Tagged Medicare

Viewpoints: Executive Orders, Obamacare Replacements And Cold, Hard Facts; Medicare’s Challenges In Health Law Debate

A selection of opinions on health care from around the country.

The Wall Street Journal: The ObamaCare Holdouts
Republicans are getting battered at town halls on ObamaCare, with constituents — or least protestors — yelling about the benefits they’ll lose if the entitlement is repealed. But maybe the better measure of public sentiment is the choices that the people who are subject to ObamaCare have made in practice. (2/23)

The New England Journal Of Medicine: Trump’s Executive Order On Health Care — Can It Undermine The ACA If Congress Fails To Act?
Within hours after taking the oath of office, President Donald Trump executed his first official act: an executive order redeeming his campaign pledge to, on “day one,” begin repeal of the Affordable Care Act (ACA). The New York Times characterized his action as itself “scaling back Obamacare,” and the Washington Post said the order “could effectively gut [the ACA’s] individual mandate” to obtain health insurance coverage. But consumer advocate Ron Pollack dismissed Trump’s action as “much ado about very little.” To put these divergent assessments into perspective, it’s important to examine the actual executive order, recognize the departures from the Obama administration that it contemplates, and assess the scope and significance of changes the administration can lawfully make by executive order or other administrative actions. (Timothy Stoltzfus Jost and Simon Lazarus, 2/22)

Vox: John Boehner Told Republicans Some Inconvenient Truths On Obamacare
Didn’t Boehner hold repeal vote after repeal vote? Didn’t he win back the House in 2010, and hold it thereafter, promising to repeal Obamacare? Didn’t he participate in the government shutdown over Obamacare in 2013? He did. But to interpret Boehner generously, Obamacare is in a very different place now than it was in 2010, 2012, or even 2013. It’s delivering benefits to about 30 million people. Dozens of states have built budgets around Medicaid dollars flowing in from the federal government. Health systems nationwide have reorganized themselves around its provisions. (Ezra Klein, 2/23)

RealClear Health: Repeal & Replace: Missing The Medicare Forest For The Obamacare Trees
The Trump Administration has promised to deliver to the American people a healthcare plan that is, in President Trump’s own words, “much less expensive and far better” than Obamacare. But While Obamacare is expected to spend over $900 billion from 2018 to 2027, focusing solely on the Obama administration’s signature achievement ignores bigger fiscal challenges; Namely, the Medicare program. (Yevgeniy Feyman, 2/24)

Tribune News Service/Lincoln (Neb.) Journal-Star: A Simple Solution On Health Care
But the largest contributing factor to the voter anger directed at Republican senators and representatives didn’t require sly scheming — because it is very real, and even frightening to many voters. They are frightened about what they are NOT hearing from Trump and most Republicans in Congress about what will happen when they succeed in repealing President Obama’s Affordable Care Act. Republicans haven’t shown voters how they will replace it or sufficiently addressed what its elimination might mean to middle class folks who voted for Trump as an act of blind trust. (Martin Schram, 2/24)

Topeka Capital Journal: Medicaid Expansion Lives In Kansas
Considering how much disagreement there is on the economic and practical dimensions of Medicaid expansion – as well as the massive impact it has on the people of Kansas – didn’t it deserve a full debate in the Legislature? To Ward, Rep. Susan Concannon (a Beloit Republican who introduced the Medicaid amendment to HB 2044) and the legislators who voted in favor of expansion: Thank you for representing the interests of your fellow Kansans. While we’re not saying legislators should vote for a bill simply because it’s popular, they do have a responsibility to take their constituents’ concerns seriously and give critical issues their full attention. The lawmakers who tried to kill the Medicaid expansion bill in committee did the opposite. (2/23)

The New England Journal Of Medicine: Protecting The Tired, The Poor, The Huddled Masses
During Donald Trump’s presidential campaign and transition period, I worried that the climate of xenophobia and the widespread misunderstanding of the immigrants and refugees already in our country would dissuade others from seeking asylum here. … as a person who believes that health is a human right and that ensuring basic human rights promotes health, I remain terrified for the world’s well-being. The suspension of the U.S. Refugee Admissions Program for 120 days was poorly planned and discriminatory, and it has only intensified the fear and anxiety of people who are fleeing terror, bombings, domestic abuse, and other types of persecution because of their religion, sexual orientation, or ethnic background. … Moreover, many U.S. clinicians have noted that their patients who are already here are refraining from seeking the medical care they need or using other vital public services for fear of being incarcerated and deported. (Katherine Peeler, 2/22)

