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Posts Tagged 'congress'

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Medicare Therapy Caps: It's Time for a Permanent Repeal

Many of us have loved ones who’ve heard those dreaded words “Medicare won’t approve any more physical therapy (or occupational therapy or speech therapy) for you this year” – or have been told the same thing ourselves.  Whether recovering from a stroke, heart attack, serious fall or myriad other conditions, few things are more frustrating for convalescing seniors than being informed they have hit a coverage limit in the midst of medically necessary therapy.

Congress imposed caps on outpatient therapies for Medicare Part B beneficiaries in 1997 as part of the Balanced Budget Act.  Since then, the National Committee and other Medicare advocates have been shouting from the rooftops that therapy caps are bad policy.

Realizing the hardship these caps would cause patients, subsequent Congresses enacted - and continually renewed – an exceptions process for exceeding the caps.  Under this process, beneficiaries could get coverage for therapy beyond the caps until they hit a higher threshold (currently $3700 per year), after which Medicare would manually review every claim before deciding whether to pay.  

However, the current Congress failed to extend the exceptions process, meaning that as of January 1st, all Medicare beneficiaries are subject to a hard, annual cap of $1,980 on physical therapy – and the same for occupational therapy.

In a letter to Congress, the Legislative Council of Aging Organizations (of which the National Committee is a member) says the therapy caps are random – and harmful.

“These arbitrary caps are aimed at federal cost-savings rather than providing clinically appropriate service and disproportionately impact the most vulnerable Medicare beneficiaries who require ongoing therapy services.” – LCAO letter to Congress

Christina Metzler, Chief Public Affairs Officer at the American Occupational Therapy Association (AOTA), says Congress has left the Medicare community in the lurch by failing to at least renew the exceptions process:

“Consumers and practitioners are in a very difficult spot right now.  While few people will hit the cap right away, if you have a severe injury or are just getting out of the hospital, your outpatient visits are going to start piling up.” – Christina Metzler, AOTA, 1/5/18

The Centers for Medicare and Medicaid Services (CMS) has issued zero guidance for providers or patients on how to handle the situation, opening the door for potential confusion and denial of proper care.

Ironically, there already is a bipartisan solution to this problem.  Last fall, Republicans and Democrats on key Senate and House committees agreed on a policy to make the exceptions process permanent – and less onerous for patients and providers.

As Metzler describes it, the bipartisan policy would result in:

*Elimination of therapy caps

*A nimbler process for obtaining coverage beyond cost thresholds

*Greater clarity for beneficiaries and providers

“The benefit of this approach is that there are no caps.  Instead, we’d have a new and different methodology for documenting and reviewing therapy claims. Patients would be assured of a permanent policy, and we wouldn’t be in a situation of confusion where beneficiaries and providers are in the dark.”  - Christina Metzler, AOTA, 1/5/18

The National Committee, AOTA, and other advocacy groups are calling on Congress to attach the bipartisan measure to pending legislation without delay.  Some Hill-watchers believe that reauthorization of the Children’s Health Insurance Program (CHIP) funding is the most likely vehicle.  (Congress would have to act on CHIP by January 19th before some states run out of money for children’s health insurance.)

“Anything less than a permanent fix that finally allows patients to receive medically necessary therapies without interruption or financial worry would be a disservice to everyone who relies on Medicare.” - National Committee president and CEO Max Richtman, 1/8/18

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Here's One Way You May be Overpaying for Prescription Drugs - And How to Avoid It

Did you know that when you lay down $10, $20, or $30 for a copay at the pharmacy that you may be overpaying for the prescription itself --- and a third party may be pocketing the difference?  Or that you might save money by not going through insurance at all and paying a reduced cash price for the medication?  Such is the head-spinning – and sometimes unethical – world of prescription drug benefits in the second decade of the 21st century.

Middlemen called Pharmacy Benefit Managers (PBMs) can skim extra profit by overcharging for medications.  The PBMs’ ostensible purpose is to negotiate favorable pricing with pharmaceutical companies on behalf of insurers, including Medicare.  But sometimes, especially with cheaper generic medicines, PBMs excessively mark up those prices and keep the remainder for themselves –  causing consumers to pay more than they should. Unfortunately, this practice is especially costly for older Americans living on fixed incomes. 

