Bipartisan Deficit Commision Unlikely To Make Big Medicare Changes

Topics: Health Costs, Medicare

Oct 01, 2010

National Journal: "For all of the attention surrounding President Obama's bipartisan commission on deficit reduction, the country's biggest cost centers — health care in general and Medicare specifically — will likely remain unscathed when the panel offers its recommendations in December. The reason is simple: When congressional Democrats crafted the health care reform package, which became law a little more than six months ago, they did so by squeezing Medicare as much as they could politically … The Democrats' nifty feat of taking out more than $500 billion from Medicare, mostly by reducing provider payments and changing how the system pays private health insurance companies, has handcuffed the Republican budget hawks who serve on the panel. The cuts have left them nibbling around the edges in an attempt to reduce the nation's $2.5 trillion health care tab" (DoBias, 10/2). This is part of Kaiser Health News' Daily Report - a summary of health policy coverage from more than 300 news organizations. The full summary of the day's news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

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How Medicare is Failing Diabetic Americans

Bill was 67-year old real estate agent. He was semi-retired. He like showing houses because he had lived in the same small town his whole life. People trusted him. But one day he got a diabetic foot infection. He called his primary care doctor and was referred to a podiatrist. But the podiatrist didn't have any more "Medicare appointment slots" available until the end of the month. While waiting for the appointment, the infection got worse. So instead of high quality care, Bill got an amputation. Now he sits in a wheelchair, wishing he could sell houses.

Retired Americans often view Health Care paid for by Medicare as one of the few perks of retiring. After a lifetime of working hard, raising children, and paying into the System, Medicare is one of the few reliable ways to get a return. But unfortunately for those who are diabetic, Medicare can be bad for your health. It's just math; not enough money equals not enough high quality medical care.

The recent attempted resurrection of President Obama's Health Care reform efforts speak to the broken system. The fact is that Medicare is an expensive program. Since 2002, Medicare has been short of money. There is only just so much money to go around. All of the federal mandates that have been written into law to save money are simply killing diabetics. As long as you understand why, you'll be able to get quality care even if you do have Medicare.

1. Difficult to Find a Medicare Doctor.

Since 1986 Medicare has set all doctor fees. Doctors don't decide how much they get paid, Medicare decides. Adjusted for inflation, over the last eight years, Medicare Has reduced fees about 20% every year. On March 1, 2010 doctors took another hit when Congress let another 21.2% reduction in doctor pay take effect. Imagine if at your job every year you get 20% less pay instead of a raise. How long would it take you to look for another job? Obviously your doctor can't just switch careers, but he can stop taking Medicare.

In some places this means less doctors are available to accept new patients. If you live in San Francisco, the cost of living may be twice that in rural Ohio. But incredibly, doctors seeing patients in San Francisco get paid comparable fees by Medicare. So your doctor has to either learn to live poor or see twice as many patients.

2. Doctors Who Accept Medicare are Swamped.

In 2008, the president of the American Medical Association (AMA) was testifying in front of Congress about declining care for Medicare patients and the problem of Medicare cuts. The AMA President informed congress that the vast majority of doctors in the United States would simply opt-out of Medicare and stop providing care for Medicare patients. Senator Stark replied that since Medicare started reducing payments to doctors many years ago, doctor's have simply seen more and more patients each year to make up for the lost revenue.

But it is now clear that doctor's can't keep seeing more and more patients. Sixty patients in a day is just plain bad medicine. Seven minutes of time in a room with a patient is not enough time to understand blood sugar readings, sugar pills, insulin shots, hypertension, peripheral vascular disease and explain diabetic foot care. It just isn't enough time to practice good medicine. Too many patients and not enough time is a prescription for a diabetic disaster.

3. Less Pay for Medicare Diabetes Doctors.

Many people don't think pay should have anything to do with the quality of the care. But the reality is, it just comes down to math. If your doctor accepts Medicare, but has to see 60 patients a day, you won't get much time. I actually have a doctor friend who says, "I just tell Medicare patients they get two problems to talk about during a visit. Just two," she said holding up two fingers.

