Tag: Patient’s Rights

Healthcare Providers Oppose Medicare Cuts In Obama’s 2015 Budget

President Barack Obama is proposing more than $400 billion in cuts to Medicare over the next decade in his fiscal 2015 budget, an almost identical amount to what he recommended last year. But those cuts are heavily weighted toward future years, with only $3.5 billion occurring in 2015.

The president’s fiscal blueprint also includes $73.7 billion in discretionary spending for HHS in fiscal 2015. That’s a reduction of $6.1 billion—or 7.6%—from the current budget.

The cost of running HealthCare.gov is pegged at $1.8 billion next year, with two-thirds of that covered by user fees.

A way to pay for a fix to the volatile Medicare sustainable growth rate is not outlined, even though the budget lauds efforts to find a solution to the issue.

Among some of the other proposals:

  • More than $200 million in increased funding in 2015 for mental health programs for children. That includes $130 million aimed at reducing the use of psychotropic drugs for children in foster care programs.
  • $770 million in savings from prohibiting pharmaceutical companies from delaying the availability of generic drugs. A similar plan was included in the administration’s 2014 budget plan, but was not enacted.
  • Expanding “quality incentives” for Medicare prescription drug plans. This would likely be similar to the star-rating system used to determine whether Medicare Advantage plans qualify for bonus payments. However, the budget doesn’t propose any appropriations for the program.
  • $25 million in funding over two years aimed at preventing fraud in the state and federal insurance exchanges.

The president’s budget includes $629 million to support operations of the federal health insurance exchange in 2015. In addition, the CMS will collect about $1.2 billion in user fees from issuers in the federally funded marketplace, as well as collections from the reinsurance and risk adjustment programs. That brings the total cost of the federal exchange to $1.8 billion for next year.

The Federation of American Hospitals, which is hosting its annual meeting in Washington, was quick to oppose the Medicare payment cuts included in the president’s proposal, which the group says comes on top of about $117.5 billion in cuts over 10 years that hospitals have faced since 2010.

“Among the threats included in the budget proposal are cuts to rural and rehabilitation hospitals,” Chip Kahn, president and CEO of the Federation of American Hospitals, said in a statement. “In addition, it further threatens seniors’ access to vital hospital services by calling for cuts in vital Medicare backstop funding,” he continued. “Many key members of Congress, Democrats and Republicans, also oppose these Medicare ‘bad debt’ payment cuts, which provide crucial protection for seniors and are core payments that hospitals in their districts depend upon.”

Richard Umbdenstock, president and CEO of the American Hospital Association, said in a statement that the president’s budget includes some “problematic policies” that would undermine hospitals’ ability to improve the healthcare system and ultimately put access to services at risk for patients.

“We are concerned that proposed cuts to teaching hospitals will jeopardize these important organizations, which play a critical role in medical research and training the next generation of caregivers,” Umbdenstock said. “While we recognize that increased funding for training new primary-care physicians is included in the president’s budget, this proposal is overshadowed by an ill-advised cut of $14.6 billion for medical education at a time when a physician shortage is real and expected to balloon as our population ages.”

The administration’s budget praised congressional leaders for agreeing to a structural fix to the Medicare SGR, which is slated to result in $24 billion in reduced payments to doctors in 2015 if nothing changes.

It will be important to watch how—if at all—the president’s 2015 budget intersects with a current bicameral proposal to repeal the SGR, said Don Moran, who worked in the Office of Management and Budget during the Reagan administration and is now president and CEO of the Moran Co., a healthcare consulting firm.

For instance, the president’s budget notes that Medicare will continue its transformation “from a passive payer to an effective purchaser of high-quality, efficient care.” It also highlights the ACA’s value-based purchasing program for hospitals and its requirement of the CMS to develop plans to implement value-based purchasing programs for skilled-nursing facilities, home health agencies and ambulatory surgery centers. So the question then becomes how these priorities might fit in with the proposals included in the SGR legislation.

“It is possible that they’re endorsing the SGR bill, but they’re not saying that,” Moran said of the Obama administration. “How does this budget help or hinder that?”

