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From the category archives: healthcare

Why All Hospital Stays Aren’t Created Equal in Medicare

For years, patients and advocates have been warning of the increasing use of the patient classification status known as “observation stays.”  A growing number of patients covered by Medicare, have spent days in the hospital, only to be surprised with large out-of-pocket costs and an inability to access long-term care because they were totally unaware the hospital never actually admitted them as a patient. 

Beginning this summer, a new federal law will require hospitals to tell their Medicare patients if they have not been formally admitted and why. Kaiser Health News reports:

“The NOTICE Act requires that starting Aug. 6, Medicare patients receive a form written in ‘plain language’ after 24 hours of observation care but no later than 36 hours. Under the law, it must explain the reason they have not been admitted and how that decision will affect Medicare’s payment for services and patients’ share of the costs. The information must also be provided verbally, and a doctor or hospital staff member must be available to answer questions.”

A Wall Street Journal investigation showed observation stays at hospitals have increased 156% and explains why many hospitals have lowered their readmissions and thus the fines that come from too many Medicare patients returning to the hospital.  

“...at hospitals around the country, more patients are entering or re-entering hospitals under something called “observation status”—a category that keeps them out of the readmission tallies. Patients on observation status can remain in the hospital for days, and typically receive care that is indistinguishable from inpatient stays, experts say. But under Medicare billing rules, the stays are considered outpatient visits, and as such, don’t trigger penalties under the health law.

The Journal’s analysis of Medicare billing data shows that increases in observation stays can skew the readmission numbers, letting hospitals avoid penalties even if patients continue to have complications and return for repeat visits. Observation stays generally are cheaper for the government, but in some cases they can lead to big bills that are the patient’s responsibility.”

The American Hospital Association has asked that the new rules be delayed and one of the law’s co-sponsors also isn’t happy with the language used to explain observation stays to patients.

“It doesn’t require the hospital to explain exactly why the patient is getting observation care instead of being admitted, he {Rep. Lloyd Doggett (D-TX)} said, and doesn’t clearly explain the difference between Medicare’s Part A hospitalization and nursing home benefit and Part B, which covers outpatient services, including doctor’s visits, lab tests and hospital observation care.

The notice, he said, also does not sufficiently explain why observation patients are ineligible for Medicare’s nursing home coverage, which under law requires at least three consecutive days as an admitted patient.”

Medicare has been taking public comment and we’ll likely hear more implementation details this month. 

Why Silence Isn’t Golden for Millions in Medicare

Nearly 30 million Americans suffer from hearing loss yet a small percentage have hearing aids.  Why? Many simply can’t afford the high cost...and Medicare does not cover hearing aids and related audiology services. 

Currently, Medicare Part B only covers hearing rehabilitation services for cases caused by an illness or accident. Progressive, age-related hearing loss is not covered, leaving many seniors to pay for their own hearing exams and hearing aids. Hearing aids are incredibly expensive, ranging from $600 to over $5,000 each. These high price tags discourage many seniors from seeking a very basic solution that could dramatically improve their lives.

Research shows even mild hearing loss can double the risk of dementia.  Untreated hearing loss also contributes to balance problems and falls, isolation, depression and a greater incidence of stress-related diseases like diabetes and heart disease.  Earlier this month, a Report from the National Academies of Sciences, Engineering, and Medicine found that hearing loss is a public health priority requiring national attention.

That’s why the National Committee is proud to join the Center for Medicare Advocacy, Rep. Rosa DeLauro (D-CT), Rep. Jim McDermott (D-WA) and hearing expert Frank R. Lin, M.D., in a briefing today on the need to expand Medicare to include hearing aids and treatment:

“Intervention would reduce the risks which come with hearing loss. This is hugely important in the case of dementia which, with the aging of the baby boomers, is a massive public health issue now.  Hearing loss may be one of the few modifiable risk factors that could reduce the risk of dementia; however, hearing health care is still broadly inaccessible and expensive.”...Dr. Frank Lin, M.D., Ph.D., Johns Hopkins School of Medicine and Bloomberg School of Public Health

“As always, there will be the critics who say “we can’t afford this” Well, yes we can. When the Affordable Care Act passed, 716 billion dollars in savings from Medicare were plowed right back into the program to provide expanded services such as preventive care and screenings at no cost to beneficiaries. And there are strategies such as restoring the pharmaceutical drug company rebates for medicines prescribed to dual-eligibles, people on both Medicare and Medicaid, which, according to CBO, could generate 121 billion dollars over ten years. If the Congressional will is there, we know it can be done.”...Max Richtman, NCPSSM President/CEO


Legislation introduced by Reps. Debbie Dingell (H.R. 1653), Jim McDermott (H.R. 5396) and Alan Grayson (H.R.3308) would close this gap in Medicare coverage. This legislation is vital to the health security of millions of Americans.