The Washington Post: Sean Spicer Seemed To Tie Marijuana Use To Opioids. The Evidence Isn’t On His Side.
The epidemic of opioid addiction in the United States has been well documented. A staggering 33,000 people died in 2015 from overdosing on prescription painkillers, heroin or similar drugs, on par with the number killed by firearms and in car accidents. The epidemic is growing, but its general causes are not in dispute. Nearly all research on the issue shows that excessive and improper prescriptions are what’s causing more people to become addicted. But White House press secretary Sean Spicer on Thursday appeared to link the surge in opioid abuse to another factor: recreational marijuana use. (Derek Hawkins, 2/24)

Milwaukee Journal Sentinel: Try Something New To Deal With Drug Crisis
In 2016, Milwaukee County saw a record high in deaths from drug overdoses, when at least 340 people died. Many of the drugs involved in this crisis such as oxytocin, vicodin and oxycodone are at first prescribed legally to treat physical pain. When users become addicted and lose avenues to these prescribed drugs, they often turn to illegal drugs. Bravo to Gov. Scott Walker, who has called for a special session of the Legislature to address this crisis. (Jerry Schultz, 2/23)

Stat: The Power — And The Fear — Of Knowing Your Cancer Genome
When it comes to cancer, all knowledge is power — even when that knowledge is scary. Knowing as much as you can about cancer lets you and your health care team act decisively in devising your treatment strategy. Even more important, it lets you act specifically in selecting treatments or clinical trials that might be best in treating your disease. … For me, learning everything about my disease has been essential to discovering how to attack and treat my cancer and, I believe, why I went into a surprising but welcome long-lasting remission. (Kathy Giusti, 2/23)

The New England Journal Of Medicine: The Perils Of Trumping Science In Global Health — The Mexico City Policy And Beyond
During his first week in office, President Donald Trump reinstated an executive order banning U.S. aid to any international organization that supports abortion-related activities, including counseling or referrals. The so-called Mexico City Policy — colloquially referred to as the “global gag rule” on women’s reproductive health — is allegedly intended to reduce the number of abortions around the world, in accordance with an antiabortion agenda. Scientific evidence suggests, however, that the policy achieves the opposite: it significantly increases abortion rates. The policy defunds — and in so doing, incapacitates — organizations that would otherwise provide education and contraceptive services to reduce the frequency of unintended pregnancies and the need for abortions. (Nathan C. Lo and Michele Barry, 2/22)

Seattle Times: Ethics And Trust Paramount In Physician, Patient Relationship
dramatic and complex changes in the health-care environment have placed a strain on medical professionalism and on physicians’ ability to exercise independent clinical judgment. We must ensure that doctors’ professionalism and independent judgment remain protected, even in our quest to have a healthy bottom line. (Jennifer Lawrence Hanscom, 2/22)

The New England Journal Of Medicine: Recreational Cannabis — Minimizing The Health Risks From Legalization
The cannabis-policy landscape is undergoing dramatic change. Although many jurisdictions have removed criminal penalties for possessing small amounts of cannabis and more than half of U.S. states allow physicians to recommend it to patients, legalizing the supply and possession of cannabis for nonmedical purposes is a very different public policy. Since the November 2016 election, 20% of the U.S. population lives in states that have passed ballot initiatives to allow companies to sell cannabis for any reason and adults 21 or older to purchase it. Although other states may move toward legalization, uncertainty abounds because of the federal prohibition on cannabis. The Obama administration tolerated these state laws; it’s unclear what the Trump administration will do. (Beau Kilmer, 2/22)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Changes To Medicare’s Primary-Care Payment Model Could Deter Physician Participation

Also, another look at what it means for a Medicare beneficiary to be “under observation.”