But Joseph Antos, a health policy expert with the Center of the American Experiment, points out that no means of paying for the agreement—which is projected to cost $138 billion over a decade—has been reached and the Obama administration didn’t provide any suggestions. “He doesn’t propose to pay for it, and neither does anybody else, so I think we can kiss that one goodbye for this year,” he said.

Elizabeth Carpenter, a director of Avalere Health, points out that many of the proposals are familiar from prior year budgets. “None of these are surprising, and there’s a lot of proposals that people have talked about for some time,” Carpenter said. “Certainly there is a greater emphasis on certain programs that are particularly appealing to folks in the president’s party.”

For instance, the budget calls for $14.6 billion over 10 years for healthcare training initiatives. That includes $5.2 billion to support 13,000 new residencies for physicians. However, the 2015 budget proposal contains only $100 million of that spending. In addition, the administration proposed spending $3.9 billion over six years to support the National Health Service Corps. That would increase the number of individuals enrolled in the program from 8,900 to 15,000.

The prospects for Obama’s $3.9 trillion budget proposal actually being enacted are bleak. That’s particularly true this year because congressional leaders hashed out a budget agreement in December for the 2014 and 2015 fiscal years. There will be little appetite for re-opening those congressional negotiations.

“The hard task has already been achieved, and that is the overall number that was agreed upon,” said Lara Brown, an associate professor at George Washington University’s Graduate School of Political Management. “The president’s budget proposal is to a certain extent a campaign document. They don’t expect the Congress to actually pick it up.”

Senate Budget Chairman Patty Murray (D-Wash) has indicated that she doesn’t intend to submit a budget for 2015. By contrast, House Budget Chairman Paul Ryan (R-Wis.), who is widely thought to be eyeing a 2016 presidential bid, plans to put forth his own fiscal blueprint, although he has not indicated when the details will be released. On Monday, Ryan issued a report, “The War on Poverty: 50 Years Later,” that provided a pointed critique of federal safety net programs, including Medicaid. It concluded that the federal healthcare program for the poor does little to improve the health of beneficiaries and in some instances dissuades them from entering the workforce. In the past, Ryan has proposed essentially turning Medicaid into a state block grant program.

But even if the president’s budget isn’t likely to gain much traction, it establishes a framework for the fiscal debate heading into the 2014 congressional elections. If Republicans are able to swing six seats and take control of the Senate, implementation of the federal healthcare law—the president’s signature domestic achievement—would be jeopardized.

The Hill reported Tuesday that the Obama administration plans to announce that it will allow health plans that don’t comply with the coverage requirements of the ACA to be expanded for another year. That would lessen the likelihood that tens of thousands of individuals would be receiving cancellation notices around the time that voters head to the polls in November.

Brown suggests that Democrats in tough re-election contests will seek to ignore the federal healthcare law, which remains broadly unpopular four years after passage. “Democrats are mostly going to change the subject as much as they can,” she said.

New ACA Causes Headaches In Some Doctors’ Offices

Sheila Lawless is the office manager at a small rheumatology practice in Wichita Falls, Texas, about two hours outside of Dallas. She makes sure everything in the office runs smoothly – scheduling patients, collecting payments, keeping the lights on. Recently she added another duty–incorporating the trickle of patients with insurance plans purchased on the new Affordable Care Act exchanges.

Open enrollment doesn’t end until March 31, but people who have already bought Obamacare plans are beginning to use them. “We had a spattering in January—maybe once a week. But I think we’re averaging two to three a day now,” says Lawless.

That doesn’t sound like many new customers, but it’s presented a major challenge: verifying that these patients have insurance. Each exchange patient has required the practice to spend an hour or more on the phone with the insurance company. “We’ve been on hold for an hour, an hour and 20, an hour and 45, been disconnected, have to call back again and repeat the process,” she explains. Those sorts of hold times add up fast.

In the past, offices have been able to make sure patients are insured quickly, by using an online verification system. But for exchange patients, practices also have to call the insurer to make sure the patient has paid his premium. If he hasn’t, the insurance company can refuse to pay the doctor for the visit, or come back later and recoup a payment it made.