But what if you have high blood pressure, diabetes, and you also have a little sore on your foot? If you can only talk about two problems, you'll ignore the diabetic foot ulcer. And if that diabetic foot sore turns in to a diabetic foot infection, you just might wind up with an amputation.

When you are allowed the time you need to talk to your doctor, you would and should talk about all of your health concerns. This of course is the way medicine used to be. The fact that most patients don't know is that your doctor is obligated ethically and in many cases legally to hear about all of your health problems that need to be treated. So if you doctor says, "We'll have to discuss that next time," just insist that he hear you out.

4. Medicare is Decreasing Services.

If you have diabetes you will be sent to a lot of different specialists. Studies have shown that having diabetes make you four times more likely to have a heart attack. You are also way more likely to develop kidney trouble, blindness, or diabetic foot infections that lead to amputation. To make sure everything is working right, your primary care doctor will likely send you for "consultations" with other diabetes specialists like podiatrists, cardiologists, opthalmologists and nephrologists.

A consult is a visit to a specialist requested specifically by your primary care doctor. The problem is that Medicare simply stopped paying "consult codes" this year. So don't expect a specialist to take any extra time explaining your health problems to you or your primary care doctor. And don't be surprised if these specialists don't work you into their schedules very quickly. They simply are making money like the once were.

Once upon a time, house calls were common, but now very few doctors who accept Medicare can afford to make house calls. There is just no way they can take the time to drive from house to house with the low rates medicare pays. This is obviously a big problem for an elderly diabetic who may have poor eyesight or an open wound on the foot. If you can't see because of your blindness and aren't supposed to walk on the foot with an open sore, how can you easily get to the doctor's office?

5. No Diabetes Prevention.

It is simply a fact that the problems related to poorly managed diabetes are preventable. Blindness, kidney failure, and diabetic leg amputations are all preventable. Doctors fully understand how elevated blood sugar levels damage the eyes, kidneys and feet. Doctors also fully understand how preventative care can prevent this damage. But Medicare won't pay for intensive diabetic foot monitoring programs. It has been shown that close monitoring of diabetic foot skin temperatures can prevent diabetic foot sores. But this sort of close monitoring by a diabetic foot expert isn't a service that Medicare will pay for. As a result, it is a service that isn't offered to you by your doctor.

So now that you know the Top 5 Reasons Medicare is bad for your diabetes, what can you do about it? First keep in mind that most doctors decided to become doctors because they really and truly want to help people stay healthy and happy. Remember that your doctor is on your team. But feel free to remind him or her that you need help, even if it might take a little extra time. In most cases your doctor will listen.

You've got to ask tons of questions. Take a list of questions so that you can stay on track and get all of your concerns dealt with in a short doctor visit. Ask your doctor about performs house calls. If not, find one that does. Even if you have to pay for it, having a doctor come to your home is an amazing convenience. Make sure you ask your doctor about any new treatments that are available, but not covered by Medicare. If you don't ask, many docs will simply not take the time to offer all available treatments if they aren't covered.

Diabetes is a serious disease. Many patients with diabetes will die from health complications directly attributable to poorly controlled blood sugar. Given that most of these problems can be managed and prevented, you owe it to yourself to insist on the very best care from your doctor.

Dr. Christopher Segler is a podiatrist in the San Francisco Bay Area. He offers House Calls for diabetic foot exams, Diabetic Foot Emergencies, and Diabetic Foot Wound Treatment. Serving San Francisco, Marin, Palo Alto, and Walnut Creek. You can learn more about house calls as solution to foot pain at San Francisco Podiatrist housecalls or visit the best info on San Francisco Podiatry.

Medicare Supplement - Common Terms

Medicare Supplement plans plug the Medicare holes so you do not have the out of pocket costs Original Medicare will leave you with. So let us talk about some of the common terms you need to be aware of with Medicare and a Medicare Supplement plan:

Common Terms:

California Open Enrollment - (Unique to California) the ability of a Medicare Supplement member to switch to another company each year on the month of their birthday. This is a guaranteed issue option. You cannot be denied the transfer because of health status.

