Archive for July, 2008
It always seems like it’s in fashion to blame the government for anything that goes wrong with prices, with the system or systems, or anything else that people can blame them for. We humans just need to have a reason for everything that happens; that’s just how we are.
There are, however, some things that can legitimately be blamed on the government, at least in part. Then there are other things that there is nobody else to legitimately blame, like the cost of gas or the problems with taxes in this country.
One area that the government gets most of the prize for is the Medicare crisis. People blame it on poor planning, poor communication, poor management and a million other reasons, but they always throw the government into the mix no matter what they feel is involved.
In looking at the effects of whatever is happening and whoever is responsible, it has become more and more evident that the Medicare system is a tangled maze that is confusing to the people who are supposed to be helped by it the most – Medicare beneficiaries. Most of these individuals are seniors, many of them are vulnerable, and all of them depend on the benefits from Medicare to help them maintain an ongoing relationship with a physician.
Many seniors who are covered by Medicare are not aware of the gaps in coverage that leave them vulnerable. For instance, one lady with cancer who used to have a $50 copay for her cancer medicine now has to pa $300 out of pocket per month for the same medication while on Medicare. She finally worked out the details and was able to get most of this covered, however, when she gets to 9 months of medication, she will hit the coverage gap – the black hole – where she has to pay for these prescriptions out of pocket for the rest of the year. The problem is that nobody warned her about any of this, and she is unable to afford the cost. As a result, she will have to go without or go to Mexico for treatment because there are no generic medications to use instead of the brand name ones she is using.
This is a confusing and frightening situation that many seniors are facing today, and it is unfortunate that the Medicare maze keeps getting more twists and turns rather than less. Hopefully the government can make some positive changes that will help simplify Medicare, and, for a change, they can get blamed for something good.
Recently, with all the wrangling back and forth between Congress and the White House regarding the new Medicare legislation that was approved, then vetoed and then approved again over the veto, we have heard a lot of the negatives of this legislation. It’s time that we focus on the positive aspects of the legislation.
This legislation helps seniors where it is most important. For one thing, it will maintain and reinforce the relationship between seniors on Medicare and their physicians. The legislation has blocked a 10.6% cut in pay to doctors who treat patients on Medicare. This is essential, since many of these doctors are treating patients on Medicare at a loss in revenue at current rates, so lowering the amount that we pay to them would make things much more difficult. In fact, not allowing that pay cut to doctors has ensured that millions of Medicare recipients will be able to keep seeing the doctors that they feel comfortable with, the doctors that know them and know how to treat their medical needs, therefore, helping them to stay healthier longer.
Other positive benefits that this legislation will provide include assistance for low income individuals who need help with co-payments and other related expenses. It is essential that our most vulnerable population – seniors, especially those with very little means – do not miss out on receiving ongoing medical care and treatment because they cannot afford a few dollars for a copy to a doctor or pharmacy.
There are more positive benefits of the legislations, as well. There is some coverage for preventative medicine. Each new enrollee to Medicare will receive a comprehensive physical. In determining the health of each individual right at the beginning of their enrollment, there is a better chance for ongoing healthcare that will help maintain and individual’s health and identify any conditions or issues that need to be addressed.
Positive benefits also include stronger Mental Health benefits by equalizing benefits. In the past, Mental Health benefits have been paid at 50% vs. medical benefits that are paid at 80%. The new legislation pays both medical and mental health services at the same rate, making it much easier for seniors to afford and access mental health services that are so essential.
Time will tell how well the new legislation works and how much it helps those individuals who depend on Medicare for their health care needs. In the meantime, there is at least tangible help available that should protect some of the most vulnerable among us.
In 2006 Medicare made it mandatory for all pharmacies accepting Medicare as payment for prescriptions become ready for E-Prescriptions. Two years later, currently in 2008, Medicare is offering doctors who use E-Prescriptions when prescribing prescription medications, a bonus for five years, beginning in 2009.
Because there have been so many errors when it comes to writing and reading prescriptions, and too many of these errors have been fatal, Medicare is doing all it can to get physicians and their offices on board with writing E-Prescriptions, including offering the financial incentive.
This creates extra money for the doctors, less problems for the pharmacies and more safety for the patients. That is one side of the situation.
