Tagged Medicare

Viewpoints: Plenty To Win Or Lose For Dem’s Presidential Candidates Weighing In On Health Care At Debate; Start Telling Us How ‘Medicare For All’ Would Work

Pay Close Attention To Subtle Changes, Cost Savings During Open Enrollment Period For Medicare, Health Officials Warn

Age-Old Health Care Debate Shifts From Insuring More People To Cutting Costs

In a new article in the BMJ journal, Julie Rovner, chief Washington correspondent for Kaiser Health News, examines the debate over the future of the U.S. health insurance system — a debate that has waxed and waned for the better part of a century. While political parties once argued over whether the government should make sure all residents have coverage, the discussion is changing. As the cost of medical services continues to grow faster than most Americans’ incomes, even people with private insurance coverage — which comes with ever-increasing expenses in the form of deductibles and copayments — are finding the cost of care becoming unaffordable. That’s true for Medicare as well. Read the article here.

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Cost and Quality Health Care Costs Insurance Medicaid Medicare The Health Law Uninsured

KHN’s ‘What The Health?’: Trump Merges Health And Immigration


Can’t see the audio player? Click here to listen on SoundCloud.


President Donald Trump has merged two of his favorite hot-button topics by requiring new immigrants to either purchase health insurance within 30 days of arrival or prove they can pay for medical expenses on their own.

Meanwhile, the Supreme Court has agreed to hear an abortion case out of Louisiana and could soon take another from Indiana. Either or both could be used to weaken or possibly roll back Roe v. Wade, the 1973 ruling that legalized abortion nationwide.

And on the Democratic presidential campaign trail, Vermont Sen. Bernie Sanders has a heart attack and South Bend, Ind., Mayor Pete Buttigieg has a drug plan. Also, Republicans have a unified message: They say Democrats are pushing socialism.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Julie Appleby of Kaiser Health News and Paige Winfield Cunningham of The Washington Post.

Among the takeaways from this week’s podcast:

  • In his surprise announcement last week setting requirements for legal immigrants to have health insurance, Trump based the new policy on concerns about the burden uninsured people put on the health system. That is an argument often used by supporters of the Affordable Care Act, which Trump strongly criticizes.
  • The Supreme Court likely has four options in the Louisiana abortion case it accepted last week. The state law in question requires that doctors performing abortions be accredited at local hospitals ― an issue at the heart of a Texas law that the justices rejected several years ago. The court could say the Louisiana law is much like Texas’ and strike it down; use the new law to overturn abortion rights; say the Texas decision was not correct and let stand the Louisiana law; or say the facts are different in Louisiana and its law can stand.
  • Somewhat overlooked in the court’s acceptance of the case is that it will also rule on another abortion issue: whether health care providers can sue to stop restrictive state laws. If the court says they can’t and instead the burden is on women seeking an abortion, it will make challenging state statutes much more difficult.
  • The executive order signed by Trump last week could result in significant changes to Medicare, allowing doctors to opt out of the program and set up private contracts with patients.
  • Sen. Bernie Sanders’ heart attack has raised questions ― again ― about how transparent presidential candidates should be about their health.
  • As both Republican critics of the ACA and its supporters await a decision by the 5th Circuit Court of Appeals on a Texas lawsuit that could strike down the federal health law, GOP officials are growing nervous about timing. The case will be appealed to the Supreme Court, but some administration officials would like that to not hit the court during the 2020 presidential campaign and are considering ways to prolong the appeal process.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Kaiser Health News’ “Why Hospitals Are Getting Into The Housing Business,” by Markian Hawryluk

Alice Miranda Ollstein: The New York Times’ “Sexually Transmitted Disease Cases Rise to Record High, C.D.C. Says,” by Liam Stack

Paige Winfield Cunningham: Bloomberg’s “AbbVie, Bristol-Myers Among Patient Advocacy Groups’ Big Backers,” by Alex Ruoff. Also, Kaiser Health News’ database of pharma contributions to patient advocacy groups can be found here.

