Resource Link


Connecting the community to regulatory
information, education, and resources.

In the Archives

Listed below are archived news for Medicare and Medicaid. For the most current news and announcements, delivered right to your email, become a member! Contact us for more information.

Breaking News | Upcoming Events | Affordable Care Act (ACA) | Federal and State Health Care Reform | CMS & HHS Releases | Community Provider News | Other Releases | Current News

Username:
Password:

Other Releases - Archived

5/10/19 – ASPE – Assessing the Costs and Benefits of Extending Coverage of Immunosuppressive Drugs under Medicare

By statute, the majority of patients with end-stage renal disease (ESRD) are eligible for Medicare, regardless of age. Kidney transplantation is ultimately considered the best treatment for ESRD, but ESRD-related eligibility for Medicare coverage extends for only 36 months post-transplant. Given the costs to Medicare associated with patients who stop taking immunosuppressive drugs due to cost and revert to developing ESRD, requiring subsequent dialysis and/or kidney transplantation, ASPE analyzed the financial implications of extending Medicare coverage of only immunosuppressive drugs for the lifetime of the patient. We estimate that extending Medicare coverage of immunosuppressive drugs beyond three years post-transplant would result in ten-year accumulated savings of approximately $73 million.

Read More


top of page

5/01/19 – Kaiser Family Foundation – Medicaid’s Prescription Drug Benefit: Key Facts

Medicaid provides health coverage for millions of Americans, including many with substantial health needs. Prescription drug coverage is a key component of Medicaid for many beneficiaries, such as children, non-elderly adults, and people with disabilities, who rely on Medicaid drug coverage for both acute problems and for managing ongoing chronic or disabling conditions. (Medicaid beneficiaries who also have Medicare receive drug coverage through Medicare.). Though the pharmacy benefit is a state option, all states cover it, and, within federal guidelines about pricing and rebates, administer pharmacy benefits in different ways. After a sharp spike in 2014 due to specialty drugs and expansion under the Affordable Care Act (ACA), Medicaid drug spending growth has slowed, similar to the overall US pattern; however, state policymakers remain concerned about Medicaid prescription drug spending as spending is expected to grow in future years. Due to Medicaid’s role in financing coverage for high-need populations, it pays for a disproportionate share of some high cost specialty drugs, and due to the structure of pharmacy benefit, Medicaid must cover upcoming “blockbuster” drugs. Policymakers’ actions to control drug spending have implications for beneficiaries’ access to needed prescription drugs. This fact sheet provides an overview of Medicaid’s prescription drug benefit and recent trends in spending and utilization.

Read More


top of page

11/13/18 –  Kaiser Health News – With Hospitalization Losing Favor, Judges Order Outpatient Mental Health Treatment

By Carmen Heredia Rodriguez

When mental illness hijacks Margaret Rodgers’ mind, she acts out.

Read More


top of page

11/13/18 –  CHCS - Helping States Support Families Caring for an Aging America

More than 17 million individuals in the United States provide care and support to an older parent, spouse, friend, or neighbor. While states are the primary payers for long-term services and supports (LTSS), in many cases their health care and social service systems are not prepared to meet the needs of an aging population or their caregivers.

Read More

Click here to view press release


top of page

10/30/18 – CHCS– Inclusion and Exclusion Criteria for Complex Care Programs: Survey of Approaches

Around the country, innovative health care organizations are developing programs to better coordinate care for people with complex medical, behavioral health, and social needs. As a first step, organizations need to consistently and efficiently identify individuals in their patient population who can benefit from enhanced care coordination and also determine when to “graduate” patients out of their programs. The Center for Health Care Strategies surveyed organizations involved in its Transforming Complex Care and Complex Care Innovation Lab initiatives to find out how they are identifying individuals for their respective complex care programs. Although this field is still emerging, the criteria used by these innovators can help inform other programs seeking to develop or refine eligibility criteria for complex care management programs.
 

top of page

10/30/18 - ACL - Evaluation of the Effect of the Older Americans Act Title III-C Nutrition Services Program on Participants’ Health Care Utilization

By James Mabli, Arkadipta Ghosh, Bob Schmitz, Marisa Shenk, Erin Panzarella, Barbara Carlson, and Mark Flick

The 2018 evaluation of the Older Americans Act (OAA) Nutrition Services Program (NSP) Outcomes Report Part II describes the effect of the OAA Title III-C NSP on participants’ Medicare-funded health care utilization. Part I of this report, available on the ACL website, provided statistical evidence that the OAA Title III-C nutrition programs are fulfilling the statutory purpose: reducing hunger and food insecurity, promoting socialization and promoting health and well-being through providing a nutritious meal. 
 

top of page

10/26/18 – ASPE – 2019 Health Plan Choice and Premiums in Healthcare.gov States

This brief presents information on qualified health plans (QHPs) available in states that rely on the HealthCare.gov eligibility and enrollment platform (HealthCare.gov states), including estimates for issuer participation, consumer options, average premiums, and subsidies in the upcoming open enrollment period (OEP), and trends since the first OEP. National estimates and summary tables are presented in each section of the text. State-specific estimates are in the Appendix. Unless otherwise specified, all estimates reflect all states using the HealthCare.gov platform for each given year.

Read More


top of page

10/25/18 – ASPE – Comparison of U.S. and International Prices for Top Medicare Part B Drugs by Total Expenditures

The prices charged by drug manufacturers to wholesalers and distributors (commonly referred to as ex-manufacturers prices) in the United States are 1.8 times higher than in other countries for the top drugs by total expenditures separately paid under Medicare Part B. U.S. prices were higher for most of the drugs included in the analysis, and U.S. prices were more likely to be the highest prices paid among the countries in our study.

Read More


top of page

10/22/18 – The Commonwealth Fund - The Potential Implications of Work Requirements for the Insurance Coverage of Medicaid Beneficiaries: The Case of Kentucky

By Sara R. Collins, Sherry A. Glied and Adlan Jackson

With encouragement from the Trump administration, 14 states have received approval for or are pursuing work requirements for nondisabled Medicaid beneficiaries. The requirements have sparked controversy, including two legal challenges.

Read More


top of page

10/17/18 – The Commonwealth Fund – Health Care in America

The Experience of People with Serious Illness

By Eric C. Schneider, Melinda Abrams, Arnav Shah, Corrine Lewis, and Tanya Shah

Most Americans expect the health care system will deliver effective treatment and support them through trying times when they get sick. But in reality, health care in America sometimes hurts even as it helps. Appointments can be difficult to get. Clinics and emergency rooms are often overcrowded. Doctors’ recommendations can be confusing and difficult to follow. And when the bills arrive, the costs can be unexpected and devastating. More than 40 million adults in the United States experienced serious illness in the past three years. More than 41 million provided unpaid care to elderly adults during the past year.

Read More


top of page

10/16/18 – Kaiser Family Foundation - What Are the Latest Trends in Medicaid?

Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2018 and 2019 at a Forum with the National Association of Medicaid Director

At 9:30 a.m. ET on Thursday, Oct. 25, KFF (the Kaiser Family Foundation) will release its 18th annual 50-state Medicaid budget survey for state fiscal years 2018 and 2019. KFF and the National Association of Medicaid Directors (NAMD) will hold a joint briefing to discuss trends in enrollment and spending and highlight key policy developments at a time when the majority of states are focused on quality and outcomes while some are pursing policies that could restrict Medicaid coverage.
 

top of page

10/16/18 – Kaiser Family Foundation - People on Medicare Will Be Able to Choose Among 24 Medicare Advantage Plans and 27 Medicare Part D Drug Plans, on Average, During the Open Enrollment Period for 2019, New Analyses Find

With Medicare Advantage playing an increasingly larger role in Medicare, the average person on Medicare will be able to choose among 24 plans during the annual Medicare open enrollment period that began Oct. 15, finds a new analysis from KFF (the Kaiser Family Foundation).

Read More


top of page

10/15/18 – Kaiser Health News - Medicare Advantage Riding High As New Insurers Flock To Sell To Seniors

By Paul Galewitz

Health care experts widely expected the Affordable Care Act to hobble Medicare Advantage, the government-funded private health plans that millions of seniors have chosen as an alternative to original Medicare.

Read More


top of page

10/15/18 – MedPAC - MedPAC comment on CMS's proposed rule on Medicare Shared Savings Program ACOs

Read More


top of page

10/2/18 – Kaiser Health News - Drugmakers Play The Patent Game To Lock In Prices, Block Competitors

By Sarah Jane Tribble

David Herzberg was alarmed when he heard that Richard Sackler, former chairman of opioid giant Purdue Pharma, was listed as an inventor on a new patent for an opioid addiction treatment. 
 

top of page

10/2/18 – CHCS -  Achieving Value in Medicaid Home- and Community-Based Care: Considerations for Managed Long-Term Services and Supports Programs

By Michelle Herman Soper, Debra Lipson, Maria Dominiak, and James Lloyd

States are increasingly adopting value-based payment (VBP) models to tie payment to outcomes including quality of care, health status, and costs for their Medicaid programs. Although most Medicaid VBP models are for primary and acute care services, states are beginning to explore VBP for long-term services and supports (LTSS).

Read More


top of page

10/2/18 – CHCS -  Rewarding Healthy Behaviors and Addressing Day-to-Day Needs: AccessHealth Spartanburg’s Gift-In-Kind Closet

Recognizing an unmet need for toiletries and household products among clients, AccessHealth Spartanburg (AHS) stocks a closet where eligible clients can “shop” for items. Clients can shop when they first enroll and at targeted intervals, plus they can earn coupons to shop for items by attending appointments, meeting with case managers, and/or achieving health-related milestones. This builds trusting relationships between clients and staff and meets basic client needs. AHS is a participant in the Transforming Complex Care initiative, a national multi-site demonstration made possible through support from the Robert Wood Johnson Foundation.

Read More


top of page

10/2/18 – CHCS - Serving Adults with Serious Mental Illness in the Program of All-Inclusive Care for the Elderly: Promising Practices

By Logan Kelly, Nancy Archibald and Amy Herrr

Program of All-Inclusive Care for the Elderly (PACE) organizations now serve a greater number of older adults with serious mental illness (SMI) than ever before, and increasingly include behavioral health providers in their care teams to meet the complex needs of this population.

Read More


top of page

06/05/18 – ICRC - Program of All-Inclusive Care for the Elderly (PACE) Total Enrollment by State and by Organization – May 2018

Read More


top of page

12/19/16 – U.S. News & World Report - Some Medicare Patients See Higher Bills

A government report says Medicare beneficiaries can end up with higher hospital bills for some medical services as outpatients than as inpatients. – By Ricardo Alonso-Zaldivar - You pay less for outpatient treatment than for a hospital admission, right? Not necessarily in the topsy-turvy world of Medicare billing, according to a government report.  People entitled to benefits under Medicare who had heart stents inserted as outpatients faced hospital bills that were $645 higher on average than those who had the same kind of procedure as inpatients, the Health and Human Services inspector general has found. Stents are tiny mesh cages that prop open narrow or weakened arteries. They usually are inserted through a tube that's threaded through an artery in either the groin or the arm.

Read More


top of page

12/21/16 – ICRC - Program of All Inclusive Care for the Elderly (PACE) Total Enrollment by State and by Organization

Read More


top of page

12/21/16 – OIG – Early Implementation Review: CMS’ Management of the Quality Payment Program

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enacted clinician payment reforms designed to put increased focus on the quality and value of care. These reforms, known as the Quality Payment Program (QPP), are a significant shift in how Medicare calculates compensation for clinicians and require CMS to develop a complex system for measuring, reporting, and scoring the value and quality of care. CMS issued final regulations on October 14, 2016, and the first performance year will begin January 1, 2017, with the first payment adjustments taking effect on January 1, 2019. Clinicians may participate in one of two QPP tracks: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs).

Read More


top of page

12/21/16 – Kaiser Family Foundation – Kaiser Health Policy News Index: 2016 in Review

By Ashley Kirzinger, Elise Sugarman, Bryan Wu, and Mollyann Brodie

The Kaiser Health Policy News Index is designed to help journalists and policymakers better understand which health policy-related news stories Americans are following, and what the public knows about health policy issues covered in the news. It also looks at how attention to health policy news stories compares to other national news stories.

Read More

Click here to view topline and methodology


top of page

12/21/16 – Kaiser Family Foundation – Turning the Spotlight on Medicare Advantage for 2017

Medicare Advantage plans, which consist primarily of HMOs and PPOs, now cover almost 18 million people – nearly one-third of all Medicare beneficiaries.  Medicare Advantage plans have been in the news lately because the proposed merger between Aetna and Humana, which together account for one-quarter of all Medicare Advantage enrollees, could further consolidate the Medicare Advantage market.

Read More

Click here to view the issue brief


top of page

12/19/16 – OIG – Vulnerabilities Remain under Medicare’s 2-Midnight Hospital Policy

CMS implemented the "2-midnight" policy in fiscal year (FY) 2014. The policy establishes that inpatient payment is generally appropriate if physicians expect beneficiaries' care to last at least 2-midnights; otherwise, outpatient payment would generally be appropriate. CMS implemented the 2-midnight policy to address three vulnerabilities in hospitals' use of inpatient and outpatient stays: improper payments for short inpatient stays; adverse consequences for beneficiaries of long outpatient stays, including that they may not have the 3 inpatient nights needed to qualify for skilled nursing facility (SNF) services; and inconsistent use of inpatient and outpatient stays among hospitals. This report follows up on previous OIG work and compares data from the year before and the year after the implementation of the 2-midnight policy.

Read More


top of page

12/16/16 – CHCS – Measuring Social Determinants of Health among Medicaid Beneficiaries: Early State Lessons

By Anna Spencer, Bianca Freda and Tricia McGinnis and Laura Gottlieb

Newer payment and care models aimed at improving health outcomes and lowering costs of Medicaid beneficiaries are leading providers and health plans to address the root causes of poor health and high health care costs, some of which relate back to underlying social needs, such as housing and nutrition. Collecting and using data to understand the health-related social needs of patients can help guide state Medicaid agencies in supporting such innovative interventions. Little is known, however, about state-based efforts to collect and use social determinants of health (SDOH) data, including what data health plans and providers are required to collect.

Read More


top of page

The Commonwealth Fund – Brazil’s Family Health Strategy: Using Community Health Care Workers to Provide Primary Care

By Hester Wadge, Yasser Bhatti, Alexander Carter, Mathew Harris, Greg Parston, and Ara Darzi

Countries around the world, including the United States, are looking to reduce costly hospital care and at the same time provide greater access to care. Some low- and middle-income countries are using community health workers (CHWs)—frontline public health workers—to provide care, a tested and cost-effective approach. CHWs are often members of the communities in which they work so therefore have valuable knowledge, understanding, and relationships.1 To date, however, they have not been deployed to the same extent in high-income countries. The use of CHWs is a low-level technical intervention; the greatest benefits occur through scaling the use of CHWs to achieve coverage over a greater geographical area, which requires coordinated, strategic change at regional or national levels.

Read More


top of page

12/09/16 – The Commonwealth Fund – How High-Need Patients Experience Health Care in the United States

By Jamie Ryan, Melinda K. Abrams, Michelle M. Doty, Tanya Shah, and Eric C. Schneider, M.D

In the United States, patients with clinically complex conditions, cognitive or physical limitations, or behavioral health problems use a disproportionate amount of health care services. In any given year, 10 percent of patients account for 65 percent of the nation’s health care expenditures. Moreover, many patients with high needs—that is, people with two or more major chronic conditions like diabetes or heart failure—also have unmet social needs that may exacerbate their medical conditions.

Read More

Click here to view the chartpack

Click here to view the tables

Click here to view the HNHC Survey Topline

Click here to view press release

Click here to view the 'Playbook' of Best Practices


top of page

12/08/16 – CHCS – Measuring Social Determinants of Health among Medicaid Beneficiaries: Early State Lessons

By Anna Spencer, Bianca Freda and Tricia McGinnis

Newer payment and care models aimed at improving health outcomes and lowering costs of Medicaid beneficiaries are leading providers and health plans to address the root causes of poor health and high health care costs, some of which relate back to underlying social needs, such as housing and nutrition. Collecting and using data to understand the health-related social needs of patients can help guide state Medicaid agencies in supporting such innovative interventions. Little is known, however, about state-based efforts to collect and use social determinants of health (SDOH) data, including what data health plans and providers are required to collect.

Read More


top of page

12/07/16 – OIG – Office of Inspector General Policy Statement Regarding Gifts of Nominal Value to Medicare and Medicaid Beneficiaries

Under section 1128A(a)(5) of the Social Security Act (the Act), enacted as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a person who offers or transfers to a Medicare or Medicaid beneficiary any remuneration that the person knows or should know is likely to influence the beneficiary’s selection of a particular provider, practitioner, or supplier of Medicare or Medicaid payable items or services may be liable for civil monetary penalties (CMPs) of up to $10,000 for each wrongful act. For purposes of section 1128A(a)(5) of the Act, the statute defines “remuneration” to include, without limitation, waivers of copayments and deductible amounts (or any part thereof) and transfers of items or services for free or for other than fair market value. See section 1128A (i)(6) of the Act. The statute and implementing regulations contain a limited number of exceptions. See section 1128A(i)(6) of the Act; 42 CFR 1003.110.

Read More


top of page

12/07/16 – Kaiser Health News – Senate Approves Landmark Mental Health Bill as Part of 21st Century Cures Act

By Liz Szabo

The Senate passed the first major mental health legislation in nearly a decade, sending the 21st Century Cures Act to President Barack Obama, who has promised to sign it.

Read More


top of page

12/07/16 – The Commonwealth Fund – Care Management Plus: Strengthening Primary Care for Patients with Multiple Chronic Conditions

By Susan L. Hayes and Douglas McCarthy

A care manager, embedded in a primary care practice and supported by specialized information technology tools, works with patients who have complex needs to develop and implement plans for care; coaches patients and their caregivers in self-management skills; and provides referrals to community-based resources.
 

top of page

12/06/16 – The Commonwealth Fund – Dental Care and Medicare Beneficiaries: Access Gaps, Cost Burdens, and Policy Options

By Amber Willink, Cathy Schoen and Karen Davis

In 2012, more than half of Medicare beneficiaries reported they went without a dental visit in the past 12 months, with lower-income beneficiaries much less likely than higher-income ones to have received dental care. Overall, only 12 percent of beneficiaries reported having any kind of dental insurance. To expand access to care and reduce out-of-pocket exposure for older adults, the authors propose two policy options for adding dental benefits to Medicare’s benefit package.

Read More


top of page

12/02/16 – Health Affairs – National Health Spending: Faster Growth In 2015 As Coverage Expands And Utilization Increases

By Anne B. Martin, Micah Hartman, Benjamin Washington, Aaron Catlin, and the National Health Expenditure Accounts Team

Total nominal US health care spending increased 5.8 percent and reached $3.2 trillion in 2015. On a per person basis, spending on health care increased 5.0 percent, reaching $9,990. The share of gross domestic product devoted to health care spending was 17.8 percent in 2015, up from 17.4 percent in 2014. Coverage expansions that began in 2014 as a result of the Affordable Care Act continued to affect health spending growth in 2015. In that year, the faster growth in total health care spending was primarily due to accelerated growth in spending for private health insurance (growth of 7.2 percent), hospital care (5.6 percent), and physician and clinical services (6.3 percent). Continued strong growth in Medicaid (9.7 percent) and retail prescription drug spending (9.0 percent), albeit at a slower rate than in 2014, contributed to overall health care spending growth in 2015.

Read More


top of page

12/01/16 – Kaiser Family Foundation – Kaiser Health Tracking Poll: November 2016

The November Kaiser Health Tracking Poll, conducted one week after the 2016 presidential election, finds health care played a limited role in voters’ 2016 election decisions, with larger shares of voters saying the biggest factor in their vote was the direction of the country (31 percent), Donald Trump’s personal characteristics (15 percent), jobs and the economy (15 percent), or Hillary Clinton’s personal characteristics (12 percent), than who say the same about health care (8 percent).

Read More

Click here to view the Topline & Methodology


top of page

11/30/16 – Kaiser Family Foundation - Paying a Visit to the Doctor: Current Financial Protections for Medicare Patients When Receiving Physician Services

By Cristina Boccuti

Under current law, Medicare has several financial protections in place that are designed to safeguard Medicare beneficiaries—seniors and people with permanent disabilities—from unexpected and confusing charges when they seek care from doctors and other practitioners.  These protections include the participating provider program, limitations on balance billing, and conditions on private contracting.  This issue brief describes these three protections, explains why they were enacted, and examines the implications of modifying them for beneficiaries, providers, and the Medicare program.

Read More


top of page

11/30/16 – KHN – Legislation to Improve Mental Health Care for Millions Faces Congressional Vote

By Liz Szabo

Efforts to strengthen the country’s tattered mental health system, and help millions of Americans suffering from mental illness, are getting a big boost this week, thanks to a massive health care package moving through Congress.

Read More


top of page

11/30/16 – CHCS – State Contracting with Medicare Advantage Dual Eligible Special Needs Plans: Issues and Options

By James Verdier, Alexandra Kruse, Rebecca Sweetland Lester, Ann Mary Phillip, and Danielle Chelminsky

Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan that serve beneficiaries dually enrolled in Medicare and Medicaid. To operate in a state, D-SNPs must have a contract with the state to facilitate coordination of Medicare and Medicaid services for enrollees, although states are not required to enter into such contracts. This technical assistance tool is based on an analysis of D-SNP contracts in 13 states, including states that have made the most extensive use of D-SNP contracting by linking D-SNPs to Medicaid managed long-term services and supports (MLTSS) programs that include the main services that Medicaid covers for Medicare-Medicaid enrollees. This tool summarizes how these states have developed those linkages and describes the specific care coordination and information-sharing requirements that the states have included in their D-SNP contracts. The D-SNP contracting approaches used by this diverse group of 13 states can provide guidance and examples for states that have varying opportunities and resources for D-SNP contracting, including states that may choose not to contract with D-SNPs.

Read More


top of page

11/22/16 – The Commonwealth Fund - Integrating Medicaid Supplemental Payments into Value-Based Purchasing

By Cindy Mann, Deborah Bachrach, Alice Lam, and Sarah Sullivan Codner

Over the past 20 years, Medicaid has emerged as the nation’s largest health insurer, covering some 69 million—nearly one of four—U.S. residents.1 Jointly funded by the federal government and states, the program accounted for over $500 billion in spending in 2015.2 It is the single largest purchaser of health services in states, one of the largest items in state budgets, and the largest source of federal revenue for states. Not surprisingly, states are increasingly intent on using Medicaid’s market power to promote the delivery of cost-effective, high-quality care for Medicaid patients and across the health system.

Read More


top of page

11/16/16 – The Commonwealth Fund – In New Survey of 11 Countries, U.S. Adults Still Struggle with Access to and Affordability of Health Care

By Robin Osborn, David Squires, Michelle M. Doty, Dana O. Sarnak, and Eric C. Schneider

An 11-country survey finds that adults in the United States are far more likely than those in other countries to go without needed care because of costs and to struggle to afford basic necessities such as housing and healthy food. U.S. adults are also more likely to report having poor health and emotional distress. Bright spots for the U.S. include rates of timely access to specialist care, discussion with a physician about ways to lead a healthy life, and coordinated hospital discharge planning.

Read More

 

top of page

11/07/16 – McKnight’s – Medicare Beneficiaries Could Choose Managed Care under Premium Support Plan

By Elizabeth Leis Newman

The Medicare Payment Advisory Commission is actively evaluating whether to recommend the creation of a premium support program within the Medicare program.

Read More


top of page

11/02/16 – Modern Healthcare - CMS Funnels $140 Million More Into Medicare Primary-Care Payments

By Virgil Dickson

The CMS Wednesday announced changes to how Medicare pays for primary care that could result in an estimated $140 million in additional funding in 2017 to providers.  The agency says several coding and payment changes could eventually lead to as much as $4 billion or more being funneled into care coordination and patient-centered care. Historically, care-management-related activities have been “bundled” into the evaluation and management visit codes used by all specialties.

Read More


top of page

11/01/16 – Kaiser Family Foundation – Visualizing Health Policy: Medicare and End-of-life Care

This Visualizing Health Policy infographic provides a snapshot of Medicare and end-of-life care. Of 2.6 million total deaths in the United States in 2014, 2.1 million were Medicare beneficiaries. Although Medicare spent significantly more on care for people at the end of life who died in 2014 ($34,529 per person) than for other beneficiaries that year ($9,121 per person), the share of total Medicare spending for people at the end of life decreased from 18.6% to 13.5% between 2000 and 2014. Medicare spending for people at the end of life also decreased with age.

Read More

Click here to view the slideshow


top of page

10/31/16 – The Commonwealth Fund – Risks for Nursing Home Placement and Medicaid Entry Among Older Medicare Beneficiaries with Physical or Cognitive Impairment

By Amber Willink, Karen Davis and Cathy Schoen

More than half of individuals who age into Medicare will experience physical and/or cognitive impairment (PCI) at some point that hinders independent living and requires long-term services and supports. As a result of Medicare’s limits on covered services, Medicare beneficiaries with PCI experience financial burdens and reduced ability to live independently.

Read More


top of page

10/24/16 – PACE Total Enrollment by State and by Organization

Read More


top of page

10/18/16 – National Association for Home Care & Hospice - COLA Hike Might Bring Big Medicare Premium Increases

Social Security’s annual cost of living adjustment (COLA) will be 0.3 percent in 2017, the federal government announced Tuesday. The increase could mean a large premium increase for many Medicare Part B beneficiaries. The COLA is pegged to consumer price inflation (CPI) in the year that ended last September.

Read More


top of page

10/17/16 – Kaiser Family Foundation – Medicare Drug Plan Enrollees Would Face an Average 9 Percent Premium Increase Unless They Switch Plans During Open Enrollment, New Analysis Finds

Current enrollees in stand-alone Medicare Part D plans are projected to face an average 9 percent increase in premiums if they remain in their current plan for 2017, according to an analysis released today by the Kaiser Family Foundation.

Read More 

Click here to view the analysis


top of page

10/13/16 – Kaiser Family Foundation – Putting Medicaid in the Larger Budget Context: An In-Depth Look at Four States in FY 2016 and FY 2017

By Kathleen Gifford, Barbara Gifford, Sarah Jagger, Pat Casanova, Robin Rudowitz, Allison Valentine, Elizabeth Hinton, and Larisa Antonisse

Medicaid has long-played an important role in the U.S. healthcare system, accounting for one in every six dollars of all U.S. health care spending while providing health and long-term services and supports coverage to millions of low-income Americans. Medicaid also plays an important role in states budgets as both an expenditure item and the largest source of federal revenue for states.

Read More


top of page

10/13/16 – Kaiser Family Foundation – Implementing Coverage and Payment Initiatives

Results form a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017

By Vernon K. Smith, Kathleen Gifford, Eileen Ellis, Barbara Edwards, Robin Rudowitz, Elizabeth Hinton, Larisa Antonisse, and Allison Valentine

Medicaid plays a significant role in the U.S. health care system, now providing health insurance coverage to more than one in five Americans and accounting for one-sixth of all U.S. health care expenditures.  The Medicaid program continues to evolve as state and federal policy makers respond to changes in the economy, the broader health system, state budgets, and policy priorities, and in recent years, to requirements and opportunities in the Affordable Care Act (ACA). This report provides an in-depth examination of the changes taking place in Medicaid programs across the country. The findings in this report are drawn from the 16th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Commission on Medicaid and the Uninsured and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors. This report highlights policy changes implemented in state Medicaid programs in FY 2016 and those implemented or planned for FY 2017 based on information provided by the nation’s state Medicaid directors. The District of Columbia is counted as a state for the purposes of this report.

Read More

Click here to view the Report Tables


top of page

10/07/16 – Kaiser Family Foundation – Spending and Utilization of EpiPen within Medicaid

By Katherine Young and Rachel Garfield

EpiPen is a brand-name epinephrine auto-injector product, used in the event of a severe allergic reaction. It is a reliable, easy-to-use medical device that delivers a life-saving drug. In 2007, Mylan acquired EpiPen from Merck. At the time, the product had a list price of $94. Since then, Mylan has steadily increased EpiPen’s price, listing the product at $608 in summer 2016. The price increases have led to public debate, particularly among people who pay the full or a sizeable share of the full list price. However, the effect of EpiPen’s high list price goes beyond individual consumers. Medicare spending before rebates on EpiPen has grown substantially over the 2007-2014 period outpacing the growth in the number of Part D EpiPen users.

Read More


top of page

10/07/16 – OIG – Medicare Improperly Paid Providers Millions of Dollars for Incarcerated Beneficiaries Who Received Services During 2013 and 2014

Both the Centers for Medicare & Medicaid Services' (CMS) policies and procedures to ensure that payments are not made for Medicare services rendered to incarcerated beneficiaries and its planned revisions to those policies and procedures did not comply with Medicare requirements.

Read More

Click here to view the complete report


top of page

10/07/16 – OIG – Medicare’s Policies and Procedures Identified Almost All Improper Claims Submitted for Deceased Individuals and Recouped Almost All Improper Payments Made for These Claims for January 2013 Through October 2015

CMS had policies and procedures to ensure that payments were not made for Medicare services ostensibly rendered to deceased individuals. These policies and procedures generally ensured that CMS did not make improper payments when its data systems indicated at the time a claim was processed that the individual had died before the claimed date of service. These policies and procedures also ensured that CMS correctly identified and recouped improper payments for almost all of the cases in which the Enrollment Database (EDB) was updated with date-of-death information after the claims had been processed and paid.

Read More

Click here to view the complete report


top of page

10/06/16 – Kaiser Health News – Dialysis at Home? Medicare Wants More Patients to Try It

By Eric Whitney

About half a million Americans need dialysis, which cleans toxins from the body when the kidneys can’t anymore. It can cost more than $50,000 a year, and takes hours each week at a dialysis center.

Read More


top of page

10/04/16 – OIG – Investigative Advisory on Medicaid Fraud and Patient Harm Involving Personal Care Services

In this investigative advisory, OIG identifies concerns about fraud and patient harm that build upon those outlined in a Portfolio report issued in November 2012, Medicaid Personal Care Services: Trends, Vulnerabilities, and Recommendations for Improvement (OIG-12-12-01). The Portfolio provided recommendations to address vulnerabilities in Medicaid PCS that OIG detected in more than two dozen previously published audits and evaluations and hundreds of completed State and Federal investigations.

Read More

Click here to view the full report


top of page

10/03/16 – New York Times – The Two Mysteries of Medicare

By Austin Frakt

A growing proportion of Medicare beneficiaries are opting out of the government-run insurance program. They are instead choosing a private plan alternative, one of the Medicare Advantage plans. The strength of this trend defies predictions from the Congressional Budget Office, and nobody can fully explain it.

Read More


top of page

10/03/16 – OIG – Early Alert: Incorporating Medical Device-Specific Information on Claim Forms

We alerted CMS to the preliminary results of our ongoing review of the costs Medicare incurred because of recalled or defective medical devices. Our ongoing review shows that the lack of medical device-specific information in the claims data impedes the ability of CMS to readily identify and effectively track Medicare's total costs related to the replacement of recalled or defective devices.

Read More

Click here to view the complete report


top of page

09/30/16 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model 

Read More


top of page

09/30/16 – OIG - Medicare Improperly Paid Millions of Dollars for Unlawfully Present Beneficiaries for 2013 and 2014

The Centers for Medicare & Medicaid Services (CMS) had policies and procedures to ensure that payments were not made for Medicare services rendered to unlawfully present beneficiaries in accordance with Federal requirements, but it did not always follow those policies and procedures. When CMS's data systems indicated that at the time a claim was processed the beneficiary was unlawfully present, CMS had policies and procedures to prevent payment for Medicare services, and CMS followed those procedures.

Read More

Click here to view the complete report


top of page

09/30/16 – Kaiser Family Foundation - Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program

By Cristina Boccuti and Giselle Casillas

For Medicare patients, hospitalizations can be stressful; even more so when they result in subsequent readmissions to the hospital. While many readmissions cannot and should not be prevented, researchers have found wide variation in hospitals’ readmission rates, suggesting that patients admitted to certain hospitals are more likely to experience readmissions compared to other hospitals. A number of studies show that hospitals can engage in several activities to lower their rate of readmissions, such as clarifying patient discharge instructions, coordinating with post-acute care providers and patients’ primary care physicians, and reducing medical complications during patients’ initial hospital stays.

Read More


top of page

09/29/16 – Kaiser Family Foundation – Kaiser Health Tracking Poll: September 2016

By Ashley Kirzinger, Bryan Wu and Mollyann Brodie

Americans say prescription drug costs are unreasonable, up slightly from 72 percent a year ago. There is widespread support for a variety of actions in order to keep costs down including requiring drug companies to release information to the public on how they set their drug prices, allowing the federal government to negotiate with drug companies to get a lower price on medications for people on Medicare, limiting the amount drug companies can charge for high-cost drugs, allowing Americans to buy prescription drugs imported from Canada, and creating an independent group that oversees the pricing of prescription drugs.

Read More

Click here to view topline and methodology


top of page

09/28/16 – Avalere – Premium Increases for Most Popular Medicare Drug Benefit Plans, Market for Medicare Advantage Plans Appears Stable in 2017

By Kelly Brantley

According to a new Avalere analysis of data from the Centers for Medicare & Medicaid Services (CMS), premiums for stand-alone prescription drug plans (PDPs) will increase and the number of PDPs available in 2017 will decrease. Conversely, the Medicare Advantage market appears strong as nearly 8 in 10 beneficiaries have access to MA plans that offer prescription drug benefits.

Read More


top of page

09/28/16 – CHCS – Considerations for a National Risk-Adjustment Model for Medicaid Managed Long-Term Services and Supports Programs

By Maria Dominiak, Michelle Herman Soper and Debra Lipson

Risk adjusting capitation rates paid to health plans helps ensure more equitable payments to each plan based on expected costs of its enrollees. Several risk-adjustment models exist for plans providing medical services, but currently there is no standardized risk-adjustment model for Medicaid managed long-term services and supports (MLTSS) programs. The development of a standardized, nationally available MLTSS risk-adjustment model for state Medicaid agencies could reduce the burden on states to establish their own models and facilitate comparisons about the key drivers of long-term services and supports (LTSS) costs within and across states.

Read More


top of page

09/27/16 – Kaiser Family Foundation – The Gap in Medigap

By Tricia Neuman and Julie Cubanski

Medicare provides coverage for a wide array of medical and drug benefits, but, with its deductibles, cost-sharing requirements, and lack of an annual out-of-pocket spending limit, many people on Medicare purchase Medigap supplemental insurance to help cover their out-of-pocket costs. Roughly 11 million of the 57 million people on Medicare—around 20 percent of all beneficiaries—have a Medigap policy, which helps protect against catastrophic expenses, spreads costs over the course of the year, and simplifies medical bills and paperwork. Thanks to a 1990 federal law, people age 65 and older are able to buy a Medigap policy when they sign up for Medicare, but younger Medicare beneficiaries with disabilities are not granted the same right unless they live in a state that requires it.