The other side of the situation is that in order for the doctors to be able to write E-Prescriptions, it will involve them buying software and other programs, which will involve them spending extra money.
Though the doctors will be receiving a 2% bonus during the first two years, it is estimated that the cost of the system alone – up front and in advance of bringing in any money – is anywhere from $2,000 to $4,000, which is a good sized investment in an already thinly-stretched medical practice whose Medicare reimbursements usually do not even cover the costs of services to the patients these doctors serve who are using Medicare as payment.
We are not talking about huge, upscale, overpriced practices here. We are talking about practices where doctors, nurses, physician’s assistants and others work hard and try to stretch every Medicare dollar in an effort to continue serving as many patients on Medicare as possible. To a practice such as this, even $1,000 can be a tremendous amount of money. Even though the doctors will receive the bonus, it may take time for them to recoup the money.
If there is a way for the doctors to sign on to the E-Prescription system and overcome the barrier of the initial cost, it will be a win-win situation for all, especially their patients. It may take some time for everything to fall into place, however, if even half of the doctors who take Medicare as payment work with E-Prescriptions, many patients lives will be safer because of it.
The news tells us on a regular basis about prescriptions gone wrong. A physician prescribes blood pressure medication for an elderly patient but the pharmacist can’t read the handwriting, so the patient ends up with a blood thinner which causes a hemmorage that lands them in the hospital. Or, a child is prescribed an antibiotic but ends up with a cancer med, causing long term health issues.
Medicare has established a way to reduce or eliminate this from happening: E-Prescribing. By prescribing on line and eliminating handwriting issues, it is estimated that the majority of misread prescriptions can be eliminated. In addition, this would reportedly save pharmacists about 150 million follow-up phone calls to doctors’ offices per year attempting to clarify prescription medication names, dosages and amounts.
Starting in 2009, Medicare will begin giving doctors who E-Prescribe a 2% bonus on top of their fee for E-Prescribing. Starting in 2011, the bonus will go down to 1%, and in 2013, it will go down to 0.5% for one year. The five years of gradually declining bonuses are an incentive to help doctors’ offices begin prescribing in this manner and get them in the habit of doing so, making prescribing and filling prescriptions safer and more efficient for doctors, pharmacies, and, most of all, the patients.
“There are terrific human and financial costs to illegible prescriptions,” Mike Leavitt, Secretary of the U.S. Department of Health and Human Services, said on Monday. “There are a lot of people hurt and a lot of time spent trying to sort out bad handwriting,” he added.
E-Prescriptions have been on the radar since about 2006, when pharmacies that participated in Medicare were mandated to be able to take the E-Prescriptions. Implementing this method of prescribing medication should create a profound reduction in prescription mistakes.
Because Congress stood firm and overturned President Bush’s veto, not only are physicians and their patients on Medicare protected for now, but other provisions have been spared as well.
The developments have made it possible for individuals dealing with Vacuum Assisted Closure (VAC) wounds and issues associated with them to be able to maintain assistance and care in their homes. Not only does this save the system money by keeping these individuals out of the hospital, it also allows them to have the treatment in privacy and comfort at home.
Kinetic Concepts, Inc. (KCI), the company that provides this technical and specialized type of treatment is on the cutting edge of medical technology and is devoted to discovery, development, manufacturing and marketing of innovative, high technology products for wound care, tissue regeneration and therapeutic support systems. KCI has been researching and developing these products and technology for over 30 years, and has become a world-renown leader in its field, helping patients around the world enhance their healing and their lives.
KCI has developed procedures that help patients dealing with complex wounds requiring advanced care, tissue-based products used for reconstructive and uro-gynecologic surgery, and development, creation and design of specialty beds, mattresses and mattress substitutes as well as other equipment to help reduce the skins breakdown, address pulmonary complications and assist caregivers in handling and moving patients of size.
Because of the stand that Congress took, making certain that many necessary Medicare benefits were not eliminated and giving lawmakers enough time to create a strong, well-thought out, long-term Medicare solution, many patients who need KCI’s VAC and other critical care supplies and treatment at home, will not have to go without it.
For Medicare recipients who need these services – and who are already dealing with the struggles of recovery – today’s vote to override the President’s veto is one less thing they will have to worry about in their efforts to get well.