Julie Appleby: Kaiser Health News’ “They Enrolled In Medical School To Practice Rural Medicine. What Happened?” by Lauren Weber


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Medicare Fraudsters Now Tap Telemedicine In Medical Equipment Scams

Dean Ernest had been living in a nursing home about a year when his son, John, got a call last winter asking if his father was experiencing back pain and would like a free orthotic brace.

The caller said he was with Medicare. John Ernest didn’t believe him, said “no” to the brace and hung up. He didn’t give out his father’s Medicare number.

And yet, not just one, but 13 braces arrived soon afterward at Ernest’s house in central Pennsylvania.

Medicare, the federal taxpayer-supported health care insurance program for older Americans, had paid over $4,000 for 10 of the braces: a back brace, two knee braces, two arm braces, two suspension sleeves, an ankle brace, a wrist brace and a heel stabilizer.

The orders came from four medical equipment companies and were prescribed by four separate health care professionals — a prescription being required to receive an orthotic brace. But Ernest said he didn’t talk to any doctors during the phone call.

That’s how the latest Medicare frauds work, said Ariel Rabinovic, who works with Pennsylvania’s Center for Advocacy for the Rights & Interests of the Elderly. He helped report Ernest’s fraud case to authorities at Medicare. Rabinovic said the fraudsters enlist health professionals — doctors, physician assistants, nurse practitioners — to contact people they’ve never met by telephone or video chat under the guise of a telemedicine consultation.

“Sometimes the teledoctors will come on the line and ask real Mickey Mouse questions, stuff like, “Do you have any pain?” explained Rabinovic. “But oftentimes, there is no contact between the doctor and the patient before they get the braces. And in almost all of the cases, the person prescribing the braces is somebody the Medicare beneficiaries don’t know.”

While prescriptions for durable medical equipment, such as orthotic braces or wheelchairs, have long been a staple of Medicare fraud schemes, the manipulation of telemedicine is relatively new. The practice appears to be increasing as the telemedicine industry grows.

“This has put telemedicine scams on Medicare’s radar with growing urgency,” said James Quiggle, director of communications for the Coalition Against Insurance Fraud.

In the past year, the Department of Health and Human Services Office of Inspector General, the Department of Justice and, in some cases, the FBI, have busted at least five health care fraud schemes that involved telemedicine. Typically in these schemes, scammers use sham telemedicine companies to scale up their operations quickly and cheaply — they can have a couple of doctors remotely writing a large number of prescriptions.

Often the doctors working for these outfits don’t perform medical consultations, but rather write prescriptions without talking to patients, as in Ernest’s case. Of course, that is not how telemedicine is designed to work.

In April 2019, the DOJ announced investigators had disrupted what they called “one of the largest Medicare fraud schemes in U.S. history.” Operation Brace Yourself cracked an international scheme allegedly defrauding Medicare of more than $1.2 billion by using telemedicine doctors to prescribe unnecessary back, shoulder, wrist and knee braces to beneficiaries.

The DOJ charged 24 people, including three medical professionals and the corporate executives of five telemedicine companies.

According to federal court documents, Willie McNeal of Spring Hill, Fla., owned two of the “purported” telemedicine companies, WebDoctors Plus and Integrated Support Plus.

Federal investigators allege that through Integrated Support Plus, McNeal hired and paid a New Jersey doctor, Joseph DeCorso, to write prescriptions for braces. DeCorso recently pleaded guilty to one count of conspiracy to commit health care fraud.

DeCorso admitted to writing medically unnecessary brace orders for telemedicine companies without speaking to beneficiaries or doing physical exams. He also admitted that his conduct resulted in a $13 million loss to Medicare. He has agreed to pay over $7 million in restitution to the federal government.

McNeal got the Medicare beneficiaries’ information for DeCorso to write the prescriptions from telemarketing companies, according to the indictment. Then, authorities allege, McNeal sent the prescriptions back to the same telemarketing companies in exchange for payments described as kickbacks and bribes.