That’s because of a provision of the law that gives exchange patients who neglect to pay their premium a “grace period” of up to 90 days. During the first 30 days, insurers have to pay any claims incurred by the patient. But for the next 60 days, nothing is guaranteed. If the patient visits the doctor, the insurer can “pend” the claim – that is, wait to pay the doctor until the patient pays his premium. At the end of the 90-day grace period, if the patient has not paid the premium, the insurer can cancel the coverage and refuse to pay the pended claims, or recoup the payments it’s already made.  And that puts the doctor’s office at risk.

So Lawless is checking first with the insurer to make sure that everything is in order before proceeding with the visit. If the premium has not been paid, Lawless gives the patient the option of rescheduling the appointment or paying in cash and then applying to his insurer for the payment.

“Most small practices run lean and mean – you’ve got one or two people to do this process plus do their other job duties that day as well, which is tend to the patients in front of them,” says Lawless. To manage the new workload, she’s had other staffers, including nurses, step in to answer the phone. And that means longer hours, more overtime, and higher overhead expenses. And then there’s the plain old annoyance factor.

“You call in and you hit option prompts and you get to listen to no less than an hour of Blue Cross Blue Shield intro music. I could sing you the tune, that’s how often I’ve had to listen to it,” she says. “My staff said yesterday, it’s a sad shame within their prompts you can’t pick your music as well. If you’re going to have to wait that long, at least let us listen to what we want to listen to!”

Blue Cross Blue Shield in Texas is the only insurer offering exchange plans in Wichita Falls. Dr. Dan McCoy, the company’s chief medical officer, says part of the problem was the health law’s compressed timeline.

“Clearly at the end of December there were a significant number of members that enrolled and it’s taken some time to work through that volume in membership,” explains McCoy. “And we know this is a new day in the transformation of American health care. So it’s going to take a little bit of time to work through that.”

Health Care Service Corp., which owns Blue Cross Blue Shield of Texas, has tried to address the situation by adding another 600 employees at its call center to handle the influx of calls and by extending business hours. McCoy has also been working directly with the Texas Medical Association to work out the kinks.

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association in Washington, D.C., a trade group for practice administrators, says the real problem is that signing up for coverage on the exchange isn’t as simple as the White House has made it sound.

“What we’ve found is that messaging out of the [Obama] administration right now that’s aimed at the public, it tends to oversimplify the complexity of what it takes to get covered on the exchanges,” says Gilberg. “Just because you enrolled in coverage doesn’t mean your coverage is effective.”

Even if patients pay their premium right away, it could be up to six weeks before their coverage actually starts. To have insurance start at the beginning of a month, the coverage generally must be purchased by the middle of the previous month. A plan purchased on Feb. 14 would be effective March 1. But a plan purchased on Feb. 16, for example, would not become effective until April 1. Go to the doctor before then, and your insurer doesn’t pay.

“It’s not a surprise that given the subtle nuances and differences of what these exchange products are, that you’re in a gray area right now where there’s a little confusion on the patient side and the practice side. And I think that’s what we’re seeing a lot of right now,” says Gilberg.

For a brand new program, that’s to be expected, he adds. And it doesn’t mean the exchange isn’t working. The real test will be what happens in April, when open enrollment ends and everyone who has purchased a plan offered through the health law’s online exchanges plan is clearly covered.

In the meantime, Lawless offers this advice to patients who have bought plans on the exchange: “If you pay your premium prior to [visiting the doctor], print that out and bring it with you because that will certainly save all a lot of grief.”

Repealing & Replacing the Sustainable Growth Rate (SGR)

  • The Sustainable Growth Rate (SGR) formula is a budget cap passed into law in 1997 to control physician spending, but it has failed to work.
  • Since 2003, Congress has spent nearly $150 billion in short term patches to avoid unsustainable cuts imposed by the flawed SGR. The most recent patch will expire on March 31st.
  • Building on bipartisan legislation unanimously reported out of the House Energy & Commerce and Ways & Means Committees, and reported out of the Senate Finance Committee, the unified legislation from the three committees repeals the SGR and transitions Medicare away from a volume-based system towards one based on value.