“Since its implementation in 1965, Medicare has enhanced health care for millions of Americans. But there are still major gaps in coverage. Given the growing numbers of older Americans who suffer from hearing loss, it’s time for that to change,” said Judith Stein, J.D., Executive Director of the Center for Medicare Advocacy.

"We don’t know exactly how much we spend on cases where we’re dealing with depression because they’re isolated...and hearing loss contributes to both. It’s absolutely critical that for an acceptable quality of life that people need to be able to hear the world around them.  In order for seniors to keep a good quality of live, just keeping them alive isn’t enough, we must have good hearing and dental care. This is not beyond our capacity to provide this for seniors.”...Rep. Jim McDermott (D-WA) 

“We’ve got millions of Americans over 45 effected by hearing loss. If untreated it has devastating impacts on our nation.  Medicare coverage should include audiology care, period. The promise of Medicare to keep Americans healthy is at stake.  Medicare should cover all the vital health needs of seniors. Why are we arbitrarily leaving some out?  There’s no reason for Medicare to remove the head from the body.”...Rep. Rosa DeLauro (D-CT)


Please call your Member of Congress or Sign our Congressional Petition today and tell them:

  We need hearing care coverage in Medicare.

(800) 998-0180

GOP Appropriators Want to Eliminate Funding for Medicare SHIP Programs

 

Each day 10 thousand Americans become eligible for Medicare.  The aging of the baby boom generation certainly isn’t a surprise to anyone and yet, instead of boosting programs to serve this increased need, Republican Congressional leaders continue to slash and now eliminate programs designed to help millions of aging Americans and their families. 

The latest target is one of the nation’s most effective consumer resources for seniors, the Medicare State Health Insurance Assistance Program (SHIP)

“The SHIP network provides critical information upon which people with Medicare rely to make informed decisions about their coverage options and enrollment decisions,” says Judith A. Stein, Executive Director, Center for Medicare Advocacy, Inc. “The SHIPs are critical to providing assistance with these increasingly complicated choices. People with Medicare and their families from all over the country depend on SHIPs as the key source of unbiased guidance.” 

Incredibly, the Senate Appropriations Committee approved a Fiscal Year 2017 budget appropriations bill that completely eliminates the $52.1 million in funding for SHIP. 

“Senate appropriators have turned their backs on a growing number of people who will need SHIP services to navigate the complexities of Medicare coverage by proposing to eliminate program funding. This kind of penny-wise, pound-foolish lawmaking will threaten the economic security of millions of Medicare beneficiaries and their families.”…Max Richtman, NCPSSM President/CEO

“Understanding the complexities and decisions required for Medicare is an overwhelming, isolating experience for seniors, people with disabilities, and caregivers who don’t know where to get help. For millions of Americans, their only option for that help is their SHIP. If SHIPs disappear, there is no replacement for the critical services they provide. The loss of SHIPs threatens the economic security and the health of all current Medicare beneficiaries and the thousands who become eligible every day.”…James Firman, President and CEO of the NCOA 

"Eliminating SHIPs would leave millions of older Americans, people with disabilities, and families who need help comparing coverage options, appealing denials, applying for financial assistance, and navigating an evolving and increasingly complex program stranded—with nowhere to turn. With 10,000 Baby Boomers aging into Medicare each day, it is imperative that the U.S. House of Representatives reject this unprecedented, nonsensical cut."…Joe Baker, President of the Medicare Rights Center

In case you have any doubt about the need for SHIP services consider this:  today’s Medicare beneficiary must choose among more than 20 prescription drug plans, an average of 19 Medicare Advantage plans, as well as various Medigap supplemental insurance policies—all with different premiums, cost sharing, provider networks, and coverage rules. SHIPs also help beneficiaries resolve fraud and abuse issues, billing problems, appeals, and enrollment in low-income health assistance programs. In 2015, SHIPs provided one-on-one assistance to more than seven million individuals and in the past decade, the number of beneficiaries receiving personalized counseling from SHIPs has tripled.