Federal investigators allege these telemarketing companies sold the prescriptions to the durable medical equipment companies, who in turn billed Medicare for the braces.

McNeal’s lawyer said he could not discuss his client’s case because it is pending. DeCorso’s lawyer did not respond to multiple requests for comment.

The U.S. attorneys allege the money made from the scheme was hidden through international shell corporations and used to buy luxury real estate, exotic automobiles and yachts.

It’s clearly a profitable business. Taxpayers are the ones who ultimately pay for Medicare fraud, which often leads to higher health care premiums and out-of-pocket costs.

Medicare spending on back, knee and ankle braces highlighted in the inspector general’s investigations increased by over $200 million from 2013 to 2017, according to an analysis of Medicare data by Kaiser Health News. While the number of Medicare fee-for-service beneficiaries increased slightly, by 5%, from 2013 to 2017, spending on the three types of braces increased by 51% during that same period.

In an April news release about Operation Brace Yourself, Assistant Attorney General Brian Benczkowski of the DOJ’s Criminal Division called the Medicare scheme “an expansive and sophisticated fraud to exploit telemedicine technology meant for patients otherwise unable to access health care.”

Nathaniel Lacktman, a lawyer who represents telemedicine companies and organizations, was quick to point out that the industry does not recognize the fraudsters involved in these schemes as legitimate businesses.

“These are actually really sketchy online marketing companies participating in these schemes who are billing themselves as telemedicine,” said Lacktman, who works in the Tampa office of the law firm Foley & Lardner. “But in fact, they’re companies we’ve never heard of.”

All of this comes at a time when Medicare and Medicare Advantage are expanding telemedicine, though the programs have been slower to adopt it than the private sector, said Laura Laemmle-Weidenfeld, a health care lawyer at the law firm Jones Day.

“I would hate for Medicare to fall even further behind with telehealth,” said Laemmle-Weidenfeld, who previously worked in the Fraud Section of the DOJ’s Civil Division. “The vast majority of telehealth providers are legitimate, but as with anything there are a few bad apples,” she said.

Even with the recent federal busts, the scams continue.

Travis Trumitch, who works for the Illinois nonprofit AgeOptions, which helps report Medicare fraud in the state, said he received three voicemails over a recent weekend reporting suspected durable medical equipment scams.

John Ernest said he still receives calls every day with individuals on the line who say they work for Medicare and ask for Dean Ernest’s information — though his father died in April.

But Ernest can’t change his phone number because it’s the main line associated with his painting business.

“It really drives me crazy,” said Ernest. “How many people are they ripping off?”

KHN data editor Elizabeth Lucas contributed to this report.

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Different Takes: Dems Need To Shake Up Stale Debate On Health Care; Trump Works On His Twofer To Destroy Health Care and Immigration Systems

CMS Wants To Make It Easier For Consumers To Find Out If Nursing Homes Have Been Penalized For Abuse, Neglect

As Medicare Enrollment Nears, Popular Price Comparison Tool Is Missing

Millions of older adults can start signing up next week for private policies offering Medicare drug and medical coverage for 2020. But many risk wasting money and even jeopardizing their health care due to changes in Medicare’s plan finder, its most popular website.

For more than a decade, beneficiaries used the plan finder to compare dozens of Medicare policies offered by competing insurance companies and get a list of their options. Yet after a website redesign six weeks ago, the search results are missing crucial details: How much will you pay out-of-pocket? And which plan offers the best value?

That’s because the plan finder can no longer add up and sort through the prescription costs plus monthly premiums and any deductibles for all those plans. A mere human can try, but it is a cumbersome process fraught with pitfalls. One plan might have the lowest premium but not the lowest drug prices. Another could exclude a plan’s preferred pharmacy that offers lower prescription prices.

“We can’t guarantee you that you’re going to be in the best plan or the cheapest plan anymore,” said Howard Houghton, the former Fairfax County coordinator for the Virginia Insurance Counseling and Assistance Program who still helps with enrollment as a volunteer.