Repeals the SGR and provides stability and 5 years of payment updates

  • Repeals the SGR and replaces it with a system focused on quality, value, and accountability.
  • Removes the imminent threat of draconian cuts to Medicare providers and ensures a 5-year period of annual updates of 0.5 percent to transition to the new system.

Improves the existing fee-for-service system by rewarding value over volume and ensuring payment accuracy

  • Consolidates the three existing quality programs into a streamlined and improved program that rewards providers who meet performance thresholds, improve care for seniors, and provide certainty for providers.
  • Implements a process to improve payment accuracy for individual provider services.
  • Incentivizes care coordination efforts for patients with chronic care needs.
  • Introduces physician-developed clinical care guidelines to reduce inappropriate care that can harm patients and results in wasteful spending.
  • Requires development of quality measures and ensures close collaboration with physicians and other stakeholders regarding the measures used in the performance program.

Incentivizes movement to alternative payment models (APMs)

  • Provides a 5 percent bonus to providers who receive a significant portion of their revenue from an APM or patient centered medical home (PCMH).
  • Participants need to receive at least 25 percent of their Medicare revenue through an APM in 2018-2019. This threshold increases over time. The policy also incentivizes participation in private-payer APMs.
  • Establishes a Technical Advisory Committee (TAC) to review and recommend physician-developed APMs based on criteria developed through an open comment process.

Expands the use of Medicare data for transparency and quality improvement

  • Posts quality and utilization data on the Physician Compare website to enable patients to make more informed decisions about their care.
  • Allows qualified entities (QEs) to provide analysis and underlying data to providers for purposes of quality improvement, subject to relevant privacy and security laws.
  • Allows qualified clinical data registries to purchase claims data for purposes of quality improvement and patient safety.

CMS Delays ‘Two Midnight’ Rule Until After Sept. 30th

Under growing pressure from hospitals and physicians, the CMS is delaying the most punitive aspects of the new “two midnight” rule for Medicare hospital admissions until after Sept. 30.

The “two midnight” policy, included in Medicare’s inpatient payment rule for 2014, directs the agency’s auditors to assume that hospital admissions with proper documentation are reasonable and necessary in cases where the patient stays in the hospital for more than a day—defined legally as spanning two midnights in a hospital bed.

The change was intended to address widespread complaints that Medicare’s rules are too vague about when a moderately sick patient should be admitted for expensive inpatient care instead of outpatient observation. Hospitals have faced aggressive auditing over short inpatient stays, even though they say the rules didn’t set clear standards.

But hospitals aren’t happy with the new rules, either. That’s because they are presumed to have made an error and provided medically unneeded care if an inpatient doesn’t spend two midnights in a hospital bed.

Medicare’s recovery auditors were set to begin enforcing the rule Oct. 1, 2013, but that was pushed back to March 31 after providers complained. On Friday, the agency punted again and said recovery auditors—who employ sophisticated data-mining to locate questionable claims—will now have to wait until after Sept. 30 to start auditing claims under the two-midnights rule.

The agency will still allow Medicare’s administrative contractors, who process claims for payment, to review short stays and deny payment if the patient record doesn’t support medical necessity. But those reviews are intended to be instructional, and will be limited to a sample of between 10 and 25 claims per hospital.

“This is welcome news,” said Ken Raske, president and CEO of the Greater New York Hospital Association, in a letter to members. “The concerns expressed by all of you and our staunch collective advocacy on this issue have clearly influenced this delay.”

Key Senate Republicans Offer Their Plan To Replace Obamacare

Republicans have offered a wide array of proposals to “repeal and replace” the Affordable Care Act since it became law in 2010. But few have come with the pedigree of the plan just unveiled by a trio of senior Senate Republicans.

The Patient Choice, Affordability, Responsibility and Empowerment Act, or CARE for short, is a proposal being floated by Sens. Richard Burr, R-N.C., Orrin Hatch, R-Utah, and Tom Coburn, R-Okla.

Hatch is the senior Republican on the Senate Finance Committee; Burr is on the health subcommittee of the Health, Education, Labor and Pensions Committee; Coburn is a physician. All three have spent much or all of their legislative careers working on health policy.

