Medicare

A coalition of nursing home caregivers is urging the Senate to repeal a delay to new Medicare payments for nursing homes during the lame-duck session. Stakeholders had sought the delays to two regulatory changes approved by the Centers for Medicare and Medicaid Services in 2009, but only one regulation was delayed at the time.

The House has already passed legislation addressing the problem, and on Tuesday the Coalition to Protect Senior Care announced a letter-writing campaign targeting the Senate. The Centers for Medicare and Medicaid Services and the Medicare Payment Advisory Committee also support a swift resolution, the coalition said.

"Nursing homes throughout America are already experiencing significant economic turbulence as a result of this persistent, ongoing recession and the ability to hire, train and retain quality staff has been an enormous challenge – especially throughout rural America, where great distance between facilities makes matters still more challenging," coalition co-chair Lisa Cantrell said in a statement. "The frontline long term caregiver is the one who delivers the majority of care to our frail elderly. From the standpoint of protecting senior's access to quality nursing home care and helping to stabilize facility staffing, Congress needs to use this 'lame-duck' session to put in place the new payment system - which has no extra cost and is uniformly backed by all stakeholders."

Correction: This post was updated at 10:15 a.m. Wednesday to clarify that the nursing homes want the delay to be repealed.

The House passed a one-month, $1 billion “fix” to the Medicare physician payment formula Monday afternoon, two days before doctors were scheduled to take a 23 percent hit in Medicare payments.

The House approved by voice vote the Senate’s plan to fund the fix through cuts to payments for certain therapy services. The bill, which had passed the Senate on Nov. 18, now awaits the president’s signature.

If signed into law, a 2.2 percent update in physician payments will be put in place through the end of the year. This will be funded by expected savings from a 20 percent reduction in payments for therapy services.

The payment cuts to physical therapists are not as steep as the 25 percent cut previously proposed by the Centers for Medicare and Medicaid Services. Savings from the cuts will be used to pay for the "doc fix" instead of being redistributed to participants in the Medicare Physician Fee Schedule.

When the Senate approved its fix earlier this month, Finance Committee Chairman Max Baucus (D-Mont.) and ranking member Chuck Grassley (R-Iowa) said in a statement they would work on a year-long fix to the Sustainable Growth Rate formula that can be enacted before the end of the year.

The American Medical Association praised Congress for passing a one-month fix, but it urged lawmakers to quickly delay the scheduled payment cuts for an additional year.

"While this short-term delay helps ensure that physicians can continue to care for seniors for the next month, congressional action early in December to stop the cut for one year will inject stability into the Medicare program and ensure that Medicare delivers on its promise of health coverage for America’s seniors," the AMA said. "It is crucial that Congress act well before the January 1 deadline so there are no disruptions in care for seniors."

Doctors would see a 23 percent cut in their Medicare payments under the Sustainable Growth Rate (SGR) formula on Dec. 1 if the House doesn't act.

Medicare payments to physicians will be cut by 23 percent come Dec. 1 if Congress doesn't act before then.

A quartet of senior Senate Democrats on Wednesday introduced a bill for a lame-duck session vote to cut off planned Medicare rate increases scheduled to hit 12 million senior and disabled Americans.

Sens. John Kerry (D-Mass.), Chris Dodd (D-Conn.), Jeff Bingaman (D-N.M.) and Robert Casey (D-Pa.) unveiled the Medicare Fairness Act, which would extend a current “hold harmless” provision to cover Medicare recipients who would otherwise see rate hikes.

“We have a responsibility to protect all Medicare beneficiaries from unfair premium increases,” Kerry said. “Every penny counts right now, and 12 million seniors and individuals with disabilities are depending on us to restore fairness to the Medicare system.”

“Without a Social Security Cost-of-Living Adjustment increase, many of our country’s senior citizens will not be able afford an increase in their monthly Medicare Part B premiums,” said Dodd.

The federal Centers for Medicare and Medicaid Services (CMS) announced 2011 Medicare rates this month, under which most beneficiaries will pay the same $96.40 premium rate — unchanged since 2008. However, a little under one-third of beneficiaries will see their rates skyrocket by at least $225.

A hold-harmless provision in federal law currently protects most Medicare patients during years when Social Security benefits do not receive cost-of-living increases. However, new enrollees, low-income enrollees and seniors who do not receive Social Security are not covered by the provision, and could see their premiums disproportionately increased.

The Democratic bill would extend the current hold harmless policy equally to all Medicare enrollees.

Similar legislation passed the House by a vote of 406 to 18 in 2009, but the Democratic senators say the GOP has blocked it in the Senate.

Federal officials on Tuesday launched a new innovation center created by the health reform law that aims to fulfill the triple goal of improving individual care, coordination between providers and prevention.