Read More


top of page

09/26/16 – Kaiser Family Foundation - 10 FAQs: Medicare’s Role in End-of-Life Care

About eight of 10 of the 2.6 million people who died in the US in 2014 were people on Medicare, making Medicare the largest insurer of health care provided during the last year of life.  In fact, roughly one-quarter of traditional Medicare spending for health care is for services provided to Medicare beneficiaries in their last year of life—a proportion that has remained steady for decades.  The high overall cost for health care received in the last year of life is not surprising given that many who die have multiple serious and complex conditions.

Read More


top of page

09/26/16 – Kaiser Family Foundation - The Medicare Part D Prescription Drug Benefit

Medicare Part D is a voluntary outpatient prescription drug benefit for people on Medicare that went into effect in 2006. All 57 million people on Medicare, including those ages 65 and older and those under age 65 with permanent disabilities, have access to the Part D drug benefit through private plans approved by the federal government; in 2016, nearly 41 million Medicare beneficiaries are enrolled in Medicare Part D plans. During the Medicare Part D open enrollment period, which runs from October 15 to December 7 each year, beneficiaries can choose to enroll in either stand-alone prescription drug plans (PDPs) to supplement traditional Medicare or Medicare Advantage prescription drug (MA-PD) plans (mainly HMOs and PPOs) that cover all Medicare benefits including drugs.

Read More


top of page

09/23/16 – OIG – Escalating Medicare Billing for Ventilators Raises Concerns

CMS has expressed concerns about the recent substantial increase in Medicare billing for noninvasive pressure support ventilators. Ventilator technology has evolved so that it is possible for a single device to treat numerous conditions by operating in several different modes-i.e., basic continuous positive airway pressure (CPAP) mode, respiratory assist device (RAD) mode, and traditional ventilator mode. Medicare covers ventilators and RADs for similar respiratory diagnoses, but the selection of the appropriate device is based on the severity of the beneficiary's condition. RADs are covered for beneficiaries with less severe conditions, whereas ventilators are covered for more severe conditions. CPAP devices are covered for the treatment of obstructive sleep apnea. The emergence of this multimodal device, when combined with Medicare coverage and payment policies that favor reimbursement for ventilators, may create incentives for suppliers to provide and bill for a ventilator when the device is actually being used as a RAD or CPAP device. 

Read More


top of page

09/22/16 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on Programs of All-Inclusive Care for the Elderly (PACE) 

Read More


top of page

09/21/16 – Kaiser Family Foundation - Medicare Part D Spending on the EpiPen Increased More than 1000 Percent from 2007 to 2014

By Chris Lee

As policymakers in Washington scrutinize the rising cost of the EpiPen auto-injector, a new analysis from the Kaiser Family Foundation shows that Medicare Part D spending for the potentially life-saving device increased by more than 1000 percent between 2007, the year after the Part D drug benefit took effect, and 2014, the most recent year for which data are available. The higher spending partly results from more Part D enrollees using EpiPens during that period, but is primarily driven by a five-fold increase in average Medicare per-prescription spending on the EpiPen, up from $71 in 2007 to $344 in 2014. The analysis illustrates that rising prices for the EpiPen affect public programs and taxpayers, as well as consumers and private insurers.

Read More


top of page

09/22/16 – MedPAC – MedPAC Comment to CMS Regarding the Hospital Star Rating Program 

Read More


top of page

09/20/16 – Kaiser Family Foundation – Medicare Advantage Plan Switching: Exception or Norm?

By Gretchen Jacobson, Tricia Neuman and Anthony Damico

Each year, Medicare Advantage enrollees have the opportunity to change plans during an annual enrollment period. This opportunity is important because Medicare Advantage plans can make changes in their benefits, cost-sharing, provider networks, and premiums each year, and beneficiaries’ health needs may change from one year to the next. The open enrollment period allows enrollees to compare plans, stick with their current plan, switch to another plan, or shift to traditional Medicare. It is also the time when beneficiaries in traditional Medicare can switch to Medicare Advantage plans.

Read More


top of page

09/16/16 – Kaiser Family Foundation – Medicare Part D in 2016 and Trends over Time

By Jack Hoadley, Juliette Cubanski and Tricia Neuman

Since 2006, Medicare beneficiaries have had access to prescription drug coverage offered by private plans, either stand-alone prescription drug plans (PDPs) or Medicare Advantage drug plans (MA-PD plans). Medicare drug plans (also referred to as Part D plans) receive payments from the government to provide Medicare-subsidized drug coverage to enrolled beneficiaries, who pay a monthly premium that varies by plan. The law that established Part D defined a standard drug benefit, but nearly all Part D plan sponsors offer plans with alternative designs that are equal in value, and plans may also offer an enhanced benefit. Part D plans also must meet certain other requirements, but vary in terms of premiums, benefit design, gap coverage, formularies, and pharmacy networks.

Read More


top of page

09/14/16 – OIG – Medicaid Fraud Control Units Fiscal Year 2015 Annual Report

By Suzanne Murrin

The mission of Medicaid Fraud Control Units (MFCUs or Units) is to investigate and prosecute Medicaid provider fraud and patient abuse or neglect under State law.  The Social Security Act (SSA) requires each State to operate a MFCU, unless the Secretary of Health and Human Services (HHS) determines that (1) operation of a Unit would not be cost effective because minimal Medicaid fraud exists in a particular State and (2) the State has other adequate safeguards to protect Medicaid beneficiaries from abuse or neglect.  Currently, 49 States and theDistrict of Columbia (States) have MFCUs. 

Read More


top of page

09/12/16 – The New York Times – Failure to Improve is Still Being Used, Wrongly, to Deny Medicare Coverage

By Paula Span

Edwina Kirby was having a hard time. She had tripped over a rug in her home in Livonia, Mich., and the fall broke a femur. After she had surgery and rehabilitation, an infection sent her back into the hospital. Her kidneys failed, requiring dialysis; she was also contending with diabetes and heart disease.

Read More


top of page

09/12/16 – Avalere – Assessing the Impact of MedPAC’s Proposed Part D Reforms to Modify Beneficiary Cost Sharing

The Medicare Payment Advisory Commission (MedPAC) June 2016 report to Congress includes a variety of Part D policy recommendations aimed at increasing the program’s financial sustainability. In order to assess how these policies may affect Medicare Part D enrollees, Avalere estimated the potential impact of two of these proposals on beneficiaries’ out-of-pocket (OOP) costs: (1) Implementing an out-of-pocket maximum in Part D, whereby beneficiaries would not be responsible for any cost sharing in the catastrophic portion of the benefit.

Read More


top of page

09/12/16 – McKnight’s – Republican Lawmakers Accuse CMS of Focusing on Recovering, Not Preventing, Improper Payments

By Emily Mongan

The Centers for Medicare & Medicaid Services relies too much on investigating improper Medicare payments after they're made instead of preventing them to begin with, Republican lawmakers said Monday.

Read More

Click here to view letter to CMS Acting Administrator Andy Slavitt


top of page

09/12/16 – AHIP – Nearly 90% of Consumers Satisfied with Their Long-Term Care Coverage

By David Merritt

Consumers with long-term care insurance are overwhelmingly satisfied with their coverage and experience. That’s the key result from a new study by LifePlans, Inc. on behalf of America’s Health Insurance Plans (AHIP).  The report gauges customer experience and satisfaction levels of long-term care (LTC) insurance policyholders.

Read More

Click here to view the full report


top of page

09/11/16 – OIG – Spotlight On…Medicaid: State Policies that Result in Inflated Federal Costs

Signed into law in 1965, Medicaid ensures health coverage for nearly 60 million Americans today. Since the Medicaid program was established, the costs and responsibilities for administering it have been shared between the States and the Federal Government. However, a number of OIG reports have cited examples of State policies that distort the cost-sharing arrangement, causing the Federal Government to pay more than its share of Medicaid expenditures. These mechanisms do not result in any increase in benefit to beneficiaries, and while they increase States' funds, they do so at the expense of the Federal Government and, ultimately, Federal taxpayers.

Read More


top of page

09/09/16 – GAO – Medicaid: Key Policy and Data Considerations for Designing a Per Capita Caps on Federal Funding

Through review of its prior reports, the literature and interviews with state Medicaid officials and subject matter experts, GAO identified several key interrelated policy considerations that could be useful should policymakers elect to pursue a per capita cap—a per-enrollee limit on federal Medicaid funding for states.

Read More


top of page

09/09/16 – AHRQ – Convening a Learning Community to Advance Medication Therapy Management for At-Risk Populations

By the Innovations Exchange Team

In October 2014, the Agency for Health Care Research and Quality (AHRQ) Health Care Innovations Exchange established three learning communities (LCs) to improve the quality of health care delivery by addressing challenges in high-priority areas that AHRQ identified. The Innovations Exchange defined an LC as a select group of potential adopters and stakeholders who engage in a shared learning process to facilitate adaptation and implementation of innovations featured in the Innovations Exchange.

Read More


top of page

09/06/16 – Modern Healthcare - GAO Finds Medicare Paying More For Drugs Than Other Agencies

By Shannon Muchmore

While Democrats and Republicans have been wary of proposed changes to how Medicare pays for drugs administered at physicians' office, a recent GAO report found that other federal agencies pay lower prices for the same drugs.  A hearing Tuesday will examine the Medicare Part B proposal and the general role of the agency that is recommending it, the Centers for Medicare and Medicaid Innovation, an agency created by the Affordable Care Act to test new methods of paying for value in medicine. Republicans in general have said the rule would be a change that is too sudden and not tested enough, but Democrats have also asked the CMS to postpone implementation.

Read More


top of page

09/07/16 – The Commonwealth Fund – Better Patient Care at High-Quality Hospitals May Save Medicare Money and Bolster Episode-Based Payment Models

By Ashish Jha, Felix Greaves, Thomas C. Tsai, Jia Zheng, E. John Orav, and Michael J. Zinner

Researchers looked at how much Medicare pays for five major surgical procedures, from the time patients are admitted to the hospital through 90 days after discharge. Patients who had their surgeries at high-quality hospitals—that is, those with low mortality rates and high patient satisfaction scores—were found to cost Medicare less than patients at low-quality hospitals. The majority of the savings achieved can be attributed to lower use of skilled nursing facilities and other postacute care services.

Read More


top of page

09/06/16 – OIG – CMS Should Address Medicare’s Flawed Payment System for DME Infusion Drugs

As required by statute, Medicare sets payment amounts for drugs infused through durable medical equipment (DME infusion drugs) at 95 percent of the average wholesale prices (AWPs) in effect on October 1, 2003. AWPs, which represent list prices rather than actual marketplace prices, have been long been recognized as a flawed pricing benchmark. In February 2013, OIG issued a report to CMS regarding Medicare payments for DME infusion drugs. In that report, we made one recommendation and suggested two options for its implementation. Because CMS had not taken steps to address our recommendation, and payments continued to be misaligned with drug costs, OIG revisited this issue in a 2015 report.

Read More


top of page

09/05/16 – McKnight’s - Study Casts Doubt On Future Of Value-Based Purchasing

By James M. Berklan

Even as some experts were predicting that value-based purchasing initiatives would be expanding in the near future, researchers from a handful of universities were casting doubts on the success of a VBP demo project.  Their study of administrative and qualitative data from nursing homes in Arizona, New York and Wisconsin showed a lack of lasting impact on Medicare spending and quality outcomes.

Read More


top of page

08/31/16 – Avalere – Medicare Part B Drug Payments Implicated in CMMI Models

By Miryam Frieder

The Center for Medicare & Medicaid Innovation is currently testing a variety of programs which place providers at risk for Medicare spending and may motivate providers to manage Medicare Part B costs, including drug spending and utilization.

Read more


top of page

08/30/16 – Kaiser Health News – Diagnosis: Unprepared – ‘America’s Other Drug Problem’: Copious Prescriptions for Hospitalized Elderly

By Anna Gorman

Dominick Bailey sat at his computer, scrutinizing the medication lists of patients in the geriatric unit.  A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.

Read more


top of page

08/29/16 – The Center for Public Integrity – Audits Of Some Medicare Advantage Plans Reveal Pervasive Overcharging

By Fred Schulte

More than three dozen just-released audits reveal how some private Medicare plans overcharged the government for the majority of elderly patients they treated, often by overstating the severity of certain medical conditions, such as diabetes and depression.

Read more


top of page

08/29/16 – Kaiser Health News – Protecting California’s Seniors From Surprise Hospital, Nursing Home Bills

By Susan Jaffe

Californians with Medicare coverage would no longer be surprised by huge medical bills stemming from “observation care” in hospitals under legislation that state lawmakers approved overwhelmingly last week and sent to Gov. Jerry Brown to sign into law.

Read more


top of page

08/29/16 – The Commonwealth Fund - New Commonwealth Fund Report Profiles The 12 Million Sickest Patients; Finds Health Care System Not Meeting Their Needs

Health Care Improvement Efforts Should Focus On Needs Of Those With Multiple Chronic Illnesses And Limited Ability To Care For Themselves

Twelve million people living at home in the United States have three or more chronic illnesses in addition to a functional limitation that makes it hard for them to perform basic daily tasks such as getting around the house or talking on the phone, according to a new Commonwealth Fund report. These adults, who face medical problems that are among the most complicated in the U.S. health care system, are older and less educated than U.S. adults overall and more likely to be female, white, low-income, and publicly insured. In fact, more than half of high-need adults are over 65, and nearly two-thirds are women. Among these sickest adults, more than one of four did not finish high school, compared with about one in six in the total adult population.

Read more

Click here to view the report.

Click here to view the chartpack.

Click here to view the appendix tables.


top of page

08/25/16 – Kaiser Health News – Doctors Raise Concerns for Small Practices in Medicare’s New Payment System

By Steven Findlay

Dr. Lee Gross is worried. He has practiced family medicine in North Port, Florida, near Sarasota, for 14 years. But he and two partners are the last small, independent practice in the town of 62,000. Everyone else has moved away, joined larger groups, or become salaried employees of hospitals or health companies.

Read more


top of page

08/25/16 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on the Physician Fee Schedule and Other Revisions to Part B for CY 2017 

Read more


top of page

08/25/16 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on the CY 2017 Home Health Prospective Payment System (Revised) 

Read more


top of page

08/24/16 – CHCS – Managed Long-Term Services and Supports Rate-Setting Resource Center

Many states pursuing Medicaid managed long-term services and supports (MLTSS) or Medicare-Medicaid integrated care programs are using capitation rate-setting methods that address the diverse needs of the populations enrolled and establish incentives to promote higher quality services and more cost-effective care. This resource center, a product of CHCS’ Medicaid Managed Long-Term Services and Supports Rate-Setting Initiative supported through the West Health Policy Center, gives states and other stakeholders practical tools to assist them in developing or refining MLTSS rate-setting methods.

Read More


top of page

08/24/16 – McKnight’s – Medicare Beneficiaries with More Continuity of Care at Lower Risk of ED Visits

By Emily Mongan

Older Medicare beneficiaries who have more continuity of care and consistently visit the same outpatient physician are less likely to visit an emergency room than those who receive care from several different physicians, according to a recent study.

Read More


top of page

08/24/16 – ICRC – Program of All-Inclusive Care for the Elderly (PACE) Total Enrollment by State and by Organization – August 2016

Read More


top of page

08/23/16 – The Commonwealth Fund – Improving Population Health Management Strategies: Identifying Patients Who Are More Likely to Be Users of Avoidable Costly Care and Those More Likely to Develop a New Chronic Disease

By Judith Hibbard, Jessica Greene, Rebecca M. Sacks, Valerie Overton, and Carmen Parotta

After reviewing medical records for approximately 98,000 adults, researchers found that patients who did not feel competent to manage their own health or navigate the health care system were more likely to develop a chronic disease over a three-year period than “activated” patients with good self-management skills. Low patient-activation levels were also linked to significantly greater likelihood of hospitalization and emergency department (ED) use for “ambulatory care–sensitive” conditions—those that are avoidable if managed properly.

Read More


top of page

08/17/16 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems 

Read More


top of page

08/17/16 – OIG – Public Summary Report: Wireless Penetration Test of Centers for Medicare & Medicaid Services’ Data Centers

We performed a wireless penetration test of select Centers for Medicare & Medicaid Services' Data Centers and facilities to determine whether CMS's security controls over its wireless networks were effective.

Read More

Click here to view the complete report


top of page

08/17/16 – AHRQ – Convening a Learning Community to Reduce Nonurgent Use of Emergency Services

By The Innovations Exchange Team

In October 2014, the Agency for Health Care Research and Quality (AHRQ) Health Care Innovations Exchange established three learning communities (LCs) to improve the quality of health care delivery by addressing challenges in high-priority areas that AHRQ identified. The Innovations Exchange defined an LC as a select group of potential adopters and stakeholders who engage in a shared learning process to facilitate adaptation and implementation of innovations featured in the Innovations Exchange.

Read More


top of page

08/16/16 – Kaiser Family Foundation – Similar but Not the Same: How Medicare Per Capita Spending Compares for Younger and Older Beneficiaries

By Juliette Cubanski, Tricia Neuman and Anthony Damico

Medicare is most commonly known as a health insurance program for people ages 65 and older, but, since 1973, the program has also provided coverage to millions of people with permanent disabilities who are younger than age 65. People under age 65 qualify for Medicare after they receive Social Security Disability Insurance (SSDI) payments for 24 months. Younger adults with end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS) are eligible for Medicare as soon as they begin receiving SSDI benefits. Over time, the share of Medicare beneficiaries under age 65 has more than doubled, from 7% (1.7 million people) in 19732 to 16% (9.1 million) this year.

Read More


top of page

08/12/16 – Kaiser Family Foundation – Medicare’s Role for People Under Age 65 with Disabilities

By Juliette Cubanski, Tricia Neuman, and Anthony Damico

Medicare was established in 1965 as the health insurance program for Americans age 65 and over; since 1973, it has also covered people under age 65 who receive Social Security Disability Insurance (SSDI) benefits. To qualify for SSDI, people must be unable to engage in “substantial gainful activity” because of a medically-determined physical or mental impairment expected to last at least 12 months or until death. Medicare also covers certain widows and widowers under age 65 with disabilities, as well as disabled adult children of retired, deceased, or disabled workers. Today, Medicare covers 9.1 million people with disabilities who are under age 65, or 16% of the Medicare population, up from 7% (1.7 million people with disabilities under age 65) in 1973. When people under age with disabilities on Medicare turn 65, their coverage from Medicare continues.

Read More


top of page

08/09/16 – The Commonwealth Fund – Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers” in Underserved Communities

By Martha Hostetter, Sarah Klein and Douglas McCarthy

The complex care initiative targets Medicaid beneficiaries who incur very high costs due to substance abuse problems and/or mental illnesses, often accompanied by significant physical health problems.  Most of the 425 current participants in the program received Medicaid coverage under New Mexico’s 2014 expansion to cover poor, childless adults.  Because the ECHO team is working with all four of the state’s Medicaid managed care plans, and because nearly all of the New Mexico’s beneficiaries are enrolled in managed care, participants are drawn from the vast majority of the state’s adult Medicaid beneficiaries.

Read more


top of page

08/02/16 – Kaiser Family Foundation – Medicaid’s Role in meeting Seniors’ Long-Term Services and Supports Needs

Although nearly all of the nation’s 46 million seniors have health insurance through Medicare, that program does not cover the long-term services and supports (LTSS) that many seniors need. Nearly half of seniors residing in the community have an LTSS need1 due to a cognitive or physical limitation. For example, people with dementia,2 mobility or coordination problems due to stroke, severe vision loss, or significant pain that prevents movement may require LTSS. LTSS provide assistance with routine self-care tasks, such as eating, bathing, and dressing, and household activities, such as preparing meals, managing medication, and doing laundry. LTSS are expensive, with a median annual cost of over $90,000 for nursing facility care, more than $40,000 for homemaker or home health services, and nearly $20,000 for adult day health care in 2015.

Read More


top of page

08/02/16 – Kaiser Health News – Medicare’s Readmission Penalties Hit New High

By Jordan Rau

The federal government’s readmission penalties on hospitals will reach a new high as Medicare withholds more than half a billion dollars in payments over the next year, records released Tuesday show.

Read More


top of page

08/01/16 – The Commonwealth Fund – Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center

By Sarah Klein, Martha Hostetter and Douglas McCarthy

Sylvia Trujillo was so desperate to have her 68-year-old mother Carolyn enrolled in MedStar Washington Hospital Center’s Medical House Call Program that she moved from one part of the District of Columbia to another—just to be in the program’s catchment area. In the years leading up to the move, her mother was in and out of the hospital every month or so as Trujillo struggled to find a physician who could manage her multiple chronic conditions. These included diabetes, depression, and early dementia, as well as a rare genetic disorder that led to a host of health problems, including multiple falls. “She easily saw 20 to 30 different physicians, because no one could figure out what was going on,” Trujillo says.

Read More


top of page

07/27/16 – McKnight’s - 1 in 7 Alzheimer's Hospitalizations Avoidable, Study Finds

By Emily Mongan

One out of seven hospital admissions among Medicare beneficiaries with Alzheimer's could be preventable, according to new research. Reducing that rate could save the federal health program more than $2 billion each year.  In a study presented Monday at the Alzheimer's Association International Conference in Toronto, researchers with Tufts Medical Center in Boston explained that proactive ambulatory care could help cut down on the number of people with dementia admitted to the hospital.

Read more


top of page

07/27/16 – ICRC – PACE Total Enrollment by State and by Organization

Read more


top of page

07/27/16 – The New England Journal of Medicine - Caring for High-Need, High-Cost Patients — An Urgent Priority

By David Blumenthal, M.D., M.P.P, Bruce Chernof, M.D., Terry Fulmer, Ph.D., R.N., John Lumpkin, M.D., M.P.H, and Jeffery Selberg, M.H.A

Improving the performance of America’s health system will require improving care for the patients who use it most: people with multiple chronic conditions that are often complicated by patients’ limited ability to care for themselves independently and by their complex social needs. Focusing on this population makes sense for humanitarian, demographic, and financial reasons.  From a humanitarian standpoint, high-need, high-cost (HNHC) patients deserve heightened attention both because they have major health care problems and because they are more likely than other patients to be affected by preventable health care quality and safety problems, given their frequent contact with the system. Demographically, the aging of our population ensures that HNHC patients, many of whom are older adults, will account for an increasing proportion of users of our health care system. And financially, the care of HNHC patients is costly. One frequently cited statistic is that they compose the 5% of our population that accounts for 50% of the country’s annual health care spending.

Read more


top of page

07/27/16 – Kaiser Health News – Some Seniors Surprised to be Automatically Enrolled in Medicare Advantage Plans

By Susan Jaffe

Only days after Judy Hanttula came home from the hospital after surgery last November, her doctor’s office called with bad news: Records showed that instead of traditional Medicare, she had a private Medicare Advantage plan, and her doctor and hospital were not in its network.

Read more


top of page

07/27/16 – Kaiser Health News – Many Well-Known Hospitals Fail to Score 5 Stars in Medicare’s New Rating System

By Jordan Rau

The federal government released its first overall hospital quality rating on Wednesday, slapping average or below average scores on many of the nation’s best-known hospitals while awarding top scores to many unheralded ones.

Read more


top of page

07/26/16 – Medicare Rights Center – Medicare Rights Center Brings Consumer Perspective to HHS Roundtable on Bundled Payments, Praises Reforms and Stresses Need for Robust Patient Engagement Strategies

Today, Joe Baker, president of the Medicare Rights Center, joined the honorable Sylvia Mathews Burwell, Secretary of the U.S. Department of Health and Human Services (HHS), for a roundtable discussion on how bundled payments can further ongoing efforts to transition Medicare from a volume-based payment system to one that reimburses for care coordination, quality, and innovation. Bundled payments are a reimbursement mechanism for the treatment of patients with specific conditions.

Read more


top of page

07/20/16 – Kaiser Family Foundation – The Facts on Medicare Spending and Financing

By Juliette Cubanski and Tricia Neuman

Medicare, the federal health insurance program for 57 million people ages 65 and over and people with permanent disabilities, helps to pay for hospital and physician visits, prescription drugs, and other acute and post-acute care services. In 2015, spending on Medicare accounted for 15% of the federal budget (Figure 1). Medicare plays a major role in the health care system, accounting for 20% of total national health spending in 2014, 29% of spending on retail sales of prescription drugs, 26% of spending on hospital care, and 23% of spending on physician services. This issue brief includes the most recent historical and projected Medicare spending data from the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary (OACT), the 2016 annual report of the Boards of Medicare Trustees and the 2016 Medicare baseline and projections from the Congressional Budget Office (CBO).

Read More


top of page

07/20/16 – Kaiser Health News – Study: Medicare Beneficiaries May Face ‘Treatment Gap’ for Painkiller Abuse, Misuse

By Carmen Heredia Rodriguez

When most people think of the victims of the nation’s opioid abuse epidemic, they seldom picture members of the Medicare set.

Read More


top of page

07/20/16 – CHCS – State Trends in the Delivery of Medicaid Long-Term Services and Supports

By Brianna Ensslin and Alexandra Kruse

Medicaid finances 51 percent of the nation’s long-term services and supports (LTSS) costs, making states eager to ensure that they are delivering the highest quality, most appropriate, and cost-effective services possible. As a result, states are increasingly pursuing Medicaid managed long-term services and supports (MLTSS) programs to provide coordinated, person-centered, and cost-effective care.
 

top of page

07/20/16 – AHRQ – Primary Care-Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations

The San Francisco Health Network embeds multidisciplinary teams within primary care practices to provide “wraparound” services to medically and psychosocially complex patients. Made up of nurses, health coaches, and social workers (and working with clinical backup from a physician), the teams provide ongoing, tailored care management and care coordination, self-management coaching, and other support, including connections to needed social services and other community-based programs. The program has significantly reduced hospital days, emergency department visits, and costs; increased patient engagement and self-management skills; and generated high levels of provider satisfaction.

Read More


top of page

07/15/16 – Kaiser Family Foundation – Turning Medicare into a Premium Support: Frequently Asked Questions

By Gretchen Jacobson and Tricia Neuman

Premium support is a general term used to describe an approach to reform Medicare that aims to reduce the growth in Medicare spending by increasing competition among health plans and providing a stronger incentive for beneficiaries to be cost-conscious in their plan selection.  On June 22, 2016, the House Republicans included in their health care reform plan a proposal to gradually transform Medicare into a system of premium supports, building on proposals of the Speaker of the House, Paul Ryan, when he was Chair of the House Committee on Budget, as well as the proposals of many other policymakers.

Read More


top of page

07/15/16 – Kaiser Health News – Fraud Concerns Emerge as Compounding Drug Sales Skyrocket

By Julie Appleby

Government spending on “compounded” drugs that are handmade by retail pharmacists has skyrocketed, drawing the attention of federal investigators who are raising fraud and overbilling concerns. Spending on these medications in Medicare’s Part D program, for example, rose 56 percent last year, with some of the costliest products, including topical pain creams, priced at hundreds or thousands of dollars per tube. The federal workers’ compensation program has also seen a recent spike in spending.

Read More


top of page

07/15/16 – MedPAC – June 2016 Data Book: Health Care Spending and the Medicare Program 

Read More


top of page

07/14/16 – Kaiser Health Foundation – Medicare Spending at the End of Life: A Snapshot of Beneficiaries Who Died in 2014 and the Cost of Their Care

By Juliette Cubanski, Tricia Neuman, Shannon Griffin, and Anthony Damico

Of the 2.6 million people who died in the U.S. in 2014,1 2.1 million, or eight out of 10, were people on Medicare,2 making Medicare the largest insurer of medical care provided at the end of life. Spending on Medicare beneficiaries in their last year of life accounts for about 25% of total Medicare spending on beneficiaries age 65 or older.3 The fact that a disproportionate share of Medicare spending goes to beneficiaries at the end of life is not surprising given that many have serious illnesses or multiple chronic conditions and often use costly services, including inpatient hospitalizations, post-acute care, and hospice, in the year leading up to their death.

Read More


top of page

07/14/16 – CHCS – The 6/18 Initiative: Accelerating Evidence Into Action

ASTHO 2016 Senior Deputies Annual Meeting

By Tricia McGinnis

On July 14, 2016, Tricia McGinnis, CHCS vice president, spoke at the 2016 Association of State and Territorial Health Officials (ASTHO) Senior Deputies Annual Meeting. Her presentation, “The 6|18 Initiative: Accelerating Evidence Into Action,” discussed how CHCS is working with ASTHO and the National Association of Medicaid Directors to facilitate the implementation of the Centers for Disease Control and Prevention’s 6|18 Initiative — a public-private partnership to improve health and control health care costs by focusing on six high-burden, high-cost health conditions. As part of this project, CHCS is assisting nine states to adopt proven prevention strategies for Medicaid populations in three high-opportunity areas — asthma, tobacco, and unintended pregnancy prevention. This presentation offers an overview of state progress to date and outlines opportunities for Medicaid to engage in the 6|18 Initiative.

Read More


top of page

07/13/16 - The National Academies of Sciences, Engineering, and Medicine – Accounting for Social Risk Factors in Medicare Payment

Criteria, Factors, and Methods

The Centers for Medicare & Medicaid Services (CMS) are moving steadily away from paying for volume (fee-for-service payments) and toward paying for quality, outcomes, and cost (also called value-based payment, or VBP). Concerns have been raised that current Medicare quality measurement and payment programs—and VBP programs in particular—that do not account for social risk factors like socioeconomic position (SEP) may underestimate the quality of care provided by health systems that disproportionately serve socially at-risk populations.

Read More

Click here to view the full report


top of page

07/07/16 – Kaiser Family Foundation - Essential Facts About Medicare and Prescription Drug Spending

Prescription drugs play an important role in medical care for 57 million seniors and people with disabilities, and account for $1 out of every $6 in Medicare spending. The majority of Medicare prescription drug spending is for drugs covered under the Part D prescription drug benefit, administered by private stand-alone drug plans and Medicare Advantage drug plans. Medicare Part B also covers drugs that are administered to patients in physician offices and other outpatient settings.

Read More


top of page

06/29/16 – Kaiser Family Foundation – Modifying Traditional Medicare’s Benefit Design Could Reduce Federal Spending But With Cost Tradeoffs Between Beneficiaries and The Federal Government

Revamping traditional Medicare’s benefit design and restricting “first-dollar” supplemental coverage could reduce federal spending, simplify cost sharing, protect against high medical costs, decrease out-of-pocket spending for many beneficiaries, and provide more help to those with low incomes — but would be unlikely to achieve all of these goals simultaneously, finds a new analysis by the Kaiser Family Foundation.

Read More

Click here to view the analysis


top of page

06/29/16 – McKnight’s – HHS Proposal Aims to Eliminate Medicare Appeals Backlog by 2021

By Emily Mongan

The current Medicare appeals backlog could be cured by fiscal year 2021 under rules proposed Tuesday, according to the U.S. Department of Health & Human Services.

Read More


top of page

06/29/16 – Kaiser Health News – HHS Proposes to Streamline Medicare Appeals Process

By Susan Jaffe

The Department of Health and Human Services Tuesday proposed key changes in the Medicare appeals process to help reduce the backlog of more than 700,000 cases.

Read More


top of page

06/22/16 – NBC News – Feds Charge 300 in Nation’s Largest Health Care Fraud Bust

By Pete Williams

Federal authorities said Wednesday that roughly 300 people in more than half the states have been charged in the largest crackdown to date on health care fraud. Those arrested account for more than $900 million in false billings to Medicare and Medicaid, according to the Departments of Justice and Health and Human Services.

Read More


top of page

06/22/16 – Modern Healthcare - Trustees' Report Says Medicare Will Be Insolvent By 2028

By Virgil Dickson

The Medicare trust fund will be insolvent by 2028, according to the 2016 Medicare trustees' report released Wednesday. The prediction is a departure from the 2030 date the Obama administration outlined in the previous two reports. The estimate is still later than the timeline released by the Congressional Budget Office in January, which estimated the program would be solvent only until 2026. The updated estimate is the result of a projected decrease in payroll taxes and a slower-than-expected decrease in inpatient utilization, Andy Slavitt, acting CMS administrator, said at a news briefing Wednesday

Read More


top of page

06/21/16 – OIG – Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases

Home health has long been recognized as a program area vulnerable to fraud, waste, and abuse. OIG home health investigations have resulted in more than 350 criminal and civil actions and over $975 million in receivables for fiscal years 2011-2015. Additionally, previous reports from OIG and the Government Accountability Office have raised concerns about questionable billing patterns, compliance problems, and improper payments in home health.

Read More


top of page

6/20/16 – Kaiser Family Foundation - A Study of Medicare Advantage Plan Networks in 20 Counties Finds That Plans Include About Half of All Hospitals in Their Area

20 Percent of Plans Do Not Have An Academic Medical Center In-Network and 41 Percent Do Not Include their County’s National Cancer Institute-Designated Cancer Center

A Kaiser Family Foundation analysis of private Medicare plan networks finds that Medicare Advantage plans include about  half of area hospitals in their network, on average, while one in five plans have no  Academic Medical Center in-network.  Among plans in an area with a National Cancer Institute-designated cancer center, more than two in five did not include the cancer center in their network.  The new study of the hospital networks of Medicare Advantage plans, which includes plan and firm-specific information for 409 plans in a geographically diverse sample of 20 counties in 2015, also finds that information about hospital networks is not readily available, sometimes inaccurate and rarely consumer friendly.  More than 17 million of Medicare’s 57 million beneficiaries are enrolled in Medicare Advantage plans, and enrollment in the private plans is projected to reach 30 million by 2026.

Read More

Click here to view the report


top of page

06/17/16 – Kaiser Health News – Senate Panel Kills Medicare Program that Offers Help on Enrollment, Billing Issues

By Susan Jaffe

A program that has helped seniors understand the many intricacies of Medicare as well as save them millions of dollars would be eliminated by a budget bill overwhelmingly approved last week by the powerful Senate Appropriations Committee.

Read More


top of page

06/16/16 – OIG – CMS is Taking Steps to Improve Oversight of Provider-Based Facilities, But Vulnerabilities Remain

We reviewed CMS's oversight of provider-based billing to ensure that only facilities that met provider-based requirements were receiving higher payments allowed by the provider-based designation. Under Medicare, payments for services performed in provider-based facilities are often more than 50 percent higher than payments for the same services performed in a freestanding facility. This increased cost is borne by both Medicare and its beneficiaries. "Provider based" is a Medicare payment designation established by the Social Security Act that allows facilities owned by and integrated with a hospital to bill Medicare as a hospital outpatient department, resulting in these facilities generally receiving higher payments than freestanding facilities. Provider-based facilities, which may be on or off the main hospital campus, must meet certain requirements (e.g., the facility generally must operate under the same license as the hospital). In addition, under current policy, hospitals may, but are not required to, attest to CMS that their provider-based facilities meet requirements to bill as a hospital outpatient department.

Read More


top of page

06/16/16 – MedPAC – Overview: Medicare Drug Spending

Prescription drugs are a critical component of health care.  Because of the role of drugs in treating conditions, it is important that Medicare ensures that its beneficiaries have access to appropriate medication therapies.  By providing benefits that include prescription drug coverage, Medicare has expanded patient access to needed medications.  However, it is becoming increasingly difficult to make that access to medications remains affordable for beneficiaries and to keep Medicare financially sustainable for taxpayers.