Modern Healthcare: Doctors, Payers May Dislike Changes To Primary-Care Model 
A tweak in the way some providers are reimbursed under a new primary-care payment model could deter providers from joining the Medicare initiative. The CMS is looking to expand its ambitious primary-care model known as Comprehensive Primary Care Plus. But there hasn’t been as much interest in the pilot as anticipated, and now the agency wants to pay incentives only to some participating providers and not others. (Dickson, 2/21)

Sun Sentinel: Being In A Hospital ‘Under Observation’ Vs. Admitted Can Limit Vital Benefits For Seniors
Going into the hospital is stressful enough. But if you’re a senior on Medicare, and you stay at a hospital under “observation status,” you may end up with serious financial pain, too. That’s because Medicare may not cover some benefits — including post-hospital rehabilitation care in a nursing home — if a hospitalized patient is classified as being under observation vs. being admitted as an inpatient. (Lade, 2/21)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Different Takes On Inside-The-Beltway Health Policy Developments

Opinion writers offer a variety of views on how the plans being advanced by the Trump administration and GOP Congress will shape a range of health concerns — from the effort to repeal, replace or repair the health law effort to federal health programs and Planned Parenthood’s future.

The Washington Post: Obamacare’s Enduring Victory
What’s the holdup, House Republicans? During the Obama administration, you passed literally dozens of bills to repeal all or part of the Affordable Care Act — knowing that none had any chance of being signed into law. Now that Donald Trump is in the White House, why can’t you seem to pull the trigger? (Eugene Robinson, 2/20)

The New York Times: Ryancare: You Can Pay More For Less!
President Trump promised to replace the Affordable Care Act with something that is better, is cheaper and covers more people. Scratch that. Republican leaders in the House and Mr. Trump’s secretary of health and human services released a plan last week that would provide insurance that is far inferior, shift more medical costs onto families and cover far fewer people. (2/19)

Los Angeles Times: ‘Death Spirals,’ Deceit And Pampering The Rich: The Republicans Face High Noon On Repealing Obamacare
Congressional Republicans who have visited their home districts over the last few weeks have gotten a faceful of constituent rage about their plans to eviscerate the Affordable Care Act, which brings health coverage to more than 20 million Americans. If past is prologue, those heading home now for the Presidents Day recess are likely to feel a lot more heat. That may be why House Republicans this week rushed out a “policy brief” on “Obamacare Repeal and Replace.” Unfortunately for the poor souls who will be meeting with constituents, the brief answers none of the key questions about the GOP’s plans for the ACA. (Michael Hiltzik, 2/17)

The Washington Post: Republicans Are Selling Health-Care Reform That People Don’t Want 
House Speaker Paul Ryan (R-Wis.) says Obamacare is failing. Club for Growth president David McIntosh warns that voters “gave Republicans the charge to repeal and replace Obamacare,” so the “delays and discussions about repairing Obamacare need to stop.” The problem is that voters fear disruption, don’t want to lose what they have and won’t find what Republicans are selling very attractive. (Jennifer Rubin, 2/20)

The Washington Post: Ryan’s Health-Care Plan Will Be Hard To Defend
House Speaker Paul Ryan (R-Wis.) outlined a health-care plan to his members yesterday. Surprisingly, it did not include much detail, either because the speaker has not gotten that far or because he’s afraid of the reaction when the numbers are revealed. (Jennifer Rubin, 2/17)

Modern Healthcare: Give Seema Verma A Chance
Seema Verma, the Indiana consultant who injected personal responsibility requirements and health savings accounts into that state’s Medicaid program, deserves a shot at working with other states that want to redesign their programs. She repeatedly testified last week that her main goal for the program, if confirmed as CMS administrator, will be to achieve better outcomes for the vulnerable populations served by the program. “This shouldn’t be about kicking people off,” she said. (Merrill Goozner, 2/18)

Fox News: Seema Verma For Medicaid/Medicare Czar Is The Final Piece In The Health Care Puzzle
Seema Verma is a bold pick by President Trump to head the Centers for Medicare and Medicaid Services. She should be approved without further delay. During a hearing by the Senate Finance Committee this week she appeared confident and informed, refusing to take positions on raising Medicare’s eligibility age, price negotiation with drug companies, or caps on Medicaid allotments to the states. She stated that these decisions are up to Congress, showing an understanding of her role’s limits. (Marc Siegel, 2/20)

The Washington Post: Staffing, Budget Shortages Put Indian Health Service At ‘High Risk’
There’s a sliver of good news for a stricken federal agency during the first alarming month of President Trump’s administration: relief from Trump’s hiring freeze for the Indian Health Service (IHS). “This exemption is a step in the right direction,” seven Democratic senators said in a statement Friday. “Indian Health Services facilities face staff vacancy rates of 20 percent or higher, and a hiring freeze would make these challenges even more severe, further impacting access to health care and even patient health.” (Joe Davidson, 2/20)