Using the old plan finder produced big savings. Counselors at Passages, the Senior Health Insurance Information Program (SHIP) serving five counties in Northern California, said in August they used it to save one woman $8,400 for this year and more than $5,000 when helping another client.

Medicare officials say the total cost calculator will be fixed in time for the annual enrollment season, which starts nationwide Oct. 15 and runs through Dec. 7. But they have yet to address multiple other issues raised by the Medicare Rights Center and industry groups.

“The new tool will provide more enhanced price and quality information” to assure informed health care decisions, Seema Verma, administrator at the Centers for Medicare & Medicaid Services, said when she unveiled the redesign in August.

During open enrollment, beneficiaries can sign up for Medicare Advantage plans, the alternative to traditional Medicare that offer drug coverage and often more benefits than the government program does. About a third of the 64 million people in Medicare choose this option. Next year, the average Medicare Advantage monthly premium is expected to drop 14% compared with 2019 to an estimated $23, according to CMS. 

This is also the only time most people in traditional Medicare can sign up for a drug plan, also known as Part D, to help cover their prescription costs. It’s a good idea to review plans every year since costs and covered drugs can change from year to year. Estimated average monthly premiums for these policies will be $30 next year, about 8% less than in 2019, CMS has reported.

Medicare Advantage plans next year are allowed to offer new additional benefits for people with certain chronic diseases, such as dementia, diabetes or heart disease. That’s on top of the non-medical benefits that are not tied to a person’s health problems they were allowed to add this year, such as home-delivered meals after a hospitalization, transportation to medical appointments and minor home improvements, such as grab bars to prevent falls in the bathroom.

Next year, the additional services some Advantage plans will offer hardly sound like insurance benefits: pest control, dog food for service animals, home-delivered meals and discounted groceries.

“It’s really shifting from reactive care to preventative care,” said Martin Esquivel, vice president for Medicare product management at Anthem, which will offer those and other new perks to some of its more than a million Medicare Advantage members.

Smaller Medicare Advantage plans have also expanded benefits. The 60,000 Alignment Healthcare members in some California, Florida and North Carolina plans will have access to free transportation to doctor appointments from Uber or Lyft.

To address social isolation, some California members who also have certain chronic diseases can receive visits from “Grandkids On-Demand,” college students who can help with light housekeeping and provide companionship for up to two hours a day. Humana and Aetna will also offer the service in some plans.

But most insurers are not embracing the opportunity to add extra benefits.

“Of those Medicare Advantage plans affected by the new rules, 10% (or about 500) offered new supplemental benefits in 2020 for people with serious chronic illnesses, such as in-home services, palliative care, respite support for people’s caregivers or adult day care,” said Robert Saunders, research director for payment and delivery reform at Duke University’s Margolis Center for Health Policy. He is still analyzing the other categories of extra benefits.

UnitedHealthcare, which controls 26% of the Medicare Advantage market, is focused“on providing the core medical benefits, which is why people purchase health insurance in the first place,” said Steve Warner, vice president of the UHC Medicare Advantage product team.”Most consumers don’t want to buy a plan that’s been loaded up with ancillary benefits that they don’t think they’re going to use.”

Instead, the insurer is offering more plans that do not restrict members to a network of health care providers and introducing specialized plans for people with diabetes or dementia, among other changes.

Because new extra benefits will not be accessible in every county, seniors may need to do some detective work to find out what’s available. Using the plan finder, it’s possible to narrow down the Medicare Advantage choices only to those plans that offer hearing, vision, dental, fitness and transportation coverage.

Bonnie Burns, a consultant to California Health Advocates, recommends that customers call insurers to confirm details before signing up.

Among the improvements in the new plan finder is the ability to compare estimated costs of Medicare Advantage plans against coverage under traditional Medicare with a separate drug plan and one of 11 kinds of Medigap supplement plans, which cover all or some of the out-of-pocket costs Medicare doesn’t pay for.