Original Medicare - Run by the Federal government and provides both Part A and Part B coverage.

Medicare Part A - is the hospital coverage Medicare pays for. You are responsible for the $1,100 deductible each benefit period (60 days) you enter a hospital.

Medicare Part B - the out patient Medicare coverage for physician, specialist and surgery services. There is a $155 Part B annual deductible you will need to pay the beginning of each calender year when you see a physician.

Part B premium - All Medicare beneficiaries are required to pay for their Part B premium. In 2010 the monthly premium is $96.40. If your annual income is higher than $85,000 your premium increases to $110.50. (other rules apply).
Assignment - an arrangement whereby a physician or hospital agrees to accept the Medicare-approved amount as full payment for services and supplies covered under Part B. Medicare usually pays 80% of the approved amount directly to the physician after the beneficiary satisfies the Part B deductible of $155.00. The Medicare Supplement member pays the other 20%.

Skilled Nursing Facility - (Medicare Part A) A medical care facility used primarily for rehabilitation. Patients are typically in a Skilled Nursing Facility when they are recuperating from an accident, illness or surgical procedure. Medicare typically pays all costs except $137.50 per day. Medicare will not continue to pay for this service is the person has a degenerative condition. In other words, the patients condition should be improving, if not, the coverage is stopped and a long term care policy or medicaid is necessary to continue to pay for these services.

Medicare Part D - Medicare Prescription Drug Coverage. Helps cover the cost of prescription drugs. Must be purchased from a private insurance company.

Part B Coinsurance - After the Part B deductible, Medicare requires you to pay 20% of all Medicare eligible expenses for physician, specialist, ambulance and hospital outpatient services and supplies.

Excess Charges - When your medical bill for Part B services exceeds the Medicare eligible expense. For example; if the Medicare allowable charge for a certain visit or procedure is $100. Medicare Part B pays $80 and the Medicare Supplement pays the remaining $20, if the Medicare Supplement pays for Excess Charges. Some plans do not cover this extra charge.

Initial Enrollment Period - (IEP) Your enrollment is guaranteed if you apply for coverage before or within six months of enrolling in Medicare Part B.
The terms above are some of the most common terms pertaining to a Medicare Supplement plan and you should become familiar with these terms when purchasing a plan. Please contact a Medicare specialist for more information.

I have been assisting clients for over 20 years in the Health Insurance and Medicare Supplement market.

I live in Sacramento with my wife and three children, and offer my services throughout California, Nevada and Colorado. When I'm not busy helping clients, I'm usually fixing my kids flat tires, helping with homework, or fighting with my backyard vineyard.

Bloomberg Analysis Finds 'Doughnut Hole' Deal To Cost Drugmakers Less Than 1% Of Profits

News outlets report how closing the Medicare 'Doughnut Hole' affects drugmakers and seniors.

Bloomberg: "Drugmakers led by Pfizer Inc., AstraZeneca and Bristol-Myers Squibb Co. may provide more than $2 billion in drug discounts to senior citizens next year under a deal pharmaceutical companies made with the White House, according to data compiled by Bloomberg." The data came from a recent report released by Medicare. "Pfizer, the world's largest drug company, will cede less than half of 1 percent of its $50 billion in annual revenue under the arrangement." Les Funteyder, a health care analyst in New York, calls it "a good deal for pharma."

The arrangement "provides Medicare beneficiaries who fall into a coverage gap known as the 'doughnut hole' 50 percent off brand-name medications. Worldwide sales by brand-name drugmakers in 2008 totaled $288 billion, according to data from the drug industry's trade association." As part of the deal struck between Democrats and drugmakers, "In return for providing the price breaks and other concessions, pharmaceutical companies avoided policies such as allowing importation of drugs and having the government negotiate drug prices for Medicare beneficiaries" (Armstrong, 10/1).