Stat: Vaccine Programs Threatened By Exemptions, ACA Repeal
Our highly successful vaccination programs will be in danger if they are not factored into the current discussion of the repeal of the Affordable Care Act (ACA). There’s a clear connection between having health insurance and getting vaccinated, so reducing the number of people with health insurance, which could likely happen if the ACA is repealed, will translate into fewer children and adults who get their recommended vaccines. (John Auerbach, 2/17)

Los Angeles Times: An Attack On Abortion Rights And A Handout To The Rich: The Republicans’ New Plan For Repealing Obamacare
Congressional Republicans who have visited their home districts over the last few weeks have gotten a faceful of constituent rage about their plans to eviscerate the Affordable Care Act, which brings health coverage to more than 20 million Americans. If past is prologue, those heading home now for the Presidents Day recess are likely to feel a lot more heat. (Michael Hiltzik, 2/17)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Lawsuit Alleges United Healthcare Overcharged Medicare For Advantage Plan Customers

The lawsuit, which was unsealed Thursday after a five-year investigation by the Department of Justice, suggests the company may have improperly collected “hundreds of millions” of dollars by claiming patients were sicker than they actually were.

Modern Healthcare: DOJ Joins Medicare Advantage Fraud Lawsuit Against UnitedHealth
The U.S. Justice Department has joined a whistleblower lawsuit claiming that UnitedHealth Group and affiliated health plans have been gaming the Medicare program and fraudulently collecting millions of dollars by claiming patients were sicker than they really were. The lawsuit, initially brought in 2011 and unsealed Thursday after a five year-long investigation by the Justice Department, alleges that Minnetonka, Minn.-based UnitedHealth has inflated its plan members’ risk scores since at least 2006 in order to boost payments under Medicare Advantage’s risk adjustment program. (Livingston, 2/16)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Perspectives On The Technicalities Of Repealing, Replacing Or Repairing The Health Law

Opinion writers offer their thoughts on a range of issues related to the health insurance marketplace, Medicaid and Medicare.

RealClear Health: Welcome Back To The Medical Underwriting Circle Of Hell
All leading Republicans who are committed to repealing all or key parts of the Affordable Care Act (ACA) also emphasize their commitment to maintaining the law’s most popular part: banning pre-existing condition exclusions and medical underwriting by preserving the ACA’s (also known as Obamacare) policy of “guaranteed issue.” But the fine print in Republican proposals betrays that commitment, including legislation filed on January 26 by House Energy and Commerce Committee Chairman Greg Walden (R-OR) threatening health security for tens of millions of Americans. (John McDonough and William Seligman, 2/15)

The Washington Post: Could The Most Conservative Members Of Congress Save Obamacare?
Try to wrap your head around this possibility: the House Freedom Caucus, the most conservative members of an extremely conservative Republican majority, might be the saviors of the Affordable Care Act. How is such a thing possible? The answer is their devotion to ideological purity, which it turns out may be as disruptive a political force when the GOP is the ruling party as it was when they were the opposition. (Paul Waldman, 2/14)

St. Louis Post-Dispatch: Senators Show Fundamental Differences On Health Care
I hope many people were able to watch the debate that CNN hosted last week between U.S. Sens. Bernie Sanders and Ted Cruz. They spent over an hour fielding questions from spectators and moderators about the present and future of health care in the United States. Sen. Cruz provided a couple misleading answers and suggestions that I believe are worth clarifying. First, he stated that his primary goal in repealing the Affordable Care Act was to remove government from the equation so that health care would be back in the hands of patients and their physicians. As appealing as he makes it sound, removing government-funded insurance would hardly make a dent in the amount of autonomy patients and their physicians have over their health care. (Jonathan Mizrahi, 2/15)

Health Affairs Blog: The Future Of Essential Health Benefits
The Essential Health Benefits (EHB) rule may be among the many parts of the Affordable Care Act (ACA) that are on the chopping block as the Trump Administration and Congress seek to repeal and replace the law. Essential Health Benefits, which define what health care benefits plans in the Marketplaces and certain other health plans must cover, go to the heart of what it means to have health insurance and what health care we, as a society, want to ensure people can access. (Ian Spatz and Michael Kolber, 2/14)