But the monthly premiums listed for Medigap policies ― at least in some areas ― are wildly off course. According to the plan finder, a senior in San Francisco can buy a Medigap plan for as little as $20.83 a month. Yet such a plan is not included in the rate chart published by the California Department of Insurance, which lists the cheapest bare-bones policy for a 65-year-old at four times more.

With a more complicated, slower enrollment process, it’s likely that older adults will need more help. And help may be scarce.

“It means fewer people that we get to see because we’re giving each one more time,” said Alicia Jones, administrator of the state SHIP program at Nebraska’s Department of Insurance.

To find your local SHIP program, call 1-877-839-2675 or visit www.shiptacenter.org/.

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Aging Cost and Quality Health Care Costs Insurance Medicare Pharmaceuticals

Trump’s New Order For Medicare Packs Potential Rise In Patients’ Costs

Vowing to protect Medicare with “every ounce of strength,” President Donald Trump last week spoke to a cheering crowd in Florida. But his executive order released shortly afterward includes provisions that could significantly alter key pillars of the program by making it easier for beneficiaries and doctors to opt out.

The bottom line: The proposed changes might make it a bit simpler to find a doctor who takes new Medicare patients, but it could lead to higher costs for seniors and potentially expose some to surprise medical bills, a problem from which Medicare has traditionally protected consumers.

“Unless these policies are thought through very carefully, the potential for really bad unintended consequences is front and center,” said economist Stephen Zuckerman, vice president for health policy at the Urban Institute.

While the executive order spells out few details, it calls for the removal of “unnecessary barriers” to private contracting, which allows patients and doctors to negotiate their own deals outside of Medicare. It’s an approach long supported by some conservatives, but critics fear it would lead to higher costs for patients. The order also seeks to ease rules that affect beneficiaries who want to opt out of the hospital portion of Medicare, known as Part A.

Both ideas have a long history, with proponents and opponents duking it out since at least 1997, even spawning a tongue-in-cheek legislative proposal that year titled, in part, the “Buck Naked Act.” More on that later.

“For a long time, people who don’t want or don’t like the idea of social insurance have been trying to find ways to opt out of Medicare and doctors have been trying to find a way to opt out of Medicare payment,” said Timothy Jost, emeritus professor at Washington and Lee University School of Law in Virginia.

The specifics will not emerge until the Department of Health and Human Services writes the rules to implement the executive order, which could take six months or longer. In the meantime, here are a few things you should know about the possible Medicare changes.

What are the current rules about what doctors can charge in Medicare?

Right now, the vast majority of physicians agree to accept what Medicare pays them and not charge patients for the rest of the bill, a practice known as balance billing. Physicians (and hospitals) have complained that Medicare doesn’t pay enough, but most participate anyway. Still, there is wiggle room.

Medicare limits balance billing. Physicians can charge patients the difference between their bill and what Medicare allows, but those charges are limited to 9.25% above Medicare’s regular rates. But partly because of the paperwork hassles for all involved, only a small percentage of doctors choose this option.

Alternatively, physicians can “opt out” of Medicare and charge whatever they want. But they can’t change their mind and try to get Medicare payments again for at least two years. Fewer than 1%of the nation’s physicians have currently opted out.

What would the executive order change?

That’s hard to know.

“It could mean a lot of things,” said Joseph Antos at the American Enterprise Institute, including possibly letting seniors make a contract with an individual doctor or buy into something that isn’t traditional Medicare or the current private Medicare Advantage program. “Exactly what that looks like is not so obvious.”

Others said eventual rules might result in lifting the 9.25% cap on the amount doctors can balance-bill some patients. Or the rules around fully “opting out” of Medicare might ease so physicians would not have to divorce themselves from the program or could stay in for some patients, but not others. That could leave some patients liable for the entire bill, which might lead to confusion among Medicare beneficiaries, critics of such a plan suggest.

The result may be that “it opens the door to surprise medical billing if people sign a contract with a doctor without realizing what they’re doing,” said Jost.