Read More


top of page

06/16/16 – MedPAC – Overview: The Drug Development and Supply Chain

Recently, the topic of prescription drug prices has been the subject of intense scrutiny in the policymaking community, with many stakeholders calling for Medicare to take the lead in addressing rapidly rising drug prices.

Read More


top of page

06/15/16 – The Commonwealth Fund - Explaining Improved Use of High-Risk Medications in Medicare Between 2007 and 2011

By Yuting Zhang, Julia Driessen, and Seo Hyon Baik

Between 2007 and 2011, there was dramatic improvement on a key measure of health care quality for the elderly: high-risk drug prescribing. The proportion of older adults using a high-risk medication decreased by 30 percent over that period, as highlighted in The Commonwealth Fund’s 2015 Scorecard on State Health System Performance. However, over the same time frame there was little change in a similar indicator of quality: the rate of potentially harmful drug–disease interactions. Commonwealth Fund–supported researchers explored the reasons behind the varied results.

Read More


top of page

06/15/16 – MedPAC – MedPAC Releases June 2016 Report on Medicare and the Health Care Delivery System

Today the Medicare Payment Advisory Commission (MedPAC) releases its June 2016 Report to the Congress: Medicare and the Health Care Delivery System. As part of its mandate from the Congress, each June MedPAC reports on issues affecting the Medicare program as well as broaderchanges in health care delivery and the market for health care services.

Read More

Click here to view the full report

Click here to view the fact sheet


top of page

06/15/16 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on the Merit-Based Incentive Payment System and Alternative Payment Models 

Read More


top of page

06/09/16 – GAO – Medicare Fee-For-Service: Opportunities Remain to Improve Appeals Process

The appeals process for Medicare fee-for-service (FFS) claims consists of four administrative levels of review within the Department of Health and Human Services (HHS), and a fifth level in which appeals are reviewed by federal courts. Appeals are generally reviewed by each level sequentially, as appellants may appeal a decision to the next level depending on the prior outcome. Under the administrative process, separate appeals bodies review appeals and issue decisions under time limits established by law, which can vary by level. From fiscal years 2010 and 2014, the total number of filed appeals at Levels 1 through 4 of Medicare's FFS appeals process increased significantly but varied by level. Level 3 experienced the largest rate of increase in appeals—from 41,733 to 432,534 appeals (936 percent)—during this period. A significant portion of the increase was driven by appeals of hospital and other inpatient stays, which increased from 12,938 to 275,791 appeals (over 2,000 percent) at Level 3. HHS attributed the growth in appeals to its increased program integrity efforts and a greater propensity of providers to appeal claims, among other things. GAO also found that the number of appeal decisions issued after statutory time frames generally increased during this time, with the largest increase in and largest proportion of late decisions occurring at appeal Levels 3 and 4. For example, in fiscal year 2014, 96 percent of Level 3 decisions were issued after the general 90-day statutory time frame for Level 3.

Read More

Click here to view the highlights page


top of page

06/08/16 – The Daily Signal - The House Is Improving Medicare, and the Senate Can Make It Even Better

By Robert Moffit and Jean Morrow

The House of Representatives has passed a short, but significant, 31-page Medicare bill, Helping Hospitals Improve Patient Care Act (H.R. 5273). The House measure would improve traditional Medicare in a number of ways, though most of these would be technical changes to current law. Because the bill was largely noncontroversial and thus enacted under a special procedure (“suspension of the rules”), there were no floor amendments. The House could have done more, however, such as lifting the Obamacare restrictions on the provision of patient care in high-performing physician-owned hospitals. But the Senate could easily remedy that deficiency.

Read More


top of page

06/06/16 – Institute for Healthcare Policy & Innovation – University of Michigan - Two Kinds of Medicare – Two Kinds of Patients?  New Findings Could Make a Difference for Health Policy

At End of Life, Traditional Medicare Patients are More Sick and Frail then Medicare Patients, New Study Shows

Nearly one in three American senior citizens choose to get their government-funded Medicare health coverage through plans run by health insurance companies. The rest get it straight from the federal government. But if health policy decision-makers assume the two groups are pretty much the same, they’re mistaken, a new study finds.

Read More


top of page

06/06/16 – OIG – Performance Data for the Senior Medicare Patrol Projects: June 2016 Performance Report

This memorandum report presents performance data for the Senior Medicare Patrol (SMP) projects, which receive grants from ACL to recruit and train retired professionals and other senior citizens to recognize and report instances or patterns of health care fraud. OIG has collected these performance data since 1997. In July 2010, the Administration on Aging (AoA)-now part of ACL-requested that OIG continue to collect and report these data to support its efforts to evaluate and improve the SMP projects' performance. (ACL was established in 2012, bringing together AoA and two other offices.)

Read More


top of page

6/1/16 – McKnight’s - Medicare Eligibility Ups Rehab Use Among Seniors, Study Finds

In the year after seniors hit Medicare eligibility, there is close to a 10% increase in those seeking rehabilitation care services, according to a new analysis.  In comparing pre-Medicare trauma patients versus those at age 65, researchers at the Center for Surgery and Public Health at Brigham and Women's Hospital also found a 6.4% decline in uninsured seniors.  Becoming a Medicare beneficiary means more patients have access to skilled nursing facilities, researchers said, allowing them to seek out rehab care that would otherwise be ignored. Medicare coverage restrictions based on hospital stay length were also associated with increased inpatient and skilled nursing care.

Read More


top of page

05/27/16 – MedPAC – MedPAC Comment on CMS Update to the Proposed Rates under the SNF PPS

Read More


top of page

05/25/16 – Kaiser Health News – Medicare’s Drug-Pricing Experiment Stirs Opposition

By Julie Appleby

A broad proposal by Medicare to change the way it pays for some drugs has drawn intense reaction and lobbying, with much of the debate centering on whether the plan gives too much power over drug prices to government regulators.

Read More


top of page

05/25/16 – MedPAC – MedPAC Comment on CMS Proposed FY 2017 Update to Payment Rates for IRFs 

Read More


top of page

05/25/16 – MedPAC – MedPAC Comment on CMS’s Post-Acute Care Quality Measures

Read More


top of page

05/23/16 – Kaiser Health News – Doctors’ House Calls Saving Money for Medicare

By Susan Jaffe

Looking for ways to save money and improve care, Medicare officials are returning to an old-fashioned idea: house calls.  But the experiment, called Independence at Home, is more than a nostalgic throwback to the way medicine was practiced decades ago when the doctor arrived at the patient’s door carrying a big black bag. Done right and paid right, house calls could prove to be a better way of treating very sick, elderly patients while they can still live at home.

Read More


top of page

05/11/16 – Kaiser Family Foundation – Medicare Advantage 2016 Spotlight: Enrollment Market Update

By Gretchen Jacobson, Giselle Casillas, Anthony Damico, Tricia Neuman, and Marsha Gold

The number and share of Medicare beneficiaries enrolled in Medicare Advantage has steadily climbed over the past decade, and this trend in enrollment growth is continuing in 2016. The growth in enrollment has occurred despite reductions in payments to plans enacted by the Affordable Care Act of 2010 (ACA).1 As of 2016, the payment reductions have been fully phased-in in 78 percent of counties, accounting for 70 percent of beneficiaries and 68 percent of Medicare Advantage enrollees.

Read More


top of page

05/10/16 – The Commonwealth Fund – On Medicare But At Risk: A State-Level Analysis of Beneficiaries Who Are Underinsured or Facing High Total Cost Burdens

By Cathy Schoen, Claudia Solis-Roman, Nick Huober, and Zachary Kelchner

Medicare provides essential health coverage for older and disabled adults, yet it does not limit out-of-pocket costs for covered benefits and excludes dental, hearing, and longer-term care. The resulting out-of-pocket costs can add up to a substantial share of income. Based on U.S. Census surveys, nearly a quarter of Medicare beneficiaries (11.5 million) were underinsured in 2013–14, meaning they spent a high share of their income on health care. Adding premiums to medical care expenses, we find that 16 percent of beneficiaries (8 million) spent 20 percent or more of their income on insurance plus care. At the state level, the proportion of beneficiaries underinsured ranged from 16 percent to 32 percent, while the proportion with a high total cost burden ranged from 11 percent to 26 percent. Low-income beneficiaries were most at risk. The findings underscore the need to assess beneficiary impacts of any proposal to redesign Medicare.

Read More

Click here to view the chartpack

Click here to view the appendices


top of page

05/09/16 – The Center for Public Integrity – Auditors: Feds Failed to Rein in Billions in Over-Billing by Medicare Advantage

GAO Report Follows Center Series on Massive ‘Upcoding’ in Popular Program

By Fred Schulte

Private Medicare Advantage plans treating the elderly have over-billed the government by billions of dollars, but rarely been forced to repay the money or face other consequences for their actions, according to a new Congressional audit.

Read More

Click here to view the full report


top of page

05/07/16 – Modern Healthcare - Commercial Insurance Margins Offset Rising Medicare Losses

By Dave Barkholz

Geisinger Health System loses money on Medicare patients who receive care on a fee-for-service basis. Conversely, the 12-hospital system posts a positive margin on the 86,000 seniors enrolled in its Medicare Advantage managed-care plan.  It's not that the care a patient receives from a Geisinger physician, nurse or technician changes based on the reimbursement scheme. Rather, in Medicare Advantage, not-for-profit Geisinger can use the capitated monthly payments that it receives for a large panel of patients to improve overall care.

Read More


top of page

05/06/16 – Kaiser Health News - Raising Medicare’s Eligibility Age Could Trigger Gov’t Savings, But Tally Higher Total Health Spending

By Michelle Andrews

Healthcare spending for some services dropped by nearly a third when people turned 65 and switched from private insurance to Medicare, according to a recent study. The decline was driven by lower prices paid by the Medicare program to doctors and other providers rather than a drop-off in the volume of services seniors receive.

Read More


top of page

05/05/16 – Kaiser Family Foundation - Fading Fast: Fewer Seniors Have Retiree Health Insurance

By Tricia Neuman and Anthony Damico

Employer- and union-sponsored retiree health benefits have served as an important source of supplemental coverage for people on Medicare.  Retiree health plans help fill the gaps in Medicare’s benefit design, often cover some or all of Medicare’s cost-sharing requirements and deductibles, and include a cap on out-of-pocket spending – a benefit that is required to be provided by all Medicare Advantage plans, but not covered under traditional Medicare, and of great value to retirees needing costly medical care.  For retirees, employer-sponsored supplemental coverage limits the costs they would otherwise incur for their medical care.

Read More


top of page

5/3/16 – U.S. News & World Report - Medicare Pays Bonuses to 231 Hospitals With Lower Quality Because of Cheaper Costs

Many low quality hospitals earned bonuses for delivering low cost care, a study finds. – By Jordan Rau - The federal government paid bonuses to 231 hospitals with subpar quality because their patients tend to be less expensive for Medicare, new research shows.  The bonuses are small, generally a fraction of a percent of their Medicare payments. Nonetheless, rewarding hospitals of mediocre quality was hardly the stated goal when the Affordable Care Act created financial incentives to encourage better medical care from hospitals, doctors and other health care providers. A study published Monday in the journal Health Affairs looked at the more than $1 billion in payments made last year in theHospital Value-Based Purchasing program, which raises or lowers Medicare payments to hospitals based on the government's assessment of their quality. 

Read More


top of page

05/03/16 – McKnight’s – Raising Medicare Eligibility Age may Boost Overall Healthcare Spending, Study Finds

By Emily Mongan

Raising a Medicare beneficiary's eligibility age to 67 may increase the nation's overall healthcare spending, according to a new study published Monday.

Read More


top of page

4/30/16 – Modern Healthcare - Docs Face Stark Choices Under New Medicare Pay Proposal

By Beth Kutscher

The new draft regulations designed to change how Medicare pays clinicians represent the most sweeping overhaul the CMS has made in a long time to the business of running a physician practice.  The goal is to have the vast majority of CMS funding flow through payment models that reward doctors for the quality of care they deliver, not just how many patients they see.  The changes have the potential to upend the way medicine is practiced today, accelerating the move toward hospital employment and making the small group practice a thing of the past. At the very least, the rule, once finalized, will inspire closer collaboration between doctors and hospitals, since physicians will have more incentives than ever to steer patients away from high-cost medical centers.

Read More


top of page

04/25/16 – McKnight’s – House Lawmakers Push CMS to Collect Medicare Beneficiaries Mental Health Data

By Emily Mongan

More “robust” data on the mental and behavioral health of Medicare beneficiaries is needed in order to improve the program's outcomes, lawmakers said last week in a letter to the Centers for Medicare & Medicaid Services. 

Read More


top of page

4/20/16 – The Boston Globe - How Medicare Penalizes Hospitals For Being Too Careful

By Jordan Rau

The puffiness along Carol Ascher’s left leg seemed like normal swelling, probably from the high dose of chemotherapy Dr. Karl Bilimoria had injected the previous day. But it could have been a blood clot. He quickly ordered an ultrasound. “We were just being abundantly cautious,” he said. Such vigilance is a point of pride at Northwestern Memorial Hospital. But the hospital’s tests have identified so many infections and serious blood clots that the federal government is cutting the institution’s Medicare payments for a year, by about $1.6 million.

Read More


top of page

4/20/16 – Kaiser Health News - Medicare Delays Plans For New Star Ratings On Hospitals After Congressional Pressure

By Jordan Rau

Bowing to pressure from the hospital industry and Congress, the Obama administration on Wednesday delayed releasing its new hospital quality rating measure just a day before its planned launch. The new “overall hospital quality” star rating aimed to combine the government’s disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare & Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others. The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best.

Read More


top of page

04/13/16 – Avalere – Programs Contributing to HHS Meeting Its Alternative Payment Model Goal Largely Consist of Upside-Only Models

HHS Confirms Continued Movement Away from Traditional FFS Payments, Yet Significant Work Remains to Move More Providers Away from Upside-Risk Models and into Downside-Risk Models

By Jared Alves and Sonia Zhang

On March 3, the Department of Health and Human Services (HHS) announced that it met its goal of tying 30 percent of all Medicare fee-for-service (FFS) payments to alternative payment models (APMs) by the end of 2016, almost a year ahead of schedule.

Read More


top of page

04/11/16 – AHIP – High-Priced Drugs: Estimates of Annual Per-Patient Expenditures for 150 Specialty Medications

Almost half of the 150 drugs studied cost in excess of $100,000 per year, with expenditures for 3 percent of the drugs studied exceeding half-a-million dollars per patient per year. We reviewed the FDA-approved dosing for a sample of 150 specialty medications prescribed to treat a variety of conditions and estimated the typical amount used in a year for a typical patient.

Read More


top of page

04/07/16 – Avalere – Proposed Medicare Part B Rule Would Reduce Payments to Hospitals and Some Specialists, While Increasing Payments to Primary Care Providers

Rule Would Decrease Medicare Reimbursements for Drugs that Cost More than $480 per Day; Seven of the 10 Most Affected Drugs Treat Cancer

By Fauzea Hussain and Adam Borden

A new Avalere analysis finds that proposed Medicare payment changes for physician-administered drugs would reduce reimbursement for those that cost more than $480 per day in 2016. As a result, specialties that use higher-cost drugs, including ophthalmologists, oncologists, and rheumatologists, would experience a reduction in payments; though, many of the drugs do not have lower cost alternatives. The analysis shows that seven of the 10 drugs that constitute the largest reduction in reimbursement are used to treat cancer. Meanwhile, some primary care physicians, who tend to use lower cost drugs, would be paid more.

Read More


top of page

04/05/16 – Kaiser Family Foundation - Visualizing Health Policy: Recent Trends in Prescription Drug Costs

This Visualizing Health Policy infographic spotlights national spending on prescription drugs and the public’s views on pharmaceutical prices. Prescription drug spending rose sharply in 2014, driven by growth in expenditures on specialty drugs, including medications to treat cancer and hepatitis C. Medicare’s spending on prescription pharmaceuticals also has risen, largely due to the addition of the Medicare prescription drug benefit in 2006: between 2004 and 2014, the program’s share of US drug expenditures increased from 2% of $193 billion to 29% percent of $298 billion.
 
 

top of page

04/01/16 – Kaiser Family Foundation – An Overview of Medicare

Medicare is the federal health insurance program created in 1965 for people ages 65 and over, regardless of income, medical history, or health status. The program was expanded in 1972 to cover people under age 65 with permanent disabilities. Today, Medicare plays a key role in providing health and financial security to 55 million older people and younger people with disabilities. The program helps to pay for many medical care services, including hospitalizations, physician visits, and prescription drugs, along with post-acute care, skilled nursing facility care, home health care, hospice care, and preventive services. Medicare spending accounted for 15 percent of total federal spending in 20151 and 23 percent of national personal health spending in 2014.

Read More


top of page

03/31/16 – Kaiser Family Foundation – Traditional Medicare…Disadvantaged?

By Tricia Neuman

Sometimes it takes a call from a friend to take a fresh look at what’s going on in Medicare.  My friend Craig, a rugged Coloradan, turned 65 a few years ago and signed up for a Medicare Advantage plan.  At the time, this decision was easy.  He wanted to stay with the same insurer he had before he was eligible for Medicare.  He liked the convenience of having one plan (his Medicare Advantage HMO) instead of three (traditional Medicare, a supplemental Medigap policy, and a separate Medicare drug plan).  He also liked the fact that his monthly Medicare HMO premium was lower than what he would have paid, had he opted for traditional Medicare with separate Medigap and Part D policies.

Read More


top of page

03/30/16 – Office of Inspector General – Hospices Inappropriately Billed Medicare Over 4250 Million for General Inpatient Care

Recent investigations by the Office of Inspector General have shown a number of instances in which hospices inappropriately billed Medicare for hospice general inpatient care (GIP). Misuse of GIP includes care being billed but not provided and beneficiaries receiving care they do not need. Such misuse has human costs for this vulnerable population as well as financial costs for Medicare. The goals of hospice care are to help terminally ill beneficiaries with a life expectancy of 6 months or less to continue life with minimal disruptions and to support beneficiaries' families and other caregivers. The care is palliative, rather than curative. Hospices must establish an individualized plan of care for each beneficiary. GIP is the second most expensive level of hospice care and is intended to be short-term inpatient care for symptom management and pain control that cannot be handled in other settings.

Read More


top of page

03/25/16 – MedPAC – MedPAC Comment on CMS’s Post-Acute Care Quality Measures 

Read More


top of page

03/18/16 – Kaiser Health News – How Medicare Drug Plans Hope to Follow Private Sector Lead

By Julie Appleby

Oral health is a critical but often overlooked component of overall health and well-being.  Although good oral health can be achieved through preventive care, regular self-care, and the early detection, treatment, and management of problems, many people suffer from poor oral health, which often has additional adverse effects on their general health and quality of life. The prevalence of dental disease and tooth loss is disproportionately high among people with low income, reflecting lack of access to dental coverage and care. Racial and ethnic disparities in these measures are also pronounced.

Read More


top of page

03/17/16 – NAHC – House Ways and Means Health Subcommittee Discusses Restructuring Medicare

Weighs Proposals to Combine Medicare Deductibles, Restructure Copays and Limit Medigap Insurance

On March 16, 2016, the U.S. House of Representatives Ways and Means Health Subcommittee held a hearing titled, “Preserving and Strengthening Medicare.” During the hearing, Subcommittee Chairman Pat Tiberi (R-OH-12) and others indicated potential support for a number of proposals to restructure Medicare cost sharing, including combining deductibles under Part A and Part B of Medicare, restructuring copays, and limiting Medigap insurance.

Read More


top of page

03/16/16 – Avalere – More than 70 Percent of Medicare Advantage Enrollees in Plans with Four or More Stars

Percentage of Medicare Advantage Enrollees in Plans with at least Four Stars Continues to Grow

By Elizabeth Carpenter

A new Avalere analysis finds that of the 17 million Medicare Advantage (MA) enrollees in 2016, 72 percent of them are in a plan with four or more stars. This represents an increase from 65 percent in 2015 and 51 percent in 2014. The MA Star Ratings program grades plans based on a series of quality measures designed to assess plan performance; the more stars a plan has, the higher quality it is deemed to be.

Read More


top of page

03/15/16 – Fact Sheet on MedPAC’s March 2016 Report to the Congress: Medicare Payment Policy

The Medicare Payment Advisory Commission (MedPAC) is required by law to annually review Medicare payment policies and make recommendations to the Congress. The 2016 report includes payment policy recommendations for nine provider sectors in fee-for-service (FFS) Medicare. MedPAC also reviews the status of Medicare Advantage (MA) plans and Medicare’s prescription drug plans (Part D).

Read More

Click here to view the press release


top of page

03/11/16 – MedPAC – MedPAC Comments on CMS’s Proposed Rule on the Medicare Shared Savings Program 

Read More


top of page

03/03/16 – The Commonwealth Fund – Better Health Care: A Way Forward

By David Blumenthal, M.D., M.P.P.

Whether measured against international or domestic standards, the U.S. health care system could perform much better than it does. For example, if health care costs had increased since 1980 at the rate they did in Switzerland, the United States could have saved nearly enough—about $15.9 trillion—to retire the national debt. And if the national rate of health insurance coverage were the same as the average of the five U.S. states with the highest rates, an estimated 20 million more Americans would have been insured in 2014.

Read More

Click here to view the full article


top of page

03/09/16 – Kaiser Family Foundation – Profile of Medicare Beneficiaries by Race and Ethnicity: A Chartpack

Medicare provides health insurance coverage for 55 million people ages 65 and over and younger adults with permanent disabilities. As the number of black and Hispanic beneficiaries has grown over time, the program has played an increasingly vital role as a source of coverage for people of color. Before the enactment of Medicare in 1965, health coverage and care was not easily accessible or affordable for many seniors, and perhaps least so for black seniors, who were often unable to receive treatment in the same facilities as whites because hospitals were segregated. The establishment of Medicare, in conjunction with the Civil Rights Act of 1964, was transformative in desegregating the nation’s health care system for patients and providers and in improving access to care.

Read More


top of page

03/08/16 – ASPE – Medicare Part B Drugs: Pricing and Incentives

By Steven Sheingold, Elena Marchetti-Bowick, Nguyen Nguyen and Robin K. Yabroff

Medicare Part B covers infusible and injectable drugs and biologics administered in physician offices and hospital outpatient departments; as well as certain other drugs required by law that are provided by suppliers such as pharmacies (e.g., inhalation drugs and certain oral anticancer, oral antiemetic, and immunosuppressive drugs). Payment for Part B drugs are made directly to these providers and suppliers based on the average sales price (ASP) calculated for each item.  There is growing concern that several features of the current Part B program do not create appropriate incentives for either providers, suppliers or patients to make high value choices among treatment options. First, under current law, most Part B drugs are paid separately; that is based on their own ASP with no reference to other drugs of similar therapeutic effectiveness. In addition, the Medicare program has not applied the types of pricing policies or formulary management practices that are commonly used to achieve better value for self-administered drugs by commercial insurers, including those sponsoring plans in Medicare Part D. In this  paper we describe the current pricing system; discuss the system’s financial incentives and provide descriptive data concerning Part B drug spending and utilization.

Read More


top of page

03/08/16 – NAHC – MedPAC Discusses Policy Principles for Potential Expansion of Telehealth in Medicare

On March 3, 2016, the Medicare Payment Advisory Commission (MedPAC) convened a session entitled, “Telehealth Services and the Medicare Program.” During the session, the Commissioners discussed the current utilization and efficacy of telehealth services, as well as policy principles to guide the potential expansion of telealth coverage under Medicare. MedPAC previously met to discuss this topic in November 2015; MedPAC has updated its research determining that “evidence of the efficacy of telehealth is mixed.” Its June 2016 report will contain a chapter with policy principles pertaining to telehealth, rather than official recommendations. However, several Commissions urged that MedPAC was being overly cautious in its approach.

Read More

Click here to view additional information on the MedPAC presentation


top of page

03/04/16 – AHIP – AHIP’s Comments on Proposed Changes to Medicare Advantage

In response to CMS' proposed changes to Medicare Advantage, America's Health Insurance Plans (AHIP) challenged several policies that would lead to cuts in beneficiaries' benefits and coverage next year.

Read More


top of page

03/01/16 – Center for Medicare Advocacy – Beneficiaries Across the Country Still Denied Coverage Due to Illegal Use of Improvement Standard

Today, Plaintiffs’ counsel, the Center for Medicare Advocacy and Vermont Legal Aid, filed a Motion for Resolution of Non-Compliance with the Settlement Agreement in the landmark case, Jimmo v. Sebelius. The filing comes after three years of urging the Centers for Medicare & Medicaid Services (CMS) to fulfill its obligation to end continued application of an “Improvement Standard” by Medicare providers, contractors and adjudicators to deny Medicare coverage for skilled maintenance nursing and therapy.

Read More


top of page

03/01/16 – MedPAC – MedPAC Comment on CMS’s Draft Quality Measure Development Plan 

Read More


top of page

03/01/16 – ICRC – Monthly Enrollment in Medicare-Medicaid Plans by Plan and by State, February 2015 to February 2016 

Read More


top of page

02/26/16 – OIG – FY 2015 Health Care Fraud and Abuse Control Programs Report 

Read More


top of page

02/18/16 – Avalere – New Analysis Finds Medicare Payments Higher for Episodes Initiated in Hospital Outpatient Departments

By Carrie Williams Bullock

A new analysis by Avalere examines differences in Medicare spending for episodes of care before and after cardiovascular imaging, colonoscopy, and evaluation and management services. Avalere applied a risk adjustment methodology to account for differences in patient demographics and patient severity across settings. The findings suggest when care is initiated in the typically higher-paying HOPD setting than in physicians' offices and ambulatory surgical centers, the services that follow also result in higher spending relative to when care is initiated in the office setting.

Read More

Click here to view the full report


top of page

02/18/16 – Avalere – Medicare has the Potential to Avoid Preventable Illness by Encouraging Broader Coverage for Adult Vaccines

By Caroline F. Pearson

A new analysis by Avalere finds that, despite efforts by policymakers to encourage broader vaccination rates, Medicare enrollees have limited access to a set of 10 recommended vaccines without having to pay out-of-pocket (e.g., co-payments).

Read More

Click here to view the full report


top of page

02/18/16 – McKnight’s – Medicare Costs Rise as Hospice Stays Lengthen, WSJ Report Finds

By Emily Mongan

Increasingly long hospice stays have nearly doubled the amount Medicare is spending on patients in recent years, according to a new report from the Wall Street Journal.

Read More


top of page

02/18/16 – The Commonwealth Fund – Developing a Framework for Evaluating the Patient Engagement, Quality, and Safety of Mobile Health Applications

By Karandeep Singh, David Bates, Kaitlyn Drouin, Lisa P. Newmark, Ronen Rozenblum, Jaehoe Lee, Adam Landman, Erika Pabo, and Elissa V. Klinger

Rising ownership of smartphones and tablets across social and demographic groups has made mobile applications, or apps, a potentially promising tool for engaging patients in their health care, particularly those with high health care needs. Through a systematic search of iOS (Apple) and Android app stores and an analysis of apps targeting individuals with chronic illnesses, we assessed the degree to which apps are likely to be useful in patient engagement efforts. Usefulness was determined based on the following criteria: description of engagement, relevance to the targeted patient population, consumer ratings and reviews, and most recent app update. Among the 1,046 health care–related, patient-facing applications identified by our search, 43 percent of iOS apps and 27 percent of Android apps appeared likely to be useful. We also developed criteria for evaluating the patient engagement, quality, and safety of mobile apps.

Read More


top of page

02/12/16 – New York Times – Surge in Medicare Advantage Sign-Ups Confounds Expectations

By Robert Pear

Five years into Medicare spending cuts that were supposed to devastate private Medicare options for older Americans, enrollment in private insurance plans through Medicare has shot up by more than 50 percent, confounding experts and partisans alike and providing possible lessons for the Affordable Care Act’s insurance exchanges.

Read More


top of page

2/9/16 – Kaiser Family Foundation - Searching for Savings in Medicare Drug Price Negotiations

By Juliette Cubanski and Tricia Neuman

After many years of slow growth, prescription drug spending growth is on the rise, raising fiscal concerns for public and private payers and worries about affordability among consumers. The recent increase in drug spending growth is mainly due to spending on new breakthrough treatments for hepatitis C that came to market starting at the end of 2013, along with fewer opportunities to control spending through greater use of generic drugs. For Medicare, which accounted for 29 percent of national retail pharmaceutical spending in 2014, per capita costs in the Part D prescription drug program are projected to increase annually by 6.5 percent in the next 10 years, after rising at only 1.5 percent per year over the past eight years. 

Read More


top of page

02/03/16 – Avalere – New Analysis Finds Proposed Telehealth Policy Changes Would Decrease Federal Spending by $1.8 Billion

A new analysis by Avalere Health estimates that three proposed policy changes to expand Medicare reimbursement of telehealth and remote patient monitoring (RPM) would collectively decrease federal spending by $1.8 billion between FY2017 and FY2026.

Read More

Click here to view the full report


top of page

1/28/16 – Kaiser Family Foundation - Kaiser Health Tracking Poll: January 2016

By Bianca DiJulio, Jamie Firth, Ashley Krizinger, and Mollyann Brodie

This Kaiser Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted January 13-19, 2016, among a nationally representative random digit dial telephone sample of 1,204 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Computer-assisted telephone interviews conducted by landline (481) and cell phone (723, including 416 who had no landline telephone) were carried out in English and Spanish by Princeton Data Source under the direction of Princeton Survey Research Associates International (PSRAI).

Read More


top of page

01/26/16 – Avalere – Nearly 60 Percent of New Medicare Advantage Plans are Sponsored by Healthcare Providers

A New Analysis from Avalere Health Finds that Hospitals and Health Systems are Increasingly taking Risks for the Cost of Medicare Patients and the Quality of the Care They Receive

By Elizabeth Carpenter

In 2016, providers represent 58 percent1 of new Medicare Advantage (MA) organizations entering the program. In total, 70 provider-sponsored parent organizations will offer 403 MA plans in 41 states.2 Increasingly, large providers are leveraging their integrated delivery networks and building on their experience bearing risk to offer insurance to consumers across the country.

Read More


top of page

01/22/16 – Avalere – Federal Government Underpays Medicare Advantage Plans for Enrollees with Multiple Diseases

A New Analysis by Avalere Finds that the Centers for Medicare and Medicaid Services (CMS) Underpay Medicare Advantage (MA) Plans for the Costs of Treating Individuals with Multiple Chronic Conditions

By Tom Kornfield and Caroline F. Perason

CMS uses a risk adjustment model to determine its payments to plans based on the expected healthcare costs of each plan’s enrollees. This process is known as risk adjustment.  Avalere finds that CMS’s risk adjustment model under-predicts costs for individuals with multiple chronic conditions by $2.6 billion on an annual basis. CMS last updated the model in 2014 and has indicated that it will make changes to the model intended to improve its accuracy for certain Medicare-Medicaid “dual eligibles” in 2017.

Read More


top of page

01/19/16 – The Commonwealth Fund – Using Behavioral Economics to Design Physician Incentives that Deliver High-Value Care

By Ezekiel J. Emanuel, Peter A. Ubel, Judd B. Kessler, Gregg Meyer, Ralph W. Muller, Amol S. Navathe, Pankaj Patel, Robert Pearl, Meredith B. Rosenthal, Lee Sacks, Aditi P. Sen, Paul Sherman, and Kevin G. Volpp

A number of health systems and provider organizations are turning to behavioral economics to encourage doctors to follow evidence-based guidelines and deliver better-coordinated care to their patients. Many are seeing promising results, although more evaluation is needed to identify the most effective physician incentive designs.

Read More


top of page

1/15/16 – MedPAC – The Medicare Advantage Program: Status Report

By Scott Harrison, Andrew Johnson and Carlos Zarabozo

We present findings on the status of the MA program, including enrollment, access to plans, payments and quality indicators. We also present information on policy development related to MA benchmarks and adjustments for coding intensity. We present two draft recommendations.

Read More


top of page

01/11/16 – The Commonwealth Fund – How High Need Patients Experience the Health Care System in Nine Countries

By Dana O. Sarnak and Jamie Ryan

U.S. health care costs are disproportionately concentrated among older adults with multiple chronic conditions or functional limitations—a population often referred to as “high-need” patients. This analysis uses data from the Commonwealth Fund 2014 International Health Policy Survey of Older Adults to investigate health care use, quality, and experiences among high-need patients in nine countries compared with other older adults. High-need patients use a greater amount of health care services and also experience more coordination problems and financial barriers to care compared with other older adults. Disparities are particularly pronounced in the United States. The comparative success of other countries, particularly in reducing financial barriers to care, may be a product of policies that specifically target high-need patients. Similarly focusing on these populations in the U.S. and effectively managing their care may improve their health status while reducing overall costs.

Read More

Click here to view the chartpack

Click here to view the appendices


top of page

top of page

01/04/16 – The New York Times – Medicare Is Changing: What’s New for Beneficiaries

By The Associated Press

Whether it’s coverage for end-of-life counseling or an experimental payment scheme for common surgeries, Medicare in 2016 is undergoing some of the biggest changes in its 50 years. Grandma's Medicare usually just paid the bills as they came in. Today, the nation's flagship health-care program is seeking better ways to balance cost, quality and access.

Read More


top of page

12/28/15 – Modern Healthcare - CMS To Launch RACs For Medicare Advantage

By Bob Herman

During a time of growing interest in covering Medicare members, the CMS is looking to vastly expand audits of Medicare Advantage plans as a way to monitor insurers that may game the system to obtain higher payments.  Last week, the CMS released a request for information (PDF) that outlined the expansion of Medicare's Recovery Audit Program, a program that has drawn the scorn of hospitals and doctors. In that program, the government hires private companies called recovery audit contractors, or RACs, to comb through medical records at hospitals and doctor offices and find instances of where Medicare is paying too much money.

Read More


top of page

12/21/15 – The Washington Times - Medicare Unveiling Online Tool To Analyze Costly Drugs

By Associated Press

Medicare officials say researchers and the public will now have an easier way to analyze spending on costly prescription drugs.  The online Medicare Drug Spending Dashboard will allow users to compare 80 drugs from thousands of covered medications. Those drugs accounted for about 40 percent of the more than $140 billion Medicare spent on prescription medications in 2014.

Read More


top of page

12/16/15 – U.S. News & World Report - Medicare Takes For-Profit Partner

The move expands access to national data about physicians and health care providers. – By Steve Sternberg - Medicare announced Wednesday that it will provide complete, national physician-level data to a San Francisco-based start-up whose goal is to help millions of consumers nationwide make "more informed health care decisions, starting with the doctors they choose." The firm, called Amino, launched in October. It is the second national organization – and the first for-profit company – to achieve special Medicare "qualified entity" status that bestows access to the full range of Medicare data for physicians and other healthcare providers.