Unsuspecting customers are particularly vulnerable when paying co-pays at their local pharmacy, where PBMs can “claw back” excess profits.  Here’s how it works:

 A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager “claws back” the remainder. – Bloomberg, 2/24/17

(See also the graphic at the bottom of this post for a more detailed explanation of clawbacks.)

Though most customers are unaware of this practice, Bloomberg news reports that it is disturbingly common.  More than 80% of independent pharmacists surveyed said that they have experienced clawbacks from PBMs at least 10 times a month. 

In some cases, there is a simple way for customers to protect themselves from clawbacks. They can simply ask the pharmacist for the cash price of the prescription.  If the cash price is lower than the co-pay, the customer can elect to pay it and bypass the insurance coverage for that medication.  Consumers can also use prescription drug apps to determine the cash price (and available discounts) for various medications.

Unfortunately, PBMs do what they can to keep customers ignorant of this option.  In fact, many PBMs (including one called OptumRx) contractually forbid pharmacists from educating customers about potential alternatives.  

 Pharmacists who contract with OptumRx in 2017 could be terminated for “actions detrimental to the provider network,” doing anything that “disparages” it or trying to “steer” customers to other coverage or discounted plans… - Bloomberg, 2/24/17

Some PBMs further restrict customers’ rights by mandating that enrollees in certain insurance plans use mail order and specialty pharmacies that they own, creating a conflict of interest.

Up to now, PBMs have operated with little transparency, so that no one really knows the inner workings of their deals with the drug companies or the details of their pricing structures.  But pressure has been building on Capitol Hill.  After all, the federal government is the largest health care provider in the country and is motivated to keep prescription drug costs under control.  Hence, a bipartisan bill called the Prescription Drug Price Transparency Act (H.R. 1316) seeks to strengthen oversight of PBMs in the Medicare, Medicaid, and Federal Employee Health Benefit programs.  

Three other bills – one in House and two in the Senate – have been introduced requiring greater transparency and accountability for PBMs. Meanwhile, New York State (under the leadership of Governor Andrew Cuomo) has unveiled new regulations for PBMs, and other states may do the same.

PBMs have also become the target of lawsuits (16 of them since October of last year) and have invited scrutiny from the U.S. Justice Department, which has alleged that the industry “is rife with conflicts of interests and undisclosed arrangements entered into at customers’ expense.”

Of course, the nascent clampdown on PBMs has to be seen in the context of soaring prescription drug prices overall, which are the main driver of rising medical costs.  President Trump pledged to bring down drug prices, but so far has not delivered.  Incremental measures to crack down on pricing abuses by PBMs are a good start. But until consumers receive actual deliverance from prescription price gouging, they will have to try their best to protect themselves.  

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Two Paths Forward on Obamacare: One Reasonable, the Other Perilous

Newly back from summer recess, Senators are taking two divergent paths on healthcare after the Republicans’ spectacular failure to repeal and replace the Affordable Care Act (ACA).  For Americans who rely on the ACA for health insurance, one path is encouraging; the other, fraught with peril. 

On the encouraging side, the Republican and Democratic leaders of the House Education, Labor, and Pensions (HELP) committee are working on a bi-partisan plan to stabilize the ACA insurance markets, recognizing that the healthcare of millions of Americans hangs in the balance.  In fact, Senators Lamar Alexander (R-TN) and Patty Murray (D-WA) are up against a hard deadline.  Insurers need to know the level of federal support for the ACA marketplaces before they set premiums for 2018 at the end of September.

The legislation they devise will likely beef up cost-sharing payments to insurers who waive certain out-of-pocket costs for lower income patients, as well as re-insurance payments to help insurers cover high-risk populations.  While President Trump and hardline conservatives in Congress have indicated they would be content to let the Affordable Care Act languish, Senator Alexander wisely recognizes that the public will hold Republicans accountable if Americans lose healthcare.  In other words, the GOP will own the ACA, whether they like it or not. 

Unlike the Senate and House leadership during the repeal and replace debacle, the HELP committee has been holding hearings (imagine that!) to get input from outside of Congress on possible fixes to the ACA.  Last week, a group of Republican and Democratic governors of widely different ideologies sang from the same hymnal:  the ACA marketplaces must be stabilized.