It is now mid-July and Congress has been going back and forth with President Bush over Medicare cuts to doctors for what seems like forever. In a strong show of bipartisanship, Congress, last week, after the July 4th break, voted to block the 10.6% cuts to doctors who accept patients on Medicare. This was a relief to thousands of doctors and millions of patients who depend on Medicare to help keep their ailments and illnesses under control. If these cuts were to go into effect, many doctors – who are struggling to keep treating Medicare patients even at the current payment rates – would have to cut the number of patients that they could continue to treat, if any. As a result, these patients would end up without a personal physician, likely escalating their diseases and costing the system even more money. So it was a relief all around when Congress voted to maintain these benefits.
That relief was short-lived, though, since President Bush, of course, who has been threatening for months to veto this vote if it went through, did just so. It is unfortunate that this president is “so out of touch,” was an observation by Barbara Boxer.
Congress, however reacted how it promised it would react by overriding the veto. Democrats and Republicans who saw the urgency and the value of the vote, stood firm and saw to it that the President’s veto did not stand.
The AMA’s reaction to Congress overriding the veto was to say in support of Congress, “Today we celebrate that Congress heard the voices of millions of patients and physicians and voted to override President Bush’s veto and protect the health of America.
For now, patients and physicians can breathe a sigh of relief, however, during the next year, Congress will have to work on a permanent solution to this issue and other issues that are cause for concern and debate regarding Medicare, and they will have to come up with a balance that will suit as many people as possible. This will not be an easy task, but for the time being, today has been a good day for Congress, physicians and their patients.
If you are an individual receiving Medicaid benefits there are various rights that you are entitled to. For example, if your are denied services for any reason, you are entitled to appeal the decision. The appeal is supposed to be addressed within 90 days from the time it is filed.
Since Medicaid is a program which is jointly funded by state and federal funds, there are definite rules that govern appeals and decisions. In Georgia, where many lawsuits have been filed – especially by and on behalf of individuals with disabilities who have been denied the right to a timely appeal.
Some lawsuits which have been filed against the officials of the Department of Community Health allege that Medicaid has been violating both state and federal law by delaying hearings for people with disabilities who have appealed decisions about their care. The lawsuit states that hundreds of Georgians – many of them disabled – have been subjected to extremely long waits that are illegal trying to get hearings for their appeals of medical services that they have been denied.
The most unfortunate part of this situation is that while there are “backlogs” and delays, individuals are not receiving the care that they desperately need, so in many cases, their health declines, eventually costing Medicaid more money.
Some examples of this situation are:
• An individual who is a paraplegic with other health issues needs 4 more hours per day of home health care or she will have to return to a nursing home which would cost many times the expense of extra home care. Medicare declined her latest request in January and she appealed in February. Her appeal has still not been heard and it is nearly August. Her case has not even been sent to the office that hears appeals.
• A second plaintiff in an individual with Multiple Sclerosis who has been living in a nursing home. He would like to be in his own apartment because it is a better environment for him and a much better environment for his children. Living in an apartment and receiving home health care would be far more cost efficient than the nursing home. He has been waiting since early March for a hearing regarding his appeal.
These are just two cases in a sea of backlogged appeals. While individuals suffer delay after delay, Medicaid continues to spend more money on services that are not necessarily appropriate or cost effective for too many people in the system. The decisions in these and other cases will hopefully set a precedent and turn the process around so that it is efficient, effective and helpful for those who are depending on it to help them enhance their lives.
The new Medicare bill that was just passed will help millions of individuals and the doctors who treat them. It provides a halt to the proposed pay cut for doctors who treat individuals covered by Medicare, and it even offers a small (1.1%) raise for those doctors in 2009.
Another essential area that will be greatly assisted and made more fair and manageable is that of mental health care. As Medicare stands now, co pays for mental health care are far greater than other medical care. Mental health care recipients on Medicare are required to pay a 50% co pay for services which is a terrible inequity. Basically, Medicare recipients who need mental health care in order to stay healthy are paying a penalty to get that care, which simply enhances the stigma over mental health issues in general.