Read More


top of page

12/15/15 – Kaiser Family Foundation – New Interactive Profiles Women’s Health in Each State

The Kaiser Family Foundation has launched a new interactive map and dashboard that offers the latest national and state-specific data on women’s health in the United States via comprehensive, easy-to-access state profiles. State Profiles for Women’s Health allows users to hover over a state in the map to see key facts for women on demographics, health coverage and access to care, sexual health, or pregnancy. Clicking on a state takes users to a dashboard of charts with state-specific data on women’s health, including insurance and Medicaid coverage, poverty, mental health, HIV, cancer, pregnancy, abortions, and use of preventive services. Many indicators provide health care information for women of different racial and ethnic groups.

Read More

Click here to view the interactive map and dashboard


top of page

12/7/15 – The Commonwealth Fund – Policy Options to Expand Medicare’s Low-Income Provisions to Improve Access and Affordability

By Cathy Schoen, Christine Buttorff, Martin Anderson, and Karen Davis

Lowering Medicare’s premiums and cost-sharing obligations for low-income beneficiaries would protect an estimated 11 million people who are now at significant risk for financial losses. Though such subsidies would increase federal spending, they would help fulfill Medicare’s mission of ensuring access and financial protection for older and disabled Americans.

Read More


top of page

12/03/15 – CHCS – Assessing Success in Medicare-Medicaid Integration: A Review of Measurement Strategies

By Nancy Archibald and Sarah Barth

More and more people who are dually eligible for Medicare and Medicaid are enrolling in integrated care programs such as the Medicare-Medicaid Plans in the capitated model financial alignment demonstrations and Fully Integrated Dual Eligible Special Needs Plans. Anecdotal evidence shows that integrated care is benefiting dually eligible enrollees; however, existing performance measures may not fully capture how these programs are improving people’s lives.

Read More


top of page

12/3/15 – The Commonwealth Fund – Primary Care Physicians in Ten Countries Report Challenges Caring for Patients with Complex Health Needs

By Robin Osborn, Donald Moulds, Eric C. Schneider, M.D., Michelle M. Doty, David Squires, and Dana O. Sarnak

Nearly one-quarter of primary care physicians in the United States report they are not prepared to care for the sickest and frailest patients, and 84 percent say they are not well prepared to manage patients with serious mental illness, according to a new 10-nation survey. The findings suggest the U.S. may need to do more to strengthen primary care and employ new ideas shown to be effective in other countries.

Read More

Click here to view the survey questionnaire

Click here to view the press release


top of page

12/03/15 – Kaiser Family Foundation - Medicare Advantage 2016 Data Spotlight: Overview of Plan Changes

By Gretchen Jacobson, Marsha Gold, Anthony Damico, Tricia Newman, and Giselle Casillas

In 2015, more than 17 million Medicare beneficiaries (31%) are enrolled in Medicare Advantage plans,1 such as health maintenance organizations (HMOs) or preferred provider organization (PPOs). Medicare Advantage plans are offered as an alternative to the traditional Medicare program. Medicare beneficiaries can enroll in a Medicare Advantage plan, change Medicare Advantage plans, or switch from Medicare Advantage to traditional Medicare during the annual open enrollment period. Changes in the Medicare Advantage marketplace have always been closely watched, and since 2010 when the Affordable Care Act (ACA) was enacted, many have been interested in the effects of the ACA phasing down federal payments to Medicare Advantage plans. More recently, proposed mergers between health insurance firms with large footprints in Medicare Advantage have raised questions about how the mergers could affect beneficiaries.

Read More


top of page

12/2/15 – Kaiser Family Foundation - Although a Small Share of Medicare Part D Enrollees Take Specialty Drugs, A New Analysis Finds Those Who Do Can Face Thousands of Dollars in Out-of-Pocket Drug Costs Despite Plan Limits on Catastrophic Expenses

Some Medicare Part D enrollees can expect to pay thousands of dollars out-of-pocket for a single specialty drug in 2016, even though Part D plans provide substantial protection against catastrophic costs, according to a new analysis from the Kaiser Family Foundation. The findings illustrate how high prescription drug prices, one of the public’s top health care concerns, pose a financial challenge not only for Medicare and other federal health programs but for people on Medicare as well.

Read More

Click here to view the full issue brief


top of page

11/20/15 – Kaiser Family Foundation - The Latest Trends in Income, Assets, and Personal Health Care Spending Among People on Medicare

Click here to view slide show


top of page

11/18/15 – AHRQ – 2014 National Healthcare Quality and Disparities Report

The National Healthcare Quality and Disparities Reports are annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). These reports provide a comprehensive overview of the quality of health care received by the general U.S. population and disparities in care experienced by different racial, ethnic, and socioeconomic groups. The purpose of the reports is to assess the performance of our health system and to identify areas of strengths and weaknesses in the health care system along three main axes: access to health care, quality of health care, and priorities of the National Quality Strategy (NQS).

Read More

Click here to view introduction and methods


top of page

11/18/15 – MedPAC – MedPAC Comment on CMS’s Development of Discharge to Community and Potentially Preventable Readmission Measures

The Medicare Payment Advisory Commission (MedPAC) welcomes the opportunity to comment on the development of a discharge-to-community quality measure and the development of potentially preventable readmission measures for post-acute (PAC) care providers.  We appreciate CMS’s ongoing efforts to develop and test quality indicators for the Medicare program.

Read More


top of page

11/16/15 – OIG – OIG’s FY 2015 Top Management and Performance Challenges Facing the Department of Health and Human Services

Protecting the integrity of Medicaid takes on heightened urgency as expenditures and beneficiaries served continue to grow. As of September 2015, 29 states and the District of Columbia are expanding Medicaid eligibility to include a larger group of qualifying adults pursuant to the Patient Protection and Affordable Care Act (Affordable Care Act) and Medicaid waivers. Further, states that have not expanded eligibility have also seen increases in Medicaid enrollment. Taking into account the obstacles associated with expanding eligibility, along with long-standing program integrity issues, Medicaid continues to be a top management challenge for the Department of Health and Human Services (Department or HHS).

Read More


top of page

11/16/15 – MedPAC – MedPAC comment on CMS’s Proposed Changes to the CMS-HCC Risk Adjustment Model for Payment Year 2017

The Medicare Payment Advisory Commission (MedPAC) welcomes the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) Request for Comment memorandum entitled “Proposed Changes to the CMS-HCC Risk Adjustment Model for Payment Year 2017” issued by the Medicare Plan Payment Group on October 28, 2015.  The Memorandum proposes changes to improve the way that the Medicare Advantage (MA) risk-adjustment system determines payments for Medicare/Medicaid dually eligible beneficiaries.  We appreciate your staff’s ongoing efforts to administer and improve payment systems for MA, particularly considering the competing demands on the agency.

Read More


top of page

11/11/15 - Kaiser Family Foundation - What's in Store for Medicare's Part B Premiums and Deductible in 2016, and Why?

By Juliette Cubanski and Tricia Neuman

On November 10, 2015, the Centers for Medicare & Medicaid Services (CMS) announced the 2016 Medicare Part B monthly premium and annual deductible amounts of $121.80 and $166, respectively.1 The Medicare Trustees had projected that Part B premium and deductible amounts would increase by an unprecedented 52 percent between 2015 and 2016,2 before the Bipartisan Budget Act of 2015 (Public Law 114-74) was passed by Congress and signed into law on November 2, 2015. According to the Trustees, the magnitude of the projected increase in the standard premium was attributable to higher-than-expected Part B spending in 2014; a need to provide for adequate reserves in the Supplementary Medical Insurance trust fund; and the effect of having no cost-of-living adjustment (COLA) for Social Security benefits in 2016. The lack of a Social Security COLA means that 70 percent of Part B enrollees are prevented from paying higher Part B premiums in 2016 due to the so-called ‘hold-harmless’ provision in the Social Security law, while the other 30 percent will face higher premiums.

Read More


top of page

11/10/15 – CNBC – A Disease on Track to Bankrupt Medicare

By Susan Caminiti

Leading Alzheimer's researchers are optimistic that effective treatments to significantly slow or even halt the symptoms of this agonizing and ultimately fatal disease will be available within the next five years.

Read More


top of page

11/6/15 – Long-Term Living – Office of Inspector General Plans to Crack Down on Fraud and Cut Costs

By Nicole Stempak, Associate Editor

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) outlined its plans for fiscal year 2016:  focus on delivery system reform and examine the effectiveness of alternate payment models, coordinated care programs and value-based purchasing.

Read More

Click here to view the full report


top of page

11/05/15 – Kaiser Family Foundation – Primary Care Physicians Accepting Medicare: A Snapshot

By Cristina Boccuti, Christa Fields, Giselle Casillas, and Liz Hamel

Policymakers, researchers, and the media have periodically raised questions about the ease or difficulty that Medicare patients experience when trying to find physicians who will see them. Previous studies show that the vast majority of physicians accept Medicare, but the proportion taking new Medicare patients is smaller, particularly among primary care physicians compared with specialists.1 Primary care is especially important for people with Medicare—55 million seniors and adults with permanent disabilities—because they are significantly more likely than others to have multiple chronic conditions.

Read More

Click here to view Appendix Table 1

Click here to view Survey Methodology

Click here to view Survey Topline


top of page

11/5/15 - 10 FAQs: Medicare’s Role in End-of-Life Care

About three-quarters of the 2.5 million people who die during the year in the US are ages 65 and older, making Medicare the largest insurer of health care provided during the last year of life.1  In fact, roughly one-quarter of traditional Medicare spending for health care is for services provided to Medicare beneficiaries in their last year of life—a proportion that has remained steady for decades.2  The high overall cost for health care received in the last year of life is not surprising given that many who die have multiple serious and complex conditions.

Read More


top of page

11/2/15 – CBS News – Medicare to Pay for End-of-Life Counseling for Terminally Ill

By Jonathan Lapook

In a major change of policy, Medicare will now pay for end-of-life counseling for terminally-ill patients.

Read More


top of page

10/28/15 – USA Today - Budget Proposal Could Mean No 52% Jump In Medicare Part B Premiums

By Robert Powell

Millions of Medicare recipients bracing for a 52% premium increase are one step away from breathing a sigh of relief thanks to a bipartisan budget deal the House passed on Wednesday. The Senate is due to vote soon. “The deal, if it gets through Congress, will substantially reduce the increase in Medicare premiums and deductibles that would otherwise take effect in 2016,” says Tricia Neuman, a senior vice president at theKaiser Family Foundation in Washington, D.C.
 

top of page

10/28/15 – AHIP – New Report: Medigap Continues Strong Enrollment Growth Among Seniors

For the fifth year in a row, enrollment in Medigap plans has continued to increase as more seniors come to rely on this important coverage option, according to a new report released today by America’s Health Insurance Plans (AHIP). Between December 2013 and December 2014, enrollment in Medigap increased to 11.2 million, up from approximately 10.6 million the previous year.
 
 

top of page

10/27/15 – CBS News – Health Care Costs for Dementia Soar at the End of Life

By Maureen Salamon

Health care and caregiving costs for dementia patients in the final five years of life are far more burdensome than they are for patients with cancer, heart disease and other illnesses, a new study suggests.

Read More


top of page

10/23/15 – U.S. News & World Report - Medicare Part D Changes Coming in 2016

By Emily Brandon

Most Medicare Part D beneficiaries will pay higher premiums next year if they stick with their current prescription drug plan, according to a Kaiser Family Foundation and Georgetown University analysis of the Medicare Part D plans that will be offered in 2016. Deductibles and other cost-sharing requirements are also projected to increase, unless existing beneficiaries take action to switch plans. Here's a look at the Medicare Part D changes you can expect to see next year.

Read More


top of page

10/20/15 – Kaiser Family Foundation -  Medicare Advantage and Traditional Medicare: Is the Balance Tipping?

By Tricia Neuman, Giselle Casillas and Gretchen Jacobson

A growing share of Medicare beneficiaries have been enrolling in Medicare Advantage plans over the past decade, prompting some to question whether the balance between traditional Medicare and Medicare Advantage could be on the verge of tipping. Since 2006, the share of Medicare beneficiaries enrolled in a Medicare Advantage plan has nearly doubled, from 16 to 31 percent, but in some counties, the percentage is much higher. In this brief, we look beneath national trends to examine Medicare Advantage penetration rates and growth rates in counties across the country to assess the extent to which Medicare Advantage plans are poised to cover more beneficiaries than traditional Medicare across the country.

Read More


top of page

10/20/15 – Modern Healthcare - Medicare Advantage Star Ratings May Change To Address Fairness Complaints

By Virgil Dickson

Top CMS officials signaled this week that the agency will consider altering Medicare Advantage quality ratings to adjust for socio-economic characteristics of a plan's enrollees. Health plans that primarily serve low-income members and people who are dually eligible for Medicare and Medicaid complain they unfairly get lower star ratings that make them ineligible for bonuses and put them in danger of losing their Medicare contracts. The CMS has the statutory authority to boot a plan if it has fewer than three stars for three straight years.

Read More


top of page

10/19/15 – Kaiser Health News – No Ready-Made Rx For Rising Drug Costs

By Julie Appleby

When Turing Pharmaceuticals raised the price of an older generic drug by more than 5,000 percent last month, the move sparked a public outcry. How, critics wondered, could a firm charge $13.50 a pill for a treatment for a parasitic infection one day and $750 the next?

Read More


top of page

10/16/15 – MedPAC – MedPAC Announces the Release of the Updated 2015 Medicare Payment Basics Series

Payment Basics is a series of brief overviews of how Medicare’s payment systems function. The Commission produces Payment Basics as a resource for Congressional staff and others to better understand how Medicare pays for health care services.

Read More


top of page

10/15/15 – New York Times - No Social Security Raises Even if Medicare Soars

By Robert Pear

The 60 million people on Social Security will not receive any cost-of-living increase in their benefits in 2016, the government said Thursday, but because of a quirk in federal law, nearly one-third of Medicare beneficiaries could have record increases in their premiums unless Congress intervenes. With millions of older Americans on fixed incomes facing that one-two punch, the Obama administration is urging Congress to stop — or at least moderate — the health insurance premium increases, which could raise the cost for some Medicare beneficiaries by about 50 percent — the largest increase in the history of Medicare. But the leadership crisis in the House of Representatives could prove to be an obstacle.

Read More


top of page

10/14/15 – Kaiser Family Foundation - Medicare Open Enrollment Preview

With Medicare Advantage (Part C) and prescription drug (Part D) open enrollment beginning October 15th, this briefing took a close look at what to expect, including trends in premiums and cost sharing, plan availability and benefit design. The day after the briefing, Medicare beneficiaries will be able to enroll in the Medicare Advantage and prescription drug programs. About one-third of beneficiaries now opt for private health plans – mostly HMOs and PPOs – through the Medicare Advantage program. And, about 69 percent of beneficiaries get prescription drug coverage, either through their Medicare Advantage plans, or by purchasing stand-alone plans.

Read More


top of page

10/13/15 – Kaiser Family Foundation - What’s In and What’s Out? Medicare Advantage Market Entries and Exits for 2016

By  Gretchen Jacobson, Anthony Damico, and Tricia Neuman Follow

During the debate surrounding the Affordable Care Act (ACA), some questioned whether plans would exit as a result of the payment reductions to Medicare Advantage plans, leading to a drop in plan choices, and eventually, a decline in enrollment. Instead, Medicare Advantage enrollment growth has exceeded expectations, increasing from 24 percent of beneficiaries in 2010 to almost one-third (31%) of beneficiaries in 2015. Between 2010 and 2015, the total number of plans declined modestly, but beneficiaries in 2015 still had the option to choose among 18 Medicare Advantage plans, on average.

Read More


top of page

10/6/15 – NPR - Seniors Tend To Quit Medicare Advantage When Health Declines

By Alison Kodjak

Senior citizens are switching from privately run insurance plans to traditional Medicare when they face serious, long-term health conditions, a study shows. Researchers at Brown University found that 17 percent of Medicare Advantage patients who entered nursing homes for long-term care chose to switch to traditional Medicare the following year. Only 3 percent of similar patients in Medicare made the decision to go to a private Medicare Advantage plan.

Read More


top of page

10/6/15 – Kaiser Family Foundation – Medicare’s Drug Benefit Is Firmly Established After Its First Decade, With Flat Premiums in Recent Years but Higher Cost-Sharing Over Time

With Medicare Part D nearing the end of its tenth year, the program — which now provides drug coverage to 72 percent of all Medicare beneficiaries — has experienced no growth in average premiums in recent years but some notable increases in cost-sharing, according to a new report from the Kaiser Family Foundation.

Read More


top of page

10/5/15 – New York Times - Congress and Obama Administration Seek Ways to Limit Increase in Medicare Premiums

By Robert Pear

Congress and the Obama administration are frantically seeking ways to hold down Medicare premiums that could rise by roughly 50 percent for some beneficiaries next year, according to lawmakers and Medicareofficials. The administration has criticized commercial insurance companies for seeking rate increases much smaller than that. Aides to Representative Nancy Pelosi of California, the House Democratic leader, and Speaker John A. Boehner are quietly exploring a possible deal that would limit the expected increase in Medicare premiums. 
 

top of page

10/5/15 – Kaiser Family Foundation - Medicare Part D at Ten Years: The 2015 Marketplace and Key Trends, 2006-2015

By Jack Hoadley, Juliette Cubanski and Tricia Neuman

Since 2006, Medicare beneficiaries have had access through Medicare Part D to prescription drug coverage offered by private plans, either stand-alone prescription drug plans (PDPs) or Medicare Advantage prescription drug plans (MA-PD plans). Now in its tenth year, Part D has evolved due to changes in the private plan marketplace and the laws and regulations that govern the program. This report presents findings from an analysis of the Medicare Part D marketplace in 2015 and changes in features of the drug benefit offered by Part D plans since 2006. Key findings are summarized below.

Read More


top of page

10/1/15 – Kaiser Family Foundation – 10 FAQs: Medicare’s Role in End-of-Life Care

About three-quarters of the 2.5 million people who die during the year in the US are ages 65 and older, making Medicare the largest insurer of health care provided during the last year of life.1  In fact, roughly one-quarter of traditional Medicare spending for health care is for services provided to Medicare beneficiaries in their last year of life—a proportion that has remained steady for decades.2  The high overall cost for health care received in the last year of life is not surprising given that many who die have multiple serious and complex conditions.

Read More


top of page

9/30/15 – GAO - Medicare: Considerations for Expansion of the Appropriate Use Criteria Program

The Centers for Medicare & Medicaid Services (CMS)—an agency within the Department of Health and Human Services (HHS)—has proposed initial plans and timeframes for implementing the Medicare appropriate use criteria (AUC) program for advanced diagnostic imaging services, such as computed tomography, magnetic resonance imaging, and positron emission tomography. AUC are a type of clinical practice guideline intended to provide guidance on whether it is appropriate to perform a specific service for a given patient. Under the Protecting Access to Medicare Act of 2014 (PAMA), a health care provider ordering advanced diagnostic imaging services generally must consult AUC as a condition of Medicare payment for providers who furnish imaging services. Consulting AUC involves entering patient clinical data into an electronic decision tool to obtain information on the appropriateness of the service. The agency's July 2015 notice of proposed rulemaking focused largely on the process for specifying applicable AUC to be used in the program and a policy for identifying providers who must obtain authorization from CMS before ordering imaging services due to their low adherence to appropriate ordering.

Read More


top of page

9/30/15 – Kaiser Family Foundation - Kaiser Health Tracking Poll: September 2015

By Bianca DiJulio, Jamie Firth and Mollyann Brodie

As the Centers for Medicare & Medicaid Services prepares to finalize a plan to pay physicians for discussing end-of-life treatment options with Medicare patients, this month’s Kaiser Health Tracking Poll finds that about 8 in 10 of the public favors Medicare and private insurance covering such discussions and about 9 in 10 say doctors should have these discussions with their patients. However, relatively few (17 percent) say they’ve had such discussions with a doctor or other health care provider, including 27 percent of people age 65 or older, while half of the public says they would want to have such a discussion. Over 8 in 10 say they would feel very comfortable talking about their end-of-life medical wishes with their spouse or partner and closer to half say they would be very comfortable talking with a doctor, their children, their close friends or their parents.

Read More

Click here to view Topline & Methodology


top of page

9/28/15 – GAO - Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy

The Centers for Medicare & Medicaid Services (CMS) is the agency within the Department of Health and Human Services (HHS) responsible for overseeing the Medicare Advantage (MA) program—Medicare's private plan alternative. Since 2011, CMS has defined an adequate MA provider network as meeting two criteria: a minimum number of providers and maximum travel time and distance to those providers. To reflect local conditions, the requirements are specific to different county types and a range of provider types. However, the MA criteria do not reflect aspects of provider availability, such as how often a provider practices at a given location. In contrast, other network-based health programs use provider availability measures to assess network adequacy. For example, federal Medicaid managed care rules address providers' ability to accept new patients and TRICARE criteria address appointment wait times for active duty servicemembers. Without taking availability into account, as is done in some other programs, MA provider networks may appear to CMS and beneficiaries as more robust than they actually are.

Read More


top of page

9/28/15 – Avalere – Pressures Mounting for Medicare Drug Benefit

Market for Medicare Advantage Plans Appears Stable in 2016

According to a new Avalere analysis of data from the Centers for Medicare & Medicaid Services (CMS), premiums for standalone prescription drug plans (PDPs) will increase and the number of PDPs available in 2016 will decrease. Conversely, Medicare Advantage (MA) premiums will decrease in 2016, and the number of MA plans on the market will increase, despite years of Affordable Care Act payment reductions.

Read More


top of page

9/27/15 – The Wall Street Journal – How House Calls Can Cut Medical Costs

For Infirm Older Patients, Medicare Finds that Personal Visits Can Keep People Out of the Hospital

By Laura Landro

For many chronically ill older patients, house calls are replacing some hospital stays. Across the U.S., home-based primary-care practices are sending doctors, nurses and other clinicians on regular house calls to older, infirm patients. The goal is to prevent costly hospital stays and admissions to long-term-care facilities, while improving the quality of care, especially for the sickest 5% of Medicare beneficiaries, who account for 50% of the federal program’s costs.
 

top of page

9/10/15 – Kaiser Family Foundation – Income and Assets of Medicare Beneficiaries, 2014 - 2030

By Gretchen Jacobson, Christina Swoope, Tricia Neuman, and Karen Smith

Many Medicare beneficiaries, including seniors and younger adults with disabilities, live on fixed incomes supplemented by the savings they accumulated during their working years. Their income and accumulation of savings is tied to many life experiences, including their education, health status, marital status, number of work years, household income, periods of unemployment, investments, years of homeownership, access to employer retirement benefits, inheritance, other financial supports, and various economic factors. As a result, the income and assets of Medicare beneficiaries vary greatly.1  This data brief updates previous work that describes the income and assets of Medicare beneficiaries now, and in the future (2030).2  It incorporates updated projections about the current and future U.S. economy, and the effects of the economic downturn and recovery on current and future beneficiaries’ income, savings, and home equity.  This brief provides context for understanding the extent to which the current and future generations of beneficiaries can afford to absorb higher health care costs.

Read More 


top of page

9/3/15 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on the Physician Fee Schedule and Other Revisions to Part B

The Medicare Payment Advisory Commission welcomes the opportunity to comment on the Centers for Medicare & Medicaid Services (CMS) proposed rule entitled “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016,” published in the Federal Register, vol. 80, no. 135, pages 41686 to 41966.  We appreciate your staff’s ongoing efforts to administer and improve payment systems for physician and other health professional services, particularly considering the competing demands on the agency.

Read More


top of page

8/31/15 – The Wall Street Journal – Drug-Industry Rule Would Raise Medicare Costs

Congressional Budget Office Estimates $1.3 Billion Increase in Federal Health-Care Costs Over a Decade

By Joseph Walker

A patent law change sought by the pharmaceutical industry could cost federal health-care programs $1.3 billion over a decade by delaying new generic medicines, an analysis by the Congressional Budget Office found this summer, according to people familiar with the matter.

Read More


top of page

8/25/15 – The Commonwealth Fund – Competition Among Medicare’s Private Health Plans: Does It Really Exist?

By Brian Biles, Giselle Casillas and Stuart Guterman

Competition among private Medicare Advantage (MA) plans is seen by some as leading to lower premiums and expanded benefits. But how much competition exists in MA markets? Using a standard measure of market competition, our analysis finds that 97 percent of markets in U.S. counties are highly concentrated and therefore lacking in significant MA plan competition. Competition is considerably lower in rural counties than in urban ones. Even among the 100 counties with the greatest numbers of Medicare beneficiaries, 81 percent do not have competitive MA markets. Market power is concentrated among three nationwide insurance organizations in nearly two-thirds of those 100 counties.

Read More

Click here to view Appendix Tables

Click here to view the Press Release


top of page

8/24/15 – The Washington Post - Medicare Reconsiders Rule That Leaves Dying Patients Facing A Stark Choice

By Michael Ollove

For more than 30 years, Medicare presented dying patients with a stark choice: They could continue treatments that might extend their lives or they could accept the medical and counseling services of hospice care meant to ease their way to death. They could not do both. Now, the federal government is experimenting with a change that would remove that either/or proposition. Beginning next year, people choosing to participate in a demonstration project will be able to receive Medicare hospice benefits while continuing treatment for the diseases that are killing them.

Read More


top of page

8/24/15 – MDHHS – State of Michigan Launches Aging Website

Older Michiganders will now have quick and easy access to information on services in their area through a new website launched today, www.michigan.gov/aging. The site was developed by the Aging & Adult Services Agency (AASA) within the Michigan Department of Health and Human Services (MDHHS), and in partnership with the Michigan Department of Management and Budget (DTMB).

Read More

Click here to view the website


top of page

8/20/15 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on the Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals

The Medicare Payment Advisory Commission (MedPAC) welcomes the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) proposed rule entitled Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services; Federal Register, Vol. 80, No. 134, p. 41198 (July 14, 2015).  We appreciate your staff’s ongoing efforts to administer and improve the payment system for hospitals and post-acute care (PAC), particularly given the many competing demands on the agency staff’s resources.

Read More


top of page

8/18/15 – Kaiser Health News – Medicare Says Doctors Should Get Paid To Discuss End-Of-Life Issues

By Kristian Foden-Vencil, Oregon Public Broadcasting and Stephanie O’Neill, Southern California Public Radio

Remember the so-called death panels? When Congress debated the Affordable Care Act in 2009, the legislation originally included a provision that would have allowed Medicare to reimburse doctors when they meet with patients to talk about end-of-life care.

Read More


top of page

8/13/15 – Office of Inspector General – Overlap Between Physician-Owned Hospitals and Physician-Owned Distributors

This work follows up on our October 2013 report Spinal Devices Supplied by Physician Owned Distributors: Overview of Prevalence and Use (OEI-01-11-00660), which found that physician owned distributors (PODs) supplied the devices used in nearly one in five spinal fusion surgeries that were billed to Medicare. When we met with CMS in September 2013 to discuss a draft of the report, agency staff expressed interest in the overlap between owners of physician-owned hospitals and PODs of spinal devices.

Read More

Click here to view the complete report


top of page

8/13/15 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on the Hospital Outpatient and Ambulatory Surgical Center Payment Systems

The Medicare Payment Advisory Commission (MedPAC) is pleased to submit comments on CMS’s proposed rule entitled: “Hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs; short inpatient hospital stays; transition for certain Medicare-dependent, small rural hospitals under the hospital inpatient prospective payment system” [published in the Federal Registry, volume 80, no. 130, pages 39200-39375].  We appreciate your staff’s ongoing efforts to administer and improve the payment system for hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs), particularly considering the agency’s competing demands.

Read More


top of page

8/10/15 – McKnight’s – Obama Signs NOTICE Act Into Law

By Emily Mongan

A bill changing notification of outpatient observation status for hospital patients has been signed into law by President Obama.

Read More


top of page

8/6/15 – Health Affairs – Health Policy Briefs - Medicare’s Hospital-Acquired Condition Reduction Program

By Amanda Cassidy

The Centers for Medicare and Medicaid Services aims to decrease preventable conditions by reducing payments to the lowest-performing hospitals.

Read More


top of page

7/29/15 – OIG - Medicare Part B Overpaid Millions for Selected Outpatient Drugs

Medicare contractors in 13 jurisdictions overpaid providers $35.8 million for selected outpatient drugs during our audit period (July 1, 2009, through June 30, 2012). For the majority of the overpayments (88 percent), providers billed either incorrect units of service or a combination of incorrect units of service and incorrect Healthcare Common Procedure Coding System (HCPCS) codes. During our audit period, the Medicare claims processing systems did not have sufficient prepayment edits in place to prevent all overpayments. In particular, Medically Unlikely Edits (MUEs) did not exist for many of the HCPCS codes associated with the outpatient drugs in our review. The 13 Medicare contractors concurred with our recommendations in the individual reports to recover the identified overpayments and use the results of our audits in ongoing provider education.

Read More


top of page

7/27/15 – McKnight’s – Alzheimer’s Misdiagnoses Running Up Big Medicare Bills

By Emily Mongan

Medicare beneficiaries who receive a misdiagnosis of Alzheimer's could amass between $9,500 and $14,000 in additional medical costs each year until they are correctly diagnosed, according to a new study.

Read More

Click here to view the full study


top of page

7/24/15 – Kaiser Family Foundation - The Facts on Medicare Spending and Financing

Medicare, the federal health insurance program for 55 million people ages 65 and over and people with permanent disabilities, helps to pay for hospital and physician visits, prescription drugs, and other acute and post-acute services.  In 2014, spending on Medicare accounted for 14% of the federal budget.  Medicare plays a major role in the health care system, accounting for 22% of total national health spending in 2013, 26% of spending on hospital care, and 22% of spending on physician services. This fact sheet includes the most recent historical and projected Medicare spending data from the 2015 annual report of the Medicare Trustees and the 2015 Medicare baseline from the Congressional Budget Office.

Read More


top of page

7/23/15 – Kaiser Family Foundation - Proposed Rule on Medicaid Managed Care: A Summary of Major Provisions

By Julia Paradise and MaryBeth Musumeci

On June 1, 2015, the Centers for Medicare & Medicaid Services (CMS) published a Notice of Proposed Rulemaking (NPRM) to modernize federal Medicaid managed care regulations. Since the rules were last updated, in 2002, states have significantly expanded their managed care programs to include beneficiaries with more complex needs; larger geographic areas; additional services; and millions of adults newly eligible for Medicaid under the Affordable Care Act. Today, over half of all Medicaid beneficiaries are enrolled in comprehensive risk-based health plans and many also receive some services, such as behavioral health care, through limited-benefit risk-based plans. In addition, millions of beneficiaries are enrolled in managed fee-for-service arrangements. CMS has articulated several principles and goals that underlie the NPRM. In particular, the proposed rule aims to: strengthen beneficiary protections; better align Medicaid managed care rules with standards for other coverage programs; increase fiscal integrity in rate-setting; address delivery and payment system reform in the context of managed care; improve the quality of care across Medicaid delivery systems; increase health plan and state accountability; and strengthen state and federal oversight of Medicaid managed care programs.
 

top of page

7/22/15 – MedPAC – Hospital Policy Issues

Statement by Mark E. Miller, PhD before the Committee on Ways and Means, U.S. House of Representatives

Chairman Brady, Ranking Member McDermott, distinguished Committee members. I am Mark Miller, executive director of the Medicare Payment Advisory Commission (MedPAC). The Commission appreciates the opportunity to discuss hospital payment issues with you today.

Read More


top of page

7/20/15 – Alzheimer’s Association - New Analysis Shows More Than 28 Million Baby Boomers Will Develop Alzheimer’s Disease; Will Consume Nearly 25% Of Medicare Spending

Urgent Need for Investment in Treatments That Delay or Prevent the Disease. New Findings Reported at the Alzheimer’s Association International Conference 2015

More than 28 million baby boomers will develop Alzheimer’s disease between now and midcentury, and the cost of caring for them will consume nearly 25 percent of Medicare spending in 2040, according to new research reported today at the Alzheimer’s Association International Conference® 2015 (AAIC® 2015) in Washington, D.C. As the baby boomers with Alzheimer’s age, there will be a shift toward more severe forms of the disease, leading to greater Medicare costs. In 2020, the projected Medicare costs of caring for baby boomers with Alzheimer’s in the community ($11.86 billion, in 2014 dollars) will be 2.1% of total Medicare spending. By 2040, when the baby boom generation is aged 76-94, the projected Medicare costs ($328.15 billion, in 2014 dollars) increase to 24.2% of total Medicare spending, according to the new analysis.

Read More


top of page

7/17/15 – Kaiser Family Foundation – To Switch or Be Switched: Examining Changes in Drug Plan Enrollment Among Medicare Part D Low-Income Subsidy Enrollees

By Jack Hoadley, Laura Summer, Elizabeth Hargrave, Samuel Stromberg, Juliette Cubanski, and Tricia Neuman

During the Medicare Part D annual enrollment period from October 15 to December 7, people on Medicare can review and compare stand-alone prescription drug plans (PDPs) and Medicare Advantage plans and switch plans if they choose.  Low-income beneficiaries who receive premium and cost-sharing assistance through the Part D Low-Income Subsidy (LIS) program have a subset of premium-free PDPs (benchmark plans) available to them, but can also choose to enroll in a non-benchmark plan and pay a premium. Each year, the list of premium-free PDPs changes. When PDPs lose their premium-free status, the Centers for Medicare & Medicaid Services (CMS) automatically reassigns many of their LIS enrollees to another premium-free PDP; however, CMS does not reassign LIS enrollees who have chosen a plan other than their assigned PDP.  LIS Part D plan enrollees, unlike non-LIS enrollees, are also permitted to switch plans at any time outside the annual enrollment period.

Read More


top of page

7/17/15 – MedPAC – Data Book: Health Care Spending and the Medicare Program

The MedPAC Data Book provides information on national health care and Medicare spending as well as Medicare beneficiary demographics, dual-eligible beneficiaries, quality of care in the Medicare program, and Medicare beneficiary and other payer liability. It also examines provider settings—such as hospitals and post-acute care—and presents data on Medicare spending,beneficiaries’ access to care in the setting (measured by the number of beneficiaries using the service, number of providers, volume of services, length of stay, or through direct surveys), and the sector’s Medicare profit margins, if applicable. In addition, it covers the Medicare Advantage program and prescription drug coverage for Medicare beneficiaries, including Part D.

