Medicare

The healthcare reform law falls far short of reforming a healthcare payment system that is bankrupting the nation, but progress remains possible, lawmakers and physicians agreed Tuesday at a panel on payment reform.

Sen. Tom Coburn (R-Okla.) launched the discussion, hosted by The Hill and sponsored by the American College of Cardiology, by acknowledging "we have designed exactly the tragedy that we have" — namely, a payment system, largely driven by Medicare, that pays for quantity rather than quality of care. That argument was repeated throughout the healthcare reform debate, but Coburn, a family physician, advocated for specific steps: 

• encourage physicians to spend more time with their patients by changing billing codes to consider time, skills sets and outcomes;
• create pilot programs in federal health programs that reward physicians who order fewer tests without decreasing the quality of care they provide; and 
• address the issue of medical liability.

Rep. Brian Baird (D-Wash.), a clinical psychologist, repeated his call for ending Medicare and Medicaid. His alternative would cover everyone by replacing the unwieldy array of federal and state health insurance programs with a needs-based voucher system.

Baird held out on supporting the healthcare reform law until the last minute because it fails to overhaul the existing programs. But he defended several provisions of the new law, particularly comparative effectiveness research he said is vital to rewarding quality care and keeping costs under control.

"Sadly," he said, "it is easy to sometimes demagogue that and say, 'Well, somebody wants to tell your doctor what they can do for you.' Well, if the doctor isn't doing what is right for you, maybe somebody ought to tell them that."

Enrollment in the controversial Medicare Advantage (MA) program will increase by 5 percent in 2011, while average premiums will drop by 1 percent, the Obama administration announced Tuesday.

White House health officials said the numbers indicate that — despite threats from conservatives and the insurance industry that the new healthcare reform law will cripple MA plans at the expense of seniors — both patients and taxpayers will benefit from the reforms.

"Despite the claims of some, Medicare Advantage remains strong and a robust option for millions of seniors who choose to enroll or stay in a participating plan today and in the future," Donald Berwick, head of the Centers for Medicare and Medicaid Services (CMS), said in a statement. “The Affordable Care Act gave us new authority to negotiate with health plans in a competitive marketplace. As a result, our beneficiaries will save money and maintain their benefits."

The MA program — under which the government pays private insurance companies to cover Medicare patients — has been a lightening rod of controversy since its creation in 2003. Seniors have flocked to MA plans because many of them cover services, like dental and eye care, that Medicare doesn't.

But the extra care hasn't come cheap. Despite promises that private plans operating under MA could eventually save money, the cost to treat the average MA patient is roughly 14 percent higher than the cost to treat the average senior under traditional Medicare. 

The Medicare Payment Advisory Commission, an independent panel that suggests reforms to Congress, has noted that part of the additional cost “consists of funds used for plan administration and profits and not direct health care services for beneficiaries.”

Such statements have fueled criticisms from patient advocates and consumer groups that MA is just a giveaway to insurance companies. Many Democrats tend to agree, and the new reform law cuts MA subsidies substantially over the next decade.

As part of that effort, Medicare will freeze payments to MA plans next year, before actual cuts take effect further down the line.

The freeze has done little to discourage plan participation, CMS said Tuesday, largely crediting the insurance companies themselves. 

"The plans are making very strong commitment to their programs," Jonathan Blum, director of CMS’s Center for Medicare, told reporters in a phone call. "We're seeing better value for beneficiaries and for taxpayers."

Among the other revelations Tuesday: 

• About 5 percent of MA enrollees will have to choose new plans in 2011, largely resulting from MA reforms enacted in 2008. Of those seniors, all but 2,300 will have the option of choosing another MA plan; 

• 99.7 percent of Medicare beneficiaries will have access to an MA plan in 2011;

• Of the roughly 2,100 MA plans submitting 2011 bids, CMS identified 300 that had proposed to hike premiums or other cost sharing on seniors, while also increasing their profit margins. After CMS threatened to deny those plans, all but seven plans reworked their bids to the benefit of seniors.

House Ways and Means Republicans on Friday renewed their request for a hearing with Don Berwick, administrator of the Centers for Medicare and Medicaid Services (CMS). Their first request was on July 14.

In a letter to Committee Chair Sandy Levin (D-Mich.), the 15 Republicans on the panel reminded Levin that on July 22 the chairman had indicated a willingness to have Berwick before the committee "after [he] has been in office for a period of time." President Obama installed Berwick by recess appointment in early July.

Berwick is controversial because of his past statements that the government should "ration with our eyes open." Republicans have picked up on those statements and the healthcare reform law's cuts in Medicare payments to insurance plans and providers to argue that Berwick would curtail seniors' benefits.