Would patients get a bigger choice in physicians?

Proponents say allowing for more private contracts between patients and doctors would encourage doctors to accept more Medicare patients, partly because they could get higher payments. That was one argument made by supporters of several House and Senate bills in 2015 that included direct-contracting provisions. All failed, as did an earlier effort in the late 1990s backed by then-Sen. Jon Kyl (R-Ariz.), who argued such contracting would give seniors more freedom to select doctors.

Then-Rep. Pete Stark (D-Calif.) opposed such direct contracting, arguing that patients had less power in negotiations than doctors. To make that point, he introduced the “No Private Contracts To Be Negotiated When the Patient Is Buck Naked Act of 1997.”

The bill was designed to illustrate how uneven the playing field is by prohibiting the discussion of or signing of private contracts at any time when “the patient is buck naked and the doctor is fully clothed (and conversely, to protect the rights of doctors, when the patient is fully clothed and the doctor is naked).” It, too, failed to pass.

Still, the current executive order might help counter a trend that “more physicians today are not taking new Medicare patients,” said Robert Moffit, a senior fellow at the Heritage Foundation, a conservative think tank based in Washington, D.C.

It also might encourage boutique practices that operate outside of Medicare and are accessible primarily to the wealthy, said David Lipschutz, associate director of the Center for Medicare Advocacy.

“It is both a gift to the industry and to those beneficiaries who are well off,” he said. “It has questionable utility to the rest of us.”

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Trump Speech Offers Dizzying Preview Of His Health Care Campaign Strategy

President Donald Trump offered a preview of what his 2020 health agenda might look like in a speech Thursday — blasting Democratic proposals for reform and saying he would tackle issues such as prescription drug prices and affordability.

He outlined the pillars of his health care vision, which included protecting vulnerable patients; delivering affordable care and prescription drugs; providing choices and control; and improving care for veterans.

In the speech, delivered in The Villages, Fla., before the president signed an executive order to expand Medicare Advantage, Trump also took aim at overhaul plans being advocated by his Democratic opponents, claiming their approach would “put everyone into a single socialist government-run program that would end private insurance.”

He said he and Republicans are committed to protecting people who have preexisting conditions — a claim that PolitiFact and Kaiser Health News previously rated False, because of his administration’s policies.

And, in keeping with the Medicare Advantage theme, he spoke about a controversial move by the Obama administration to reduce future payments to that program by $800 billion. (This point, previously examined by PolitFact, was found to be Half True — but Trump didn’t note that the reductions didn’t affect the program’s beneficiaries, or that he has used a similar approach in projecting future Medicare spending reductions.)

He challenged Congress to approve legislation to curb surprise medical bills and lauded improvements in the veterans’ health system.

But the speech included several other claims directed at Democrats and the currently buzzy proposal of “Medicare for All” that could easily have left some people befuddled. We broke down a few.

Trump told his audience that “Democrats are draining your health care to finance the open borders.”

We asked the White House for the basis of this remark and never got a specific answer. But there are various issues to examine.

In August, the president argued that Democrats “support giving illegal immigrants free healthcare at our expense.” But that isn’t accurate. The statement, part of a Trump 2020 television advertisement, was rated Mostly False.

That claim examined Democratic candidates who had said during one of the televised debates that their health care plans would provide coverage to undocumented immigrants. But the question posed by a debate host didn’t ask whether coverage would be free. In fact, multiple candidates said coverage for undocumented people would not be free. Some, meanwhile, include copays and deductibles in their health care proposals. Plus, if any Medicare for All plan was financed through, for instance, payroll taxes, undocumented immigrants would also be subject to paying those.

Trump argued that Democratic proposals for universal health care “would totally obliterate Medicare” — adding that “whether it’s single-payer or the so-called public option … they want to raid Medicare to fund a thing called socialism.”

The argument here is nuanced but, fundamentally, Trump’s characterization misses the mark and is misleading.