The Washington Post: As A Christian, I Defended Obamacare. But I Really Support Single-Payer.
A video of me questioning Rep. Diane Black (R-Tenn.) about how her party will replace the Affordable Care Act went viral last Friday. I had gone to her town hall meeting on Thursday near my home to ask what the poor and sick would do once they’re left without the law’s protections. The next night, I had the really weird experience of seeing myself on national television, and the even weirder experience of hearing and reading other people’s interpretation of my own words. My town hall question has been described as a “Christian defense of Obamacare” and “an impassioned case for the ACA’s individual mandate.” (Jessi Bohon, 2/15)

Sacramento Bee: California Provides Model To Replace The Affordable Care Act 
The new administration and Congress are under intense pressure to craft a market-based alternative to the Affordable Care Act. It won’t be easy. To achieve the financial stability required to make the market work, reformers should heed some important lessons from California. (Leonard Schaeffer and Dana Goldman, 2/14)

The Wall Street Journal: Donald Trump’s Medicaid Promise
In the midst of the tumult that now grips Washington, it is easy to forget that President Trump has yet to send Congress either a budget or a single piece of legislation. When he does, some longstanding tensions within the Republican coalition are likely to occupy center stage. (William A. Galston, 2/14)

Lincoln Journal-Star: Americans Deserve Their Medicare
AARP believes Medicare is a deal with the American people that must not be broken. That’s why we will oppose proposals in Congress to turn Medicare into a voucher system, which would drive up costs for current and future retirees and erode protections that Americans have earned through a lifetime of hard work and taxes. Unfortunately, in a short-sighted attempt to save money vouchers are being promoted on Capitol Hill as an answer to rising costs. (David Holmquist, 2/15)

The Washington Post: We Created Medicare For The Elderly. Why Not Do The Same For Children?
With all eyes focused on the nation’s health-care system, our leaders have an opportunity to put the health and future of America’s children first. Congress should consider building a tailor-made national health-care plan just for children. Just as we created Medicare for the elderly, we need an approach to pediatric health care that not only provides coverage to every child but also ensures adequate funding for essential services that meet child-specific needs. (Kurt Newman, 2/14)

The Wall Street Journal: The ObamaCare Merger Deathblow
The conceit that the five major commercial health insurers will consolidate to three seems to be dissolving, as four of those insurers called off a pair of mega-mergers on Tuesday. The immediate reasons were legal objections, but perhaps this retreat is a sign of hope for insurance markets. (2/14)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Docs Bill Medicare for End-of-Life Advice As ‘Death Panel’ Fears Reemerge

End-of-life counseling sessions, once decried by some conservative Republicans as “death panels,” gained steam among Medicare patients in 2016, the first year doctors could charge the federal program for the service.

Nearly 14,000 providers billed almost $35 million — including nearly $16 million paid by Medicare — for advance care planning conversations for about 223,000 patients from January through June, according to data released this week by the Centers for Medicare & Medicaid Services. Full year figures won’t be available until July, but use appears to be higher than anticipated.

Controversy is threatening to reemerge in Congress over the funding, which pays doctors to counsel some 57 million Medicare patients on end-of-life treatment preferences. Rep. Steve King, R-Iowa, introduced a bill last month, the Protecting Life Until Natural Death Act, which would revoke Medicare reimbursement for the sessions, which he called a “yet another life-devaluing policy.”

“Allowing the federal government to marry its need to save dollars with the promotion of end-of-life counseling is not in the interest of millions of Americans who were promised life-sustaining care in their older years,” King said on Jan. 11.

While the fate of King’s bill is highly uncertain — the recently proposed measure hasn’t seen congressional action — it underscores deep feelings among conservatives who have long opposed such counseling and may seek to remove it from Medicare should Republicans attempt to make other changes to the entitlement program.

Proponents of advance care planning, however, cheered evidence of program’s early use as a sign of growing interest in late stage life planning.

“It’s great to hear that almost a quarter million people had an advance care planning conversation in the first six months of 2016,” said Paul Malley, president of Aging with Dignity, a Florida nonprofit. “I do think the billing makes a difference. I think it puts it on the radar of more physicians.”

Use of the counseling sessions are on track to outpace an estimate by the American Medical Association, which projected that about 300,000 patients would receive the service in the first year, according to the group, which backed the rule.

Providers in California, New York and Florida led use of the policy that pays about $86 a session for the first 30-minute office-based visit and about $75 per visit for any additional sessions.