"For too long, health care in the United States has been fragmented - failing to meet patients' basic needs, and leaving both patients and providers frustrated," Donald Berwick, the administrator of the Centers for Medicare and Medicaid Services (CMS), said in a statement announcing the center. "The Innovation Center will help change this trend by identifying, supporting, and evaluating models of care that both improve the quality of care patients receive and lower costs."

The innovation center's acting director, Richard Gilfillan, added that the center aims to improve the care of Medicare and Medicaid patients alike by working to "identify, validate, and scale models that have been effective in achieving better outcomes and improving the quality of care."

CMS launched the center on Tuesday with a stakeholder meeting including representatives for the health care industry, consumers, states and employers. The goal is to create public-private partnerships, Berwick said, and the innovation center will consult with stakeholders every step of the way and create an "open innovation community" to serve as an information clearinghouse of best practices.

A wide array of stakeholders immediately applauded the announcement. American Medical Association President Cecil Wilson, who was on a CMS call with reporters, applauded the partnership aspect.

But "for the models to succeed," he warned lawmakers, "it is crucial that Congress fix the broken Medicare physician payment system" and prevent a 23 percent cut in physician rates next month that could lead to an exodus of doctors out of the program.

Consumer advocate Debra Ness of the National Partnership for Women and Families also applauded the news.

"For those of us who are working on better coordination, better care and better outcomes for patients," she said, "today’s launch of the Innovation Center is good news indeed. It will help us realize the promise of reform."

The launch was accompanied by the announcement of four new initiatives:

• Eight states have been selected to participate in an evaluation of medical professionals working in a more integrated fashion and receiving more coordinated payment from Medicare, Medicaid and private health plans. They are Maine, Vermont, Rhode Island, New York, Pennsylvania, North Carolina, Michigan and Minnesota;

• Another demonstration will test the effectiveness of doctors and other health professionals working in teams to treat low-income patients at community health centers;

• A new state plan option will let Medicaid enrollees designate a provider as a 'health home' that would help coordinate their treatment; and

• States will soon get a chance to apply for contracts to support development of new models aimed at improving care quality, care coordination, cost-effectiveness, and overall experience of beneficiaries who are eligible for both Medicare and Medicaid, also known as 'dual eligibles'.  The Innovation Center expects to award up to $1 million in design contracts to as many as 15 state programs for this work.

The type of care cancer patients receive often has more to do with what hospital they happen to be treated at than their own wishes, according to a new study by researchers at Dartmouth.

About 80 percent of patients who are receiving end-of-life cancer care say they'd prefer to be at home, in familiar settings and close to family, for their last days, Dartmouth says. But the new study of Medicare data found that about 29 percent of cancer patients who died during the period from 2003 to 2007 did so in a hospital, with wide regional variations.

"What we found is that the care for patients varies markedly from region to region and from hospital to hospital," researcher David Goodman said in a conference call with reporters. "The care patients receive has less to do with what they want than with the hospital" they happen to be treated at.

Cancer patients were most likely to die away from home in the Manhattan hospital referral region, where 46.7 percent died in a hospital, according to Dartmouth. That rate is about six times higher than the rate in the Mason City, Iowa, region, where only 7 percent of cancer patients died in the hospital.

Dartmouth also reported wide variations in the use of intensive care in the last days of life, when it does little but add to patients' pain and discomfort.

The new study comes in the wake of two Institute of Medicine studies that documented overly aggressive and invasive treatments in many U.S. hospitals and an under-investment in care that would improve patients' quality of life, such as pain management.

Goodman said there were two main reasons for the disparities.

The first has to do with a variation in investment in hospital beds and Intensive Care Units, which leads to physicians using those resources to their limit rather than relying on palliative care.

Physicians also often have wrong assumptions about what patients and their families want, Goodman said. 

"That attitude has caused a lot of harm," he said, because "what it doesn't recognize is that patients hope for a lot of different things. 

"What patients really want is for physicians to be honest with them," he said. "Patients want to live long but they also want to live well."

Medicare administrator Donald Berwick will also say the law does not cut guaranteed Medicare benefits, according to his prepared remarks.

The Medicare agency is encouraging beneficiaries to take advantage of the annual Open Enrollment period, which started Monday. This is the one time every year when people with Medicare can review and, if necessary, change their current health care coverage.

Open enrollment this year began Nov. 15 and runs through Dec. 31. 

The Centers for Medicare and Medicaid Services on Friday announced the Medicare premiums, deductibles and co-insurance amounts to be paid by Medicare beneficiaries in 2011.