Not a day goes by that we don’t hear horror stories of seniors and their families who face severe economic hardship and even bankruptcy because of a bad choice made in their healthcare options.  That’s exactly why SHIP is so vitally important.    

We’re proud to join a coalition of aging organizations including; The Center for Medicare Advocacy, Medicare Rights Center, and National Council on Aging (NCOA) to fight for a reversal of this outrageous Senate move to eliminate seniors’ access to desperately needed SHIP services.

We urge you to call your Senators and Representative and tell them:  Americans Need SHIP.

 

1-800-998-0180

Nursing Homes Say: Hold the Meatloaf...Pass the Lo Mein, Please

There’s a growing trend among the nation’s more than 15 thousand nursing homes to break away from rigid meal schedules and standard menus to individualized meals which acknowledge their residents’ dietary, ethnic and cultural diversity.  Rather than chicken and mashed potatoes Tuesdays imagine instead a Thai-style soup with fresh ginger, vegetables and thin-sliced beef as an option.

The Associated Press reports:

“...the federal government is proposing regulations that would require facilities to create menus that reflect religious, cultural and ethnic needs and preferences, as well. Further, the proposed rules would empower nursing home residents with the "right to make personal dietary choices."

The government acknowledges that the nation's 1.4 million nursing home residents are diverse and that ‘it may be challenging’ to meet every preference. But it wants facilities to offer residents ‘meaningful choices in diets that are nutritionally adequate and satisfying to the individual.’ “

Advocates have argued for these changes for decades but cost is a challenge. 

“Janet Burns, chief executive at Sunny Vista, said the cost of fresh food is lower than prepackaged meals, but labor costs are higher. Her dietary costs were $1.08 higher than the nation's average in 2014. However, she said, higher costs are offset by things like preventing weight loss, a problem experienced by many nursing home residents. For example, she said, medication to increase a resident's appetite is more expensive than preparing a special meal. Costs aside, Burns said, ‘It's the right thing to do.’"

The benefits of more appealing and healthier food options could improve not only the quality of life but the health of residents.

“Sandra Simmons, a professor at Vanderbilt University who studies quality of care and life in institutional settings, says studies have shown that the daily caloric intake of 50 percent to 70 percent of nursing home residents is below recommended levels, she said.”

Something as simple as providing more appealing menus could make the difference. 

New Medicaid Rules Designed to Put Care Over Profit

CMS has announced tightened Medicaid rules for private insurance plans that administer most Medicaid benefits for the poor. The Obama administration says the rules will limit profits, ease enrollment, require minimum levels of participating doctors and eventually provide quality ratings.  However, those ratings would still be years away as the industry continues to fight against such measures. 

Kaiser Health News provides details on the biggest changes for Medicaid managed care in a decade.  The new rules will:

  • Require states to set rules ensuring Medicaid plans have enough physicians in the right places. The standards will include “time and distance” maximums to ensure doctors aren’t too far away from members.
  • Limit insurer profits by requiring rate setting that assumes 85 percent of revenue will be spent on medical care. Unlike a similar rule for other plans, such as insurance sold through Obamacare marketplaces, the requirement would not compel Medicaid insurers to rebate the difference if they don’t hit 85 percent. Future rates would be adjusted instead.
  • Make plans regularly update directories of doctors and hospitals. A 2014 investigation by the Department of Health and Human Services’ inspector general found that half the doctors listed in official insurer directories weren’t taking new Medicaid patients.
  • Push plans to better detect and prevent fraud by providers, including mandatory reporting of suspected abuse to the states.
  • Tighten rules for Medicaid plans and states to collect patient data and submit it to HHS.
  • Make it easier for states to offer managed-care plans incentives to improve clinical outcomes, reduce costs and share patient information among hospitals and doctors.

Nearly two-thirds of Medicaid’s 72 million member are enrolled in private managed-care plans.  Consumer advocates have pushed HHS to set stricter rules for managed-care plans, which they said too often favored profits over patients. The industry and some state Medicaid directors resisted, saying plans needed flexibility to serve different members in different states.

The rules will be phased-in over the next three years, starting next summer. 


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