The rule requires no specific diagnosis and sets no guidelines for the end-of-life discussions. Conversations center on medical directives and treatment preferences, including hospice enrollment and the desire for care if patients lose the ability to make their own decisions.

The new reimbursement led Dr. Peter Sutherland, a family medicine physician in Morristown, Tenn., to schedule more end-of-life conversations with patients last year.

“They were very few and far between before,” he said. “They were usually hospice-specific.”

Now, he said, he has time to have thorough discussions with patients, including a 60-year-old woman whose recent complaints of back and shoulder pain turned out to be cancer that had metastasized to her lungs. In early January, he talked with an 84-year-old woman with Stage IV breast cancer.

“She didn’t understand what a living will was,” Sutherland said. “We went through all that. I had her daughter with her and we went through it all.”

The conversations may occur during annual wellness exams, in separate office visits or in hospitals. Nurse practitioners and physicians’ assistants may also seek payment for end-of-life talks.

The idea of letting Medicare reimburse such conversations was first introduced in 2009 during debate on the Affordable Care Act. The issue quickly fueled allegations by some conservative politicians, such as former Republican vice presidential candidate Sarah Palin and presidential candidate John McCain, that they would lead to “death panels” that could disrupt care for elderly and disabled patients.

The idea was dropped “as a direct result of public outcry,” King said in a statement.

“The worldview behind the policy has not changed since then and government control over this intimate choice is still intolerable to those who respect the dignity of human life,” he said.

But in 2015, CMS officials quietly issued the new rule allowing Medicare reimbursement as a way to improve patients’ ability to make decisions about their care.

End-of-life conversations have occurred in the past, but not as often as they should, Malley said. Many doctors aren’t trained to have such discussions and find them difficult to initiate.

“For a lot of health providers, we hear the concern that this is not why patients come to us,” Malley said. “They come to us looking to be cured, for hope. And it’s sensitive to talk about what happens if we can’t cure you.”

2014 report by the Institute of Medicine, a panel of medical experts, concluded that Americans need more help navigating end-of-life decisions. A 2015 Kaiser Family Foundation poll found that 89 percent of people surveyed said health care providers should discuss such issues with patients, but only 17 percent had had those talks themselves. (KHN is an editorially independent program of the foundation.)

Use of the new rule was limited in the first six months of 2016. In California, which recorded the highest Medicare payments, about 1,300 providers provided nearly 29,000 services to about 24,000 patients at an overall cost of about $4.4 million — including about $1.9 million paid by Medicare.

The data likely reflect early adopters who were already having the talks and quickly integrated the new billing codes into their practices, said Dr. Ravi Parikh, an internal medicine resident at Brigham and Women’s Hospital in Boston, who has written about advance care planning. Many others still aren’t aware, he said.

Data from Athenahealth, a medical billing management service, found that only about 17 percent of 34,000 primary care providers at 2,000 practices billed for advance care planning in all of 2016.

The numbers will likely grow, said Malley, who noted that requests from doctors for advance care planning information tripled during the past year.

To counter objections, providers need to ensure that informed choice is at the heart of the newly reimbursed discussions.

“If advance care planning is only about saying no to care, then it should be revoked,” Malley said. “If it truly is about finding out patient preferences on their own turf, it’s a good thing.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

Categories: Medicare, Syndicate

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Judge Upends Effort To Limit Charity Funding For Kidney Patients’ Insurance

Every night, Jason Early attaches a catheter in his chest to a machine by his bed that, over the course of nine hours while he sleeps, removes his blood from his body, cleanses it and returns it because his kidneys are no longer able to do the job.

It’s been about 18 months since the 28-year-old Dallas resident started getting dialysis after his kidneys failed as a complication from the Type 1 diabetes with which he was diagnosed as a child.

Like many patients with end-stage renal disease, Early, who is completing a bachelor’s degree in finance at the University of North Texas at Dallas, turned to a charity for financial assistance to cover his health insurance costs.

Michelle AndrewsInsuring Your Health

Such “third-party payments” by nonprofit groups, health care providers and others are controversial. The federal government has expressed concern that providers and organizations they’re affiliated with might be inappropriately “steering” patients to marketplace plans instead of Medicare or Medicaid, for which they are often eligible. The public programs reimburse for the dialysis services at lower rates than most private plans. The efforts by charities have also long been a sore spot with health insurers, who say they encourage sick patients who have expensive health care needs to opt for private coverage.