The standard Part B rate is $115.40 a month, a 4.4 percent increase over last year; but most seniors will pay the same Part B premium as they have since 2008: $96.40 per month. Richer seniors — the top 5 percent of earners — will pay between $161.50 and $369.10 because of a surcharge adopted in Republicans' 2003 prescription drug benefit.

Medicare says the premium is going up because of "growth in the use of services like outpatient hospital care, home health and physician-administered drugs." The premium also incorporates potential congressional action to avert a 23 percent physician pay cut scheduled for Dec. 1.

The deductible for Part A Medicare (hospital and nursing home care) goes up $32 next year, to $1,132.

For prescription drug plans, the average premium for all plans will rise by 9.49 percent, according to estimates by the policy group Avalere. Under the new healthcare reform law, according to Forbes, the richest seniors will pay an extra $12 to $69.10 a month for their coverage.

President Obama's fiscal commission proposes to get the government's healthcare spending under control with a laundry list of oft-debated solutions that neither party has been able to enact because of entrenched ideological and industry opposition.

The co-chairmen's mark, unveiled Wednesday, suggests "asking doctors and other health providers, lawyers and individuals to take responsibility for slowing healthcare cost growth." The proposals include tort reform, drug rebates and Medicare payment cuts, all of which have been lobbied to a halt in the past.

The proposal also recommends mandatory premium increases and payment cuts after 2020 if federal healthcare costs continue to grow faster than the rate of growth of GDP plus 1 percent. And it rekindles the debate over taxing health benefits and instituting a public option.

The commission's proposal starts with preventing a scheduled 30 percent cut called for by the physician payment formula, known as the Sustainable Growth Rate (SGR). The "doc fix" pay freeze would cost $276 billion over 10 years, which would be paid for "not through deficit spending but through savings from payment reforms, cost-sharing and malpractice reform, and long-term measures to control healthcare cost growth."

The proposed offsets include: 

• Paying doctors and other providers less, improving efficiency and rewarding quality by speeding up payment reforms and increasing drug rebates. The proposal would replace the SGR with "modest reductions" through 2015 and then establish a new payment system (saves $24 billion); the proposal would also require manufacturers to offer rebates on brand-name drugs as a condition for participating in the Medicare prescription drug program (saves $59 billion);

• Reducing the cost of defensive medicine by adopting comprehensive tort reform (capping non-economic and punitive damages and making other changes in tort law would save $64 billion);

• Expanding cost-sharing in Medicare to promote informed consumer health choices and spending (eliminating first-dollar coverage in Medigap plans would save $50 billion; replacing existing cost-sharing rules with universal deductible, single coinsurance rate and a catastrophic cap for Medicare Part A and Part B would save another $85 billion);

• Expanding successful cost-containment demonstrations;

• Strengthening the healthcare reform law's Independent Payment Advisory Board (IPAB); and

• Recommending additional health savings.

During the healthcare reform debate, early calls for tort reform and drug rebates were quickly squashed after heavy lobbying by lawyers and drugmakers. As for the IPAB, rather than strengthening it, a number of Republicans have called for its repeal.

But the fiscal commission thinks the appointed board has promise if it can get some teeth after being watered down considerably during the reform debate. The 15-member board would make recommendations for cuts in Medicare payments to providers if federal health expenditures grow faster than a specified target.

The commission proposal would strengthen the IPAB by: 

• Eliminating special carve-outs for hospitals and certain other providers;

• Increasing the spending rate reduction target to 1.5 percent starting in 2015 instead of 2018;

• Eliminating the trigger that would turn off the IPAB in 2019 if other cuts called for in the healthcare reform bill are achieved;

• Allowing cost-saving recommendations even if spending doesn't surpass target growth rate;

• Allowing proposals that apply reforms to health plans in the exchange; and

• Creating a "back-up sequester" that would automatically increase premiums and reduce provider payments if IPAB recommendations (or equivalent savings) are not adopted.

The proposal would set a global target for all federal health spending after 2020 of GDP plus 1 percent, and review costs every two years. If costs grow too fast, the president would be required to submit — and Congress would have to consider — reforms that could include a public option.

In addition, the proposal tackles healthcare costs on the tax side.

It lays out one option, named after Sens. Judd Gregg (R-N.H.) and Ron Wyden (D-Ore.), that would cap the income-tax exclusion for employer-provided healthcare at the amount of the actuarial value of the standard option under the Federal Employees Health Benefits Plan. Taxing health benefits would likely lead employers to drop more expensive plans and almost doomed healthcare reform after unions revolted against the tax on so-called "Cadillac" plans, which ended up being significantly delayed and watered-down.

Another solution consists of a "tax reform trigger" that calls for an across-the-board "haircut" for itemized deductions, employer health exclusion and general business credits that would take effect in 2013 if reform is not yet enacted.