable components for long-term care. As regular readers know, the Community Living Assistance and Social Support Act is a voluntary disability and long-term care insurance program for workers. Slated to begin next year, the CLASS Act will be financed through monthly insurance premiums. After five years of vesting qualifying beneficiaries will receive a cash benefit for qualifying expenses that will vary with disability and will be sheltered from Medicaid asset tests. Over time, CLASS has the potential to keep millions of people off Medicaid and out of an institution. It will also cover many expenses that disabled people and their care givers would otherwise bear without help.

  The health law also includes other provisions and demonstration projects to improve home and community-based services. For example, it includes improved medical bankruptcy protections for the spouses of disabled persons receiving home or community-based services. Unfortunately, these humane measures are not scheduled to take effect until Jan. 1, 214, and will expire on Dec. 31, 2019.

  Despite these components, the overhaul left much undone. CLASS addresses the risk of future disability among current workers. It does not help people whose disabilities prevent them from working in the first place. Its benefits also are modest when compared with the cost of nursing home care. CLASS’ voluntary contributory structure limits its reach, though no one at this delicate stage really knows how many people will take up this benefit or how employers will react to the new program.

  Health reform did not address other prominent concerns. States face large and growing burdens for Medicaid, the single largest payer in the long-term care services. In part in reaction to these burdens, and in part in reaction to political battles over health reform, some states have announced at least the prospect of significant cuts to programs for the elderly and the disabled. For example, South Carolina has announced that its Medicaid program will stop covering hospice care and that the statae will cut its meals-on-wheels program.

  Individuals who require long-term care services face other burdens, too. They and their care givers require more access to home- and community-based services, and greater help in choosing services that are most effective for their specific circumstances. Individuals and families face big financial risks, including the genuine risk that one could lose one’s life savings in the event one requires long-term care. Each of these problems is likely to worsen in the years ahead.

    Moreover, the firms that provide long-term care insurance also need help. One of the largest players in this market, Metropolitan Life, recently announced that it would not offer new long-term care insurance policies after Dec. 30. Other firms have left the business or seek steep premium increases.

  The Met Life story didn’t get much play. I believe we will see more stories like it, given increasingly serious economic challenges that beset the long-term care insurance market. Fundamentally, private insurance is just poorly suited to providing reliable and effective coverage for long-term care.

  Why is this? Private insurance markets work best to protect individuals against well-understood idiosyncratic risks. Insurance markets work poorly when risks are strongly correlated across the population, and when  people don’t trust insurers to cover what will become the reasonable standard of care.

  Nearly 20 years ago, David Cutler noted that the above challenges are particularly daunting in long-term care. Many of the biggest risks are systematic. How much will it cost to care for dementia patients in 2047. No one really knows.

  Adverse selection also is a key concern. Will individuals with chronic illnesses be able to buy coverage when they need it and at what cost? There is wide variation in people’s health status. Moreover, a relatively small fraction of people now own such policies. It is a big challenge to ensure that relatively young and healthy people are willing to buy coverage. At the moment, anyway, the American public seems allergic to the individual mandate, the single most powerful mechanism to address this problem. If anything, an explicit or implicit mandate is more important for LTC than it is in addressing the issues that dominate the current health reform debate.

  There is also a delicate trust issue. WhenI buy a LTC policy today, I have no idea what the reasonable standard of care will be in 2040 for dementia or heart failure. Tens of millions of Americans do not trust this industry to exercise its discretion fairly in deciding what should, eventually be covered.

  One’s insurer might also go broke over the coming decades. How will these firms’ investments perform, relative to medical care cost growth, over the years ahead? Will future financial crises damage insurers. American International Group’s commercials featured the tagline: “the strength to be there.” AIG’s travails remind us of the obstacles and risks that can arise within the overall economy.

  Finally, there is the role of Medicaid – whatever it will look like 30 years from now. Incentives to buy long-term care insurance are lessened by real or perceived possibilities that patients may be bailed out through public coverage.

  For these reasons and more, our current arrangements for long-term care and financing are badly frayed.

  Many approaches to restructure these arrangements have been presented. The best of these approaches embed private insurance within Medicare and Medicaid. All of these models include market expansion of the public role, particularly the federal role, relieving states of a difficult burden. At minimum these arrangements provide a catastrophic insurance backstop for private coverage. At maximum, they provide more expansive universal public coverage. None of these approaches presume that private coverage, in its current form, can provide a viable financial foundation for long-term care, except within a minority of rather affluent Americans.

  Health care reform is a continuing project, not something that can be enacted in a single bill on a single congressional session. Long-term care is one of the biggest agenda items left unfinished in the health care law. We’ll have to face it. Better sooner than later.

GOP plan unveiled

KHN, Dec. 14

    Rep. Michael Burgess, a Republican physician from Texas, wants his party to aggressively attack the sweeping health care law, a signature policy achievement for President Barack Obama and Democrats. In January, Burgess begins his fifth term in the House where he founded a health care caucus to host forums and tell members and the press more about the health law. Like many in the GOP, Burgess says the measure gives the federal government too much power and that it is ”way too big, it’s way too costly, [and President Obama and Democrats] did it way too fast.” He wants it repealed and replaced with ideas Republicans favor to expand health coverage, including broadening the use of health savings accounts and allowing consumers to purchase health coverage across state lines. His observations of the national health care debate will be included in a soon-to-be-published book. KHN’s Mary Agnes Carey and Marilin Werber Seerafini recently spoke with Burgess. Edited excerpts of the interview follow.

  Q. What’s the GOP strategy to repeal the health care law?

  A. We were elected . . . on the promise that we would bring up a repeal vote very quickly. . . . If I ran the show [the vote] would be the afternoon before the president does his State of the Union address. . . . I understand that we didn’t win the Senate. I understand we didn’t win the White House. But I think it is important from the House perspective that we have that vote. I would even make it a call of the roll, just like the vote for speaker, [which is] going to be on swearing-in day. I would call everyone’s name and make them answer affirmatively yes or no if they support the repeal. People feel so strongly about this. [The health law] just violates what this country was founded on. . . . This much bureaucratic change foisted on society is going to lead to chaos.

  Q. You want to the chair the Energy and Commerce Oversight and Investigations Subcommittee. What do you want to accomplish there?

  A. Part of the job right now is to make people aware that [the law is being implemented]. It’s not going to wait until 2014. . . . There are new federal agencies being created every day under this law. . . . What are these panels? Why does the [Health and Human Services] secretary have so much power? Where is the money coming from for these things? . . . Our committee needs to do its job in oversight, to put some of these things out there in the public domain for public discussion and see what happens. . . . We want to study every flaw in the bill.

  Q. Do you think you’ll get any Democratic support to repeal the individual mandate?

  A. Maybe in the Senate. You’d be surprised. There are a lot of people over there who are trying to rehabilitate themselves before 2012. If the [individual mandate] goes then the whole house of cards comes down pretty quickly afterwards. . .  Why do you think the [Medicare physician payment patch] was for 13 months? So we don’t have an opportunity to tag something like a repeal of the individual mandate to a must-pass doc fix in January or February.

  Q. You’ve said this bill does nothing to control costs and may make health care more expensive for consumers. Can you give us an example?

  A. Would [the law] hurt my ability to have a high deductible plan if I choose to have that in the individual market? It could. Because in a high deductible health plan you want less money spent on actual medical care because that’s what helps keep the premiums do