Read More

Click here to view Section 1: National health care and Medicare spending

Click here to view Section 2: Medicare beneficiary demographics

Click here to view Section 3: Medicare beneficiary and other payer financial liability

Click here to view Section 4: Dual-eligible beneficiaries

Click here to view Section 5: Quality of care in the Medicare program

Click here to view Section 6: Acute inpatient services

Click here to view Section 7: Ambulatory care

Click here to view Section 8: Post-acute care

Click here to view Section 9: Medicare Advantage

Click here to view Section 10: Prescription drugs

Click here to view Section 11: Other services


top of page

7/17/15 – Kaiser Family Foundation – Medicare And Medicaid At 50

By Mira Norton, Bianca DiJulio and Mollyann Brodie

Medicare and Medicaid were signed into law by President Lyndon Johnson on July 30, 1965 in a bipartisan effort to provide health insurance coverage for low-income, disabled, and elderly Americans. In their 50 year history, each of these programs has come to play a key role in providing health coverage to millions of Americans today and make up a significant component of federal and state budgets. Medicare, a federal government program, provides health insurance coverage for Americans age 65 and older, regardless of income, as well as those under age 65 with permanent disabilities. Medicaid provides coverage for medical care and long-term care services to low-income people and is jointly financed by federal and state governments, with each state deciding how to structure benefits, eligibility, and care delivery within guidelines set by the federal government. Medicaid is also one of the primary ways the Affordable Care Act expanded coverage to millions more low-income, uninsured adults. Today, both programs cover 111 million Americans and cost an estimated $1,035 billion this year.1

Read More

Click here to view Topline & Methodology


top of page

7/16/15 – Commomwealth Fund – Serving Older Adults with Complex Care Needs: A New Benefit Option for Medicare

By Marilyn Moon, Ilene L. Hollin, Lauren H. Nicholas, Cathy Schoen, and Karen Davis

Medicare was originally designed to protect beneficiaries from the financial burden of acute episodes of illness. As lifespans lengthen, Medicare must adapt to serve beneficiaries with substantial long-term physical or cognitive impairment who need personal care assistance. These beneficiaries often incur high out-of-pocket costs for Medicare-covered services as well as home and community care not covered by Medicare. This latter category of care is often key to continued independence. To improve Medicare’s capacity to serve such beneficiaries, and to prevent unnecessary institutionalization, this issue brief, one in a series on Medicare’s future challenges, proposes a complex care benefit option that would include home and community services, and describes how it might be structured to balance the goals of improving care for beneficiaries and ensuring affordability.

Read More

Click here to view the Chartpack


top of page

7/16/15 – MedPAC – June 2015 - A Data Book – Health Care Spending and the Medicare Program

The MedPAC Data Book provides information on national health care and Medicare spending as well as Medicare beneficiary demographics, dual-eligible beneficiaries, quality of care in the Medicare program, and Medicare beneficiary and other payer liability. It also examines provider settings—such as hospitals and post-acute care—and presents data on Medicare spending, beneficiaries’ access to care in the setting (measured by the number of beneficiaries using the service, number of providers, volume of services, length of stay, or through direct surveys), and the sector’s Medicare profit margins, if applicable. In addition, it covers the Medicare Advantage program and prescription drug coverage for Medicare beneficiaries, including Part D.

Read More


top of page

7/14/15 – Kaiser Family Foundation – Data Note: Medicare Advantage Enrollment, by Firm, 2015

By Gretchen Jacobson, Anthony Damico and Tricia Neuman

In recent weeks, a number of potential mergers and acquisitions between large firms that offer health insurance have been reported in the press, including the July 3, 2015 announcement of a merger between Aetna and Humana. These mergers could affect consumers in the individual market, enrollees in the new federal and state Marketplaces, employees with employer-sponsored insurance, as well as people covered by public programs such as Medicare. Nearly 17 million Medicare beneficiaries – almost one-third of the total Medicare population – are enrolled in private Medicare plans, known as Medicare Advantage plans, raising questions about the potential impact of these mergers on Medicare enrollees.
 

top of page

7/14/15 – Commonwealth Fund – Quality-Spending Interactive

See the Relationship Between Medicare Quality and Spending in Your State or Local Area

To view the relationship between health care quality and spending in your state or local area, use the graph, known as a scatter plot, or map. Choose a health care setting, such as hospitals, and then a quality measure to view performance. Curious about how your region compares to someplace else? Click on your selected location and then drag your mouse to the state or local area you want to compare it to and hover. You can see which location has lower spending and higher quality relative to the U.S. median. Use what you learn to motivate improvement toward higher levels of performance. Share your views of it with us at webeditor@cmwf.org.

Read More


top of page

7/13/15 – Commonwealth Fund – Predictable Unpredictability: The Problem with Basing Medicare Policy on Long-Term Financial Forecasting

By Sherry A. Glied and Abigail Zaylor

The authors assess how Medicare financing and projections of future costs have changed since 2000. They also assess the impact of legislative reforms on the sources and levels of financing and compare cost forecasts made at different times. Although the aging U.S. population and rising health care costs are expected to increase the share of gross domestic product devoted to Medicare, changes made in the program over the past decade have helped stabilize Medicare’s financial outlook—even as benefits have been expanded. Long-term forecasting uncertainty should make policymakers and beneficiaries wary of dramatic changes to the program in the near term that are intended to alter its long-term forecast: the range of error associated with cost forecasts rises as the forecast window lengthens. Instead, policymakers should focus on the immediate policy window, taking steps to reduce the current burden of Medicare costs by containing spending today.

Read More


top of page

7/8/15 – Yahoo News - Medicare To Cover End-Of-Life Counseling

By Matt Sedensky and Ricardo Alonso-Zaldivar

Medicare said Wednesday it plans to pay doctors to counsel patients about end-of-life care, the same idea that sparked accusations of "death panels" and fanned a political furor around President Barack Obama's health care law six years ago. The policy change, to take effect Jan. 1, was tucked into a massive regulation on payments for doctors. It suggests that what many doctors regard as a common-sense option is no longer seen by the Obama administration as politically toxic. Counseling would be entirely voluntary for patients.

Read More


top of page

7/8/15 – The Commonwealth Fund - Modernizing Medicare's Benefit Design and Low-Income Subsidies to Ensure Access and Affordability

By Cathy Schoen, Karen Davis, Christine Buttorff, and Martin Andersen

Insurance coverage through the traditional Medicare program is complex, fragmented, and incomplete. Beneficiaries must purchase supplemental private insurance to fill in the gaps. While impoverished beneficiaries may receive supplemental coverage through Medicaid and subsidies for prescription drugs, help is limited for people with incomes above the poverty level. This patchwork quilt leads to confusion for beneficiaries and high administrative costs, while also undermining coverage and care coordination. Most important, Medicare’s benefits fail to limit out-of-pocket costs or ensure adequate financial protection, especially for beneficiaries with low incomes and serious health problems. This brief, part of a series about Medicare’s past, present, and future, presents options for an integrated benefit for enrollees in traditional Medicare. The new benefit would not only reduce cost burdens but also could potentially strengthen the Medicare program and enhance its role in stimulating and supporting innovations throughout the health care delivery system.

Read More


top of page

7/3/15 – Forbes - Aetna's $37B Humana Deal Expands Role In Medicare's Value-Based Care Push

By Bruce Japsen
 
Following weeks of speculation, Aetna (AET) made it official this morning, agreeing to buy rival Humana (HUM) for $37 billion as merger-mania sweeps the health insurance industry. For now, the deal appears to put the two insurers into the top three health plans in the U.S. with more than 33 million medical members and will increase Aetna’s Medicare Advantage membership to 4.4 million. UnitedHealth Group (UNH) remains the nation’s largest health insurance company with Anthem (ANTM) at No. 2 though both have had discussions with smaller plans about merging and Anthem has made several recent overtures to Cigna (CI).
 

top of page

6/30/15 – Kaiser Family Foundation - Medicare Advantage Enrollment Continues to Climb, but Financial Protections for Enrollees Are Eroding

Enrollment in Medicare Advantage continues to climb steadily as spending reductions enacted in the Affordable Care Act reduce historical overpayments to the private plans, according to a new analysis by the Kaiser Family Foundation. But limits on out-of-pocket spending for Medicare-covered services are rising, providing less protection for enrollees with relatively high health care expenses.

Read More


top of page

6/30/15 – Kaiser Family Foundation - Medicare Advantage 2015 Spotlight: Enrollment Market Update

By Gretchen Jacobson, Anthony Damico, Tricia Neuman and Marsha Gold

Despite concerns that reductions in payments to Medicare Advantage plans enacted in the Affordable Care Act of 2010 (ACA) would lead to reductions in Medicare Advantage enrollment, the number and share of Medicare beneficiaries enrolling in Medicare Advantage plans has continued to climb.1 Since the enactment of the ACA, Medicare Advantage enrollment has increased by 5.6 million, or by 50 percent. The ACA payment reductions aimed to reduce historical overpayments to Medicare Advantage plans, relative to traditional Medicare.

Read More


top of page

6/29/15 – The Commonwealth Fund - Medicare Payment Reform: Aligning Incentives for Better Care

By Gerard Anderson, Karen Davis, Stuart Guterman

The Affordable Care Act (ACA) has provided the Medicare program with an array of tools to improve the quality of care that beneficiaries receive and to increase the efficiency with which that care is provided. Notably, the ACA has created the Center for Medicare and Medicaid Innovation, which is developing and testing promising new models to improve the quality of care provided to Medicare beneficiaries while reducing spending. These new models are part of an effort by the U.S. Department of Health and Human Services to increase the proportion of traditional Medicare payments tied to quality or value to 85 percent by 2016 and 90 percent by 2018. This issue brief, one in a series on Medicare’s past, present, and future, explores the evolution of Medicare payment policy, the potential of value-based payment to improve care for beneficiaries and achieve savings, and strategies for accelerating its adoption.

Read More


top of page

6/22/15 – Avalere Health – Lack of Quality Measures for Cancers and Other Serious Diseases Limits Medicare’s Ability to Pay for Value

A New Avalere Assessment of the Quality Measures Landscape Shows that Many Important Medical Conditions are not Fully Represented in Medicare Pay-For-Quality Programs, Which Limits Medicare’s Ability to Pay for Value

By Avalere Health LLC

The release frames the importance of the American Society of Clinical Oncology’s (ASCO) new conceptual framework for determining/reviewing the value of various cancer treatments.

Read More


top of page

6/17/15 – Kaiser Family Foundation - 10 FAQs: Medicare’s Role in End-of-Life Care

About three-quarters of the 2.5 million people who die during the year in the US are ages 65 and older, making Medicare the largest insurer of health care provided during the last year of life.1  In fact, roughly one-quarter of traditional Medicare spending for health care is for services provided to Medicare beneficiaries in their last year of life—a proportion that has remained steady for decades.2  The high overall cost for health care received in the last year of life is not surprising given that many who die have multiple serious and complex conditions.

Read More


top of page

6/16/15 – McKnight’s – Lawmakers Ask for CMS Fraud Review

By Holly Petrovich

Two House committees have requested a review of the Centers for Medicare & Medicaid Services' Fraud Prevention System, according to a letter sent to the Government Accountability Office.

Read More

Click here to view the letter


top of page

6/16/15 – Kaiser Family Foundation – Poll Finds Nearly Three Quarters of Americans Say Prescription Drug Costs are Unreasonable, and Most Blame Drug Makers Rather Than Insurers for the Problem

Nearly three quarters (73%) of the public view prescription drug costs as unreasonable, and far more blame pharmaceutical companies more than insurers for the high prices, finds the June Kaiser Health Tracking Poll.

Read More

Click here to view the Health Tracking Poll: June 2015

Click here to view the Topline and Methodology


top of page

6/15/15 – MedPAC – MedPAC Releases June 2015 Report on Medicare and the Health Care Delivery System

Today the Medicare Payment Advisory Commission (MedPAC) releases its June 2015 Report to the Congress: Medicare and the Health Care Delivery System. As part of its mandate from the Congress, each June MedPAC reports on issues affecting the Medicare program as well as broader changes in health care delivery and the market for health care services. 

Read More

Click here to view the Fact Sheet

Click here to view the Executive Summary

Click here to view the entire report


top of page

6/10/15 – Kaiser Family Foundation - Poverty Among Seniors: An Updated Analysis of National and State Level Poverty Rates Under the Official and Supplemental Poverty Measures

By Juliette Cubanski, Giselle Casillas, and Anthony Damico

Payments from Social Security and Supplemental Security Income have played a critical role in enhancing economic security and reducing poverty rates among people ages 65 and older. Yet many older adults live on limited incomes, and have modest savings. In 2013, half of all people on Medicare had incomes less than $23,500, which is equivalent to 200 percent of poverty in 2015. In recent policy discussions, some have proposed policies to strengthen financial protections under Medicare for lower-income seniors, while others would impose greater costs on beneficiaries along with other changes to scale back spending on Medicare, Social Security and other programs. This brief presents data on poverty rates among seniors, as context for understanding the implications of potential changes to federal and state programs that help to bolster financial security among older adults.

Read More


top of page

6/9/15 – MedPAC – MedPAC Comment on CMS’s Proposed Rule on the Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System

The Medicare Payment Advisory Commission (MedPAC) welcomes the opportunity to comment on the Medicare proposed rule entitled Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions to Quality Reporting Requirements for Specific Providers, including Changes Related to the Electronic Health Record Incentive Program published in the Federal Register on April 30, 2015. The rule revises the hospital inpatient prospective payment system, the long-term care hospital (LTCH) payment system, and quality reporting requirements for specific providers. In view of their competing demands and limited resources, we especially appreciate your staff‘s efforts to improve these hospital payment systems. 
 

top of page

6/8/15 – EurekAlert - Study Finds High Medicare Advantage Copays For Hospital, Nursing Care

By Dr. Amal Trivedi, Laura Keohane, Regina Grebla and Vincent Mor

Millions of seniors with Medicare Advantage plans, including more than a million with low incomes, were on the hook to have large out-of-pocket costs for a 27-day course of hospital and skilled nursing care, according to a new study. "Policymakers are very concerned about how much Medicare beneficiaries need to spend for essential medical services," said Dr. Amal Trivedi, associate professor of public health at Brown University and corresponding author of a new study in the June issue of the journal Health Affairs.

Read More


top of page

6/3/15 – Kaiser Family Foundation – Medicare’s Income-Related Premiums: A Data Note

By Juliette Cubanski and Tricia Neuman

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)—a new law to repeal and replace Medicare’s Sustainable Growth Rate (SGR) formula for physician payments—includes a provision to increase Medicare premiums for some higher-income beneficiaries to help offset the cost of the law.  The Congressional Budget Office estimated that this provision would increase Medicare’s premium revenues (and thereby reduce program spending) by $34.3 billion between 2018 and 2025.1  This idea is not a new one, having been raised in the context of earlier proposals to reduce federal spending and also included in the Obama Administration’s proposed budgets in recent years.2,3,4

Read More


top of page

6/2/15 – The Fiscal Times - Medicare Advantage Fraud: Heat on Justice Dept. to Investigate

By Brianna Ehley

The way the federal government calculates benefits for the Medicare Advantage program has been under scrutiny for years—with reformists and health policy experts claiming that the formula used to calculate benefits can be easily inflated and potentially wastes billions of tax dollars a year. Criticism of Medicare Advantage’s rating system, which determines how much the government spends on each beneficiary, has just ratcheted up, with at least two high-ranking senators calling on the Justice Department to investigate the program.

Read More


top of page

6/2/15 – MedPAC -  MedPAC Comment on CMS’s Proposed Rule on the Hospice Wage Index and Payment Rate Update and Hospice Quality Report Requirements

The Medicare Payment Advisory Commission welcomes the opportunity to comment on the Centers for Medicare & Medicaid Services proposed rule entitled Medicare Program; FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Report Requirements, Federal Register, Vol. 80, N0. 86, p. 25832 (May 5, 2015).  We appreciate your staff’s ongoing efforts to administer and improve the payment system for hospice, particularly given the many competing demand on the agency staff’s resources.

Read More


top of page

5/29/15 – GAO -  Report to Congressional Requesters

Medicaid – Additional Actions to Help Improve Provider and Beneficiary Fraud Controls

GAO found thousands of Medicaid beneficiaries and hundreds of providers involved in potential improper or fraudulent payments during fiscal year 2011— the most-recent year for which reliable data were available in four selected states: Arizona, Florida, Michigan, and New Jersey. These states had about 9.2 million beneficiaries and accounted for 13 percent of all fiscal year 2011 Medicaid payments.
 
 

top of page

5/28/15 – MedPAC - MedPAC comment on CMS’s Proposed Rule on the Inpatient Psychiatric Facility Prospective Payment System

The Medicare Payment Advisory Commission (MedPAC) appreciates the opportunity to submit comments on the Centers for Medicare & Medicaid Services (CMS) proposed rule entitled Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System—Update for Fiscal Year Beginning October 1, 2015 (FY 2016); Proposed Rule, Federal Register 80, no. 84, 25012-25065 (May 1, 2015). We appreciate your staff’s continuous efforts to administer and improve the Medicare payment system for inpatient psychiatric facilities (IPFs), particularly given the competing demands on the agency.

Read More


top of page

5/28/15 – MedPAC - MedPAC comment on CMS’s Proposed Rule on the Inpatient Rehabilitation Facility Prospective Payment System

The Medicare Payment Advisory Commission (MedPAC) appreciates the opportunity to submit comments on the Centers for Medicare & Medicaid Services (CMS) proposed rule entitled Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2016; Proposed Rule, Federal Register 80, no. 80, 23332-23399 (April 27, 2015). We appreciate your staff’s continuous efforts to administer and improve the Medicare payment system for inpatient rehabilitation facilities (IRFs), particularly given the competing demands on the agency.

Read More


top of page

5/22/15 – MedPAC – Report to the Congress: Overview of the 340B Drug Pricing Program

The 340B Drug Pricing Program allows certain hospitals and other health care providers (“covered entities”) to obtain discounted prices on “covered outpatient drugs” (prescription drugs and biologics other than vaccines) from drug manufacturers. Manufacturers must offer 340B discounts to covered entities to have their drugs covered under Medicaid. The discounts are substantial. The Health Resources and Services Administration (HRSA), which manages the program, estimates that covered entities saved $3.8 billion on outpatient drugs through the program in fiscal year 2013. According to HRSA, the intent of the 340B program is to allow certain providers to stretch scarce federal resources as far as possible to provide more careto more patients (Health Resources and Services Administration 2014e). HRSA calculates a 340B ceiling price for each covered outpatient drug, which represents the maximum price a manufacturer can charge a covered entity for the drug. Although the ceiling prices are proprietary, we estimated that, on average, hospitals in the 340B program receive a minimum discount of 22.5 percent of the average sales price for drugs paid under the outpatient prospective payment system.
 

top of page

5/20/15 – U.S. Department of Health and Human Services Met Many Requirements of the Improper Payments Information Act of 2002 But Did Not Comply for Fiscal Year 2014

The Improper Payments Elimination and Recovery Act of 2010 (IPERA; P.L. No. 111-204) requires Offices of Inspector General (OIGs) to review and report on agencies’ annual improper payment information included in their Agency Financial Reports (AFRs) to determine compliance with the Improper Payments Information Act of 2002 (IPIA; P.L. No. 107-300) as amended by IPERA as well as the Improper Payments Elimination and Recovery Improvement Act of 2012 (IPERIA; P.L. No. 112-248). (“IPIA” will refer to this law as amended by IPERA and IPERIA.) Our objectives were to (1) determine whether the Department of Health and Human Services (Department) complied with the IPIA for fiscal year (FY) 2014 in accordance with related Office of Management and Budget (OMB) guidance, (2) evaluate the Department’s assessment of the level of risk and the quality of the improper payment estimates and methodology for high-priority programs, and (3) assess the Department’s performance in reducing and recapturing improper payments. This is the fourth annual review of improper payments that we have conducted.
 

top of page

5/20/15 – MedPAC – Hospital Short-Stay Policy Issues

Statement of Mark E. Miller, Ph.D. before the Committee on Aging, U.S. Senate

Chairman Collins, Ranking Member McCaskill, distinguished Committee members. I am Mark Miller, executive director of the Medicare Payment Advisory Commission (MedPAC). The Commission appreciates the opportunity to discuss its recommendations on hospital short-stay policy issues.

Read More


top of page

5/14/15 – MedPAC – Improving Care for Medicare Beneficiaries with Chronic Conditions

Statement of Mark E. Miller, Ph.D. before the Committee on Finance, U.S. Senate

Chairman Hatch, Ranking Member Wyden, distinguished Committee members. I am Mark Miller, executive director of the Medicare Payment Advisory Commission (MedPAC). The Commission appreciates the opportunity to discuss improving care for Medicare beneficiaries with chronic conditions.

Read More


top of page

5/11/15 – The Detroit News – Patients Don’t Have to Trade Treatment for Comfort

By Robin Erb

His nurse works for Hospice of Michigan, but Frederick Tinsley is pretty clear: He has no intentions of dying yet. That's just fine. The retired metallurgy technician is part of a growing program by Hospice of Michigan that upends what most people think about hospice care.

Read More


top of page

5/9/15 – NAHC – Assume On-Demand, In-Home Services as the New Standard

A number of new technology driven business platforms are providing greater access to in-home services to disabled and seniors customers who expect to age-in-place at home, in their community.  From Amazon to Uber, these and other companies are entering markets where more traditional private duty home care services companies have been operating, and offering them new completion. “With a renewed focus on aging-in-place and the development of electronic care plans for long-term services and supports (eLTSS), the disable and elderly will benefit greatly from the expansion of these technology enabled in-home services,” stated Richard Brennan, Executive Director of the Home Care Technology Association of America.

Read More


top of page

5/8/15 – GAO – Medicaid: A Small Share of Enrollees Consistently Accounted for a Large Share of Expenditures

A small percentage of Medicaid-only enrollees—that is, those who were not also eligible for Medicare—consistently accounted for a large percentage of total Medicaid expenditures for Medicaid-only enrollees. In each fiscal year from 2009 through 2011, the most expensive 5 percent of Medicaid-only enrollees accounted for almost half of the expenditures for all Medicaid-only enrollees. In contrast, the least expensive 50 percent of Medicaid-only enrollees accounted for less than 8 percent of the expenditures for these enrollees.

Read More


top of page

5/8/15 – Kaiser Family Foundation – Corruption and Global Health: Summary of a Policy Roundtable

By Josh Michaud, Jennifer Kates and Stephanie Oum

Global health efforts, like all development programs, are vulnerable to corruption.  Corrupt acts, where and when they occur, can divert global health funding from its intended purpose and dilute the impact of programs aimed at preventing disease, treating illness, and saving lives. Corruption, though, has been hard to define and even harder to comprehensively track and understand.  While most recognize that corruption exists and can negatively impact development programs, including those of the U.S. government (USG), there are ongoing debates about the scope and impact of corruption and whether and how global health programs should address it.

Read More


top of page

4/30/15 – The Commonwealth Fund - Medicare: 50 Years of Ensuring Coverage and Care

By Karen Davis, Cathy Schoen, Farhan Bandeali

As Medicare prepares to mark its 50th anniversary in July 2015, there is a lot to celebrate. For 50 years, Medicare has accomplished its two key goals: ensure access to health care for its elderly and disabled beneficiaries, and protect them against the financial hardship of health care costs. Before Medicare, 48 percent of Americans 65 and older had no insurance; today, that figure is just 2 percent. Today, older Americans pay 13 percent of their health care expenses directly out-of-pocket, compared with 56 percent in 1966. By ensuring access to care, Medicare has contributed to a five-year increase in life expectancy at age 65. Medicare covers 55 million Americans, about 17 percent of the U.S. population. Its beneficiaries are the nation’s oldest, sickest, and most disabled citizens. Three-quarters of them have one or more chronic conditions, and one-quarter rate their health as fair or poor. Today nearly 30 percent of beneficiaries are either over age 85 or disabled and under age 65.

Read More

Click here to view the interactive timeline


top of page

4/29/15 – Reuters - Special Report: Banned from Medicare, Still Billing Medicaid

By M.B. Pell and Kristina Cooke - A doctor who took kickbacks from a Pennsylvania hospice involved in a multimillion-dollar fraud. An Ohio psychiatrist who billed for treating no-show patients. A Georgia optometrist who claimed he conducted 177 eye exams in one day.

Read More


top of page

4/27/15 – OIG - Medicaid Rebates For Brand-Name Drugs Exceeded Part D Rebates By A Substantial Margin

Drug rebates reduce the program costs of both Medicare Part D and Medicaid. Medicaid rebates are defined by statute and include additional rebates when prices for brand-name drugs increase faster than inflation. In contrast, Part D sponsors (or contractors acting on their behalf) negotiate rebates with drug manufacturers, and there are no statutory requirements regarding the amounts of these rebates. A 2011 Office of Inspector General (OIG) report found that statutorily defined Medicaid rebates for selected brand-name drugs exceeded Part D rebates by a substantial margin. The report also found that the inflation-based additional rebate, meant to protect Medicaid from large increases in drug prices, was the primary reason that Medicaid rebates were higher than Part D rebates. A Member of Congress requested an update to the previous OIG report. Specifically, the Member asked OIG to reexamine the prices and rebates under Part D and Medicaid, given the increase in Medicaid rebates under the Affordable Care Act, and to determine the proportion of rebate dollars attributed to inflation-based rebates under Medicaid.

Read More


top of page

4/23/15 – AHIP – New Report: Medigap Remains Vital Coverage for Rural, Low-Income Seniors

By Clare Krusing

Medigap continues to be an important source of health coverage for low- and moderate-income beneficiaries, especially those living in rural areas, according to a new report from America’s Health Insurance Plans (AHIP).

Read More

Click here to view the report


top of page

4/21/15 – OIG – Review of Medicare Contractor Information Security Program Evaluations for Fiscal Year 2013

Each Medicare contractor must have its information security program evaluated annually by an independent entity. These evaluations must address the eight major requirements enumerated in the Federal Information Security Management Act of 2002 (FISMA). The Social Security Act (the Act) also requires evaluations of the information security controls for a subset of systems but does not specify the criteria for these evaluations. The Inspector General, Department of Health and Human Services, must submit to Congress annual reports on the results of these evaluations, to include assessments of their scope and sufficiency. This report fulfills that responsibility for fiscal year (FY) 2013.

Read More


top of page

4/20/15 – McKnight’s - Social Security Numbers To Be Removed From Medicare Beneficiary Cards

By John Hall

After more than 10 years of warnings by government investigators, the Centers for Medicare & Medicaid Services now has a mandate to remove Social Security numbers from enrollees' cards — a practice identified as one of the top personal financial threats seniors face today. CMS states at the top of its own website, “Identity theft is a serious crime that happens when someone uses your personal information without your consent to commit fraud or other crimes.”

Read More


top of page

4/20/15 – Forbes - AARP's New Evidence That Medicare's Hospital Observation Rules Are a Mess

By Howard Gleckman

Of all the complex rules that plague fee-for-service Medicare, few are harder to understand and potentially more important for seniors than observation status. By now, many older adults have heard the phrase. But they are still not clear what it means.
A new study by AARP sheds some light on the consequences for seniors of hospital observation stays. But they turn out to be a muddle, in part because Medicare pays for hundreds of millions of dollars of skilled nursing facility care that probably should be billed to patients.
 
 

top of page

4/17/15 – MedPAC – Star Rating System for Medicare Home Health Agencies

CMS proposes to establish a star rating system to help consumers in comparing and selecting a home health provider.  The star rating system would grad agencies on a 10-point scale, starting with a half-star for the lowest rated agencies and increasing in half-star increments to five stars for the highest rated agencies.  

Read More


top of page

4/16/15 – MedPAC – Medicare Post-Acute Care Reforms

PAC providers include skilled nursing facilities (SNFs), home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs). PAC providers offer important recuperation and rehabilitation services to Medicare beneficiaries. In 2013, about 42 percent of Medicare beneficiaries discharged from prospective payment system (PPS) hospitals went to a PAC setting: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH.

Read More


top of page

4/13/15 – Kaiser Family Foundation - Medigap Enrollment Among New Medicare Beneficiaries

By Gretchen Jacobson, Tricia Neuman and Anthony Damico

Over the past several years, policymakers have considered a variety of proposals to discourage or prohibit people on Medicare from purchasing first-dollar supplemental insurance, often in the context of deficit and debt reduction efforts.  On March 26, 2015, the House of Representatives passed H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, which would replace the Sustainable Growth Rate (SGR) formula, among other changes; the bill is currently pending in the U.S. Senate.  H.R. 2 includes a provision that would prohibit Medicare supplemental insurance (Medigap) policies from covering the Part B deductible for people who become eligible for Medicare on or after January 1, 2020.

Read More


top of page

4/2015 - Quality Improvement Organizations – 2014 QIO Program Progress Report

As of August 1, 2014, CMS redesigned its Quality Improvement Organization (QIO) Program to further enhance the quality of services for Medicare beneficiaries. The new QIO Program structure follows a functional model with two types of QIOs: Quality Innovation Network-QIOs (QINQIOs) and Beneficiary and Family Centered Care-QIOs (BFCCQIOs). Fourteen regional QIN-QIOs work with providers, community partners and beneficiaries on multiple data-driven quality improvement initiatives to improve patient safety, reduce harm, engage patients and families, improve clinical care and reduce health care disparities. Two BFCC-QIOs manage all beneficiary complaints and appeals across the nation, ensuring that beneficiaries are treated fairly.

Read More

 

top of page

4/6/15 – McKnight’s – MedPAC Mulls Plan to Stop Covering Some “Low Value” Procedures

By John Hall

Congress' advisory panel for Medicare payment policy is considering a plan that would stop covering certain “low-value” procedures and tests because their return on investment isn't good enough. Such procedures are costing the program nearly $6 billion a year while yielding little benefit, panel members noted — the latest in a series of developments driving value-based purchasing across the continuum of care.

Read More


top of page

3/20/15 - Kaiser Family Foundation - Medicare’s Income-Related Premiums: A Data Note

By Juliette Cubanski and Tricia Neuman

A pressing debate in current Medicare policy circles is how to cover the cost of repealing and replacing Medicare’s Sustainable Growth Rate (SGR) formula for physician payments. As part of this discussion, some policymakers have proposed to increase Medicare premiums for higher-income beneficiaries—an idea that also has been raised in the context of proposals to reduce federal spending.1 Under current law, most Medicare beneficiaries pay the standard monthly premium, which is set to cover 25 percent of Part B and Part D program costs, while the relatively small share of beneficiaries (around 6 percent in 2015) with incomes above $85,000 for single people and $170,000 for married couples are required to pay higher premiums for Medicare Part B and Part D—ranging from 35 percent to 80 percent of program costs, depending on their incomes.

Read More


top of page

3/20/15 – Kaiser Family Foundation - A Primer on Medicare: Key Facts About the Medicare Program and the People it Covers

By Juliette Cubanski, Christina Swoope, Cristina Boccuti, Gretchen Jacobson, Giselle Casillas, Shannon Griffin and Tricia Neuman

July 30, 2015 marks the 50th anniversary of the date in 1965 that President Lyndon Johnson signed the law establishing the Medicare program. Medicare is a social insurance program that helps to provide health and financial security for people ages 65 and older and younger people with permanent disabilities. Prior to 1965, roughly half of all seniors lacked medical insurance; today, virtually all seniors have health insurance under Medicare. Since Medicare’s beginning, a number of changes have been made to expand benefits, revise the way Medicare pays providers, modify beneficiary out-of-pocket costs for Medicare-covered services, improve access and coverage for low-income individuals, expand the role of private plans in providing Medicare-covered benefits, strengthen quality, and address the growth in program spending.

Read More


top of page

3/19/15 – Kaiser Family Foundation - Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations

By David Lipschutz, Andrea Callow, Karen Pollitz, MaryBeth Musumeci and Gretchen Jacobson

Private plans that provide health coverage to people with Medicare or Medicaid, and in the new Marketplaces collectively serve more than 70 million Americans as of January 2015 – and the numbers are on the rise.1 These plans – Medicare Advantage plans, Qualified Health Plans (QHPs) and Medicaid Managed Care Organizations (MCOs) – operate under rules established by the federal government, many of which are designed to ensure that enrollees have access to coverage and the full scope of benefits and providers to which they are entitled. The rules for plans in each of the three markets differ, even though each market is overseen and regulated, to some degree, by the same federal agency, the Centers for Medicare and Medicaid Services (CMS).

Read More


top of page

3/18/15 – AJMC - Is the Medicare Bundled Payments for Care Improvement Initiative Designed to Succeed?

By Lane Koenig, PhD; Julia Doherty, MHSA; Richard C. Mather III, MD, MBA; Jennifer Nguyen, BA; and Sheila Sankaran, MA

CMS recently announced that more than 6500 Medicare providers had signed up to participate in its pilot program to test bundled payments—an arrangement in which a single payment is established to cover some or all of the services delivered during an episode of care.1 With that many participants, the Bundled Payments for Care Improvement (BPCI) Initiative is one of the largest demonstrations in Medicare history. To policy makers and health policy experts, bundled payments are an attractive alternative to current Medicare fee-for-service payment approaches in that they encourage more coordination among providers, which can lead to cost efficiencies. The Medicare Participating Heart Bypass Center Demonstration, conducted from 1991 through 1996, resulted in savings of approximately 10%.

Read More


top of page

3/16/15 - OIG – Compendium of Unimplemented Recommendations

This document, entitled the Compendium of Unimplemented Recommendations (Compendium), is a core publication of the Department of Health and Human Services (HHS) Office of Inspector General (OIG). With this edition, we focus on the top 25 unimplemented recommendations that, on the basis of OIG’s professional opinion, would most positively impact HHS programs in terms of cost savings and/or quality improvements and should, therefore, be prioritized for implementation. The recommendations come from OIG audits and evaluations, performed pursuant to the Inspector General Act of 1978, as amended. The Appendix of the Compendium includes a comprehensive list of OIG’s significant unimplemented recommendations, including the top 25 unimplemented recommendations as well as other open recommendations that are not in the top 25 list.

Read More


top of page

3/13/15 – MedPAC – Report to the Congress March 2015

The Medicare Payment Advisory Commission (MedPAC) is required by law to annually review Medicare payment policies and make recommendations to the Congress. The 2015 report includes payment policy recommendations for ten of the health care provider sectors in fee-for-service (FFS) Medicare. MedPAC also reviews the status of Medicare Advantage (MA) plans and Medicare’s prescription drug plans (Part D).

Click here to view the fact sheet

Click here to view the news release

Click here to view the full report


top of page

3/12/15 – The Commonwealth Fund - Solving the Sustainable Growth Rate Formula Conundrum Continues Steps Toward Cost Savings and Care Improvement

By James D. Reschovsky, Larisa Converse and Eugene C. Rich

Congress is considering legislation that would replace Medicare’s current payment formula with one that rewards physicians and other providers for delivering high-value care. The new approach would increase payments for providers who outperform their peers on cost and quality measures, as well as those who participate in alternative payment models that encourage more coordinated, efficient care. In this Commonwealth Fund–supported article in Health Affairs, James D. Reschovsky and colleagues at Mathematica Policy Research describe key features of the proposed payment methodology, assess its strengths and weaknesses, and make recommendations for refining it.

Read More


top of page

3/12/15 – Oliver Wyman – Maps and Charts: Analysis of Estimated Impacted of Proposed Reductions to Medicare Advantage Organizations between 2013-2016

By Glenn Giese

On Friday, February 20, 2015, the Centers for Medicare & Medicaid Services (CMS) released their Advance Notice of Methodological Changes for Calendar Year 2016 Medicare Advantage (“MA”) Capitation Rates and Part C and Part D Payment Policies. The Notice calls for 2016 reductions to Medicare Advantage Organizations (“MAOs”) of 1.2%. Coupled with the payment reductions of 4.0% in 2014 and 5.2% in 2015, indications are that these payment reductions are having an adverse effect on MAOs and Medicare beneficiaries.