“Obamacare just isn’t working,” Hatch said on the Senate floor Monday afternoon. “Try as he might during tomorrow night’s State of the Union address, President Obama will not be able to convince the American people that his health care law is anything other than an unmitigated disaster.”

At a briefing for health reporters, aides to the senators said the goal of their proposal is to focus on bringing down costs. Hence the plan would repeal the ACA’s requirements that most people have insurance, as well as requirements that insurers offer minimum benefits and employers offer insurance or face potential fines.

The Republican proposal also would eliminate most of the taxes and fees that the law imposes to pay for the generous tax credits offered to help people pay for the required insurance.

And the plan would repeal the requirement that insurers cover people with pre-existing health conditions, although people who remain “continuously covered” for at least 18 months could not be denied or charged more. And while the plan would keep the ACA’s ban on insurers’ imposing a lifetime limit on insurance benefits, annual limits could return.

The GOP plan offers its own set of tax credits to help those with lower incomes afford coverage, and like those in the ACA, they would be adjusted for age but not for geography. That means the tax credit would be the same across the nation, even though insurance costs differ widely in different parts of the country.

The tax credits also would be available to those earning up to three times the federal poverty line, or $34,470 in 2013. That’s less than in the ACA, which provides help for those earning up to four times the poverty level, or $45,960.

The GOP plan also would let insurers charge older people more than the ACA does, which could lower premiums for younger people. The ACA limits premium differences for older people to three times more than those for young people; the GOP proposal would allow premiums for older people to be as much as five times higher, although states could opt for different “age rating,” staffers said.

The proposal would leave the Medicare provisions of the health law untouched (“this is not about Medicare,” said one of the aides). But it would dramatically remake the Medicaid program, which is undergoing a big expansion as a result of the ACA.

The GOP plan would end the expansion of Medicaid to include all people below a certain income level. It would cap Medicaid’s currently unlimited funding, except for the elderly and disabled. States would instead get payments based on the number of low-income families and children, described by staffers as the program’s “traditional populations.” But there apparently would be no plan to continue insurance for people who are currently signing up for Medicaid in the half of states now expanding the program. Instead, those people would be offered tax credits.

And while the aides insisted that the overall plan is intended to create less disruption for people insured through their jobs, the GOP plan would be financed via a highly controversial mechanism: capping the so-called employer health insurance exclusion at 65 percent. That means that for the average worker, 35 percent of the health insurance benefits that are currently tax-free would instead be considered taxable income.

Economists across the political spectrum have recommended such a change as a way to curb the growing generosity of employer-provided health benefits. But the first small step toward that, a so-called Cadillac tax in the ACA, has proved so radioactive that most people doubt it will ever take effect as scheduled in 2018.