"We are eager to hear his plans for CMS," the letter states, "because Medicare's own actuaries predict that the one-half trillion dollars in cuts to Medicare in the recently enacted health law could result in providers no longer treating seniors, jeopardizing their access to care."

Senate Finance Republicans Chuck Grassley (Iowa) and Orrin Hatch (Utah) sent a letter to Berwick himself on Monday asking him to request a hearing with their panel. 

The chairman and ranking member of the House Ways and Means health subcommittee introduced legislation Wednesday that would allow the Department of Health and Human Services to ban corporate executives from doing business with Medicare if their companies were convicted of fraud, even if the conviction takes place after their departure.

The bill, introduced by Reps. Pete Stark (D-Calif.) and Wally Herger (R-Calif.), would also give the HHS Office of the Inspector General the ability to exclude parent companies that may be committing fraud through shell companies.  

The OIG's chief counsel asked for the two changes during a hearing on Medicare fraud in June, according to the bill's sponsors.

"This legislation gives the Office of Inspector General the authority to go after crooked executives and corporations that continue to bilk Medicare," Stark said in a statement. "Stopping these swindlers will save taxpayer money and protect Medicare beneficiaries. I appreciate the OIG making this request for more authority, and thank my Democratic and Republican colleagues, especially Mr. Herger, for working together to address this issue."

Rep. Pete Stark (D-Calif.), the chairman of the House Ways and Means health subcommittee, said Tuesday that the federal government could end up paying too much for dialysis drugs under Medicare.

Stark was reacting to the findings of a study he requested from the Office of the Inspector General of the Department of Health and Human Services. The report found the cost of dialysis drugs dropped between 2003 and 2009 but the index the Medicare program uses to reimburse prescription drugs rose. 

"This report shows that we must find the right payment levels that preserve Medicare beneficiaries’ access to quality care," Stark said in a statement. "Dialysis drug costs have dropped while the index the government will use to increase prices over time has risen. If these trends continue, the government will be overpaying for dialysis drugs. We must continue to carefully track drug cost and utilization trends for dialysis treatment."

Sen. Tom Carper (D-Del.) on Tuesday blasted the Medicare agency for what he considers an inadequate response to his concerns about the prescription-drug program's integrity.

"The Centers for Medicare and Medicaid response to my concerns about the $1.2 billion in Medicare prescription drug claims that contained invalid prescriber identifiers left a lot to be desired," Carper said in a statement.

Carper wrote to the Centers for Medicare and Medicaid Services on July 29 and requested the agency establish a process to ensure valid identification numbers on reimbursed prescriptions under the Part D program. The law requires the identification numbers to ensure drugs are being prescribed by legitimate health professionals, but an audit by the Health and Human Services Office of Inspector General found that $1.2 billion in reimbursements in 2007 — representing more than 18 million claims — contained invalid prescriber identification.

In its response to Carper, CMS points out that invalid identifiers don't automatically indicate an invalid prescription or a fraudulent claim. Some 98 percent of the errors the OIG found were related to a problem with invalid Drug Enforcement Agency numbers that has since been fixed, the agency added.

CMS said it would begin a prescriber identification project this month, while also allowing some prescriptions with wrong identifiers to go forward to avoid penalizing patients.

"Preserving beneficiary access to necessary prescription medications is at the heart of CMS’ mission for the Part D program," the agency wrote, "and the problem identified by the OIG, while serious, should be addressed by CMS in a manner that does not jeopardize the Agency’s mission to provide needed medical services and supports for our beneficiaries."

Carper was unimpressed.

"Instead of immediately addressing this problem," he said, "CMS is instead only reminding the Medicare prescription drug plans to follow the existing law and hiring yet another contractor to study the problem for a year. That just won't cut it."

Carper is a member of the Senate Finance Committee, which has jurisdiction over Medicare.

Rep. Joe Courtney (D-Conn.) is circulating a 'Dear Colleague' letter seeking support for his bill that would make it easier for patients to qualify for Medicare nursing-home benefits worth hundreds of dollars a day.

The proposal comes as the new healthcare reform law and other recent changes to Medicare may unintentionally make it harder to qualify, according to the nursing-home industry and a recent analysis by Kaiser Health News.

Read more...

The anesthesiologist lobby is pushing back this week against a New York Times editorial hinting that nurse anesthetists are as qualified as physicians to deliver anesthesia care. 

Alexander A. Hannenberg, president of the American Society of Anesthesiologists (ASA), said a shift to certified registered nurse anesthetists (CRNAs) — and away from the better-trained doctors — "is both dangerous and ironic and condemns Americans to the end of improvement in anesthesia."