Read More


top of page

3/9/15 – Integrated Care Resource Center – State Contracting with Medicare Advantage Dual Eligible Special Needs Plans: Issues and Options

By James Verdier, Alexandra Kruse, Rebecca Sweetland Lester, Ann Mary Philip, and Danielle Chelminsky

Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan that serve beneficiaries dually enrolled in Medicare and Medicaid. To operate in a state, D-SNPs must have a contract with the state to facilitate coordination of Medicare and Medicaid services for enrollees, although states are not required to enter into such contracts. This technical assistance tool is based on an analysis of D-SNP contracts in 12 states, including states that have made the most extensive use of D-SNP contracting by linking D-SNPs to Medicaid managed long-term services and supports (MLTSS) programs that include the main services that Medicaid covers for Medicare-Medicaid enrollees. This tool summarizes how these states have developed those linkages, and describes the specific care coordination and information-sharing requirements that the states have included in their D-SNP contracts. The D-SNP contracting approaches used by this diverse group of 12 states can provide guidance and examples for states that have varying opportunities and resources for D-SNP contracting, including states that choose not to contract w ith D-SNPs.
 

top of page

3/9/15 – Kaiser Health News - Obamacare, Private Medicare Plans Must Keep Updated Doctor Directories In 2016

By Susan Jaffe

Starting next year, the federal government will require health insurers to give millions of Americans enrolled in  Medicare Advantage plans or in policies sold in the federally run health exchange up-to-date details about which doctors are in their plans and taking new patients. Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year. Networks can also vary among plans offered by the same insurer. So it’s not always easy to figure out who’s in and who’s out, and many consumers have complained that their health coverage doesn’t amount to much if they can’t find doctors who accept their insurance.

Read More


top of page

2/27/15 – The Lewin Group – CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4: Year 1 Evaluation & Monitoring Annual Report

By Laura Dummit, Grecia Marrufo, Jaclyn Marshall, Aylin Bradley, Laura Smith, Cornelia Hall, Youn Lee, Jon Kelly, Megan Hyland, Rebecca Cherry, Adaeze Akamigbo, Court Melin, and Ellen Tan

The Bundled Payments for Care Improvement (BPCI) initiative is designed to test whether bundled payments can reduce Medicare’s costs while maintaining or improving the quality of care. The three-year initiative (which may be extended by up to two years) links payments for services related to an episode of care that is triggered by a hospitalization. BPCI participants may benefit financially from providing services in the bundle more efficiently and are at risk if their costs for the bundle are higher than a historical benchmark. The Lewin Group, with its partners, Abt Associates, Inc., GDIT, Telligen, and Optum, is under contract to the Centers for Medicare & Medicaid Services (CMS) to evaluate and monitor Models 2, 3, and 4 of the BPCI initiative. This is the first Annual Report, which synthesizes the findings from various evaluation and monitoring activities under the contract.

Read More


top of page

2/25/15 - Oliver Wyman - 2016 Advance Notice: Changes to Medicare Advantage Payment Methodology and the Potential Effect on Medicare Advantage Organizations and Beneficiaries

The Centers for Medicare & Medicaid Services (CMS) released the Advance Notice of Methodological Changes for Calendar Year 2016 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies (the 2016 Advance Notice) on February 20, 2015. This notice outlines the planned changes to Medicare Advantage (MA) capitation rates applied under Part C for CY 2016 and other regulatory changes that will affect plan reimbursement. Based on information released in the 2016 Advance Notice and reductions already being implemented by the Affordable Care Act (ACA), Medicare Advantage Organizations (MAOs) are likely to experience additional payment reductions for 2016. Such reductions, coupled with the reductions experienced in 2014 and 2015, would have a significant impact on the sustainability of MAO program participation and the ability of MAOs to provide stable benefits and beneficiary premiums to their members.
 

 


top of page

2/19/15 – Kaiser Health News - In The Medicare Bonus Round, The Winners Are…Small, Specialty Hospitals!

By Michael Tomsic, WFAE - In Medical Park hospital in Winston-Salem, North Carolina, Angela Koons is still a little loopy and uncomfortable after wrist surgery. Nurse Suzanne Cammer jokes around with her. When Koons says she’s itchy under her cast, Cammer laughs and says, “Do not stick anything down there to scratch it!”  Koons smiles and says, “I know.” Cammer is wearing charm-bracelets and jangly earrings, so she literally jingles as she works around Koons. Her enthusiasm for her job puts Koons at ease and is making her hospital stay more comfortable. “They’ve been really nice, very efficient. Gave me plenty of blankets because it’s really cold in this place,” she says.

Read More


top of page

2/13/15 – McKnight’s - Medicare, Medicaid Stay On 'High Risk' List

Medicare overpayment issues and poor Medicaid data are two of many problems keeping long-term care's biggest payers on a government watch list of “high-risk” programs, according to a new General Accountability Office report. Improvement will come only through much improved management and oversight, the GAO said. For Medicare, for example, that means improvements in beneficiary use of services and quality of care, and physician incentive payments and profiling. According to GAO researchers, Medicare reported an estimated $60 billion in improper payments in 2014.

Read More

Click here to read the GAO report


top of page

2/12/15 – Federal Register - Medicare Program; Contract Year 2016 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs

This final rule amends the Medicare Advantage (MA) program (Part C) regulations and Medicare Prescription Drug Benefit Program (Part D) regulations to implement statutory requirements; improve program efficiencies; strengthen beneficiary protections; clarify program requirements; improve payment accuracy; and make various technical changes. Additionally, this rule finalizes two technical changes that reinstate previously approved but erroneously removed regulation text sections.

Click here to read the full rule


top of page

2/12/15 – MDCH - Pharmacy Service Changes to Upcoming Michigan Managed Care Request for Proposal

The Michigan Department of Community Health (MDCH) today announced changes in the new upcoming request for proposal (RFP) for the Comprehensive Health Plan Contract for Michigan’s Medicaid Health Plans. The Comprehensive Health Plan Contract provides health care services to Michigan’s Medicaid managed care beneficiaries, and is being rebid during fiscal year 2015 for new contracts beginning in fiscal year 2016. 

Read More


top of page

2/3/15 – Kaiser Family Foundation - Summary of Medicare Provisions in the President’s Budget for Fiscal Year 2016

By Gretchen Jacobson, Cristina Boccuti, Juliette Cubanski, Christina Swoope and Tricia Neuman

On February 2, 2015, the Office of Management and Budget released President Obama’s budget for fiscal year (FY) 2016, which includes provisions related to Medicare. The President’s budget proposal would use federal savings and revenues to reduce the deficit, replace sequestration of Medicare and other federal programs for 2016 through 2025, and pay for new spending priorities. The President’s FY2016 budget proposal would reduce net Medicare spending by $423 billion between 2016 and 2025, and is estimated to extend the solvency of the Medicare Hospital Insurance Trust Fund by approximately five years.

Read More

Click here to view the Budget of the United States Government Fiscal Year 2016


top of page

1/28/15 – The New England Journal of Medicine - Medicare at 50 – Moving Forward

By David Blumenthal, M.D., M.P.P, Karen Davis, Ph.D., and Stuart Guterman, M.A.

As Medicare enters its 50th year, this popular federal program faces profound challenges to its effectiveness and sustainability in future decades. In this report, we review these problems, building on the issues raised in our earlier article. We also review several options to strengthen the program and enhance its viability.

Read More


top of page

1/20/15 – The Detroit News - Groups Split On Merging State Social Services Agencies

By Chad Livengood

Groups interested in social services were split Tuesday after Gov. Rick Snyder announced he plans to combine two huge state departments with a combined total of nearly 14,000 employees and budgets totaling more than $21 billion. Under the executive order, the departments of Community Health and Human Services will become the Department of Health and Human Services, making it the state's largest agency, Snyder said. His merger of the two departments in a few weeks will constitute the biggest state government shakeup since former Gov. John Engler reorganized Community Health and the administration of the Medicaid health care program for low-income residents in 1996.

Read More


top of page

1/20/15 – MedPage Today - MedPAC Endorses Per-Beneficiary Primary Care Bonus - Change would be another step away from fee-for-service

By Shannon Firth

The Medicare Payment Advisory Commission (MedPAC) has unanimously recommended a revised primary care bonus that would be paid on a per-beneficiary basis. Commission members have long argued that primary care providers are undervalued by Medicare's fee schedule, often paid half of what specialists earn. The current primary care 10% bonus, slated to expire at the end of 2015, is paid on a fee-for-service basis, but if Congress agrees to enact a proposed change, the new bonus would be paid prospectively per beneficiary "at the level of the current bonus." Patients would not have any cost-sharing responsibilities. The program would be financed by reducing fees outside of Primary Care Incentive Programs (PCIPs), such as those for procedures, imaging, and tests, by 1.4%.

Read More


top of page

1/16/15 – Associated Press - Medicare Chief Steps Down, Ran Health Care Rollout

By Ricardo Alonso-Zaldivar – Medicare's top administrator unexpectedly resigned Friday, becoming the latest casualty in the turmoil over the president's health care law, which is still struggling for acceptance even as millions benefit from expanded coverage.  Marilyn Tavenner's departure underscores the uncertainty overshadowing President Barack Obama's health care law nearly five years after its party-line passage by a then-Democratic-led Congress. The Supreme Court will hear a challenge to the legality of the law's financial subsidies this spring, and a new Republican Congress is preparing more repeal votes.

Read More


top of page

1/14/15 – Health Affairs – Medicare Per Capita Spending By Age And Service: New Data Highlights Oldest Beneficiaries

By Patricia Neuman, Juliette Cubanski, and Anthony Damico

Medicare per capita spending for beneficiaries with traditional Medicare over age 65 peaks among beneficiaries in their mid-90s and then declines, and it varies by type of service with advancing age. Between 2000 and 2011 the peak age for Medicare per capita spending increased from 92 to 96. In contrast, among decedents, Medicare per capita spending declines with age.  As the US population ages and more people on Medicare live into their 80s, 90s, and beyond, analysts and policy makers are examining the impact of these trends on the federal budget and the Medicare program. At the same time, geriatricians and other providers who care for older patients are paying greater attention to the question of how best to meet the needs of an aging population. By 2050 the number of people on Medicare ages 80 and older will nearly triple; the number of people in their 90s and 100s will quadruple.

Read More


top of page

1/12/15 - Associated Press - Medicare Aims To Improve Coordinating Seniors' Chronic Care

By Lauran Neergaard

Adjusting medications before someone gets sick enough to visit the doctor. Updating outside specialists so one doctor's prescription doesn't interfere with another's.
Starting this month, Medicare will pay primary care doctors a monthly fee to better coordinate care for the most vulnerable seniors — those with multiple chronic illnesses — even if they don't have a face-to-face exam. The goal is to help patients stay healthier between doctor visits, and avoid pricey hospitals and nursing homes. "We all need care coordination. Medicare patients need it more than ever," said Sean Cavanaugh, deputy administrator at the Centers for Medicare and Medicaid Services.
 

top of page

1/6/15 - Kaiser Family Foundation - Visualizing Health Policy: Medicare Spending: A Look at Present, Short-Term and Long-Term Trends

This Visualizing Health Policy infographic provides an overview of Medicare spending, including information on current federal spending relative to other government programs (e.g., Social Security) and percent-share of spending across Medicare services, as well as projected Medicare spending over the next decade and beyond. Recent federal spending on Medicare is about a third of Defense and Social Security spending combined. In the short term, Medicare spending per person is expected to be lower relative to previous projections and to grow more slowly than private health insurance. In the long term, Medicare spending as a share of the economy is projected to grow, and Medicare is projected to lack sufficient funds to pay all hospital bills beginning in 2030.

Read More


top of page

1/5/15 - MedPAC – Comment On The CMS “List of Measures Under Consideration For December 1, 2014”

The Medicare Payment Advisory Commission welcomes the opportunity to comment on the Centers for Medicare & Medicaid Services (CMS) “List of Measures under Consideration for December 1, 2014,” issued by the agency to comply with section 1890A(a)(2) of the Social Security Act, which requires the Department of Health and Human Services (HHS) to make publicly available, no later than December 1 of each year, a list of certain categories of quality and efficiency measures that it is considering for adoption through rulemaking for the Medicare program. We appreciate your staff’s ongoing efforts to administer and improve quality and resource use measurement systems for the complex Medicare program, particularly considering all of the competing demands on the agency.

Read More


top of page

1/5/15 – Health Affairs - Variations in County Level Costs Between Traditional Medicare and Medicare Advantage Have Implications for Premium Support

By Brian Biles, Giselle Casillas and Stuart Guterman

Concern about the future growth of Medicare spending has led some in Congress and elsewhere to promote converting Medicare to a “premium support” system. Under premium support, Medicare would provide a “defined contribution” to each Medicare beneficiary to purchase either a Medicare Advantage (MA)–type private health plan or the traditional Medicare public plan. To better understand the implications of such a shift, we compared the average costs per beneficiary of providing Medicare benefits at the county level for traditional Medicare and four types of MA plans. We found that the relative costs of Medicare Advantage and traditional Medicare varied greatly by MA plan type and by geographic location. The costs of health maintenance organization–type plans averaged 7 percent less than those of traditional Medicare, but the costs of the more loosely structured preferred provider organization and private fee-for-service plans averaged 12–18 percent more than those of traditional Medicare. 

Read More


top of page

12/17/14 – Kaiser Family Foundation - How Much of the Medicare Spending Slowdown Can be Explained? Insights and Analysis from 2014

By Chapin White, Juliette Cubanski and Tricia Neuman

Analysts have warned federal policy makers for many years that long-term growth in spending on health care threatens to upend the federal budget and consume an unsustainable share of the nation’s economy.1 Medicare is by far the largest federal health program in terms of spending,2 and, historically, spending growth in the program has been driven by persistent increases in enrollees and spending per enrollee. Because Medicare has accounted for a rising share of the federal budget and the nation’s economy, concerns about Medicare spending growth have prompted a steady stream of proposals for major changes to the program, such as increasing the age of eligibility, restructuring Medicare’s benefit design, or shifting the program to a defined contribution arrangement. Against this backdrop, a seemingly incongruous storyline has emerged in recent years: Medicare spending growth of late has been remarkably low relative to historical norms. Annual growth in aggregate spending has averaged just over 3 percent since 2009, despite rapid enrollment growth due to the aging of the “baby boom” generation. 

Read More


top of page

12/16/14 – McKnight’s - Congress Leaves Medicare And Medicaid Untouched In $1.1 Trillion Spending Bill

By Tim Mullaney

The $1.1 trillion spending bill passed by the Senate on Saturday will fund the government through September 2015, without any major changes to Medicare or Medicaid. The measure abides by limits set in a December 2013 budget deal worked out by Sen. Patty Murray (D-WA) and Rep. Paul Ryan (R-WI). That deal lifted most of the spending reductions caused by sequestration, but left in place a 2% cut to Medicare provider reimbursements. These cuts currently are scheduled to be phased out by the end of 2023. The latest spending bill does not call for any significant changes to Medicare or Medicaid. However, it will allow benefits to be cut for retirees on certain large pension plans. Some of these plans are in bad financial shape, and failures could bankrupt the government's pension safety net, according to the Wall Street Journal.

Read More


top of page

12/10/14 – Kaiser Family Foundation - Medicare Advantage 2015 Data Spotlight: Overview of Plan Changes

By Gretchen Jacobson, Anthony Damico, Tricia Neuman and Marsha Gold

In 2014, more than 16 million Medicare beneficiaries (30%) were enrolled in Medicare Advantage plans – private plans, such as HMOs or preferred provider organization (PPOs) that receive funds from the federal government (Medicare) to provide Medicare-covered benefits to enrollees. Under the current Medicare program, Medicare Advantage plans are offered as an alternative to the traditional Medicare fee-for-service program, and Medicare beneficiaries can enroll in a Medicare Advantage plan, change Medicare Advantage plans, or switch from Medicare Advantage to traditional Medicare during the annual open enrollment period. Federal payments to Medicare Advantage plans were gradually reduced by the Affordable Care Act of 2010 (ACA) with the goal of creating greater parity in payments between the traditional Medicare program and Medicare Advantage by 2017. Beneficiaries will be able to choose from 18 Medicare Advantage plans, on average, in 2015, the same number of plans as in 2014. 

Read More


top of page

12/9/14 – MedPAC – Context for Medicare Payment Policy and Recommendations

By Mark E. Miller, Ph.D.

The Commission’s goal is to achieve a Medicare program that ensures beneficiary access to high-quality care, pays health care providers fairly, rewards efficiency and quality, and spends tax dollars responsibly. When we examine Medicare’s payment policies across payment models and across different sites of care, we observe several opportunities for policy development. In the testimony that follows, I will first summarize the context for Medicare payment policy in terms of health care spending growth and its impact on beneficiaries, tax payers, and the federal budget. Second, I will discuss the short-run policies the Commission has advanced to improve the Medicare program, both through changes to the level and structure of payments to providers and health plans, and through changes to the incentives faced by Medicare beneficiaries. Last, I will outline the Commission’s longer run vision for the Medicare program, to align policies across Medicare’s different payment models.

Read More


top of page

12/4/14 – Crain’s Detroit Business - Doctors See Potential Revenue Boost Under Medicare Changes, Telehealth

By Jay Greene

Primary care physicians stand to earn additional revenue starting Jan. 1 under Medicare's new fee schedule for care coordination of chronically ill patients and for using certain telehealth services. To bill for the $40.40 per member per month fee, physicians must offer some type of 24/7 access, a minimum of 20 minutes per month of clinical team time, a creation of care plan, coordinate community-based services and agree to manage hospital, emergency department and home care services. Several doctors in metro Detroit interviewed by Crain's believe some provisions of the 2015 Medicare fee schedule — that also includes expansion of billable telehealth services — have the potential to add to practice revenue and improve continuity of care.

Read More


top of page

12/3/14 – The Wall Street Journal - New Medicare Rules Aim to Reduce Abuse

Agency Can More Easily Ban Providers Suspected of Suspicious Billing; Some Worry About Impact of Innocent Errors

By Janet Adamy - The Obama administration on Wednesday strengthened Medicare’s authority to kick doctors and other medical providers out of the federal program for abusively billing the government. The move represents a significant shift in how the government tackles waste in Medicare, the insurance program for the elderly and disabled. The Centers for Medicare and Medicaid Services estimates that for the fiscal year ended Sept. 30, the main part of Medicare issued $45.8 billion in improper payments, representing nearly 13% of its total spending. The new rules allow Medicare to revoke the billing privileges of any doctor, medical-equipment seller or other health-service provider who demonstrates a pattern of billing the program inappropriately. Under the current system, Medicare is often slow to kick out bad actors because it first must undertake lengthy, expensive audits and claims reviews. Other times, it can’t ban such providers because it lacks the authority, agency officials say.

Read More


top of page

12/2/14 – USA Today - Medicare House Calls On Rise In Michigan -- So Is Fraud

By Meghan Hoyer

Medicare spending on doctors who make house calls rose to $236 million in 2012 — a 40% increase since 2006. But the effort to help aging patients with limited mobility get medical care has been riddled with fraud due to lax regulations in some areas of the U.S. Nowhere is this more pronounced than in Michigan, where nearly a fifth of all the spending on Medicare home visits nationwide takes place. In 2012, physicians in Michigan received Medicare funds for home visits equal to 42 other states combined, a USA TODAY data analysis reveals. The result: more than $60 million in fraudulent billing by Michigan doctors in the past few years. Advocates say demand for home-visit services has skyrocketed nationally as a generation of seniors ages in place, and that Michigan's payments have boomed because it is home to several major visiting-physician businesses. Recent studies suggest that home visits, where doctors examine patients and perform tests, can reduce the likelihood of repeat hospital stays and drive down overall Medicare costs. 

Read More


top of page

11/24/14 – Modern Healthcare - Unreported GPO Fees May Cause Medicare To Overpay Hospitals

By Jaimy Lee

A government watchdog wants to know if hospitals accurately report revenue they receive from group purchasing organizations, a question that may have broader implications for the federal safe harbor that allows GPOs to earn and distribute such administrative fees. The Government Accountability Office on Monday released a highly anticipated report (PDF) on GPOs that found HHS' Office of the Inspector General does not routinely assess whether fees from GPOs to hospitals are accounted for on Medicare cost reports, which are used to help set hospital payment rates for Medicare. “To the extent that administrative fee revenue is not reflected on cost reports, Medicare could be overpaying hospitals,” the GAO said. GPOs are allowed to operate under a safe harbor of the anti-kickback statute because they are expected to help hospitals negotiate better prices on medical supplies, yielding lower Medicare costs.
 

top of page

11/22/14 – Modern Healthcare - Were patients really sicker? Lawsuits say Medicare Advantage plans inflated diagnoses to boost payments

By Lisa Schencker

For an 82-year-old man with diabetes and rheumatoid arthritis, the CMS will pay a Medicare Advantage plan a certain amount of money each month. Add renal failure and hemiplegia to the list of maladies, and the CMS' monthly payment to his plan skyrockets. It could mean $2,282 a month versus $1,149, experts say. The CMS pays private Medicare Advantage plans under a severity-adjusted model designed to give insurers a financial incentive to take sicker enrollees. But critics, including HHS' Office of the Inspector General, say the severity-adjusted payment model is being abused by some plans and providers, costing taxpayers billions annually. A few federal whistle-blower cases filed under the False Claims Act have become public, with more thought to be in the pipeline. The lawsuits allege that providers and Advantage plans, some operated by the nation's largest insurers, have defrauded the Medicare program by manipulating Advantage members' medical data to make the members appear sicker than they were to get higher capitation payments.
 

top of page

11/18/14 – OIG - Fighting Waste and Fraud and Promoting Value in Medicare Parts A and B 

To secure the future of health care for Medicare beneficiaries, the Department must be vigilant in reducing wasteful spending and promoting better health outcomes at lower costs. The Institute of Medicine estimated that 30 percent of U.S. health spending (public and private) in 2009—roughly $750 billion—was wasted. Waste in health care programs is a multi-dimensional problem. Key areas of focus for reducing waste in Medicare Parts A and B include reducing improper payments, fighting fraud, fostering economical payment policies, and transitioning from volume to value in health care. HHS faces challenges—and opportunities—in each of these areas.
Reducing Improper Payments. CMS reported an error rate of 10.1 percent for Medicare fee for service (Parts A and B), corresponding to an estimated $36 billion in improper payments in FY 2013. 
 

top of page

11/10/14 – The Wall Street Journal - Doctors Cash In on Drug Tests for Seniors, and Medicare Pays the Bill

Pain specialists order costly tests for illegal drugs such as cocaine and angel dust, which few seniors ever use

By Christopher Weaver and Anna Wilde Mathews 

Doctors are testing seniors for drugs such as heroin, cocaine and “angel dust” at soaring rates, and Medicare is paying the bill. It is a roundabout result of the war on pain-pill addiction. Medical guidelines encourage doctors who treat pain to test their patients, to make sure they are neither abusing pills nor failing to take them, possibly to sell them. Now, some pain doctors are making more from testing than from treating. Spending on the tests took off after Medicare cracked down on what appeared to be abusive billing for simple urine tests. Some doctors moved on to high-tech testing methods, for which billing wasn’t limited. They started testing for a host of different drugs—including illegal ones that few seniors ever use—and billing the federal health program for the elderly and disabled separately for each substance. Medicare’s spending on 22 high-tech tests for drugs of abuse hit $445 million in 2012, up 1,423% in five years.
 

top of page

11/10/14 – The New York Times - Medicare Proposes Paying for Lung Cancer Screenings for Older Longtime Smokers

By Sabrina Tavernise

Medicare will cover annual screenings for lung cancer for older Americans with long histories of heavy smoking, the federal government said Monday in a proposal that would cover an estimated four million people, many of whom are at greatest risk for the disease. Monday’s draft decision by the Centers for Medicare and Medicaid Services would extend coverage for CT scans to Medicare beneficiaries who smoked at least a pack a day for 30 years or the equivalent, even if they quit as long as 15 years ago. Scans would cost recipients nothing; the coverage would apply to beneficiaries through age 74. The proposal follows a more sweeping recommendation last year by an influential government health panel that such smokers ages 55 to 80 get annual screenings, a policy shift that experts said had the potential to save 20,000 lives a year. That recommendation focused on current and former smokers at highest risk, a population of about 10 million Americans.
 

top of page

11/7/14 – The Washington Post - How to keep Medicare costs down? Help the sickest.

By Jeff Guo

Most of the nation’s medical costs come from a small fraction of very sick patients, so one way to tamp down on health-care spending is to look at who’s racking up the biggest bills. In 2012, the top 5 percent of patients accounted for half of all health-care spending. Less than 3 percent of costs came from the bottom 50 percent, who remained relatively healthy. The story is the same for Medicare. The Congressional Budget Office estimated that the top 5 percent of Medicare patients represented 43 percent of expenditures in 2001. On average, these patients cost the system $63,000 a year — while the median patient cost Medicare only $1,620. For years, Medicare has looked for ways to save on high cost patients. First, who are they? When the CBO compared Medicare patients in the top 25 percent and the bottom 25 percent, there didn’t seem to be any big demographic differences. The high-cost and low-cost patients were about the same age, about as likely to be female or black.
 

top of page

11/6/14 – Kaiser Family Foundation - What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?

By Marsha Gold and Giselle Casillas 

While the majority of Medicare beneficiaries still receive their benefits through the traditional Medicare program, 30 percent now obtain them through private health plans participating in Medicare Advantage. As the number of Medicare Advantage enrollees continues to climb, there is growing interest in understanding how the care provided to Medicare beneficiaries in Medicare Advantage plans differs from the care received by beneficiaries in traditional Medicare. Despite the interest, the last comprehensive review of research evidence on health care access and quality in Medicare Advantage and traditional Medicare is more than 10 years old and did not focus exclusively on Medicare (Miller and Luft 2002). That study found that health maintenance organizations (HMOs) provide care that is roughly comparable in quality to the care provided by non-HMOs (mainly traditional indemnity insurance), and that quality varied across health plans. It also found that HMOs used somewhat fewer hospital and other expensive resources in delivering care, with enrollees rating them worse on many measures of access and satisfaction.
 

top of page

11/3/14 – The Center for Public Integrity - More scrutiny coming for Medicare Advantage, Obamacare

HHS inspector general announces new round of fraud audits

By Fred Schulte

Federal officials are planning a wide range of audits into billing and government spending on managed health care in the new fiscal year, ranging from private Medicare Advantage groups that treat millions of elderly to health plans rapidly expanding under the Affordable Care Act.
The Health and Human Services Office of Inspector General, which investigates Medicare and Medicaid waste, fraud and abuse, said it would conduct “various reviews” of Medicare Advantage billing practices with an eye toward curbing overcharges. Results are due next year. The Inspector General also announced from five to ten new audits into Obamacare, ranging from the accuracy of “financial assistance” payments for new enrollees to controls to prevent fraudulent sign ups. The Inspector General’s office did not say if individual Medicare Advantage plans would be audited, but indicated it would focus on concerns that some health plans exaggerate how their sick patients are to overcharge the government — the subject of a recent Center investigation.
 

top of page

10/29/14 – The Wall Street Journal - Insider-Trading Probe Focuses on Medicare Agency

SEC Investigates Whether CMS Employees Leaked News 

By Brody Mullins, Susan Pulliam and Christopher Weaver

The day Medicare officials began discussing whether to set new coverage limits on a costly new prostate-cancer treatment, the official in charge emailed three colleagues to put a “close hold” on the process. That meant: Keep quiet until an announcement later that month. Yet by the end of that same day, June 7, 2010, shares of the company that made the treatment, Dendreon Corp. , had plunged 10%. Before long, federal investigators took notice. Today, the trading in Dendreon around that time is at the center of one of three federal probes exploring whether employees of the Centers for Medicare and Medicaid Services, the agency that oversees billions in health spending, have leaked news that ended up in the hands of Wall Street traders, according to people with direct knowledge of the investigations.
 

top of page

10/26/14 – The Washington Post - ALS Patients Face Loss Of Medicare Coverage For Devices Used To Help Speech

By Shefali Luthra 

Starting Dec. 1, people with ALS — a disease that impairs motor function so people often can’t talk or even move — could lose access to technological advances that help them communicate, a change that is the result of a federal review of what Medicare can cover. ALS, or amyotrophic lateral sclerosis, drew national attention this summer with the viral “ice bucket challenge.” But while public awareness about the disease soared, Medicare changes that could curtail coverage of communication tools were — by “sheer dumb luck” — already in the works, said Kathleen Holt, associate director at the Center for Medicare Advocacy. Patient advocates have begun shoring up arguments to push back against the impending change, Holt said.
 

top of page

10/23/14 – Kaiser Family Foundation - What’s In and What’s Out? Medicare Advantage Market Entries and Exits for 2015 

By Gretchen Jacobson, Tricia Neuman and Anthony Damico

During the debate over the Affordable Care Act (ACA), some questioned whether the Medicare Advantage market would shrink in response to the reductions in payments to Medicare Advantage plans included in the ACA, expressing concern that plans would exit markets across the country, leading to a drop in enrollment, similar to what occurred after the Balanced Budget Act of 1997 (BBA97).  Since 2010, enrollment has far exceeded expectations, increasing by nearly 5 million beneficiaries, continuing a steady upward climb that started a decade ago. Between 2010 and 2014, the total number of plans has declined modestly, but beneficiaries in 2014 still had the option to choose among 18 Medicare Advantage plans, on average. Medicare Advantage plans enter and exit markets for a number of reasons related to business strategies, local market conditions, and profitability.
 

top of page

10/23/14 – Kaiser Family Foundation - Open Enrollment: Insights from Medicare for Health Insurance Marketplaces

By Tricia Neuman

As the November open enrollment period approaches, consumers in the federal and state marketplaces will soon have the opportunity to renew or change health plans for 2015. Health insurance plans often change from one year to the next, and some of these changes could have a real impact on costs and coverage, including changes in premiums, cost-sharing, benefits, formularies and choice of doctors and hospitals. Consumers are advised to review their options carefully before deciding whether to renew their current plan or enroll in a new one. But will they? This question will sound familiar to those who have been tracking the Medicare Part D and Medicare Advantage markets, and based on this experience, the advice to review plan options makes good sense. 
 

top of page

10/22/14 – The Wall Street Journal - How Medicare ‘Self-Referral’ Thrives On Loophole

A Florida Medical Group’s Urologist Send Tests to Lab, Share in Lab’s Revenue

By John Carreyrou and Janet Adamy

In a letter to a friend, the manager of a Florida urology practice worried in 2010 that her company would attract federal scrutiny for its frequent use of an expensive bladder-cancer test. The manager’s concern involved a program at 21st Century Oncology Holdings Inc.—a national chain of cancer practices—that gives its urologists a financial incentive to order the test from a central in-house lab. A federal law since the 1990s has prohibited “self-referral,” in which doctors can profit from Medicare-reimbursed procedures they order. But 21st Century Oncology and many physician groups around the country have found ways to do it anyway, exploiting an exception to the law in ways its writers didn’t anticipate. The manager attached an email from a 21st Century Oncology executive who touted an increase in the number of tests ordered through the central lab, and encouraged doctors in her office to direct business to the lab and share in the revenue. The surge in orders for the bladder-cancer test was so sharp, she wrote to her friend, that it would “surely bring the OIG to our door!”
 

top of page

10/17/14 – MedPAC - New from MedPAC: 2014 Payment Basics Series 

MedPAC announces the release of the updated 2014 Medicare Payment Basics series. The documents in the series provide an overview of 18 payment systems.
 

top of page

10/12/14 – The New York Times - U.S. Finds Many Failures in Medicare Health Plans

By Robert Pear

Federal officials say they have repeatedly criticized, and in many cases penalized, Medicare health plans for serious deficiencies, including the improper rejection of claims for medical services and unjustified limits on coverage of prescription drugs. The findings, cataloged in dozens of federal audit reports, come as millions of older Americans prepare to sign up for private health plans and prescription drug plans in Medicare’s annual open enrollment period, which will begin on Wednesday and continue through Dec. 7. About 16 million people, accounting for 30 percent of the 54 million beneficiaries, are in private Medicare Advantage plans, which provide a full range of health care services under contract with the government. An additional 23 million people are in prescription drug plans, which cover only medications.
 

top of page

10/10/14 – Kaiser Family Foundation - Medicare Part D: A First Look at Plan Offerings in 2015

By Jack Hoadley, Juliette Cubanski, Elizabeth Hargrave and Laura Summer

The Centers for Medicare & Medicaid Services (CMS) recently released information about the Medicare Part D stand-alone prescription drug plans (PDPs) that will be available in 2015. Of the 37.9 million Medicare beneficiaries enrolled in Part D plans, about 61 percent (23.2 million) are in PDPs; the others are enrolled in Medicare Advantage drug plans. This issue brief provides an overview of the 2015 stand-alone PDP options and key changes from prior years. The analysis focuses on Part D plan availability, premiums, benefit design, and low income subsidy plan availability. It shows that Medicare Part D in 2015 continues to be a marketplace with an array of competing plans offered at a wide range of premiums and benefit designs.
 

top of page

10/8/14 – Kaiser Health News - Many Medicare Outpatients Pay More At Rural Hospitals, Federal Report Says

By Jordan Rau

Many Medicare beneficiaries treated at primarily rural “critical access” hospitals end up paying between two and six times more for outpatient services than do patients at other hospitals, according to a report released Wednesday by the inspector general at the Department of Health and Human Services. There are more than 1,200 critical access hospitals, which are generally the sole hospital in rural areas and can have no more than 25 beds. Medicare pays them more generously so they won’t go out of business. In Illinois, 50 hospitals, more than a quarter, hold this designation. Medicare requires patients to pay 20 percent of the amount a critical access hospital charges. At other hospitals, patients also pay 20 percent coinsurance, but it is based on the amount Medicare decides to reimburse the hospital, which is almost always significantly below what the hospital charges.
 

top of page

9/30/14 – Kaiser Health News - Medicare Open Enrollment Is Fast Approaching -- Here's What We Know So Far

Medicare beneficiaries who want to make changes to their prescription drug plans or Medicare Advantage coverage can do so starting Oct. 15 during the Medicare's program’s annual open enrollment period. There will be somewhat fewer plans to pick from this year, but in general people will have plenty of options, experts say. And although premiums aren’t expected to rise markedly overall in 2015—and in some cases may actually decline—some individual plans have signaled significantly higher rates. Rather than rely on the sticker price of a plan alone, it’s critical that beneficiaries compare the available options in their area to make sure they’re in the plan that covers the drugs and doctors they need at the best price. 
 

top of page

9/19/14 – Kaiser Family Foundation - The Medicare Prescription Drug Benefit Fact Sheet

The Medicare Modernization Act of 2003 (MMA) established a voluntary outpatient prescription drug benefit for people on Medicare known as Part D, which went into effect in 2006. All 54 million people on Medicare, including those ages 65 and older and those under age 65 with permanent disabilities, have access to the Medicare drug benefit through private plans approved by the federal government. Beneficiaries with low incomes and modest assets are eligible for assistance with Part D plan premiums and cost sharing. The Affordable Care Act of 2010 (ACA) made some important changes to Part D—in particular, phasing out the coverage gap by 2020. The Medicare drug benefit is offered through stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans (mainly HMOs and PPOs) that cover all Medicare benefits including drugs. In 2015, 1,001 PDPs will be offered across the 34 PDP regions nationwide (excluding the territories). 
 

top of page

9/10/14 – Kaiser Family Foundation - Visualizing Health Policy: The Role of Medicare Advantage

This Visualizing Health Policy provides a snapshot of the role of Medicare Advantage plans, an alternative to traditional Medicare, including information about the proportion of Medicare beneficiaries who are enrolled in Medicare Advantage plans, geographic differences in Medicare Advantage penetration, the trend of increasing enrollment in Medicare Advantage plans, and the concentration of enrollment within a small number of firms and affiliates. It also shows the extent that Medicare has been paying more for beneficiaries in Medicare Advantage plans than for those in traditional Medicare, although that payment differential is projected to decline.
 

top of page

9/10/14 – Reuters - What Cancer Patients Want And What Medicare Covers May Differ

By Kathryn Doyle

When asked what Medicare should cover for cancer patients in their last months of life, many patients and their caregivers choose benefits the federal insurance does not offer, like home-based long term care and concurrent palliative care, according to a new study based on interviews. Given an array of options, a limited budget and a chance to discuss the choices, patients and caregivers were not very likely to devote all coverage to curative cancer treatment, said lead author Donald H. Taylor Jr, of the Sanford School of Public Policy at Duke University in Durham, North Carolina. “It is important to not over-interpret our results, because they were obtained in a hypothetical context, meaning the choices stated did not impact the actual care they received,” Taylor told Reuters Health by email.
 

top of page

9/5/14 – Gov Info Security - SSNs on Medicare Cards: Is End Near? 