The “single-payer” bill he refers to is the Medicare for All proposal pushed by Democratic Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts. The bill would put all Americans — including the seniors currently covered by Medicare — into a single health plan. It would share Medicare’s name but look dramatically different: Unlike the existing program, the proposal envisions covering virtually all medical services and eliminating cost sharing. It would not be administered by private, for-profit contractors.

Predicting what this looks like is difficult since it’s grounded in hypotheticals. And one could argue that using the term “obliterates” is not completely off base because Medicare in its current form would no longer exist. But that misses the broader impact. Under the proposal as it’s written, seniors would be insured through a program at least as generous — if not more — than what they currently receive.

As for “public option” proposals put forth by candidates such as former Vice President Joe Biden and South Bend, Ind., Mayor Pete Buttigieg, they would leave Medicare more or less as it is, while also creating a public health plan uninsured people could buy into.

Describing Medicare for All, Trump said the plan would “reduce Americans’ household income by $17,000 a year.”

We contacted the White House to find out the source of this number. The administration acknowledged receipt but never sent an answer.

That said, it’s unclear where this number comes from, because the evidence simply doesn’t exist to make such a precise claim. After all, many details about Medicare for All are still being worked out. That makes it exceptionally difficult to figure out how much such a system would cost — let alone how an individual household’s finances might change under such a system. (This ambiguity is why the Congressional Budget Office has declined to estimate single-payer’s fiscal impact.)

And different households would likely make out differently under Medicare for All. Some might end up paying more. But others would likely pay more in taxes while still seeing their health care costs go down — meaning they could ultimately save money.

Trump said, “the Democrat plans for socialized medicine will not just put doctors and hospitals out of business, they will also deny your treatment and everything that you need.”

This statement relies on a talking point that’s been widely debunked.

We focused on the first part of this claim. Both conservatives and moderate Democrats have argued that single-payer health care, in particular, would drive hospitals and doctors to shutter en masse. (Conservatives have made this argument about a public option as well.) In a past related fact check, we rated this as False.

The argument springs from the way Medicare currently reimburses hospitals, at 87 cents for every dollar spent on health care. But the Sanders bill does not set a reimbursement rate, and instead would charge the federal government with devising an appropriate rate.

Some hospitals might struggle under a new system — but others, health care economists have previously told us, would likely do better.

“It really depends on which hospitals you’re talking about,” Gerard Anderson, a health policy professor at Johns Hopkins University and an expert in hospital pricing, told Kaiser Health News in July.

Study Finds Surprising Increase In Heart Valve Infections For Hospitalized Patients

The study showed hospital-acquired heart valve infections have increased as the number of community-acquired heart valve infections have declined. Meanwhile, news outlets report on the recent penalties levied on hospitals with high rates of readmissions and new data looking at hospitals’ lowered profitability.

Medicare’s ACO Program, Which Offers Doctors, Hospitals Rewards For Better Care, Saved $740M Last Year

The program, initiated under the Affordable Care Act, is designed to reward top-performing health providers with bonuses while pushing those that do poorly to repay Medicare. In her announcement, Seema Verma, the head of the Centers for Medicare & Medicaid Services, said nearly 11 million Medicare beneficiaries are served by an accountable care organization. Other Medicare news includes the penalties hospitals face for having too many readmissions.

New Round of Medicare Readmission Penalties Hits 2,583 Hospitals

Medicare cut payments to 2,583 hospitals Tuesday, continuing the Affordable Care Act’s eight-year campaign to financially pressure hospitals into reducing the number of patients who return for a second stay within a month.

The severity and broad application of the penalties, which Medicare estimates will cost hospitals $563 million over a year, follows the trend of the past few years. Of the 3,129 general hospitals evaluated in the Hospital Readmission Reduction Program, 83% received a penalty, which will be deducted from each payment for a Medicare patient stay over the fiscal year that begins today.

Although Medicare began applying the penalties in 2012, disagreements continue about whether they have improved patient safety. On the positive side, they have encouraged hospitals to focus on how their patients recuperate, and some now assist them in procuring medications and follow-up appointments.