Insurers suffered a setback recently when a federal judge temporarily blocked a new rule from the Department of Health and Human Services that was set to go into effect Jan. 13. It would require that dialysis centers inform insurers if the centers are making premium payments either directly or indirectly through a third party for people covered by marketplace plans. Insurers would then have the option of accepting or denying the payments.

In granting the preliminary injunction last month, U.S. District Court Judge Amos Mazzant in Sherman, Texas, criticized the government’s administrative process for establishing the regulation and said it hadn’t considered the benefits of private individual insurance or the fact that the rule would leave thousands of patients without coverage.

Jason Early has been getting dialysis for about 18 months and he turned to a charity to help cover his health insurance premiums. (Courtesy of UNT Dallas Marketing Communications | untdallas.edu)

Jason Early has been getting dialysis for about 18 months and he turned to a charity to help cover his health insurance premiums. (Courtesy of UNT Dallas Marketing Communications | untdallas.edu)

Insurers were not pleased. “Inappropriate steering and third-party payments increases costs for all consumers, and it risks harm to patients who are often eligible for public coverage options,” said Kristine Grow, a spokesperson for America’s Health Insurance Plans, an industry group. “We continue to urge [the Department of Health and Human Services] to prohibit these payments when there is alternative coverage for patients.”

But patient advocates were delighted. “We thought this was an important win for dialysis patients because it not only spoke to the procedural elements of the rule but to the substance, the potential of dialysis patients to have their coverage taken away,” said Hrant Jamgochian, the chief executive of Dialysis Patient Citizens, an advocacy group and the lead plaintiff in the lawsuit.

Premium assistance has been critical to improving Early’s quality of life. “Without the [American Kidney Fund] assistance I would be living to pay my medical costs,” he said. “They give me an opportunity to get a breather from medical costs so that I can live my life outside of my illness.”

Although some patients, such as Early, are able to undergo dialysis at home, many must spend four hours at a dialysis center three times a week. The process is debilitating and time-consuming.

Many people lose their employer-sponsored health insurance because they are unable to work. Medicare is often an alternative because under the law, people with end-stage renal disease — even those younger than 65 — are generally eligible for coverage.

Others may sign up for private coverage on the exchanges. Some may qualify for Medicaid.

Advocates for kidney patients say coverage on the individual market is better than Medicare for some people. In marketplace plans, the maximum amount that someone can be required to pay out-of-pocket for covered services in 2017 is $7,150. But there’s no cap on beneficiaries’ spending in Medicare, and patients are on the hook for 20 percent of the cost for doctor visits and other outpatient services such as dialysis. Supplemental “Medigap” plans can help cover out-of-pocket costs, but 23 states don’t require insurers to sell those plans to people with end-stage renal disease who aren’t yet 65.

Last year, Early bought an Aetna silver plan with a $1,500 deductible and a $6,000 out-of-pocket maximum on the Texas health insurance exchange. The American Kidney Fund paid the $359 monthly premium. The policy covered all of his diabetes drugs and equipment. By the end of the first month of dialysis copayments, Early reached his spending maximum and the plan paid everything after that.

But Aetna exited several marketplaces this year, including Texas, and Early signed up for Medicare in January. Now he’s responsible for a $134 monthly Part B premium, $65 for his prescription drug plan and $300 a month in copays for drugs. Medicare doesn’t cover the insulin pump he uses, so he’ll have to pay $300 monthly out of pocket for that too. At the moment he’s also paying $478 each month for the basic Medigap “A” supplemental plan available in Texas to patients younger than 65 with end-stage renal disease. The Medigap plan covers his 20 percent coinsurance payments for dialysis and other outpatient care.

He said he’s been told that the American Kidney Fund, a charity that provides assistance to about 20 percent of the more than 450,000 people who are on dialysis and receives funding from dialysis providers, will start picking up his Medigap premiums soon. He hopes so.

“I miss my Aetna plan,” he said.

Sixty percent of the people who receive premium assistance from the American Kidney Fund get help with their Medicare or Medigap plans rather than marketplace or other private coverage, said LaVarne Burton, the president and CEO. Even though the judge’s order doesn’t apply to people in public plans, she hopes it will discourage insurers that are increasingly erecting barriers to third-party payment.

“We want to protect the ability that these individuals have to make the choice that meets their needs,” Burton said.

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Categories: Health Industry, Insurance, Insuring Your Health, Medicare, Syndicate