Proposal to Revamp ID Cards Included in Draft of Fraud Bill

By Marianne Kolbasuk McGee 

While the current Congress is often criticized for accomplishing little, the House Ways and Means Subcommittee on Health is floating draft legislation in an attempt to do something about Medicare and Medicaid fraud, abuse and waste. The proposal calls for moving forward with often-discussed plans to eliminate the use of Social Security numbers on Medicare ID cards in the quest to reduce the risk of those numbers being stolen or inappropriately used. It also calls for investigating a shift to smart cards. Also included in the draft is a plan for enhancing incentives under a provision of HIPAA for individuals to report Medicare fraud and abuse, and extending those incentives to reporting Medicaid fraud. The Protecting Integrity in Medicare Act of 2014 was released on Aug. 7 by health subcommittee chairman Kevin Brady, R-Texas. The committee collected public comments on the discussion draft through Sept. 1.
 

top of page

9/4/14 – The Heritage Foundation - Progress in Medicare Advantage: Key Lessons for Medicare Reform

By Robert E. Moffit, Ph.D. and Alyene Senger

Medicare Advantage (MA) is a program of competing private health plans. For the vast majority of senior citizens, it is the only viable alternative to enrollment in traditional Medicare. MA, while imperfect, has made significant progress in delivering a wide range of integrated benefits among a variety of competing plans, including specialized health plans focused on patients with serious illnesses and disabilities. MA has achieved high levels of patient satisfaction, higher even than that recorded in traditional Medicare. MA’s record provides valuable lessons for Congress in undertaking comprehensive Medicare reform. If structured correctly, Medicare reform can secure serious cost control for Medicare beneficiaries and taxpayers alike, and ensure that Medicare patients have access to high-quality care when they need it.
 

top of page

9/3/14 – Health Data Management - CMS Needs to Fully Develop Plans for Medicare Advantage Encounter Data 

By Greg Slabodkin

The Centers for Medicare and Medicaid Services has not fully developed plans for using Medicare Advantage encounter data--information on the services and items furnished to enrollees. That is the conclusion of a Government Accountability Office report on Medicare Advantage--the private plan alternative to the traditional Medicare program--which provides healthcare for nearly 15.5 million enrollees, about 30 percent of all Medicare beneficiaries. CMS began collecting encounter data in January 2012. And, while it announced that it will begin using diagnoses from both encounter data and the data it currently collects for risk adjustment to determine payments to Medicare Advantage organizations (MAOs) in 2015, the agency has not established timeframes or specific plans to use encounter data for other potential purposes, according to the GAO.
 
 
To read the GAO report, click here.

top of page

9/2/14 – Kaiser Family Foundation - Medicare at a Glance

Medicare is the federal health insurance program created in 1965 for all people ages 65 and older, regardless of income or medical history, and expanded in 1972 to cover people under age 65 with permanent disabilities. Now covering 54 million Americans, Medicare plays a vital role in providing financial security to older people and those with disabilities. Medicare spending accounted for 14% of total federal spending in 2013 and 20% of national personal health spending in 2012. Most people ages 65 and older are entitled to Medicare Part A if they or their spouse are eligible for Social Security payments and have made payroll tax contributions for 10 or more years. Nonelderly people who receive Social Security Disability Insurance (SSDI) payments generally become eligible for Medicare after a two-year waiting period, while those diagnosed with end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS) become eligible for Medicare with no waiting period.
 

top of page

8/26/14 – MedPAC – Comment Letter: CMS’s Proposed Rule Entitled: Hospital Outpatient Prospective Payment And Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Physician-Owned Hospitals: Data Sources for Expansion Exception; Physician Certification of Inpatient Hospital Services; Medicare Advantage Organizations And Part D Sponsors; Appeals Process For Overpayments Associated With Submitted Data

The Medicare Payment Advisory Commission (MedPAC) is pleased to submit comments on CMS’s proposed rule entitled: “Hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs; physician-owned hospitals: data sources for expansion exception; physician certification of inpatient hospital services; Medicare Advantage organizations and Part D sponsors: appeals process for overpayments associated with submitted data” [CMS-1613-P]. We appreciate your staff’s ongoing efforts to administer and improve the payment system for hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs), particularly considering the agency’s competing demands. As you know, the outpatient prospective payment system (OPPS) classifies services provided in outpatient departments into ambulatory payment classifications (APCs). Each APC group has a relative weight, which is an indexed measure of the resources needed to furnish a service. The OPPS determines payment rates for APCs as the product of the relative weights and a conversion factor.
 

top of page

8/21/14 – Forbes - For Medicare, Private Is Better Than Public

By John Goodman 

Although Barack Obama ran against Medicare Advantage plans in the 2008 election and although many Democrats regard them as unhealthy “privatization,” this is the only place in all of Medicare where the president’s health reform promise is being realized: they are producing better care for a lower cost. Medicare Advantage plans are private health plans, typically operated by private insurers. About 30 percent of the Medicare population is enrolled in them and that number is steadily growing. The plans receive a risk adjusted premium from Medicare, reflecting the expected cost for each enrollee and in some cases the enrollees may also be charged a small premium. One way to think about these plans is to see that quite apart from anything else they do they are solving a social problem. They combine traditional Medicare coverage with Medigap coverage for below-average income seniors who otherwise would have difficulty paying the premiums for supplemental insurance.
 

top of page

8/18/14 – The New York Times - Medicare Advantage Is More Expensive, But It May Be Worth It 

By Austin Frakt

Medicare Advantage plans — private plans that serve as alternatives to the traditional, public program for those that qualify for it — underperform traditional Medicare in one respect: They cost 6 percent more. But they outperform traditional Medicare in another way: They offer higher quality. That’s according to research summarized recently by the Harvard health economists Joseph Newhouse and Thomas McGuire, and it raises a difficult question: Is the extra quality worth the extra cost? It used to be easier to assess the value of Medicare Advantage. In the early 2000s, Medicare Advantage plans also cost taxpayers more than traditional Medicare. It also seemed that they provided poorer quality, making the case against Medicare Advantage easy. It was a bad deal.
 

top of page

8/18/14 – The Kaiser Family Foundation - Medicare Part D in Its Ninth Year: The 2014 Marketplace and Key Trends, 2006-2014

By Jack Hoadley and Laura Summer and Elizabeth Hargrave and Juliette Cubanski and Tricia Neuman

Since 2006, Medicare beneficiaries have had access through Medicare Part D to prescription drug coverage offered by private plans, either stand-alone prescription drug plans (PDPs) or Medicare Advantage prescription drug plans (MA-PD plans). Now in its ninth year, Part D has evolved due to changes in the private plan marketplace and the laws and regulations that govern the program. This report presents findings from an analysis of the Medicare Part D marketplace in 2014 and changes in features of the drug benefit offered by Part D plans since 2006.
 

top of page

8/16/14 – The New York Times - Medicare to Start Paying Doctors Who Coordinate Needs of Chronically Ill Patients

By Robert Pear 

In a policy change, the Obama administration is planning to pay doctors to coordinate the care of Medicare beneficiaries, amid growing evidence that patients with chronic illnesses suffer from disjointed, fragmented care.
Although doctors have often performed such work between office visits by patients, they have historically not been paid for it. Starting in January, Medicare will pay monthly fees to doctors who manage care for patients with two or more chronic conditions like heart disease, diabetes and depression. “Paying separately for chronic care management services is a significant policy change,” said Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services. Officials said such care coordination could pay for itself by keeping patients healthier and out of hospitals.
 

top of page

8/15/14 – MedPAC – Comment Letter: CMS’s Proposed Rule Entitled: Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

The Medicare Payment Advisory Commission (MedPAC) welcomes the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) proposed notice entitled “Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies,” published in the Federal Register, vol. 79, no. 133, pages 40208 to 40315. This proposed rule includes provisions that update the end-stage renal disease (ESRD) payment system for 2015 and the ESRD quality incentive program (QIP). We appreciate your staff’s ongoing efforts to administer and improve payment systems for physician and other services, particularly considering the competing demands on the agency. Our comments address provisions in the proposed rule about the proposed rebasing and revising the ESRD bundled market basket.
 

top of page

8/14/14 – The Wall Street Journal - How Agents Hunt for Fraud in Trove of Medicare Data

Law-Enforcement Officials Estimate Fraud Accounts for as Much as 10% of Medicare's Yearly Spending

By Christopher S. Stewart

Eleven armed FBI agents crept around a stone-and-glass house here just before dawn. An AR-15 rifle and four other guns were registered to the man in the house. "FBI warrant," the agents called out, and a man in a T-shirt and shorts emerged. It was no drug lord. The target was a doctor who moonlighted as a movie producer with an Alec Baldwin comedy to his credit. The Justice Department charged the doctor, Robert A. Glazer, with writing prescriptions and certifications resulting in $33 million of fraudulent Medicare claims. The raid in May capped a year-long investigation by the Medicare Fraud Strike Force, a joint effort by the Justice Department and Department of Health and Human Services. Raids that day in six cities resulted in the busts of 90 Medicare providers, including 16 doctors, who were separately charged with generating a total of $260 million of false Medicare billings.
 

top of page

8/6/14 – The Washington Post - Watchdog: Some Medicare Spending On HIV Drugs Appear Questionable In 2012 Audit

By Charles Ornstein

Medicare spent more than $30 million in 2012 on questionable HIV medication costs, the inspector general of the Department of Health and Human Services said in a report set for release Wednesday. The report offers a litany of possible fraud schemes, all paid for by Medicare’s prescription drug program known as Part D. Among the most egregious: In Detroit, a 77-year-old woman purportedly filled $33,500 worth of prescriptions for 10 different HIV medications. But there’s no record that she had HIV or that she had visited the doctors who wrote the scripts. A 48-year-old in Miami went to 28 pharmacies to pick up HIV drugs worth nearly $200,000, almost 10 times what average patients get in a year. The prescriptions were supposedly written by 16 health providers. And on a single day, a third patient received $17,500 worth of HIV drugs — and none the rest of the year. She acquired more than twice the recommended dose of five HIV drug ingredients.
 

top of page

8/1/14 – Medicare & Medicaid Research Review - Measuring Coding Intensity In The Medicare Advantage Program

By Richard Kronick and W. Pete Welch

Enrollment in the Medicare Advantage Program has increased dramatically, growing from 9.3 million beneficiaries in March 2008 to 15.4 million in March 2014, an increase of 66% in just six years. Concerns about overpayment as a result of favorable risk selection have confronted the Medicare program throughout the history of Medicare contracting with health maintenance organizations and other private plans. In the late 1980s, Medicare paid health plans using a system that adjusted for demographic factors such as age and gender, but plan enrollees were healthier than fee-for-service beneficiaries with the same demographic characteristics, and, as a result, health plans were estimated to be overpaid by approximately 11%.
 

top of page

8/1/14 – Senior Journal - Medicare Drug Plan Premiums Up $1 Next Year, More Reports on Low Medicare Costs

Unprecedented low levels of growth in Medicare spending, continued savings for seniors citizens

The average premium for a basic Medicare Part D prescription drug plan in 2015 will increase by about $1, to an estimated $32 per month, continuing its historically low growth rate. This projection by the Centers for Medicare & Medicaid Services (CMS) comes on the heels of the 49th anniversary of the signing of Medicare and Medicaid into law. This news comes after the announcements this week of continued unprecedented low levels of growth in Medicare spending and continued savings by seniors and people with disabilities on out of pocket drug costs. According to the recent Medicare Trustees report, the life of the Trust Fund has been extended to 2030, up from its projection of 2017 in 2009.
 

top of page

7/28/14 – The Kaiser Family Foundation - The Facts on Medicare Spending and Financing

Medicare, the federal health insurance program for 54 million people ages 65 and over and people with permanent disabilities, helps to pay for hospital and physician visits, prescription drugs, and other acute and post-acute services. In 2013, spending on Medicare accounted for 14% of the federal budget (Exhibit 1). Medicare also plays a major role in the health care system, accounting for 20% of total national health spending in 2012, 27% of spending on hospital care, and 23% of spending on physician services. Medicare benefit payments totaled $583 billion in 2013; roughly one-fourth was for hospital inpatient services, 12% for physician services, and 11% for the Part D drug benefit. Another one-fourth of benefit spending was for Medicare Advantage private health plans covering all Part A and B benefits; in 2014, 30% of Medicare beneficiaries are enrolled in Medicare Advantage plans.
 

top of page

7/21/14 – The Kaiser Family Foundation - How Much Is Enough? Out-of-Pocket Spending Among Medicare Beneficiaries: A Chartbook

By Juliette Cubanski and Christina Swoope and Anthony Damico and Tricia Neuman

As part of efforts to rein in the federal budget and constrain the growth in Medicare spending, some policy leaders and experts have proposed to increase Medicare premiums and cost-sharing obligations. Today, 54 million people ages 65 and over and younger adults with permanent disabilities rely on Medicare to help cover their health care costs. With half of all people on Medicare having incomes of less than $23,500 in 2013, and because the need for health care increases with age, the cost of health care for the Medicare population is an important issue. Although Medicare helps to pay for many important health care services, including hospitalizations, physician services, and prescription drugs, people on Medicare generally pay monthly premiums for physician services (Part B) and prescription drug coverage (Part D). 
 

top of page

7/20/14 – The Washington Post - Some Seniors Win Medicare Exemptions For Nursing-Home Coverage In Pilot Program

By Susan Jaffe

Medicare is exempting some patients at dozens of hospitals from the controversial requirement that seniors be admitted to the hospital for at least three days to qualify for follow-up skilled nursing home care. The exemptions are at hospitals participating in Affordable Care Act pilot projects meant to test ways to improve Medicare service while reducing costs or holding them steady. The pilot projects are conducted under a provision of the ACA that created the Center for Medicare and Medicaid Innovation to develop ways of improving Medicare. “We’re testing whether it leads to better care and lower costs,” said Medicare’s deputy administrator Sean Cavanaugh. “And if those are successful, the secretary [of Health and Human Services] has the authority to expand those tests.” The health law allows the government to extend successful pilot projects nationwide.
 

top of page

7/13/14 – USA Today - Hospitals, Regulators Spar Over In-Patient Care Policy

By Jayne O’Donnell

Fewer patients linger for days in hospitals without being admitted because of a new federal rule, but hospital and consumer groups are suing the government because they say the policy compromises Medicare patients' care, and patients are often stuck with costly, unexpected bills. Doctors now have to certify that a patient has a serious enough condition to need at least two overnight stays for Medicare to cover an inpatient admission under the rule, which took effect in October. However, patients can remain in an outpatient or "observation" status — that can even include staying overnight for several nights in a typical hospital room — even though they haven't been formally admitted as an inpatient.
 

top of page

7/9/14 – The Wall Street Journal - Report Raises Red Flags on Medicare Lab Billing Questionable Payments Shows Health Program's Vulnerability to Abuse 

By Janet Adamy

Medicare allowed $1.7 billion in 2010 payments to clinical laboratories for claims that raised red flags, according to a report to be released Wednesday, the latest example of how the federal insurance program for the elderly and disabled is susceptible to misspending and abuse.
The report, by the Department of Health and Human Services' Office of Inspector General, found that more than 1,000 laboratories showed five or more measures of questionable billing during that year, the latest available when the office began compiling the data. That includes various metrics signifying higher-than-average billing, using ineligible physician identification numbers and administering duplicate tests, among other things.
 

top of page

7/9/14 – The Center For Public Integrity - Feds Seek New Authority To Recoup Medicare Advantage Overcharges

By Fred Schulte

Federal officials, facing criticism they overpay Medicare Advantage plans for the elderly by billions of dollars annually, are seeking new power to recover excessive charges. The Centers for Medicare and Medicaid Services says its wants to set up “a formal process to recoup overpayments” made to the health plans. The draft regulation is set to be published on July 14 and a final decision on the proposal is due by November 1. Federal officials have struggled to pay the senior care plans accurately for years. A Center for Public Integrity investigation published last month found that Medicare paid the health plans nearly $70 billion in “improper” payments — mostly inflated fees from overstating the health risks of patients — from 2008 through 2013 alone.
 

top of page

7/8/14 – Time - Why Most Seniors Can’t Afford to Pay More for Medicare

Replacing Medicare with vouchers would push costs higher and put older Americans at risk.

By Mark Miller

Should seniors pay more for Medicare? Republicans think so; they have repeatedly called for replacing the current program with vouchers that would shift cost and risk to seniors. There’s no doubt this is where Republicans will take us if they capture control of Congress this year, and the White House in 2016. Representative Paul Ryan, the Wisconsin Republican who chairs the House Budget Committee, advocates “premium support” reforms that would give seniors vouchers to buy private Medicare insurance policies in lieu of traditional fee-for-service Medicare.
 

top of page

7/8/14 – The Kaiser Family Foundation - The Mystery of the Missing $1,000 Per Person: Can Medicare’s Spending Slowdown Continue?

By Tricia Neuman and Juliette Cubanski

As Medicare and budget wonks eagerly await the 2014 edition of the Medicare Trustees’ report, the big story in the Medicare world these days is the slowdown in program spending. Based on our comparison of CBO’s August 2010and April 2014 baselines, Medicare spending this year will be about $1,000 lower per person than was expected in 2010, soon after passage of the Affordable Care Act (ACA), which included reductions in Medicare payments to plans and providers and introduced delivery system reforms that aimed to improve efficiency and reduce costs. By 2019, Medicare spending per person is projected to be nearly $2,400 lower per person than was expected following passage of the ACA. Medicare spending projections in CBO’s August 2010 and subsequent baselines take into account the anticipated effects of the ACA, along with other factors that are expected to affect future Medicare spending. So it seems that the ACA may be having a bigger than expected effect, but something else may be going on here too.
 

top of page

7/2/14 – Forbes - A Modest Step To Improve Medicare Post-Acute Care

By Howard Gleckman

Medicare has a huge and growing problem caring for patients after they have been discharged from the hospital. After years of talk, Congress may be about to take a modest but important first step toward cleaning up the mess, and making sure that patients get care that gives them the best chance to live a healthy and active life after a surgery or acute medical episode such as a stroke. A wide-range of treatment and rehabilitation services live under the umbrella of Medicare post-acute care. That itself is a big part of the problem. Remarkably, the top Democrats and Republicans on both the House Ways & Means Committee and the Senate Finance Committee—who have been unable to agree on anything for years—are sponsoring a bill aimed at starting to fix the tangle of problems that bedevils the post-acute system.
 

top of page

6/25/14 – MedPAC – CMS’s Hospice Proposed Rule Main Header

The Medicare Payment Advisory Commission (MedPAC) welcomes the opportunity to comment on the Centers for Medicare & Medicaid Services (CMS) hospice proposed rule for fiscal year 2015, published in the Federal Register on May 8, 2014. We appreciate your staff’s efforts to improve Medicare’s hospice payment system, especially considering the competing demands on the agency and the limited resources. Payment system reform. We are disappointed that CMS did not take action to revise the 
hospice payment system for fiscal year 2015. We believe that there is ample evidence that 
the current payment system is misaligned with hospices’ costs and that an initial step to 
revise the hospice payment system should occur in 2015.
 

top of page

6/25/14 – The Center For Public Integrity - Medicare Advantage Plans Require More Scrutiny

By Fred Schulte

Federal officials need to step up efforts to investigate fraud and abuse in Medicare Advantage health plans treating millions of elderly Americans, a top government investigator says. Gary Cantrell, a deputy Inspector General with the Department of Health and Human Services said reviews are “hampered by a lack of accurate, timely and complete data that would facilitate oversight” of the fast-growing health insurance plans. His comments came in testimony prepared for a Wednesday hearing of the oversight subcommittee of the House Committee on Energy and Commerce. The hearing was called to assess fraud and abuse safeguards in Medicare, which last year covered about 51 million people at a cost to taxpayers of about $604 billion. Officials estimate that almost $50 billion of that amount was paid improperly, including $11.8 billion to Medicare Advantage plans.
 

top of page

6/18/14 – MedPAC - Report to the Congress: Medicare and the Health Care Delivery System

As part of its mandate from Congress, each June the Commission reports on issues affecting the Medicare program, including changes in health care delievery in the U.S. and the market for health care services. In this year’s report, the Commission has begun to explore the concept of synchronizing Medicare policy across the three major Medicare payment models – traditional, fee-for-service (FFS), Medicare Advantage, and the newest model, the accountable care organization (ACO). The Commission’s interest in this topic is motivated by concern that Medicare’s payment rules and quality measurement programs are different across the three models. The inconsistencies result in different levels of program support for one model over another and an inability to discern whether one provides higher quality care to beneficiaries than another. 
 

top of page

6/10/14 – USA Today - Seniors' Use Of Potent Meds Via Medicare Staggering

By Peter Eisler 

The number of senior citizens getting narcotic painkillers and anti-anxiety medications under Medicare's prescription drug program is climbing sharply, and those older patients are being put on the drugs for longer periods of time, a USA TODAY examination of federal data shows.
From 2007-2012, the number of patients 65 and older getting Medicare prescriptions for powerful opioid pain medications rose more than 30% to upward of 8.5 million beneficiaries, the data show. Use of some of the most commonly abused painkillers, such as hydrocodone and oxycodone, climbed more than 50%. And the supply of each narcotic provided to the average recipient grew about 15% to about three months. The figures suggest that one in five of the nation's 43 million seniors get Medicare prescriptions to take pills like Vicodin or Percocet for their aches and pains, often on a long-term basis.
 

top of page

6/9/14 – Crain’s Detroit Business - Medicare Sustainable Growth Rate Remains Focal Point Of Docs' Ire At AMA Meeting

By Modern Healthcare

A major theme of the address by American Medical Association President Ardis Dee Hoven, M.D. at the opening session of the AMA House of Delegates meeting in Chicago was a familiar one: Congress let doctors and senior citizens down when they once again failed to pass Medicare payment reform. This spring, Congress was poised to repeal the hated Medicare sustainable growth-rate physician payment formula, which mandates huge cuts in physician reimbursement each year. But after partisan disagreements developed over how to pay for an sustainable growth rate replacement, Congress instead passed its 17th temporary legislative SGR “patch,” which froze Medicare pay rates through March 2015 and kicked the decision-making can down the road yet another time. Hoven, an infectious disease expert whose term as president ends June 10, said that the SGR repeal effort wasn’t a total waste. She highlighted how a physician task force developed a set of principles for SGR replacement that was then endorsed by 100 physician organizations. The principles were then incorporated into a bill with bipartisan, bicameral support.
 

top of page

6/4/14 – The Center For Public Integrity - Why Medicare Advantage Costs Taxpayers Billions More Than It Should

Regulators have kept problems secret, and there's no fix in sight

By Fred Schulte

In South Florida, one of the nation’s top privately-run Medicare insurance plans faces a federal investigation into allegations that it overbilled the government by exaggerating how sick some of its patients were. In the Las Vegas area, private health care plans for seniors ran up more than $100 million in added Medicare charges after asserting patients they signed up also were much sicker than normal — a claim many experts have challenged. In Rochester, New York, a Medicare plan was paid $41 million to treat people with serious diseases — even though the plan couldn’t prove the patients in fact had those diseases. These health plans and hundreds of others are part of Medicare Advantage, a program created by Congress in 2003 to help stabilize health care spending on the elderly. But the plans have sharply driven up costs in many parts of the United States — larding on tens of billions of dollars in overcharges and other suspect billings based in part on inflated assessments of how sick patients are, an investigation by the Center for Public Integrity has found.
 

top of page

6/2/14 – U.S. News & World Report - Why Retirees Don’t Switch Medicare Part D Plans, But Should

Seniors are reluctant to put in the effort to select a new prescription drug plan, even to save money.

By Emily Brandon

Medicare Part D prescription drug plans are allowed to change their premiums, covered medications and preferred pharmacies each year, and many plans do. Plan participants are invited to switch plans once a year during the open enrollment period, but few Medicare beneficiaries actually pick a new plan. Here’s why retirees are reluctant to change Medicare Part D plans and what might motivate them to do it. The cost of the plan. Most Medicare beneficiaries consider the premiums and deductibles when initially selecting a Part D plan, but they don’t continue to shop around for the lowest cost plan each year, according to recent findings from a series of focus groups with Medicare beneficiaries in Baltimore, Seattle, Memphis, Tennessee, and Tampa, Florida conducted by the Kaiser Family Foundation and PerryUndem Research and Communication. Seniors in the focus groups said they tolerated and expected their premiums and copays to rise and would only start looking for a new plan if the price increase reached around $75 more a month. “People sign up for their plan maybe when they first come on Medicare, and they stay on their plan unless premiums really jump through the roof,” says Tricia Neuman, senior vice president of the Kaiser Family Foundation. 
 

top of page

6/2/14 - WebMD - Medicare Could Save Billions On Drug Plan

By Julie Rovner

A new study finds that Medicare is spending billions of dollars more than it needs to on prescription drugs for low-income seniors and disabled beneficiaries. In 2013, an estimated 10 million people who participate in the Medicare prescription drug program, known as Part D, received government subsidies to help pay for that coverage. They account for an estimated three-quarters of the program’s cost. Most of those low-income enrollees are randomly placed in a plan that costs less than the average for the region where the person lives. But even though these are lower-cost plans, they often end up costing the government and the beneficiary more. If Medicare instead assigned those people to a drug plan based on the actual drugs they took, it could save those patients hassle and money, and potentially save the government billions of dollars, according to the study by researchers from the University of Pittsburgh. The study appears in the June issue of the policy journal Health Affairs.
 

top of page

6/2014 – Kaiser Family Foundation - Visualizing Income and Assets Among Medicare Beneficiaries: Now and in the Future

Many Medicare beneficiaries live on fixed incomes supplemented by the savings they accumulated during their working years. Their income and accumulation of savings is tied to many life experiences, including their education, health status, marital status, number of work years, household income, periods of unemployment, investments, years of homeownership, access to employer retirement benefits, inheritance, other financial supports, and various economic factors. This interactive tool describes the income, savings and home equity of people on Medicare in 2013, and in 2030 (in 2013 inflation adjusted dollars).
 

top of page

6/1/14 – Forbes - To End VA Doctor Shortage, Medicare Funding Needs Boost

By Bruce Japsen

As the nation grapples with the imbroglio at the Department of Veteran Affairs and a doctor shortage cited in months-long delays at VA Hospitals, policymakers are focusing on ways to boost the nation’s physician supply. The fix may lie with the Medicare health insurance program for the elderly, which currently holds the purse strings. And that will begin to be addressed this week and next when the American Medical Association – the nation’s largest doctor group – convenes at its annual meeting later this week. A major problem is Medicare given the bulk of funding for graduate medical education, known as GME, specifically pays for residencies at the nation’s teaching hospitals, and it hasn’t risen in nearly two decades to allow more training slots. The AMA will discuss a report its members ordered up on physician workforce issues and “GME financing” at its annual policy-making House of Delegates meeting, which begins next weekend in Chicago.
 

top of page

5/28/14 – Healthcare Finance News - New Rates And Policies Bring Medicare Advantage To A Crossroads

By Anthony Brino

Another round of successful lobbying to avoid Medicare Advantage rate cuts has netted a small increase of 0.4 percent to the average plan, and insurers are looking at the programs continuing to grow. But changes are afoot. Yes, the Centers for Medicare & Medicaid Services increased rates instead of cutting, and yes, MA programs are predicted to grow at a rate of around 10 percent through 2016, to the point where in a few years it could be covering one-third of all seniors or more, but there will be pressures – the sort of pressures that may bring about significant changes. For instance, during a conference call about MA 2015 rates, Jonathan Blum emphasized that although the agency granted a rate increase for 2015, it will be staying true to the Affordable Care Act's directive of bringing the per-beneficiary costs down over time.
 

top of page

5/21/2014 – MedPAC – Testimony: Medicare Fee-For-Service Payment Policy Across Sites of Care

The Commission’s goal is to achieve a Medicare program that ensures beneficiary access to high-quality care, pays health care providers fairly, rewards efficiency and quality, and spends tax dollars responsibly. When we examine Medicare’s payment policies across different sites of care, we observe several opportunities for policy development. In the testimony that follows, I will present the Commission’s work on price differences across settings for ambulatory care and post-acute care (PAC), as well as the use of standard patient assessment tools and other payment policies to encourage care coordination in PAC. In other Commission products, we provide important information and recommendations about setting payments in Fee-For-Service (FFS) Medicare to the level of the efficient provider and revising the payment systems to make them more equitable among providers. 
 

top of page

5/21/14 – Kaiser Health News - Should Medicare Pay The Same No Matter Where The Patient Gets Care?

That question was the focus of a House subcommittee hearing Wednesday, and it's an important issue in the context of the debate over ending the Medicare SGR. Mary Agnes Carey and CQ HealthBeat's John Reichard discuss.
 
 

top of page

5/15/14 – NPR - For Some Doctors, Almost All Medicare Patients Are Above Average

By Charles Ornstein And Ryann Grochowski Jones

Office visits are the bread and butter of many physicians' practices. Medicare pays for more than 200 million of them a year, often to deal with routine problems like colds or high blood pressure. Most require relatively modest amounts of a doctor's time or medical know-how. Not so for Michigan obstetrician-gynecologist Obioma Agomuoh. He charged for the most complex — and expensive — office visits for virtually every one of his 201 Medicare patients in 2012, his billings show. In fact, Medicare paid Agomuoh for an average of eight such visits per patient that year, a staggering number compared with his peers.
 

top of page

5/13/14 – Kaiser Family Foundation - How are Seniors Choosing and Changing Health Insurance Plans?

Findings from Focus Groups with Medicare Beneficiaries

By Gretchen Jacobson, Christina Swoope, Michael Perry and Mary C. Slosar

For many seniors, the process of choosing a Medicare plan, either a Medicare Advantage or Part D plan, can be daunting. In 2014, the typical Medicare beneficiary can choose from among 18 Medicare Advantage plans and 31 Part plans. With dozens of plans offered to seniors across the country, the hope is that seniors will choose among competing plans for one that will work well for them, and change plans during the open enrollment period, if another plan would provide better coverage or lower their costs. Based on focus groups conducted in four cities (Baltimore, Tampa, Seattle and Memphis), this report explores seniors’ attitudes and experiences in choosing plans, and making changes during the annual enrollment period.
 

top of page

5/12/14 – Reuters - Medicare Pays Billions Of Dollars For Wasteful Procedures

By Sharon Begley

As many as 42 percent of U.S. Medicare patients were subjected to procedures providing little if any medical benefit, costing the government program up to $8.5 billion in wasteful spending, according to a study published on Monday. The research, reported in JAMA Internal Medicine, is the first large-scale analysis of what Medicare spends on procedures widely viewed as unnecessary, from advanced imaging for simple lower back pain to pre-operative chest X-rays and putting stents in patients with stable heart disease. The study looked at the frequency at which doctors used 26 such procedures in 2009.
 

top of page

5/10/14 – Forbes - Seniors Flock To Star - Rated Medicare Plans Under ACA Rollout

An effort under the Affordable Care Act to encourage the health insurance industry to provide higher quality benefits to seniors is rewarding Medicare beneficiaries and the bottom lines of health plans that are achieving high government-backed ratings. More than half of seniors enrolled in so-called Medicare Advantage plans are now enrolled in plans with ratings of four stars or more on a five-star scale, a ranking system created under the health law to guide seniors to cost-effective and higher quality benefits. Plans are rated on such measures like cutting call waiting times as well as how well they encourage preventive care such as getting regular blood tests for diabetes.
 

top of page

5/7/14 – Kaiser Family Foundation - Medicare Advantage: Take Another Look

By Tricia Neuman and Gretchen Jacobson

While health policy observers are mainly focused on the number of people enrolled in the new federal and state marketplaces, fewer are keeping a close eye on fairly big changes in the estimates and projections for enrollment in Medicare Advantage plans. The number of Medicare beneficiaries in Medicare private plans reached an all-time high this year of nearly 16 million beneficiaries, 6.3 million higher than the Congressional Budget Office (CBO) had projected in 2010 soon after the Affordable Care Act (ACA) was enacted (Figure 1). The CBO now projects Medicare Advantage enrollment will reach 22 million beneficiaries by 2020, more than double the number projected shortly after the ACA was enacted.
 

top of page

4/24/14 – Bloomberg News - Medicare’s $5 Billion Ambulance Tab Signals Area Of Abuse

By Shannon Pettypiece

The patient smoked cigarettes in the passenger seat of the ambulance every week, chatting with the driver while taxpayers foot the $1,000 bill to drive him four blocks for his dialysis treatment. The routine was part of a $1.5 million scheme to defraud Medicare by Penn Choice Ambulance Inc., according to an indictment against the Philadelphia company. The case helps explain part of why Medicare paid $5 billion to ambulance companies in 2012, more than went to cancer doctors or orthopedic surgeons, according to newly released federal data. The U.S. Department of Health and Human Services has identified ambulance service as one of the biggest areas of overuse and abuse in Medicare -- companies billing millions for trips by patients who can walk, sit, stand or even drive their own cars.
 

top of page

4/23/14 – Reuters - U.S. Official Responsible For Reforming Medicare Is Leaving Post

By David Morgan

The Obama administration on Tuesday announced the departure of the top health official responsible for reforming Medicare under President Barack Obama's healthcare reform law. Jonathan Blum, Medicare director and principal deputy administrator of the U.S. Centers for Medicare and Medicaid Services (CMS), has presided over a range of reform initiatives during a five-year tenure including efforts to move the $635 billion healthcare program for the elderly and disabled away from costly fee-for-service medicine. His work involved two proposals that drew bipartisan opposition in Congress this year. During Blum's tenure, Medicare has seen annual per capital cost growth slow to historic lows, though analysts are divided over how much credit can be attributed to reforms ushered in by the law known as Obamacare.
 

top of page

4/14/14 – Kaiser Family Foundation - Retiree Health Benefits At the CrossroadsMain Header

By Frank McArdle, Tricia Neuman and Jennifer Huang

Retiree health benefit plans are an important source of supplemental coverage for roughly 15 million Medicare beneficiaries and a primary source of coverage for more than two million pre-65 retirees in the public and private sectors.1 But the state of retiree health coverage is at a critical juncture after decades of change, with still more to come on the horizon. The share of employers sponsoring retiree health coverage has declined and employers that continue to offer coverage are redesigning their plans on a virtually annual basis in response to rising health care costs. Ongoing concerns about costs, coupled with changes in Medicare, notably the addition of prescription drug coverage, and more recent changes made by the Affordable Care Act of 2010 (ACA), have triggered a major reassessment by employers of whether and in what form they should continue to offer retiree health benefits. Further, a number of policy proposals are under consideration that could have a significant impact on retiree health benefits and costs. This report reviews the role of retiree health coverage for early and Medicare-eligible retirees, examines changes underway, and considers the outlook for the future.
 

top of page

4/8/14 – Reuters - Final Medicare Payments To Insurers 'Less Worse': Analysts 

By Caroline Humer 

The Obama administration's announcement on Monday that it would roll back proposed cuts to privately managed Medicare plans is a positive for insurers because the final plan is "less worse" than the one proposed, Wall Street analysts said on Tuesday. The government agency that oversees Medicare said after the stock market closed on Monday that on average, reimbursements to insurers for private Medicare plans would rise 0.4 percent, reversing what it said was a proposed cut of 1.9 percent. Analysts who looked closely at the government's numbers saw an improvement of about 2 percent to 3 percentage points. They also described an apples-and-oranges comparison between the government's and their calculations of the total impact. They said they saw a decrease in final payments of about 3 percent in 2015, versus their initial calculations of a cut of 5 percent or 6 percent.
 

top of page

4/4/14 – AHIP - New Bipartisan Letter Urges CMS to Protect Seniors in Medicare Advantage 

“We urge you to take the necessary actions to keep MA payment rates stable for 2015…We have heard an outcry of concern from our constituents who rely on this program.” 

