The Medicare Payment Advisory Commission wants a copayment to discourage misuse of home health care services.

The congressionally appointed commission voted 13-1 to recommend that lawmakers impose the new charge. Two commissioners abstained and one was absent.

According to the Associated Press, home health services, which are currently covered under Medicare, cost taxpayers approximately $20 billion a year.

The co-pays, commission chairman Glenn Hackbarth said, would help avoid the benefit turning into a “long-term care social support system.”

Concerns with Medicare fraud and a tight budget have motivated the commission to look for cuts. Home health care was originally considered a “cost saver.” Now increasing costs and big differences in how communities around the country use the benefit have given lawmakers reason to make changes.

Exemption from the recommendation would include low-income patients covered by Medicaid, as well as those just discharged from the hospital. According to the AP, more than 30 million beneficiaries in traditional Medicare would be directly subject to the fee.

The recommendation was strongly opposed by AARP lobbyists who support a strong network of home providers to assist the more than 3 million seniors and disabled people on Medicare who are not able to easily leave home.

In September, AARP strongly supported The Home Health Care Planning Improvement Act of 2010, House Bill 4993 and Senate Bill 2814, which was a bi-partisan effort to expand the roles of nurse practitioners and physician assistant to allow them to certify home healthcare plans for Medicare patients.

In rural parts of the country, areas where the nation suffers from shortages of physicians, many Americans see nurse practitioners as their primary care provider.

As the health care debate raged onwards in 2009, the number of uninsured American adults rose by 3 million from 2008. Overall, approximately 46.3 million people in this country do not have health insurance covered.  In Texas, over one out of every four people was uninsured in 2009, compared to the 15.4 percent nationally.

The Center for Disease Control (CDC) survey found that almost 60 million people went without health insurance for at least part of the year, and 33 million of the uninsured had gone without for over a year.  People who were fortunate to keep their private coverage ended up paying more, while high-deductible plans also grew in popularity—especially among people who purchase their own health insurance plans.

3 Million More Uninsured in 2009

Fewer children are going without health insurance plans because they are enrolled in public policies.  See my previous article onCHIP and enrollment strategies the government may be using to get more kids into the program. However, almost one third of Americans between the ages of 18 and 24 did not have health insurance, the highest percentage of any other age group. Still, the fact that the ranks of the uninsured actually expanded in 2009 are worrisome to me.

Although individuals can still pay out of pocket for services, health insurance remains the most crucial portal to receiving adequate health care.  People who are enrolled in health insurance plans, regardless of the level of coverage, have far more access to preventative medical services. There is no denying that adequate medical care is expensive—rising medical costs in addition to the economy make insurance critical to obtaining health services.  If you are uninsured, you are more apt to delay health care until your illness is severe. According to research by the Harvard Medical School, around 45,000 Americans die every year because they are uninsured and therefore cannot receive adequate health care.

This study highlights the importance of health insurance in the United States today.  For the most part, people without health insurance are more likely to have lower incomes, and face an uphill battle when it comes to paying for care out of pocket.  Increasing rates of uninsured Americans is undoubtedly linked to the recession, which keeps them away from receiving the care they need. The fact that so many Americans remain uninsured—whether by choice or by economic necessity—proves very relevant to the 2010 Affordable Care Act. Escalating rates of un-insurance and skyrocketing medical costs are huge problems in the United States today.

When 2014 rolls around, enrolling the uninsured in new health insurance plans will be a daunting task.  The Affordable Care Act will broaden insurance to over 30 million citizens, who will likely need a little prodding when it comes time to enroll.  Canvassing campaigns in low-income neighborhoods aim at enrolling uninsured children in CHIP or Medicaid,working as a test run for the 2014 expansion of health insurance coverage.

As in my last blog about Massachusetts Health Care Reform, it is not the broader coverage that I am concerned about. Hopefully, the government will take cues from Massachusetts and ensure that the reform will not grow so costly that expenses outweigh coverage benefits.

Public Option Not Dead On the Hill

The bill, sponsored by Rep. Lynn Woolsey (D-CA), has 125 co-sponsors and is similar to the public option originally passed by the House Education and Labor Committee earlier this year but adjusted to fit within the framework of insurance exchanges which eventually made it into the reform debate’s final product. Woolsey says the non-partisan Congressional Budget Office has scored this legislation better than the public option in the House’s original healthcare bill. This bill sets public option reimbursement rates at 5% above Medicare rates.

Though most proponents admit it’s unlikely the bill would come to a vote this Congress, its co-sponsors argue if passed it would help bring down the deficit. For this reason, although it is unlikely the bill will pass this year its co-sponsors defend its introduction on a symbolic basis. By reintroducing it, they hope to remind legislators and votes alike that the public option is a viable option.