In a reported column, NorthJersey.com explains the seniors' perspective: "Over time, the Affordable Care Act will close the doughnut hole entirely. In 2011, pharmaceutical companies will provide a discount of 50 percent on brand-name drugs to low- and middle-income beneficiaries who find themselves in the gap. Then, the doughnut hole itself will shrink a bit every year, ultimately disappearing entirely in 2020. But for starters, doughnut-hole victims get a one-time, tax-free $250 rebate check this year" (Miller, 10/1).

Meanwhile, in a second story, Bloomberg reports that "Wal-Mart Stores Inc., the world's largest retailer, said it will team with health insurer Humana Inc. to offer the cheapest prescription drug plan in the U.S., as the companies seek to take sales of medications from rivals. The companies will begin marketing the plan today to Americans in Medicare ..., William Fleming, a Humana vice-president, said in a conference call yesterday. The policies, which take effect Jan. 1, will cost $14.80 a month, less than half the average premium this year, and will boost sales for both companies" (Nussbaum and Boyle, 10/1).

This is part of Kaiser Health News' Daily Report - a summary of health policy coverage from more than 300 news organizations. The full summary of the day's news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

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My Medicare Advantage Plan is Not Renewing For 2011 - What Should I Do?

Insurance companies that offer Medicare Advantage plans engage in a familiar ritual every fall. Beginning in early October, they introduce their plans for the coming year. This is also the time, if plans are not being renewed for the following year, that notices are sent to those plan members informing them of their plans renewal status and detailing the options that they have available.

If your Medicare Advantage plan is not renewing for 2011, there are certain things that you need to be aware of and several steps that you need to take to make sure that you are properly protected in the coming year.

Understanding the realities of your plans renewal status and knowing what steps to take can give you the piece of mind required to make an informed decision for the following year.

Why do insurance companies choose not to renew their plans?

Often, when Advantage plan members receive a notice from their insurance company informing them that their Medicare Advantage plan will not be renewed, the first response is anger. Most of us like some degree of certainty. Having the rug pulled out from under our feet, especially when it comes to our insurance and health care, is unsettling.

If we understand the reality of how an Advantage plan works, we should be able to anticipate possible changes. When an insurance company contracts with CMS (Centers for Medicare and Medicaid), they agree to an annual contract in a defined County or service area. By design, you should be aware that things can change from year to year. Understanding this can alleviate any anger.

Beginning in January 2011, companies that offer PFFS (private fee-for-service) Advantage plans, will be required to allow those members access to a provider network should they decide to utilize it. A PFFS plan is not a network based plan, but rather members are able to visit any provider that accepts Medicare assignment. The provider must agree to accept the plans payment terms and conditions, as well as having the right to accept the plan on a visit-by-visit basis.

If a company decides not to renew your Medicare Advantage plan for 2011, this could be due to not having a credible network in place for your County or service area. If an insurance company only has one plan available, and it is a PFFS plan, it may be an easier and a more cost efficient solution for them to merely pull out of the market.

What do I need to know?

First, you need to be aware that the insurance company has a contractual obligation to honor their commitment to you. Your plan is still a valid plan for you to use for the remainder of the calendar year. Claims will still be paid and customer service will still assist you with any issues that may arise.

In addition, you now have a guaranteed enrollment period to apply for a Medigap insurance policy. If you decide to apply for a Medigap policy, which is also known as a Medicare supplement, the company cannot refuse to sell you any plan that they offer. Health conditions will not prevent you from purchasing a Medicare supplement during a guaranteed enrollment period.

What do I need to do?

If your Medicare Advantage plan is not renewing for 2011, you need to assess you options. It is comforting to know that you have several choices.

Return to traditional Medicare and purchase Part D drug coverage. Enroll in another Advantage plan. Purchase a Medicare supplement and Part D drug coverage.

If your Medicare Advantage plan is not renewing for 2011, start exploring you options early. Your current Advantage plan will end at midnight December 31st. You are not required to stay with the same company should they have an alternative plan available. It is in you best interests to take this time to look at all available options. Armed with knowledge, you can choose the right coverage and be protected for the following year.