A bipartisan group of 29 members of Congress sent a new letter to the Centers for Medicare and Medicaid Services (CMS) urging the Medicare agency to protect seniors in Medicare Advantage by maintaining current payment rates for 2015. The letter—spearheaded by Rep. Ron Barber (D-AZ) and Rep. Patrick Murphy (D-FL)—is signed by 22 Democrats and 7 Republicans. The letter adds to a bipartisan group of 270 members of Congress from the House and Senate who have expressed concerns about the proposed 5.9 percent cut to Medicare Advantage and urged CMS to protect seniors in the program. 
 
 

top of page

3/26/14 – Modern Healthcare - Medicare Advantage Plans Fight Proposal To Require Confirmation Of Diagnoses

By Paul Demko

Molina Healthcare has roughly 40,000 Medicare Advantage customers, 20% of whom are severely disabled. Under new payment policies proposed by the CMS, the company fears that it would have to transport these patients to medical facilities in order to be fully compensated by the federal government. “What's the point of taking someone who's disabled, perhaps wheelchair bound, and dragging them to a doctor's office if that's unnecessary?” asked Dr. J. Mario Molina, president and CEO of the Long Beach, Calif.-based company. “We don't really understand why the place where the diagnosis is made should matter.” At issue is a proposal put forth by the CMS last month in its proposed payment policies for 2015. Insurers that participate in the Medicare Advantage program are compensated in part based on “risk adjustment” scores. These assessments, based on medical diagnoses, can change payments by as much as 25% in some cases.
 
 

top of page

3/26/14 – The Detroit News - Senate Hears From Michigan Women On Medicare Fraud

Two Michigan women testified Wednesday before a U.S. Senate committee on the growing problem of Medicare fraud. Patricia Gresko, a retired Romeo public school employee, told the Senate Aging Committee that she was a victim of Medicare fraud. She started seeing a doctor, Farid Fata, who diagnosed her with immune system problems. Fata of Oakland Township has been charged with health care fraud. “This doctor told me I had a problem with my immune system, and that I needed an IV medication monthly. So I began these infusions in January of 2013,” Gresko said, according to a copy of her written testimony. “During my very first treatment, I had side effects. I had chest pains, and was worried that it was my heart. The doctor told me that he needed to slow down the rate of the infusion. So, I continued to get these treatments for seven months. Each of these treatments took 7 hours.
 

top of page

3/19/14 – Yahoo Finance - Medicare PDP Growth Rate Declines Year-over-Year

Stand-alone prescription drug plans (PDPs), also referred to as Medicare Part D plans, enrolled 23.3 million people as of February 1, 2014, an increase of 857,583 enrollees from February 1, 2013. According to Mark Farrah Associates (MFA),www.markfarrah.com, the 3.8% growth rate is a significant decline from the 14.7% increase PDPs experienced the previous year. Between February 2012 and February 2013, employer group plans drove much of the growth whereby PDP plans gained more than 2.7 million covered lives. During the 2012 to 2013 period, enrollment from employer plans increased nearly 2.2 million, while enrollment in products sold to individuals increased by 560,000 from 2012 to 2013. From 2013 to 2014 enrollment from employer plans increased only 300,000 and enrollment from individual plans increased 528,000. According to Debra A. Donahue, a Vice President at MFA, "It appears the conversion of employer plans resulted in a onetime spike and now that most have converted to managed care plans, overall enrollment gains for PDP plans has leveled off."
 

top of page

3/18/14 – AHIP - New Video Highlights Congressional Hearing on Proposed Cuts to Medicare Advantage

- Experts, Medicare Advantage Beneficiary Discuss Impact Of CMS’ Proposed Cuts On Seniors - The House Energy & Commerce Committee recently held a hearing on the impact new proposed cuts to Medicare Advantage would have on seniors. Witnesses included Glenn Giese, Principal, Oliver Wyman Consulting Actuaries; Dr. Mitchell Lew, CEO and Chief Medical Officer, Prospect Medical Systems; and Frank Little, a Medicare Advantage beneficiary. Recently, CMS, the Medicare agency, proposed a 5.9 percent cut to Medicare Advantage. Witnesses and members of the Committee discussed the impact of cuts on seniors enrolled in the program and the value of Medicare Advantage to over 15 million Medicare beneficiaries. Recently, 258 members of Congress signed bipartisan letters to CMS urging the agency to protect seniors in Medicare Advantage, including more than 200 House members and 40 senators. A broad array of other organizations – representing employers, providers, consumers, lawmakers, and health care stakeholders – have also sent letters urging the agency to keep rates flat to protect seniors from further harm in 2015. If the new changes proposed by CMS for 2015 are implemented, the program would be hit by a double-digit cut over just a two-year period resulting in increased costs, reduced benefits, and fewer coverage options for seniors, according to a recent Oliver Wyman report. New state-by-state data from Oliver Wyman show the estimated impact of the proposed payment cuts for states across the country.
 
 

top of page

3/15/14 – NPR - House Passes Payment Fix For Medicare Docs, But At What Cost?

By Julie Rover

Bipartisan support dissolved this week for compromise legislation that would have fixed a longstanding problem with the way Medicare pays physicians. Though the bill passed the House of Representatives Friday, it now contains a provision almost certain to invite veto unless a Senate version can quickly nudge the ultimate bill back toward compromise. Republican leaders in the House finally brought to a vote this week the legislation they'd unveiled in February. It was the product of several years of collaborative work by the Republican and Democratic leaders of the key congressional committees that oversee the Medicare program. The leaders, from both houses of Congress, also got input and buy-in from physician groups, and from groups representing Medicare patients.
 

top of page

3/14/14 – MedPAC – Medicare Payment Advisory Commission Releases Report On Medicare Payement Policy

The Medicare Payment Advisory Commission (MedPAC) releases its March 2014 Report to the Congress: Medicare Payment Policy. The report includes MedPAC’s analyses of payment adequacy in fee-for-service (FFS) Medicare and Medicare Advantage (MA), and provides information on the prescription drug benefit, Part D. Fee-for-service payment rate recommendations. The report presents MedPAC’s recommendations for 2015 rate adjustments in fee-for-service (FFS) Medicare. These “update” recommendations—which MedPAC is required by law to submit each year—are based on an assessment of payment adequacy taking into account beneficiaries’ access to and use of care, the quality of the care they receive, supply of providers, and providers’ costs and Medicare’s payments. 
 
 
 
 

top of page

3/11/14 - AHIP Coverage - New State-by-State Data Show Impact on Seniors of Proposed Cuts to Medicare Advantage

Seniors in some states will experience premium increases and benefit reductions of $65-75 per month if the new proposed cuts are finalized Seniors across the country will experience increased costs, reduced benefits, and fewer coverage options if new proposed cuts to Medicare Advantage payments take effect on April 7, according to new state-by-state data from Oliver Wyman. The new data is a follow up to a recently released Oliver Wyman report which found that changes to Medicare Advantage payments recently proposed by CMS would result in a 5.9 percent cut to payments in 2015, causing benefit reductions and premium increases for seniors of an average $35-$75 per month, or $420-$900 for the year. If the new changes proposed by CMS for 2015 are implemented, the program would be hit by a double-digit cut over just a two-year period, according to the recent Oliver Wyman report. Cuts of this magnitude could result in a “high degree of disruption in the MA market,” including the “potential for plan exits, reductions in service areas, reduced benefits, provider network changes, and MA plan disenrollment,” the report stated.
 

top of page

3/11/14 – The Kaiser Family Foundation - Summary of Medicare Provisions in the President’s Budget for Fiscal Year 2015

By Gretchen Jacobson & Christina Swoope

On March 4, 2014, the Office of Management and Budget released President Obama’s budget for fiscal year (FY) 2015, which includes provisions related to federal spending and revenues, including Medicare savings. The President’s budget would use federal savings and revenues to reduce the deficit and replace sequestration of Medicare and other federal programs for 2015 through 2024. This brief summarizes the Medicare provisions included in the President’s budget proposal for FY2015.
The President’s FY2015 budget would reduce Medicare spending by more than $400 billion between 2015 and 2024, accounting for about 25 percent of all reductions in federal spending included in the budget. Most of the Medicare provisions in the FY2015 budget are similar to provisions that were included in the Administration’s FY2014 budget proposal. The proposed Medicare spending reductions are projected to extend the solvency of the Medicare Hospital Insurance Trust Fund by approximately five years.
 

top of page

3/10/14 – Reuters - US Administration Pulls Back On Medicare Drug Benefit Proposals

By David Morgan

The Obama administration, in an abrupt about-face, said on Monday it would drop proposed changes to Medicare drug coverage that met wide opposition on grounds they would harm health benefits for the elderly and disabled. Late last week, more than 370 organizations representing insurers, drug makers, pharmacies, health providers and patients urged the Centers for Medicare and Medicaid Services (CMS) to withdraw changes it had proposed for Medicare Part D. One of the federal government's most successful and cost-effective healthcare programs, Part D provides drug benefits for the elderly and disabled through private insurers to 36 million enrollees.
 

top of page

3/6/14 – Health Affairs - Geographic Variation in Medicare Spending Main Header

Researchers continue to study why Medicare spending per beneficiary varies significantly from one part of the country to another. While geographic variation in Medicare spending per beneficiary is itself well documented, the causes of that variation, whether it is appropriate, and what can be done to reduce spending in high-cost areas are less clear. This brief describes the research on geographic variation in Medicare spending and different interpretations of what it suggests for Medicare payment policy. Medicare is the largest single payer in the United States, providing health insurance for 52 million elderly and disabled beneficiaries. Three out of four Medicare beneficiaries are in traditional fee-for-service (FFS) Medicare, which covers a wide range of acute and post-acute care services including inpatient and outpatient hospital services, physician visits, stays in skilled nursing facilities, home health care, durable medical equipment, and prescription drugs. The types of services covered by FFS Medicare are essentially the same across the country.
 

top of page

2/26/14 – JAMA - Physicians and Medicare

This month’s Visualizing Health Policy takes a look at physicians and Medicare, including information about Medicare’s payment formula for physicians and about access to health care for people covered by Medicare.
 

top of page

2/26/14 – AHIP - Members of Congress Speak Out Against Proposed Cuts to Medicare Advantage

New video of Senate floor speeches highlights value of Medicare Advantage, impact of proposed cuts on seniors; Letter from GOP leadership expresses “deep concerns” with proposed cuts to Medicare Advantage - Several Republican senators gave speeches on the Senate floor yesterday highlighting the value of Medicare Advantage to approximately 15 million Medicare beneficiaries and noting the potential impact of proposed new cuts on seniors. “Our constituents like, they like the choices Medicare Advantage offers,” said Senate Minority Leader Mitch McConnell. Senate Minority Whip John Cornyn said, “the truth is these cuts in Medicare Advantage will force many seniors to pay higher premiums and further undermine their existing health care arrangements.” Senators McConnell and Cornyn joined four other members of the Senate GOP leadership in sending a letter to the Department of Health and Human Services (HHS) yesterday expressing “deep concerns” with proposed new cuts to Medicare Advantage that would “increase premiums, reduce choices, and cause America’s seniors to lose access” to the benefits they depend on.
 

top of page

2/24/14 – Crain’s Detroit Business - Federal Crackdown On Medicare Fraud In Metro Detroit Hits It Big

By Chad Halcom 

The U.S. Department of Justice could dub 2013 the year its fight against Medicare billing fraud in Southeast Michigan yielded the first real payoff. Last year, the Detroit Medicare Fraud Strike Force, deployed here from Washington, and a locally organized Health Care Fraud Unit of prosecutors together brought charges in fraud schemes billing more than $380 million to the federal program. That's more than double the bad billing amount charged in any preceding year. It's been a slow build since the strike force came to Detroit in 2009 as part of the national Health Care Fraud Prevention and Enforcement Action Team, referred to as HEAT, to ferret out what data analysis suggested was hundreds of millions worth of fraud here.
 
 

top of page

2/10/14 – AHIP - Minority Organizations Urge CMS to Keep Medicare Advantage Rates Flat in 2015

The National Hispanic Medical Association (NHMA) and the National Caucus & Center on Black Aged (NCBA) recently sent letters to the Centers for Medicare and Medicaid Services (CMS) urging the Medicare agency to protect the approximately 15 million seniors and people with disabilities enrolled in Medicare Advantage (MA) plans by maintaining current payment levels in 2015. The two letters add to a growing number of diverse voices representing a broad array of individuals, businesses and health care stakeholders expressing concern about the impact additional cuts would have on seniors.
 

top of page

2/10/14 – Health Management Technology - 12 Things To Know About The SGR Repeal Bill

Democratic and Republican leaders in both houses of Congress have finally agreed on a bill that would repeal Medicare's much-maligned physician payment system. But the measure leaves a few questions unanswered. For one thing, the bill doesn't outline a way to pay for itself, which is well recognized as the biggest hurdle to doing away with the sustainable growth rate (SGR) payment formula, especially in an election year. But the language of the deal lawmakers announced Thursday will be pretty close to the one signed into law, if this bill reaches that point. So, it's worthwhile to take a deeper dive now into how the bill -- the SGR Repeal and Medicare Provider Payment Modernization Act -- will change Medicare payments under Part B.
 

top of page

2/10/14 – Yahoo News - AMA Supports Overhaul Of Medicare Doctors' Pay 

AMA Supports Bipartisan Bill To Reward Doctors For Quality Care, Not Just Volume Of Services 

The American Medical Association says it strongly supports legislation that would change the way Medicare pays doctors, to emphasize quality care and not just sheer volume of services. The endorsement Monday from AMA President Ardis Dee Hoven provided a boost for a bipartisan bill moving through Congress. The bill would repeal the centerpiece of the current payment system. That approach relies on automatic cuts to doctors to limit Medicare spending and has proven unworkable.
 

top of page

2/6/14 – Oliver Wyman – Early Indications of Changes to the 2015 Medicare Advantage Payment Methodology and the Potential Effect on Medicare Advantage Organizations and Beneficiaries 

By Glenn Giese FSA, MAAA and Kelly Backes FSA, MAAA

The reimbursement reduction and needed adjustments to MAO pricing will vary considerably by market (e.g., CMS calculates FFS costs on a county level basis). Our purpose here was to estimate reductions and impacts for all MAOs combined. The opinions and conclusions expressed herein reflect technical assessments and analyses, and do not reflect statements or views with respect to public policy. The Actuarial Practice of Oliver Wyman was commissioned by America’s Health Insurance Plan to prepare this report in response to the early indication of CMS’ Advance Notice of Methodological Changes for Calendar Year 2015 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies.
 

top of page

1/19/14 – The Washington Post - Medicare Agency Seeks To Speed Up Appeals For Coverage 

By Susan Jaffe 

Medicare beneficiaries who have been waiting months and even years for a hearing on their appeals for coverage may soon get a break as their cases take top priority in an effort to remedy a massive backlog. Nancy Griswold, the chief judge of the Office of Medicare Hearings and Appeals (OMHA), announced in a memo sent last month to more than 900 appellants and health-care associations that her office has a backlog of nearly 357,000 claims. In response, she said, the agency has suspended action on new requests for hearings filed by hospitals, doctors, nursing homes and other health-care providers, which make up nearly 90 percent of the cases. She said that she expected the suspension would last about two years.
 

top of page

1/13/14 – The Kaiser Family Foundation - Medigap Reform: Setting the Context for Understanding Recent Proposals 

By Gretchen Jacobson, Jennifer Huang and Tricia Neuman 

In recent years, policymakers have focused on a wide range of options to inform the national debt reduction debate, including proposals to help reduce Medicare spending by reforming the current Medicare supplemental insurance (Medigap) market. Due to Medicare’s relatively high cost-sharing requirements, the vast majority of beneficiaries have some source of coverage that supplements Medicare, including 9 million Medicare beneficiaries who purchase Medigap policies. Some beneficiaries with Medigap policies also have other sources of supplemental coverage, including coverage from employer or union-sponsored retiree health plans, the Department of Veterans Affairs (VA) or Medicare Advantage plans. Nationwide, nearly one in four of all Medicare beneficiaries had a Medigap policy in 2010, including beneficiaries with multiple sources of supplemental coverage. Among beneficiaries in traditional Medicare (excluding people in Medicare Advantage), more than one in five (26%) has a Medigap policy.
 

top of page

1/13/14 – The Kaiser Family Foundation - Medicare and the Federal Budget: Comparison of Medicare Provisions in Recent Federal Debt and Deficit Reduction Proposals 

By Gretchen Jacobson 

Medicare savings provisions are often included among broader proposals to reduce the federal deficit and debt. Over the long-term, Medicare faces financial challenges due to the aging of the population and rising healthcare costs (that affect all payers);1 however, over the next decade, Medicare spending, is projected to grow slower than private insurance on a per capita basis, and at about the same rate as the economy. Total Medicare spending increased by 3 percent in 2012 and is projected to increase by 4 percent in 2013, the lowest rates of growth since 2000.2 Nonetheless, ongoing efforts to constrain the growth in Medicare spending are often viewed as important components of deficit and debt reduction proposals.
 

top of page

1/9/14 – MedPAC – Temporary Payment Policies in Medicare 

The Medicare Payment Advisory Commission is a Congressional support agency that provides independent, nonpartisan policy and technical advice to the Congress on issues affecting the Medicare program. The Commission’s goal is to achieve a Medicare program that ensures beneficiary access to high-quality care, pays health care providers and plans fairly, rewards efficiency and quality, and spends tax dollars responsibly. As part of the Commission’s Congressional mandate, each year MedPAC makes recommendations to the Congress on how payments to health care providers in Medicare should be updated or improved. Occasionally the Congress requests that the Commission review specific payment policies in Medicare, including temporary policies that require annual reauthorization at a budgetary cost to the taxpayer. In these instances, the Commission reviews the available data, policy options, and implications, and includes this analysis in our standing reports to Congress.
 

top of page

1/6/14 – Forbes - More Cuts In Store For Medicare Plans -- Here Are The Options That Will Shrink Most For Seniors 

By Scott Gottlieb Sub Header goes here 

The privately run Medicare plans known as “Medicare Advantage” have been in the political crosshairs of the Obama White House. Even after facing steep cuts under Obamacare, the Advantage plans are now slated to take a brand new round of reductions in 2015. These new cuts will cause the private Medicare option to shrink further in the next few years, and pressure the insurance companies that offer them. The latest cuts are the consequence of a slowdown in the overall growth of Medicare spending — some of it owing to reduced utilization of medical services as a result of the slack economy. The Medicare program recently told the private plans that, since per capita costs are trending lower than prior estimates, the feds are now assuming that Medicare Advantage will take another cut in 2015, on top of existing reductions.
 

top of page

12/20/13 – Forbes - Medicare Reports Fraud And Waste Grew In 2013 After Years Of Decline 

By Evan Albright  

Despite expanding its efforts to curtail fraud and waste, a Medicare internal auditor found that the agency’s fee-for-service program’s improper payments grew by almost 19 percent after years of decline. In the U.S. Department of Health and Human Services annual financial report, published Dec. 16, Medicare’s Comprehensive Error Rate Testing (CERT) Program estimated that the agency improperly paid through fraud, waste, and errors, an additional $6.5 billion to healthcare providers over 2012. In all, Medicare paid more than $36 billion in erroneous fee-for-service claims, representing more than one dollar out of every 10 spent on beneficiaries for Medicare Parts A and B. The almost 20 percent increase comes after three years of steady declines, from 10.8 percent in 2010 to a low of 8.5 percent last year. Overall, Medicare improper payments grew from $45 billion to $49 billion.
 

top of page

12/16/13 – U.S. News & World Report - Retirement Benefit Changes for 2014 

By Emily Brandon 

Social Security, Medicare and retirement accounts will all change in modest but important ways in 2014. And for the first time, retirees too young to qualify for Medicare will be guaranteed the right to buy private insurance via their state's health insurance marketplace. Here's what to expect for your retirement benefits next year: Obamacare for early retirees. People who retire before age 65 will now have the option to buy a health plan through their state's health insurance marketplace. "People can no longer be charged more because of their health status or health history," says Karen Pollitz, a senior fellow at the Kaiser Family Foundation. "If you are offered the choice of retiree health benefits, you can compare that cost to what is offered on the exchange and pick the plan that is the better deal for you." If your household income is less than $45,960 ($62,040 for couples) in 2014, you may additionally qualify for a premium subsidy.
 

top of page

12/6/13 – USA Today - Medicare Advantage Ruling May Affect Thousands 

Federal judge temporarily blocks United Healthcare from dropping 2,200 physicians. 

By Susan Jaffe

In a decision that could have national implications, a federal judge in Connecticut temporarily blocked United Healthcare late Thursday from dropping an estimated 2,200 physicians from its Medicare Advantage plan in that state. While the judge's decision affects only the physicians in Fairfield and Hartford Counties who brought suit, several other medical groups are considering filing similar actions. "This is very good news from Connecticut," said Dr. Sam L. Unterricht, president of the Medical Society of the State of New York. "We will definitely seriously consider filing a suit in New York as well."
 

top of page

12/11/13 – The New England Journal of Medicine - Improving Value in Medicare with an SGR Fix Main Header 

By Gail R. Wilensky, Ph.D  

With the end of another year approaching and a scheduled reduction of 24.4% in physician fees, physicians and policymakers are once again concerned about what the sustainable growth rate formula (SGR) that is used to calculate Medicare's physician fees could mean for physician payment. This year, however, is different from most years, when attention has generally been limited to finding ways to postpone the scheduled payment reductions (which have actually been enacted only once). This year, for the first time, bipartisan, bicameral attention is being directed toward developing an alternative reimbursement system that rewards physicians who improve the quality and efficiency of care, rather than just kicking the proverbial SGR can down the road for one more year. Since 1992, Medicare has been reimbursing physicians according to a fee schedule called the resource-based relative-value scale combined with a spending limit that since 1997 has been called a sustainable growth rate. The relative-value scale was designed to create more rational relationships among the payments for the various services that physicians provide. It sets relative prices on the basis of the amount of work associated with a service, the average practice expenses involved, and a geographic adjustment factor. The relative values are converted to dollars by means of a metric called the conversion factor.
 

top of page

12/10/13 – Medpage Today - Medicare: Fines for Readmits Drop 

By Jordan Rau 

During the first 8 months of this year, fewer than 18% of Medicare patients ended up back in the hospital within a month of discharge, the lowest rate in years, the government reported Friday. This drop occurred during the first year that Medicare financially penalized hospitals for their readmission rates, and the government seized on the decrease as evidence the incentives are having an effect. The government is targeting rehospitalizations as a significant indicator of gaps in medical quality in the nation's hospitals. While some elderly patients inevitably return to the hospital, the government and some researchers believe many of those returns are avoidable if hospitals monitor patients after their release to ensure they get appropriate medications and follow-up visits with doctors.
 

top of page

12/5/13 – The Wall Street Journal - Medicare Patients Will Get A Financial Break In 2014 

For Many Retirees, The Most Common Premiums Won’t Rise Next Year 

By Elizabeth O’Brien 

Medicare beneficiaries got some good news this fall, when government officials announced that the Part B monthly premium and annual deductible would remain flat for 2014. The cost picture is more complicated when it comes to other parts of Medicare, however, and beneficiaries face a narrowing window to make changes to coverage before open enrollment ends on Dec 7. That makes this a particularly good time to consider what’s happening on the spending front. The government spent $554.3 billion on Medicare in 2011. That’s a whopping sum, but it belies the recent success the program has had in limiting the growth in spending per enrollee. Medicare per capita spending grew by an annual average of just 2.8% from 2007 to 2011, versus the historic average of 7.9% a year from 1969 to 2011, according to the Centers for Medicare and Medicaid Services, which runs Medicare. This in turn has helped keep costs down for beneficiaries, experts say.
 

top of page

11/26/13 – The Washington Post - What Medicare Can Teach Us About The Future Of Obamacare

By Amy Lerman

Congressional Republicans have consistently voiced their determination to delay implementation of the Patient Protection and Affordable Care Act (ACA). Given the policy’s markedly troubled rollout, Republicans might be right that “Obamacare is not ready” and that postponement is good public policy. However, the recent drop in support for the ACA would seem to suggest that postponement might be good politics, too. Conservative opposition to the ACA is partly driven by fears that, once fully implemented, the program will prove popular and thus be difficult to roll back.

top of page

11/25/13 – Kaiser Family Foundation - Medicare Advantage 2014 Spotlight: Plan Availability and Premiums

By Marsha Gold, Gretchen Jacobson, Anthony Damico and Patricia Neuman

Under the current Medicare program, beneficiaries may enroll in either the traditional Medicare fee-for-service program, or in a private plan, such as an HMO or preferred provider organization (PPO), in what is now known as the Medicare Advantage program. Medicare Advantage plans receive funds from the federal government (Medicare) to provide Medicare-covered benefits to enrollees. As of September 2013, 15 million Medicare beneficiaries (29%) were enrolled in a Medicare Advantage plan. The Affordable Care Act of 2010 (ACA) enacted reductions in payments to Medicare Advantage plans with the goal of creating greater parity in payments between the traditional Medicare program and Medicare Advantage. Beneficiaries will see limited changes in the number of plans offered in 2014. Our analysis finds that beneficiaries will be able to choose from 18 plans, on average, in 2014, down from an average of 20 plans in 2013.
 

top of page

11/14/13 – The Commonwealth Fund - International Profiles of Health Care Systems, 2013: Australia, Canada, Denmark, England, France, Germany, Italy, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States

Edited by Sarah Thomson, London School of Economics and Political Science, Robin Osborn, The Commonwealth Fund, David Squires, The Commonwealth Fund, and Miraya Jun, London School of Economics and Political Science

This publication presents overviews of the health care systems of Australia, Canada, Denmark, England, France, Germany, Japan, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. Each overview covers health insurance, public and private financing, health system organization and governance, health care quality and coordination, disparities, efficiency and integration, use of information technology and evidence-based practice, cost containment, and recent reforms and innovations. In addition, summary tables provide data on a number of key health system characteristics and performance indicators, including overall health care spending, hospital spending and utilization, health care access, patient safety, care coordination, chronic care management, disease prevention, capacity for quality improvement, and public views.
 

top of page

11/13/13 – Yahoo News - 4 Keys To Scrutinizing Medicare Advantage Cuts

4 Enrollment Issues To Consider As Insurers Adjust To Medicare Advantage Funding Cuts

By Tom Murphy

Ominous warnings about Medicare Advantage plans have sounded for more than a year now. Health insurers say federal funding cuts to these privately run versions of Medicare will force them to whack plan benefits, hike premiums or leave some geographic markets entirely as they continue to fight rising health care costs. The government is paring back the money it provides for this coverage as part of its effort to fund the health care overhaul, which aims to cover millions of uninsured people. Plan changes are starting to crystallize for Medicare Advantage customers who are about a month into the annual open enrollment window in which they can search for new coverage. Benefits experts say patients are seeing fewer plan choices this year, and more are losing doctors from their insurance coverage networks. Open enrollment lasts until Dec. 7, and many customers wait until the final weeks to pick a plan.
 

top of page

11/11/13 - Forbes - Obamacare Tax Could Surprise Some Wealthy Filers

If the 0.9 percent Medicare surtax will hit you next tax season, you might lessen its impact if you act now.

By Ashlea Ebeling

It's hard to keep all the new Obamacare taxes straight, but there's one that some couples won’t see until they file their 2013 taxes next April, and bizarrely it could mean a surprise tax bill or a refund. It's the 0.9 percent Medicare surtax on wages and self-employment income (not to be confused with the separate new 3.8 percent net investment tax on capital gains, dividends and passive income). Can you lessen the bite of the 0.9 percent surtax? In some cases, yes, if you act before year-end, says Mark Nash, a partner in PWC's Private Company Services practice in Dallas. The surtax -- or additional Medicare tax (it is levied on top of the Medicare tax you already pay) -- is effective Jan. 1, 2013 and applies to wages and self-employment income above $250,000 per couple or $200,000 for a single. It applies to active income from a general partnership, but retirees get a break -- distributions from retirement accounts and Social Security benefits aren’t assessed the surtax.
 

top of page

10/30/13 – Office of the Inspector General - Medicare Improperly Paid Millions Of Dollars For Prescription Drugs Provided To Unlawfully Present Beneficiaries During 2009 Through 2011

By Daniel R. Levinson

Federal health care benefits are generally allowable when provided to a beneficiary who is either a U.S. citizen or a U.S. national or to an alien who is lawfully present in the United States. But when the alien beneficiary is present in the United States on an unlawful basis (unlawfully present), Federal health care benefits are not allowable. We are conducting a series of reviews examining Medicare payments made on behalf of unlawfully present beneficiaries. We previously reported that Medicare made improper Part A and Part B payments totaling $91.6 million to health care providers for services to unlawfully present beneficiaries. This is a review of payments made on behalf of unlawfully present beneficiaries in Medicare Part D. The objective of this review was to determine the extent to which the Centers for Medicare & Medicaid Services (CMS) accepted prescription drug event (PDE) records submitted by sponsors on behalf of unlawfully present beneficiaries during calendar years (CYs) 2009 through 2011. 
 

top of page

10/24/13 – Reuters - U.S. CBO: Savings From Higher Medicare Age Shrink Dramatically

By David Lawder

For U.S. budget negotiators who may want to raise the retirement age by two years to shrink deficits, the Congressional Budget Office has some bad news: the savings would be considerably less than previously thought. The CBO said in a report released on Thursday that raising the normal eligibility age for Medicare health coverage to 67 from 65 in 2016 would reduce federal budget deficits by only $19 billion through 2023. That compares with $113 billion in 10-year savings estimated in a 2012 CBO study of a similar move. The difference is a new analysis of Americans who are 65 and 66. 
 

top of page

10/20/13 – Forbes - Should U.S. Import U.K. Model For Medicare And Medicaid?

By Tomas Philipson

Critics of the Obama administration’s recent health care reform rightly focus on the $1 trillion cost of the legislation and fears that it will add to already unsustainable federal health care commitments for Medicare and Medicaid. Defenders point to the legislation’s cost-saving provisions, like the Independent Payment Advisory Board (IPAB) which, starting in 2014, will recommend automatic Medicare spending cuts if costs grow faster than an average of the consumer price index and health care inflation. For the fiscally minded, so-called “automatic” cuts may sound good, but in this case they’re a mixed blessing. That’s because their impact is likely to fall first on pharmaceutical or medical-device innovation (hospitals and physicians are exempted from IPAB’s knife until 2020).
 

top of page

10/11/13 – Detroit Free Press - What's New For 2014 And Beyond

By Cathy Nelson

This year, Medicare is marking the 48th anniversary of the enactment of the law promising health care coverage to older and disabled Americans. And while the passage of the Affordable Care Act in 2010 resulted in some changes to Medicare, such as more coverage for preventive services, the way you buy and receive Medicare remains the same. “Most of the changes in the Affordable Health Care Act do not affect Medicare,” says Karen Wintringham, vice president of Medicare programs for HAP. “Rather, a major portion of the ACA relates to establishment of coverage for individuals who are not covered by Medicare and for small businesses.”
 

top of page

10/10/13 – Kaiser Family Foundation - To Switch or Not to Switch: Are Medicare Beneficiaries Switching Drug Plans To Save Money?

By Jack Hoadley, Elizabeth Hargrave, Laura Summer, Juliette Cubanski and Patricia Neuman

Each year during the Medicare Part D annual enrollment period that runs between October 15 and December 7, people on Medicare have the opportunity to review and compare the plan options available to them and switch plans if they choose. This analysis examines rates of plan switching among Part D enrollees between 2006 and 2010, focusing on enrollees who do not receive the program’s Low-Income Subsidy. The study finds that relatively few people on Medicare have used the annual opportunity to switch Part D prescription drug plans (PDPs) voluntarily—even though those who do switch often lower their out-of-pocket costs as a result of changing plans.
 

top of page

10/10/13 – Reuters - Sicker Medicaid, Medicare Emergency Patients Less Profitable

By Anne Harding

When a patient with private health insurance seeks outpatient care at the emergency room, the sicker he or she is, the more money the hospital stands to make, a new study shows. But the opposite is true for patients with Medicaid or Medicare insurance: the sicker the patient, the less profitable he or she is to the hospital, Dr. Philip Henneman of the Tufts University School of Medicine in Boston and his colleagues report in the Annals of Emergency Medicine. The results suggest hospitals that seek to move outpatient services off-site (for example, to stand-alone "doc-in-a-box" clinics) may wind up losing money, according to Henneman.
 

top of page

10/1/13 – Kaiser Family Foundation - Obamacare and You: If You Have Medicare… 

If you have Medicare, you will not have to make any changes to your health insurance coverage as a result of Obamacare. You can continue to rely on Medicare to help pay your hospital, physician and other medical expenses. You will still have the option to choose between traditional Medicare or a Medicare Advantage plan (such as a Medicare HMO) offered in your area, and among Medicare prescription drug plans. If you are on Medicare, and low income, you may also qualify for extra help with premiums and cost sharing. The law did not change these options. For more information about your Medicare coverage options, you can visit http://www.medicare.gov or call the 1-800-MEDICARE help line.
 

top of page

Community Resource Center
Get the latest and breaking news sent directly to your mailbox

Have a question for Resource Link?