Medicare Fraud Identity Theft

One issue plaguing the Medicare reforms is Medicare fraud. Every year, both seniors and the government lose quality health care and billions of dollars to corrupt providers.  Medicare fraud isn’t new (see my previous blogs on fraud and scams), but as the new health care reforms have passed, fraud has been in the spotlight. Medicare fraud affects everyone, from the government to seniors to taxpayers.

Cutting costs for health care is integral to health care reform. According to the United States government, taxpayers lose over 60 billion dollars every year due to Medicare fraud.  The government uses taxpayer money to finance Medicare, so when people abuse the system, it is the taxpayers who pay the price.

South Florida is the hotbed of these schemes, full of phantom pharmacies and providers, where criminals can earn tremendous amounts of money by cheating the government. Scammers sometimes purchase businesses like pharmacies, along with Medicare licenses and patient records, and use that information to charge Medicare for drugs and other services. According to a report by ABC news, one man’s Medicare card was used to purchase two prosthetic legs—even though the man had both of his legs, Medicare was slow to respond. Because Medicare moves very slowly, even when dealing with something like fraud, it is easy for con men to get away with their crimes.

Con men and fraudsters aren’t the only ones to participate in Medicare fraud schemes. Some corrupt health care providers overcharge Medicare for certain services that may or may have been performed improperly. Not only does this swindle the government out of millions of dollars, but also can harm the health of Medicare beneficiaries.  Most doctors and other providers are not involved in any of these scams, but the minority who do fraudulently charge Medicare waste government cash and harm senior health.

Preventing Medicare fraud could save the government—and taxpayers—billions of dollars annually, making it imperative to crack down on scammers and corrupt providers.  In the current system, responses to fraud are often slow and cumbersome, with little action taken. When Medicare cracked down on fraudulent equipment sales in South Florida, Medicare durable medical equipment claims dropped by $1.76 billion. By making more of an effort to combat fraud, it will be possible to save billions of dollars.

Recently the Department of Health and Human Services proposed that individual workers found responsible for Medicare fraud should be removed from the Medicare program.  Currently, only people who are still working for a company convicted of Medicare fraud can be excluded from the program, so employees can leave the company in order to evade exclusion.  Two Representatives from Florida proposed legislation that cracks down on individual executives, preventing them from working with Medicare after they have been convicted.

President Obama plans to sign a memo that would create a “do not fraud” list to combat Medicare fraud.  Consequently, the government would not send payments to deceased people, suspended contractors, or other delinquents to cut down on fraudulent payments. According to the Washington Post, within a three year time span, CMS sent approximately $182 million to dead people. CMS will use an online tool that will detect fraud, and provide more comprehensive background tests on providers, hoping to cut down on fake payments.

In general, I feel that the crackdown on such scams will be beneficial to the Medicare system. By preventing employees responsible for fraud from again working with Medicare, and keeping more detailed records of payments and providers, the government can save billions of dollars that will be better used elsewhere.  Hopefully these measures will improve the current health care environment in the United States.

Entitlement Reform: What happens when Medicare and Social Security Are Bankrupt?

This threat has been looming in the background for years, and though successive administrations have “kicked the can” down the road we must confront the fact that the financial health of our two major entitlement programs has withered more during this recession than at any time since the mid-1990s. Though the economic downturn has contributed significantly to the programs’ rate of decline given the fact that worsening unemployment figures mean fewer workers are paying into the trusts’ funds through payroll taxes, the pressure of baby-boomers aging into the programs has pushed their financial health to the breaking point independent of current economic conditions.

These facts point glaringly to the need for entitlement reform. Obama administration officials have suggested that if the legislature were to act the programs’ insolvency could be bridged in three ways: by raising workers’ Social Security payroll taxes by 2 percentage points, by reducing benefits by 13 percent, or by a combination of the two.

What will the new MAPD ranking system look like?

I feel that improving the ratings system is integral to Medicare reform. While costs and coverage are indeed incredibly important facets of every Advantage plan, quality of care and benefits are equally important for seniors. Relying on price alone may net a senior an affordable plan while sacrificing quality.  Unfortunately, many seniors do rely on price. According to Jaffe, over 75% of Advantage plan beneficiaries select plans with less than 3 stars.  Improving the ratings system can make seniors more aware of the quality of their Advantage plan, and possibly provide them with improved health care.  Adding the incentive to perform better could ultimately help seniors out.  However, that incentive needs to be clear and the ratings system needs to be solid.

Another part to the issue raised by Jaffe is that not all plans are rated, and not all areas boast 4 or 5 star rated plans.  By expanding the ratings system, and breaking down all the benefits and coverage associated with the plan, perhaps CMS can provide more comprehensive analyses to facilitate Advantage plan selection for seniors. At the same time, plans need the opportunity to improve their ratings and quality. Improvement should be recognized as a factor in the ratings.   Perhaps adding incentives for improvement in addition to overall rating might be helpful, although not necessarily cost-effective. By making providers accountable for their services and seniors more aware of the ins-and-outs of Advantage plans, perhaps there can be genuine improvements in the Medicare system.