Senators Alexander and Murray must finish their hearings, mark-up the bill, pass it out of committee, and hope that it reaches the Senate floor.  If Senate leadership feels the bill has bipartisan support, it may come to a vote.  Whether all of that can happen by the end of September is anyone’s guess.

On the discouraging side, Senators Bill Cassidy (R-LA) and Lindsey Graham (R-SC) just won’t let go of the repeal and replace agenda.  Undaunted by the GOP’s failure to get rid of the Affordable Care Act, Senators Cassidy and Graham are working on legislation to try, try again.  The Cassidy-Graham amendment is just as bad as - if not worse than - the failed Senate repeal bill last summer, and retains many of the most objectionable parts of the House-passed legislation.  Among other things, Cassidy-Graham:

*Ends the ACA’s Medicaid expansion  

*Cuts hundreds of billions of dollars in Medicaid spending

*Imposes per capita caps on Medicaid payments to the states

*Ends ACA subsidies and replaces them with inadequate block grants

*Leaves older and poorer Americans with no guarantee of affordable or adequate coverage

Were Senators Cassidy and Graham not paying attention when Americans at town halls across the nation expressed outrage at the GOP repeal and replace plans, including drastic cuts to Medicaid and more than 20 million people losing health coverage?  Did they not take seriously the Congressional Budget Office reporting on the negative impacts of repeal and replace on everyday Americans?  Apparently not. 

Fortunately for seniors – and all Americans who need healthcare – Senators Cassidy and Graham are running out of time.  Under Senate rules, their amendment cannot pass with a simple majority vote after the fiscal year ends on September 30th.  If they wanted to keep pushing for passage after that, they’d need 60 votes under regular order – a threshold they are not likely to meet.

Of course, it is premature for supporters of the ACA to declare victory.  We have seen seemingly dead repeal and replace bills suddenly spring back to life.  The legislative rollercoaster of last Spring and Summer are fresh in our memories.  Advocates and everyday Americans must keep the pressure on their elected representatives to work in a bipartisan fashion (like Sens. Alexander and Murray) to strengthen the Affordable Care Act– and reject repeal and replace once and for all.

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Coming soon to a pharmacy or grocery store near you: Hi-Quality Over the Counter Hearing Aids

Seniors suffering from hearing loss have good reason to cheer. They should soon be able to purchase quality hearing aids over the counter. The Over the Counter (OTC) Hearing Aid Act of 2017 is poised to become law.  Passed by Congress this summer, the Act authorizes the FDA to create a new category of regulated, over the counter hearing aids.  With 30 million Americans (and 4 in 5 seniors) experiencing hearing loss, this is sweet relief for seniors’ pocketbooks and overall health.

Prescription hearing aids can cost as much as $2,500 each (or $5,000 a pair).  The hefty price tag can be a severe strain for seniors living on fixed incomes, especially since Medicare does not cover hearing aids. That’s why some 70% of Americans between age 65 and 84 with hearing loss are not using hearing aids.  They simply cannot afford to. 

The anticipated new generation of OTC hearing aids – meant for people with “mild to moderate” hearing loss – will retail for a fraction of the prescription price:

“By opening the market to OTC aids, manufacturers of consumer electronics --- from giants such as Apple and Samsung to small startups --- could enter the hearing aid space and sell directly to consumers… [at a retail price] between $150 and 299.” - The Hill Newspaper

Imagine being able to buy high-quality hearing aids at your local pharmacy or grocery store for as little as $150, bypassing the time-consuming and expensive process of acquiring them from an audiologist.  Of course, those with more serious hearing impairment will and should continue to seek prescription hearing aids through a specialist.

As we discussed yesterday on Facebook Live, this is not just a matter of personal cost.  It’s a public health issue. Hearing loss is a gateway to other potential medical problems – including fatigue, stress, depression and memory loss.  Access to affordable, high-quality OTC hearing aids means that millions of seniors will likely be able to hear better and stay healthier.

