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

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? . . . .

Surprises Lurk for People Re-Enrolling on HealthCare.gov

This year, there may be surprises in store for those who do not do a subsidy "re-determination", and then shop for new plans and coverage.  If you were given subsidy money to purchase a policy under the new Affordable Care Act through Healthcare.gov last year, you may need to go back in and do a subsidy re-determination - especially if you believe your income for 2015 will be different than what you have projected for 2014.

Even if income stays the same, the plan choices and level of subsidy offered for the same income could differ considerably.

The Wall Street Article below spells it out pretty well. 

Surprises Lurk for People Re-Enrolling on Healthcare.gov 

I know that in the Kansas & Missouri markets there will be additional insurers entering the Federal Exchange/marketplace that were not present last year.  Insurers will also be offering some new plan designs that may impact what choices people make - even if they have been satisfied with their current coverage.

"Off-Exchange" policies will also offer more choice, for those who already know they will not qualify for subsidies.  If you do not qualify for a subsidy, there's really no good reason to shop through Healthcare.gov - unless you really want to go through the entire income verification process before you can purchase.

If you know you're going to purchase "off-exchange", you can go directly to the carrier to purchase, or work through an agent/broker (like me) who can run side-by-side quotes for you to choose from.

Open enrollment for individuals and families begins on 11/15/2014 and goes until 2/15/2015.  If you need to have coverage in place for a January 1 effective date, you'll need to be enrolled in a plan no later than 12/15/2014.

Tax refunds may get hit due to health law credits

Get ready - here it comes!  Now that we're approaching the end of the year it's time to consider whether or not those of you who are benefitting from Advanced Tax Credits to pay for their health insurance underestimated their 2014 income.  If so, you may be subject to claw-backs at tax time.

This consideration also must be taken into account before the upcoming enrollment period, which is from 11/14/2014 through 2/15/2015.    During this next enrollment, you'll have to "estimate" your 2015 income.  If you've miscalculated for 2014, you'll want to be sure you don't build on that mistake.

Read the AP Article here . . . .

Missouri Exchange Rates - A Snapshot

Many of my clients in MO have been wondering what rates for the new ACA compliant insurance plans will cost.  Here is a quick snapshot of what the rates currently look like.

Snapshot of Missouri Exchange Rates

Those who are eligible for a subsidy, would be able to have some help paying for these plans.  You can use the calculator below to determine how much help you might receive.  I've posted this before, but here it is again.

Kaiser Foundation Subsidy Calculator

Since Healthcare.gov hasn't been accessible, using the tools above may be a quick way to estimate what your premiums might be under the new system.

If you don't need the federal money, there are plenty of plans that you can buy "off-exchange" if you need to purchase insurance.

If you already have insurance, you may want to keep your current plan, if you are able to do so.

As always, my clients can always e-mail me or call with questions.

Is the Affordable Care Act Actually Affordable?

I've been wondering that myself as I complete the training associated with being able to assist clients as the law is implemented.

My conclusion is that maybe it won't be - especially for some segments of the population.  Even with the federal subsidy money, I've been wondering whether or not people with very limited incomes will be able to afford the portion of the health insurance premium that is left for them to pay once the subsidy is taken into account.  Apparently, I'm not the only one.

This article from AlterNet takes a closer look:

Read the full article here.

Enrollment for new, ACA compliant plans is scheduled to begin on October 1 and will continue through 12/31/2013.  This is an extended enrollment period, since the government realizes that there will be a lot of confusion in the marketplace about when they must enroll or make changes.  After this year, the annual enrollment period for individuals and families under the age of 65 will be from October 15 - December 7 each year.

As new information becomes available, I'll be sure to communicate it.

Here's what's "got my goat" today about our Medical system . . . .

I had a Doctor's appointment scheduled for next week, and today got a call from the office today stating that when I come in I'd have to bring $100 "earnest money".  I've never been asked for this before, since I have a $40 co-pay to see a specialist.  But - since the practice was sold to the adjacent hospital, they are now saying that my doctor is an "outpatient clinic" and the co-pay no longer applies.  Therefore, I'd have to pay out of pocket until meeting my deductible.

Basically, they've redefined what an office visit is or is not - simply to suit themselves.  No one cares that I've paid for my insurance & included features like co-pays because I was willing to pay the premium for them.

With the advent of health care reform arriving on the scene, I've been seeing more consolidation - on the insurance company side of the business & now on the provider side.  As providers begin to consolidate, it seems they are re-defining what certain visits are, as well as, how certain hospital stays can be billed.

One example of what's happening with 'in-facility' stays, is the new phenomenon of keeping someone overnight (mainly after a visit to the emergency room) for "observation", and giving the impression that the patient has been admitted, when in fact, they have not.  What happens here can make a huge difference to some of my Medicare Advantage beneficiaries, since they pay a daily hospital rate if they are an inpatient that includes everything that happens while they are there (all tests, surgeries, etc).  If they are kept in an outpatient status, that same Medicare Advantage beneficiary would be subject to paying 20% of everything that happens there - so it's very much like 'a-la-carte' billing - resulting in a much higher bill.

Today, the patient has to be ever vigilant & ask very pointed questions about how they will be billed prior to having procedures done.  We're entering an age where none of this is about the patient & patient care, but is all about the money and the various corporate entities that are deciding everything about how care will be administered.

Look alert!  Make sure that if you have any type of serious illness or ongoing need for care, you involve a family member or friend to advocate on your behalf.  When you become seriously ill, you just won't have it in you to fight the good fight.

As for my situation, I told them to cancel my appointment and that I'd find another doctor who would honor my insurance with the features that I've been paying for. . . .

Back to the Future? . . . . .

This article from the Kaiser Foundation and USA today discusses possible ways that insurers will manage risk, once they have to accept all applicants regardless of health history.  It projects that they may choose to manage risk by limiting the types of services & more costly medical approaches through the introduction of tightly managed plans that have narrower networks.

Read the article here . . .

What are your thoughts on this?