Current Medicare rules dictate that CRNAs can't administer anesthesia services without a physician present — unless states choose to opt out of that requirement (15 have done so in the past decade). Some medical experts say the quality of care is the same in either case, and they're pushing Medicare to eliminate the physician-supervision requirement.

The Times's editorialists on Tuesday hinted that they support that plan.

"From a patient’s point of view, it would seem preferable to have a broadly trained anesthesiologist perform or supervise anesthesia services, but, in truth, the risk is minuscule either way," the Times wrote on Tuesday. "As health reformers seek ways to curb medical spending, they need to consider whether this is a safe place to do it."

But the anesthesiologists are quick to argue that the reduction of risk surrounding anesthesia treatments didn't happen by accident. 

"Anesthesia safety has improved so dramatically in the past 20 years precisely because physicians are developing and testing the drugs, techniques and monitors leading to those improvements," Hannenberg said in an e-mail. "When The New York Times proposes to drop physicians from anesthesia because of those advances, it is both dangerous and ironic and condemns Americans to the end of improvement in anesthesia."

This debate, it would seem, is far from over.

Editorialists at The New York Times jumped this week into the hotly contested issue of whether doctors or nurses should be chiefly responsible for providing anesthesia care — and suggest that the cost savings related to nurse-administered treatments shouldn't be ignored. 

"It costs more than six times as much to train an anesthesiologist as a nurse anesthetist, and anesthesiologists earn twice as much a year, on average, as the nurses do ($150,000 for nurse anesthetists and $337,000 for anesthesiologists, according to a Rand Corporation analysis)," the Times editorialists wrote Tuesday. "Those costs are absorbed by various institutions and public programs within the health care system."

Under current Medicare rules, surgeons or anesthesiologists must oversee the care provided by certified registered nurse anesthetists (CRNA) in order for those treatments to be reimbursed. In 2001, the Centers for Medicare and Medicaid Services allowed states to opt out of that requirement, which 15 states have done.

The different state models have allowed researchers to compare the outcomes of care delivered by CRNAs working alone to that of CRNAs monitored by a physician. In a report published last month, experts at the Research Triangle Institute found there was no measurable difference, in terms of quality of care, between the two models.

The anesthesiologist lobby has been quick to defend its turf, arguing that the years of training endured by physicians makes them better suited to administer treatments — particularly in those cases where complications arise on the operating table. Patients prefer having the more experienced doctors deliver those services, the anesthesiologists say.

The Times notes that the mortality rate surrounding anesthesia care is tiny in both cases. 

"From a patient’s point of view, it would seem preferable to have a broadly trained anesthesiologist perform or supervise anesthesia services, but, in truth, the risk is minuscule either way," the Times writes.

"As health reformers seek ways to curb medical spending, they need to consider whether this is a safe place to do it."

The Obama administration this week rebuffed a request from House lawmakers that Medicare announce the first round winners of the agency's competitive bidding program for durable medical equipment (DME).

"We do not believe it would be appropriate or in the public interest to release any bidders' names before the contracting process is complete, as there are a number of risks associated with doing so," Donald Berwick, head of the Centers for Medicare and Medicaid Services (CMS), wrote in an Aug. 30 letter to Rep. Jason Altmire (D-Pa.).

Altmire had spearheaded the lawmakers' request that CMS announce the winners more quickly.

"Without knowing the identity as well as the appropriate overall qualifications of these providers, we cannot evaluate the program's impact in terms of quality and access to care for seniors we represent," the lawmakers wrote in an Aug. 11 letter to Berwick.

More than 130 House members representing both parties endorsed the move. 

CMS has said it will announce the contract winners later in September, "once all contracts have been finalized."

Berwick reiterated that timeline Monday, arguing that providing "interim lists" of winning bidders would both confuse beneficiaries and undermine "the orderly and effective implementation of the program."

"In addition, we have not yet notified the suppliers whose bids were not among the winning bids, and we believe that these suppliers should be notified before the names of the suppliers with winning bids are released to the public," Berwick wrote. 

"Further, announcing a subset of suppliers before the contracting process is complete could be viewed as giving those suppliers an unfair competitive advantage." 

Finally, Berwick added, "standard procurement rules prohibit disclosing the identities of bidders until after contracts are final."

Medicare's competitive bidding program is designed to control costs and rein in fraud in the durable medical equipment industry.

In July, CMS announced Medicare patients in the nine regions affected by the first round of the program would save, on average, 32 percent on DME products, which include oxygen supplies, power wheelchairs and hospital beds.

The DME lobby, however, says the program will put many small companies out of business, threatening seniors' access to vital equipment. The industry has fought to have the program scrapped altogether. 

This post was updated at 1:51 p.m.