The new bill, called The Medicare Improvements for Patients and Physicians Act of 2008, deals with that inequity and will reduce the co pays for mental health care. While the co pays for other services have stayed at 20%, many seniors who are in need of mental health services have not even tried to access them because with a 50% co pay, these services are beyond what they can afford. As a result, some of the most vulnerable citizens – our seniors – are going without essential care because of a basic and unfair flaw in the system. In fact, due to this barrier, about half of the treatment for serious mental health issues has been given to seniors as inpatients in the hospital rather than less expensive outpatient treatment.
With the new bill this will no longer be the case. High mental health co pays will now be phased out to bring co pays in line with the co pays for seeing a physician. There will also be additional funds to help rural areas, community health centers and tele-health centers.
This new bill which is now a permanent act has been long overdue and has given many doctors and the seniors that are their patients many reasons for hope. With continued payments to physicians, lowered co pays where possible for seniors and enhanced services, hopefully this is the beginning of better health for the Medicare system and the people it serves.
Many doctors and caregivers have long felt that with the right information, equipment and know-how, patients can get – and stay – well with the help of family and maintain or increase their recovery and their health.
To that end, the Patient Centered Primary Care Collaborative (PCPCC) was pleased that The Medicare Improvements for Patients and Providers Act of 2008 that was just passed by the Senate, included a provision for a demonstration project for the PCPCC model.
The PCPCC is a collaborative of over 150 major employers, consumer groups, physicians groups and others working together to raise the quality of care to patients by giving them a “medical home.” This system of care will also improve delivery of services by using
The PCPCC works with the whole person – in a situation where primary care physicians are responsible for arranging that person’s care. The person sees a particular physician and the physician’s team, who will arrange for specialists and others who can help the individual. In addition, where appropriate and wherever possible, primary care physicians coordinate and collaborate with families of their patients regarding their care. The primary physician works across all fields of medicine and coordinates all care to make it easier and less confusing to the patient.
In addition, patients would be able to access care on an open-scheduling basis. Since they would be cared for by a team and would not have to necessarily go to the physician’s office for all treatment and assistance, some help could be obtained by using technical assistance during expanded hours.
The PCPCC promotes a new way of thinking when it comes to medicine and could especially help individuals covered by Medicare and Medicaid. It is endorsed by The American Academy of Family Physicians, The American Academy of Pediatrics, The American College of Physicians and The American Osteopathic Association.
The demonstration project funding as well as funding for further full-blown pilot projects will help determine if the PCPCC has developed an idea that will create better outcomes for patients while paying doctors and other medical professionals what they should rightfully be paid and still contain costs, especially to programs such as Medicare and Medicaid. Hopefully this will create a win-win situation for all parties.
There is good news today for doctors who treat Medicare recipients, and for those recipients who are their patients.
Congress and the Bush Administration have been playing tug of war regarding proposed 10.6% cuts in payments to doctors treating patients on Medicare. Doctors have said that they might have to stop treating these particular patients if the cuts went into effect, because it would just be too costly for them. As Congress went into recess for the 4th of July break, it looked like those predictions would have to come true, because a block of the cut had not been achieved.
Today, however, is a different day. The Senate voted over 2 to 1 to pass the bill which halts the cuts, giving enough time to explore the situation further and try to come up with a solution that will work for all involved.
The bill called “The Medicare Improvements for Patients and Providers Act of 2008” not only halts these cuts to doctors, ensuring that for the next 18 months or more, patients and doctors can continue their relationships, but also institutes a small pay increase of 1.1% to doctors in 2009 and bolsters preventative and mental health care benefits, as well.
This has been a bitterly contested issue, and the House already passed the measure. The vote on this issue is so important that Barak Obama came off the campaign trail to be present for it, and Senator Edward Kennedy, who has been very ill battling brain cancer, was also present for the vote.
The passing of this legislation will help millions of Medicare recipients and thousands of doctors who treat them from having to eliminate their treatment. It is essential since there are not enough doctors who treat Medicare recipients as is, and the potential loss of thousands more would leave some of the most vulnerable patients without a personal physician.
For now, at least, everyone can breath a sigh of relief. Given enough time to work with the situation, Congress may be able to create a long-term solution to keep doctors on board and help patients keep the quality of care they need.
We’ve been hearing about it in the news for months and it has become a critical issue waiting for a last minute pre-fourth of July solution for the crisis with Medicare fees for doctors. The country – especially the seniors in this country – has been holding its breath waiting for Congress to put a stop to the cuts in Medicare payments to doctors.