But the hospital industry and some academics have raised concerns that some hospitals may be avoiding readmitting patients who require additional inpatient care out of fear of the financial repercussions, while others have said the program is not showing major benefits.

“A lot of hard work has gone into trying to reduce readmissions, and the needle has not moved very far,” said Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis, who has been skeptical of the initiative. “It’s been a huge investment by hospitals but not very much in outcomes, but some good things have come out of it.”

A few studies have even found an increase in mortality since the penalties took effect, but other studies, including a recent one by the Medicare Payment Advisory Commission (MedPAC), an independent body that helped devise the approach for Congress, identified no such link.

“I don’t believe the HRRP kills people,” David Grabowski, a commission member and health policy professor at Harvard Medical School, said at the commission’s meeting last month, using the acronym for the penalty program.

The MedPAC staff’s preliminary analysis, made public last month, found that the frequency of Medicare patients being readmitted within 30 days of discharge dropped from 16.7% in 2010 to 15.7% in 2017. However, the analysis said the decrease was more significant once it took into consideration that the average patient was frailer in 2017 than in 2010 and thus more likely to end up back in the hospital, with all other things being equal.

“On a risk-adjusted basis, it appears that readmissions have declined in 2010 to 2018 without causing a material increase in mortality,” Jeff Stensland, a MedPAC analyst, told the commission.

The penalties are based on the frequency of readmissions of Medicare patients who had originally been treated for heart failure, heart attack, pneumonia, chronic lung disease, hip and knee replacement or coronary artery bypass graft surgery. Readmissions that were scheduled to occur are not counted.

Medicare counts the readmission of patients who returned to a hospital within 30 days even if that hospital is not the one that originally treated them. In those cases, the penalty is applied to the first hospital. This year’s penalties are based on discharges from July 1, 2015, to June 30, 2018.

“This is like driving your car by looking in the rearview mirror of the car three cars behind you,” Dr. Jonathan Perlin, the chief medical officer of HCA Healthcare in Nashville and a MedPAC commission member, said at last month’s meeting. “It’s very difficult to operationalize.”

The average penalty will be a 0.71% decrease in payment for each Medicare patient who leaves the hospital over the next year, according to a Kaiser Health News analysis. The KHN analysis also found:

  • 1,177 hospitals received a higher penalty than they did last year.
  • 1,148 hospitals received a lower one than last year.
  • 64 hospitals received the same penalty as last year.
  • 194 hospitals that had not been penalized last year are being punished this year.
  • The maximum penalty — a 3% reduction in payments — was assessed against 56 hospitals.
  • 372 hospitals avoided penalties in both years.

These figures do not include 2,142 hospitals that Medicare exempted from the program this year, either because they had too few cases to judge; served veterans, children or psychiatric patients; or were critical-access hospitals, which are the only hospitals within reach of some patients.

Also, Maryland hospitals were excluded because Congress lets that state set its own rules on how to distribute Medicare money and handle readmissions.

The Centers for Medicare & Medicaid Services determines its penalties by looking at national averages for each of the conditions, so hospitals that have reduced their readmissions from previous years can still take a hit. The hospital industry argues it may be approaching the limits of how much it can do to prevent readmissions. A repeat stay, hospitals say, is sometimes necessary no matter what precautions are taken.

Akin Demehin, director of policy at the American Hospital Association, said: “It raises the question: Is the value of the program to improve care or just to enact penalties on hospitals?”

Look Up Your Hospital: Is It Being Penalized By Medicare?

Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. For the readmission penalties, Medicare cuts as much as 3 percent for each patient, although the average is generally much lower. The patient safety penalties cost hospitals 1 percent of Medicare payments over the federal fiscal year, which runs from October through September. Maryland hospitals are exempted from penalties because that state has a separate payment arrangement with Medicare.

Below are look-up tools for each type of penalty. Hospitals not penalized for 2020 are not listed if searching by year.  To see results from all hospitals, search by “Hospital penalized in any year.”