David Forbes is President of Alliance Marketing Associates, Inc. David enables older adults to make informed decisions to protect their health and wealth. He also offers helpful advice on topics related to insurance for seniors, including finding an affordable Medicare Plan.

Sign up for your Free Mini-Course on Medicare Plans at http://www.affordablemedicareplan.com/

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Medicare Disability Benefits Are More Comprehensive When You Enroll in a Medicare Advantage Plan

Medicare benefits are available for people under 65 due to a disability or ESRD (end stage renal disease). If you or someone you know is eligible for Medicare benefits due to a disability, you will have the same benefits as a Medicare beneficiary who is over 65. That is the good news. The bad news is, you may not have as many options for supplemental coverage as the person over 65.

Generally, when you turn 65 and enroll in Medicare, you have three options.

Enroll in Medicare and pay out-of-pocket for the portion of charges that Medicare does not cover. Purchase a Medicare supplement (Medigap policy) during your open enrollment period. Enroll in a Medicare Advantage plan that may even include the Part D Medicare drug coverage.

If you are receiving Medicare disability benefits, you can choose the first option and pay the out-of-pocket charges that Medicare does not cover. This will include a hospital deductible, hospital co-pays for extended stays and 20% of the charges for outpatient services. This can be a slippery slope. You are more than likely on a fixed income of SSI and the gaps in Medicare can be unpredictable and potentially financially devastating. Due to the nature of your Medicare eligibility, a qualifying disability, your health care costs may be higher than someone becoming eligible due to turning 65.

The second option, purchasing a Medicare supplement, may not even be available to you. Federal law does not currently require insurance companies to sell you a Medicare supplement if you are younger than 65. Although, some States require companies to do so, it generally means that you will pay a much higher premium than someone who is 65.

A Medicare Advantage plan is available to all beneficiaries, including those receiving Medicare disability benefits. If you have both parts A and B of Medicare, live in the plans service area and do not have ESRD, you are allowed to enroll in a Medicare Advantage plan.

These are the benefits of an Advantage plan for those receiving Medicare disability benefits.

An Advantage plan offers the certainty of fixed costs, including; co-pays, co-insurance and deductibles. The uncertainty of outpatient costs (20%) are eliminated with co-pays and co-insurance. The premium (if required) is usually a fraction of the premium for a Medicare supplement. The Part D Medicare drug plan is often included. Advantage plans often include benefits beyond what Medicare includes. Extras can include dental, vision, hearing, gym memberships, discounts on alternative health services and transportation to and from medical appointments. A Special Needs Plan may be available for qualifying chronic conditions. These plans include a comprehensive level of managed care related to your health condition.

An Advantage plan can give you a more comprehensive health plan than Medicare alone while costing considerably less than a Medicare supplement. When you compare the choices available to you, it is easy to see that a Medicare Advantage plan has a great deal to offer you if you are receiving Medicare disability benefits.

Medicare Advantage Plan Comparison

David Forbes is President of Alliance Marketing Associates, Inc. David offers helpful advice on topics related to insurance for seniors, including finding an affordable Medicare Plan

Sign up for your Free Mini-Course on Medicare Plans at http://www.affordablemedicareplan.com/

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What Can I Do If My Medicare Advantage plan gets canceled in 2010?

Health insurers withdraw plans for different reasons, e.g. when they introduce a new similar plan or because of their inability to meet CMS enrollment thresholds.

For 2010, many Medicare Advantage Plan providers canceled their private fee-for-service (PFFS) plans in anticipation of the termination of all PFFS plans after December 31, 2010.

When insurers cancel plans, the plan members may be automatically enrolled in a similar plan. This automatic roll-over however does not mean that the insured cannot select other plans that are more suited to their needs, even if that means opting for another carrier.

Contact a local health insurance broker or visit plan comparison sites like Medicare Advantage Supplement Info to obtain information on other Medicare Advantage Plans available to you.