Doctors Cut from Medicare Advantage Networks Struggle with What to Tell Patients

Thousands of primary-care doctors and specialists across the country have been terminated from privately run Medicare Advantage plans, sparking a battle between doctors who say patient care is being threatened and insurers that insist they have to reduce costs and streamline their operations. Medical associations, which describe the dismissals as the largest in the program’s history, say the cuts are forcing some patients to leave their doctors in mid-treatment and creating gaps in the types of medical specialists covered in some areas. They’re taking their protests to court, and having some success. In December, a federal judge in Connecticut issued an injunction that temporarily prohibits an insurer from dismissing doctors in Fairfield and Hartford counties, and an appeals court in Texas has upheld a similar court order. Another lawsuit is pending in New York, and doctors groups in several other states are threatening legal action. The American Medical Association, the nation’s premier doctors organization — along with 39 state affiliates and 42 patient and medical specialty groups — has called on the Obama administration to intervene and put pressure on insurers to reverse the terminations. Insurers say they must shrink their physician networks because they face billions of dollars in government-payment cuts over the next decade — reductions that are being used partly to fund insurance coverage for millions of people under the federal Affordable Care Act. They also say the smaller networks will allow them to curb premium increases and to remain nimble as they prepare for an influx of patients under the law. Medicare Advantage, an alternative to traditional Medicare, covers 13 million beneficiaries, or 27 percent of the people in the federal health-care program for the elderly. Besides providing the standard benefits, the thousands of Medicare Advantage plans often offer extra perks such as free eyeglasses and adhesive bandages. They can do that because, for years, the government has paid the plans more, per patient, than it spends on regular Medicare. That has been a sore point for Democrats, who used the health-care law to cut payments to Medicare Advantage by $156 billion over the next decade. The doctor terminations, most of which took effect Jan. 1, are striking a nerve partly because of the way insurers have notified some physicians. Arthur Vogelman, a gastroenterologist, received a letter in the fall from United Healthcare informing him that he had been dropped from the insurer’s physician network. He said the letter contained no information about the reason for the termination. He appealed to the company and documented his successful treatment of thousands of patients, but his request was denied with no reason given. “It is an outrage. I have patients in their 80s and 90s who have been with me 20 years, and I’m having to tell them that their insurer won’t pay for them to see me anymore. The worst thing is I can’t even tell them why,” Vogelman said. One of his patients, Jorge Otoya, 68, who is retired from Morgan Stanley’s trading desk, said he had tried, without success, to find a plan that includes both Vogelman and his primary-care doctor at New York University. “I am a cancer survivor and have been going to this doctor for 15 years,” Otoya said. “He knows my system, left and right. I trust him. I called United Healthcare to protest, but they didn’t care.” Medical associations say a number of insurers are trimming their networks this year, but the most dramatic reductions may be occurring in United Healthcare’s Medicare Advantage plan. With 3 million members, the AARP-endorsed plan is the largest of its kind in the nation. United Healthcare said that it aims to reduce its national network of physicians by 10 to 15 percent by the end of 2014. The company declined to provide specific numbers, but medical associations say that in some states, thousands of doctors have been cut. Jack Larson, United Healthcare chief executive for Medicare and retirement, said in an interview that he believes the smaller networks will lead to better patient care, because insurers will be able to work more closely with doctors. “I’m not diminishing at all the short-term disruption when someone loses access to their physician. That’s a hard thing. .?.?. But we do believe that to have a quality health-care system we need to seek those physicians who have exceptional quality related to cost,” Larson said. A few weeks ago, the insurance industry, led by America’s Health Insurance Plans, a trade group, launched a public-awareness campaign that includes TV, print, digital and display ads and encourages seniors, a group with substantial political clout, to write and tweet about their concerns over the payment cuts. Industry officials have been appearing on Sunday talk shows and pressing lawmakers to restore some of the funding. A spokesman for the federal Centers for Medicare and Medicaid Services said that the agency is reviewing information about affected areas of the country but that health plans are allowed to change their networks at any time of year, as long as they provide adequate notice to providers and patients. Doctors who have been cut from the networks say they are angry and confused about the sudden terminations, how they were communicated, the possible damage to their reputations, and the financial effect on their practices. Some doctors say they did not receive letters informing them that they were no longer part of an insurer’s network. Others say their patients were told before they were. “The way this was handled was completely wrong,” said Patricia McLaughlin, an ophthalmologist in Manhattan. She discovered that she had been cut from one plan’s network when she was searching for doctors online for her own family and noticed that she was no longer in the company’s provider database. She added that because insurers haven’t been forthcoming about why some providers were cut and others were not, the terminations have made for awkward conversations with patients. “Many patients don’t understand that this isn’t their doctor’s fault, and that’s just despicable,” McLaughlin said. The terminations have forced doctors to make difficult decisions about how to handle longtime patients whose insurance will no longer pay for the doctors’ services. Vogelman’s office is canceling appointments made by his 143 patients enrolled in United Healthcare’s Medicare Advantage plan, because, he explained, “I won’t get paid.” He is referring those patients to doctors he trusts. Vlad Fridman, a Brooklyn cardiologist who was also cut from United Healthcare’s network, is taking a different approach. His practice decided to waive the customary $100 fee for the 100 or so existing patients enrolled in that plan. But Fridman said he’s not sure how the details will work out, whether the plan will cover tests his practice orders or what will happen when patients have to be hospitalized. “Honestly, we are telling those patients we will see them for free. It’s just fair. Me and my partner have been seeing them for years” Fridman said. “But the rest of it I have no control over, and we are at a loss about what to do.”