Hospitals Brace for New Medicare Payment Rules

A bundled payment initiative related to hip & knee replacements takes effect today - and no - it's not an April Fool's joke!

This could be a huge change in the way that people in need of hip & knee replacements are evaluated & subsequently treated for the surgery.  It puts the onus on hospitals for the costs of the procedure for the first 90 days.  After that, if they've handled the surgery & post operative care "economically", the hospital may benefit.  If not, the providers could potentially OWE Medicare money.

This will most likely have a profound effect on who gets treated and how.  High risk patients, or patients who cannot go directly home after the surgery, would be most at risk for either being denied care or receiving limited care.

It is understood that Medicare spending overall needs to be evaluated and reigned in somehow, but we may find that the net effect of blanket policies, rather than case by case evaluation of long term impacts of care may come back to bite us.

Let's say someone is denied a knee replacement due to high risk, post operative complications.  Overall, short term, it may seem like an expensive procedure, but long term - may provide the patient with necessary mobility to stay in their home without care for a longer term.  Without the surgery - they could potentially become immobile, leading to all sorts of more expensive care & poor quality of life in the long run.

There should be a better way to get at the long term costs and benefits of a given treatment for a patient, rather than making a blanket "rule", for a particular thing that really shouldn't be evaluated in a vacuum.

What do you think?  Read the Wall Street Journal Article below:

Hospitals Brace for New Medicare Payment Rules

Why the Obamacare 2016 Open Enrollment Stalled: The Big Unwritten Story About Obamacare––How Unaffordable It Is For the Working and Middle Class

Now that the most recent Open Enrollment period for the "Affordable Care Act" has ended, Bob Laszewski has written another article about the law and its impact that is right on the money.  The big "untold" story is about how it has impacted premiums for the segment of the individual market that do not qualify for subsidies and now have to bear the weight of astronomical premium increases.

You can read Bob Laszewski's blog post here . . . .

HIPAA'S USE AS CODE OF SILENCE OFTEN MISINTERPRETS THE LAW

Many of us have had an experience, especially if caring for a family member or a friend, of not being able to get the most basic information when contacting a provider or a hospital on the status of a patient in our care.  Even very basic information is withheld sometimes, under the guise of "HIPAA rules won't allow us to share that". 

The New York Times published a recent article about the subject that I thought would interest you.

Here it is . . . .

I found some of the additional comments related to the article to be telling as well.  Many come from doctors and people working in the healthcare field about the reality of working with the law's requirements.

Enjoy!

When Turning 65 - People Who Have Marketplace Plans or Other Individual Insurance Need to Review Options

Now that the Affordable Care Act has been offering plans through the Marketplace for 2 full years, there is new confusion for those turning 65.  Normally, in the pre-Affordable Care Act (ACA) world, someone turning 65 in an individual plan would have coverage cease upon their eligibility date for Medicare.  They were not able to continue.

In this new Post-ACA world, especially when plans are purchased through the Marketplace - people turning 65 often are not notified that they should be looking at enrolling in Medicare.  Further, those getting subsidies are often unaware that if they are Medicare eligible, they are no longer able to collect subsidies through the Marketplace to help pay for insurance.

Know that there are penalties in the Medicare system if you do not enroll when eligible.  These penalties are imposed once Medicare is actually picked up and last a lifetime.  Financially, they can be large, and many people do not understand this unless someone is advising them.

My advice to someone turning 65?  Enroll in Medicare when eligible, unless you are an unusual case, such as a person who has immigrated here and would have to pay for Part A since they haven't paid enough Medicare taxes to warrant "premium free" Part A coverage.  (Part A - Hospitalization is automatic for most people at age 65 and costs nothing, if you've worked 40 quarters (10 years) or more in this country.  The fees to support this have already been paid for through payroll during a person's lifetime while working in the US.)

Part B - which covers outpatient services, carries a monthly premium.  If you do not sign up for that when first eligible, there are penalties associated with enrolling later.

Here's a good article from Kaiser Health News that discusses this in more detail.  Read more here . . .

FAQ: Congress Passes A Bill To Fix Medicare’s Doctor Payments. What’s In It?

Well, our Congress has finally reached a decision on SOMETHING . . . .this time it's about how to stop the madness around the decreases to physician's payment schedules under what was known as the SGR or "sustainable growth rate" formula.  That's good news for physicians.  Maybe not such good news for some Medicare beneficiaries.