At the same time, I feel that it might be difficult for the bonus system to work as it should, especially because standards of care vary across the country.  Jaffe quotes Vicki Gottlich of the Center for Medicare Advocacy, who raises the concern that a simple average score might bury a plan’s deficiencies beneath its stronger points. And is it really fair to rate a 3 star plan in say, Idaho, to a 5 star plan in Florida? How can the rating system be most effective when there are so many variables involved?

Although the new bonuses may help improve the quality of care available for Medicare, CMS must ensure that all the wrinkles in the rating system are ironed out before applying the ratings to all plans. Perhaps a better path for CMS to follow would be to improve the ratings, helping out both consumers and providers, before analyzing each Medicare Advantage plan.

Medicare fraud is among the most common types of health care fraud. The Obama administration has requested a funding increase in an effort to cut down the Medicare fraud. These efforts have been successful in the Miami area, which has the highest rates of both Medicare fraud and prosecutions.

Recently, the fraud teams have been set up in cities like Detroit and Brooklyn, area’s where Medicare fraud was starting to turn up more. Many of those cases were developed by the same Miami criminals who were looking to move to an area where there was less crackdown and scrutiny.

The schemes are constantly changing, however, making catching those involved difficult. One of the first popular scams was based on durable medical equipment like wheelchairs and walkers. Then HIV infusion clinics and home health care were targeted. The enforcement teams are often left simply trying to play catch up with the constantly changing schemes and locations.

It is very important to make sure you are using a legitimate carrier for your health plan and a reliable source for your health care needs. This is why choosing a plan is such an important decision. By going though MedicareSolutions.com you know you can trust your plan, we only represent the best rated carriers. You can be sure that any plan you buy through us is a genuine plan. You can call our representatives at 800-328-7305.

NPR – Miami Serves As Model In Medicare Fraud Crackdown

In addition to making draconian cuts to the Medicare Advantage program, the bill largely increases the number and cost of beneficiaries in Medicare. For example, both the House and Senate bills reduce the coverage gap, or “doughnut hole” in Part D coverage by $500 beginning in 2010. Other additions include increased benefits for dual Medicare-Medicaid eligible and eliminating cost-sharing for preventative services (beneficiaries will not have to pay for any of the cost). Such great cost reduction is certainly an enormous benefit for any senior, but puts a new strain on the need for more Medicare funds.

Additionally, the Senate bill plans to tax companies receiving prescription drug subsidies. Since 2003, companies that continued to provide their own prescription drug benefits qualified for a 28% tax-free subsidy (about $600 per year per retiree). The advantage for companies was the ability to list the subsidy as a reduction to their retiree health liability. The Senate bill will tax the subsidy, thus increasing companies’ tax liabilities and companies will be required to register the change as a loss in earnings.

The response expected from these companies will be to no long provide prescription drug benefits on their own. Thus, the cost falls back on Medicare who will see a dramatic increase in Part D beneficiaries. Increasing the number of Medicare eligibles will only add fuel to the fire: these change merely bring the day of reckoning for Medicare closer than 2016.

At the urging of Senate Finance chairman Max Baucus who describes Humana’s letters as “mislead[ing] seniors regarding the subject,” CMS ordered Humana to stop sending out such letters. Both Baucus and CMS have put a warning to Humana and any other insurer that might get mixed up in health care reform politics, Baucus stating “it is wholly unacceptable for insurance companies to mislead seniors,” but, as the Wall Street Journal points out, “Humana merely made the mistake of trying to tell seniors the truth about what will happen to their coverage.”

CMS does not currently have a model for how insurance companies should respond to health care politics but, clearly, attempting to inform your current customers is not allowed. It should be noted that Humana has been extremely supportive of health care reform, save these changes to Medicare Advantage, despite all the fingers pointed at the insurance companies and their growing reputation as the “bad guys.” Finally, Humana attempts to defend itself through these letters, pointing out that if benefits were to be cut, it is not a consequence of Humana’s actions, but of the government. But Humana gets slammed.

Rather than arguing over words, Senator Baucus should set reimbursement levels for Humana and other managed care providers, so that they perform the way they were intended to! Save the government and taxpayers money, while offering high quality health plans. Humana should stop the clumsy PR campaign and defend their program with how they help taxpayers and beneficiaries—not simply scaring their members—be their claims true or not.

The members of the council would be given the authority to make broad recommendations about Medicare, but they would focus on setting appropriate payment rates for Medicare Part A and Part B. The council would give two annual recommendation reports: the one due by October 1st of each year would deal with Medicare Part A and the one due by December 31st of each year would address Part B. These recommendations would be sent to the White House for the president’s approval before being brought before Congress. This legislation, if enacted will go into effect after Obama’s first term as president on September 15, 2014.

Other proposals are also being given consideration with respect to Medicare. In particular, the Obama administration wants to give the Medicare Payment Advisory Commission (MedPAC) the authority to determine cuts and makes other changes to Medicare.