The unfortunate thing is that Democrats and Republicans have been having heated arguments during the past week leading up to the of July holiday, the idea was that they were supposed to come to an agreement to help seniors to be able to continue their care through their primary care physicians that they are familiar with.
If Congress does not pass a bill reversing the situation and postponing the 10% cut in doctors’ Medicare payments, many doctors have already said that they won’t be able to afford to treat Medicare patients if the cut goes into effect.
It is possible for Congress to reverse the fee cut, making the reversal retroactive and reimbursing the doctors for any losses they suffered during the time that the decrease was in effect. The vote on Friday was so close that one more vote would have stopped the pay cuts to doctors and kept seniors protected. 600,000 doctors are along with millions of Medicare recipients.
With both sides in a tug of war over details, there are promises of another round starting immediately after the break when Congress reconvenes. Mike Leavitt, Director of the Department of Health and Human Services has said that the department will do everything possible to minimize the impact on doctor and beneficiaries, and when the higher fee schedule is restored they will reprocess claims at the higher rates as soon as possible.
We will all be watching to see what Congress comes up with next week.
It has been about two years since the Deficit Reduction Act went into effect (7/1/06) requiring all immigrants to give proof of legal immigration or citizenship when they are applying for Medicaid for the first time. This applies to children, as well. Most legal immigrants cannot receive Medicaid benefits for the first five years that they are in the U.S. and undocumented immigrants can only receive emergency Medicaid services.
Once the bill became law, it also restricted citizens, as well. Medicaid enrollment has declined since the law was enacted, partially because even U.S. citizens are finding it difficult to locate some of the documents required to enroll for Medicaid services. This is because some of the documents need to be original documents, and it can be difficult to obtain original documents in many cases.
As far as Medicaid goes, they receive matching federal funds to help run the program and pay claims. As a result, even if they wanted to assist individuals without documentation it would be a problem for Medicaid both in a financial sense and in a legal sense.
The rules are so stringent that CMS has instituted a rule that even requires child welfare agencies to document citizenship for children being placed into foster care. There are some issues where people receive extra time to provide documentation, however, they are limited and must adhere to very specific rules and time frames.
Once an individual has completed the documentation process and is approved for coverage, they will be covered retroactively to the date of the application or to the month of the application depending on the state they are living in and a few other variables.
The primary types of identification include a state driver’s license, Certificate of Naturalization, Certificate of Citizenship or a U.S. passport. Secondary types of identification for naturalized citizens include a U.S. Birth Certificate, data verification with Systematic Alien Verification for Entitlements (SAVE) documentation, or documentation and data match with a state verification agency, as well as other documents.
It is important to know the law, your rights, your responsibilities and your entitlements in order to receive the benefits you need. You can research them on the web by going to the CMS website.
We have all been hearing about he Bush Administration’s idea to cut payments to doctors seeing patients covered by Medicare. The issue on the table has been to cut payments to doctors by 10%. This would create a huge problem for Medicare recipients because many doctors would not be able to afford to continue seeing these most vulnerable patients. As a result, more and more individuals on Medicare would be without a personal physician, leaving them in a situation where they would be open to the increase of health problems – especially if they had chronic health issues such as diabetes or high blood pressure.
With too few doctors accepting Medicare at current rates, a cut in their payments would be devastating. This would be a case of saving pennies to spend dollars. A lot of dollars. If individuals who had their ongoing health issues monitored and under control and care by a personal physician, lost that relationship, they would very likely end up doing their best to take care of themselves, however, they would probably end up at the emergency room due to lack of proper ongoing care.
Which makes more sense – paying for a doctor’s visit and some generic medicine or paying for an emergency room visit, hospital visit or hospital stay? Most of us – including Congress – understand the answer to this. Congress is trying to find a solution to help doctors and Medicare recipients continue caring for their ongoing needs.
The Bush Administration has given Congress some extra time after the 4th of July break to process this information further and work toward a solution. At the same time, however, the administration has halted all Medicare payments of claims for the first 10 days of the month, which will only add to the back log of claims that already exists.
We will all have to wait and tune in after the 4th of July to see how the rest of the situation develops. Hopefully the extra time will make it possible for Congress to continue working toward a workable solution to this complex problem.