They are always looking for ways to pay for their changes to the system, and that is valid - it's WHAT they look at sometimes that puzzles me.  It is known that Insurance companies were caught increasing their risk scores (meaning that they over-inflated their numbers of high risk beneficiaries in their Medicare Advantage programs), so that they could receive more money to support those programs. 

Instead of reigning in that type of fraud, they decided to take away things like first dollar coverage for Medicare supplement plans C and F.  In other words, they are taking away more consumer choices, that have no impact on Medicare expenditures.  In 2012, this very issue was looked at to see if having first dollar coverage led to "overutilization" of medical care.  The National Association of Insurance Commissioners (NAIC) conducted its own study, concluding that it did not.  And, logic says that it cannot, since Medicare supplement plans can only pay AFTER Medicare pays.  So, if there is overutilization - it occurs at the Medicare payment level - not because someone has a first dollar Medicare supplement plan.

It's too bad we can't take away some of the wonderful choices around insurance that we provide to our legislators, while we tell them that we think that by taking away their choices, it will somehow "change their bad behavior".

There are other elements to the legislation that fixes the payments to physicians under Medicare.  You can read more here

A Detailed Analysis of the Republican Alternative to Obamacare

Bob Laszewski has offered a detailed look at the Republican's alternative to "Obamacare".  I agree with Bob, that it may have been easier to accept "Obamacare" as the baseline, in need of major renovations - but it seems that it won't happen.

Some of the ideas in these proposals make perfect sense, but they will have different consequences for different consumers within the market.  The other big challenge here is that these solutions proposed are also very complicated for the average person to really understand.  What do you think?

Here's Bob's article . . . .Health Care Policy and Marketplace Review - Bob Laszewski

Congress Is Back And Looking At Limiting Your Health Insurance Choices - But Now It's About Medicare!

Yes, that's right!  They are busy at work to begin examining ways to limit a Medicare Eligible person's insurance options.  Like your Medicare supplement?  Want to buy one that offers full coverage, and pays for gaps that Medicare does not cover?  Well, you may not have that option anymore if certain members of Congress get their way.

This article explains some of the options that were discussed at the hearing to discuss ways to solve the physician pay "sustainable growth rate" (SGR) problem - or "doc fix" as some call it:

"Why Medigap Sellers' Ears are Burning"

I guess I am mystified as to how limiting the purchase of a private insurance plan that only pays after Medicare pays its share, or eliminating certain types of private coverage help reign in Medicare spending on the whole.  The argument is that if you give someone the option to buy "first dollar" coverage, they will over-utilize medical care. 

I know that based on the people I deal with regularly in my own client base, many of my people who purchase first dollar coverage for themselves do not over-utilize care.  If anything, many of them are healthy people.  They have the means to buy the best coverage that they can, and do so - for peace of mind.

That should be their option.  If you have the money, and want a good plan - you should be able to purchase it.

When the whole notion of limiting over-utilization in the under 65 health insurance market were done after the advent of "high deductible" health plans were introduced, studies showed that in some instances, medical expenditures actually rose due to the fact that people delayed seeking care when they really needed it. Some ended up spending more on reactive care that could have been prevented if they had sought care initially.

The Congressional representatives who always talk about this issue of "over-utilization" continually talk about the patient having more "skin in the game".  This always strikes me as ludicrous coming from a set of people who have no "skin in the game" at all. 

They have coverage provided to them via the Federal Government that we all pay for.  Maybe they should have their own "skin in the game" and have to purchase insurance on the open market like the rest of us.

If members of Congress had to go to Medicare at age 65, and then find ways to supplement their coverage - don't you think most of them would be purchasing first dollar coverage for themselves? They can certainly afford it. 

In addition, if they had to have Medicare as their primary means of insurance coverage, they would have to acquire Medicare Part B, which at their salary levels would also result in them having to pay the Income Related Monthly Adjustment Amount or IRMAA.

Forcing members of Congress - and all Federal employees and retirees for that matter - to go into full Medicare at 65 could be a better way to fund the SGR problem.  With the extra money from their part B premiums, and the IRMAA that would also be collected, we could probably bring enough money into the basic Medicare program to fund it without denying the rest of the American public choices on the private market that work for them.

But - don't worry, even though no patient advocacy groups were represented at the hearing, I'm sure Congress will consider the needs of the American public first!  Right? . . . .