National Committee President Max Richtman hailed the new law as a victory for seniors and all Americans with hearing impairment:

“As someone who suffers from hearing loss, I understand what this new law means for seniors’ health – and their pocketbooks.  While we hope that Medicare will eventually cover hearing aids, the OTC Hearing Aid Act is a common sense, compassionate measure that will improve seniors’ access to quality devices.” – Max Richtman, President of the National Committee to Preserve Social Security and Medicare

The new law is the product of the kind of bipartisanship that most Americans yearn for.  It was cosponsored by Senators Elizabeth Warren (D-MA) and Charles Grassley (R-IA). The House bill was cosponsored by Democratic representative Joe Kennedy III and Republican Congresswoman Marsha Blackburn. The Over the Counter Hearing Aid Act of 2017 proves that, under the right circumstances, sensible members of both parties can come together to improve the lives of ordinary Americans.

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Summertime No Time to Stop Protecting Seniors' Healthcare

Washington, D.C. is noticeably mellower with Congress beginning its August recess.  Our “worst-in-the-U.S.” traffic is noticeably lighter.  The sidewalks are emptier.  The news from Capitol Hill has slowed to a trickle.  But the summer doldrums are no time for advocates here in D.C. or the 50 states to let our guard down.  (We just discussed this on "Behind the Headlines" from Capitol Hill on Facebook Live.) 

Last week, we narrowly escaped the passage of healthcare legislation that would have been devastating for poorer, older, and sicker Americans. The heroism of three GOP Senators and a united Democratic party pulled us back from the brink by voting against the latest Obamacare repeal bill.  

Make no mistake, intense grassroots activism in Congressional districts across the country played no small part in the defeat of repeal legislation in both houses of Congress.  From New Hampshire to Nevada, everyday Americans challenged their elected representatives to protect their healthcare – and won in a heart-pounding showdown.  

In the end, only Senators Collins, Murkowski, and McCain had the courage to defy party leadership and do the right thing.  That’s a thin reed on which to hang future hopes.  If a single one of those votes had gone the other way, at least 22 million Americans would have been well on their way to losing healthcare coverage – and the Medicaid program would have been decimated.  In fact, it’s disappointing that some of the Republican moderates who seemed to oppose the various repeal bills voted yes in the end.  Perhaps it’s because Senator McCain’s no vote gave them cover.  But where is the courage in that?

While Senate Majority Leader Mitch McConnell says it’s time to “move on,” Speaker Paul Ryan signaled that the House isn’t done trying to repeal the Affordable Care Act.   Meanwhile, President Trump continues to threaten to cut off crucial cost-sharing payments, spooking insurers and threatening to drive up premiums.  As Phil Moeller pointed out in his column for PBS NewsHour, there’s a real danger that the majority party will re-attack Obamacare after August recess ends.  

With Capitol Hill’s largely silent and long-postponed summer vacations underway, there is little appetite for re-engaging in nasty policy fights. But when the leaders and their troops are rested, there is little doubt that [they] will be back at it again. – Phil Moeller, PBS NewsHour

This means that we in the advocacy community cannot simply relax this month – tempting as that may be.  Advocates and everyday activists must continue to deliver the message to our elected representatives that it’s time to stop trying to destroy the Affordable Care Act and work across the aisle to improve it, as National Committee President Max Richtman argued in The Hill newspaper this week.  We must maintain the drumbeat whenever and wherever we encounter members of Congress this summer:  at their district offices, by phone, by email, or around town.

Make no mistake:  the activism we saw last winter and spring made a difference.  Members of Congress heard their constituents loud and clear at contentious town halls.  Phone lines, fax lines, and email accounts were jammed. Congress heard us when we said “Hands Off Our Healthcare!”

But even after all that full-throated activism, several GOP moderates in the House and Senate still caved when it was time to cast crucial votes. We came dangerously close to losing the Affordable Care Act. If anything, we must step up our activism.  We must make the case for protecting the healthcare of seniors – and all Americans – even more vociferously, letting our leaders know in personal terms the true impact of changes to our healthcare coverage. But we must also demand that our elected representatives talk to us. Hold town halls, don’t cancel them.  Keep phone lines open instead of shutting them down.  Hear us instead of hiding. And if there are future votes to undermine our healthcare, we must insist that more GOP moderates stick to their stated principles instead of running with the herd.


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