Court Rejects Regulation on Dialysis

Advocates for dialysis patients, including Dialysis Patient Citizens, are welcoming a federal court ruling in Texas that granted a preliminary injunction preventing the U.S. Department of Health and Human Services from implementing a regulation that could force patients off their current health insurance and jeopardize their access to care.

In enjoining the regulation’s enforcement, the U.S. District Court for the Eastern District of Texas held that the rule was first procedurally defective because HHS adopted it without first giving the public notice of it and seeking comment on it, and second “arbitrary and capricious” because HHS failed to consider the benefits of private coverage and ignored the disadvantages of adopting the rule.

The court concluded that the regulation cannot be implemented because HHS “failed to consider the benefits of private qualified health plans and ignored the disadvantages of the Rule,” including that “the rule would leave thousands of Medicare-ineligible dialysis patients without health insurance.”

The court went beyond invalidating the rule on procedural grounds and questioned the policy itself.

“Congress has long recognized the importance of dialysis treatment for end-stage renal disease patients and has afforded patients the opportunity to elect coverage that best serves their needs,” the opinion stated. The court added that, “For decades, dialysis patients have had the choice of selecting private insurance options over Medicare if those options better served their treatment needs. Private insurance is particularly attractive to dialysis patients with families because Medicare does not provide coverage for spouses and dependents.”

California Has the Most LTCi Policyholders

In California, more than 600,000 are covered under a traditional long-term care insurance policy, according to the American Association for Long-Term Care Insurance. “This is certainly due to the size of California as well as the fact that the state has been very active in making residents aware of the importance of planning. While the California Partnership program has little relevance to consumers today, in former years it was valuable protection that I strongly advocated and which was actively marketed by insurance professionals,”   explains Jesse Slome, executive director of the American Association for Long-Term Care Insurance (AALTCI). Roughly seven million Americans have traditional long-term care insurance protection and another million have coverage under a linked-benefit or alternative product.

“A significant number of the inbound phone calls we handle and the online request for information come from Californians. Admittedly, there are fewer specialists today than there were a few short years ago, but there are still good avenues available for those who want to get information and compare their choices and options,” he said. For more information, visit or call 818-597-3227.

Integrated Health Care Is the Best Approach to Fighting Diabetes

by Collette Manning
A growing trend in population health management aims to address treating a patient’s whole body, rather than individual parts. Integrated health care connects dental, vision, and disability data through a patient’s insurance carrier, which promotes early detection and improved management of chronic conditions. Integrated health care programs help improve patients’ health by coordinating medical and specialty care, making every patient-provider interaction more meaningful with richer information.

These programs not only help improve patient outcomes but can also reduce medical costs. For example, retinal scans can often lead to early diagnosis of diabetes since eye care providers can detect early signs of the disease in the eye. With an integrated health plan, vision patients, who are showing signs of early diabetes, trigger a referral to the care management team that helps them get the best care possible.

This approach can also help people with diabetes manage their condition through regular checkups and reminders. Regular vision check-ups are critical since diabetes is the leading cause of adult-onset blindness. With this approach, there is a free flow of data between a patient’s diabetes care provider and their vision specialist, so the specialist can monitor the patient’s eyesight even more closely for signs of deterioration.

Integrated care helps manage diabetes by managing disease in other areas of the body. Diabetics face an increased risk of periodontal disease. Inflammation in the mouth can make it harder to manage blood sugar, leading to a cycle of patient health concerns and potential escalating cost. According to the CDC, diabetics who treat their periodontal disease through increased care have 39% fewer hospital admissions and 40% lower medical costs. With an Integrated health care program, patients with diabetes who have medical and dental coverage get enrolled automatically into a care-management program with enhanced dental services. They are notified of coverage for an added cleaning—three, instead of the usual two per year.

Diabetes cases are expected to increase. Prevention, early detection, and management of the disease will be essential to ensuring the best outcomes for patients while mitigating the cost burden. Integrated health care programs, are the future of better care and can achieve this goal. Diabetes cannot be treated in a vacuum, and health care plans should seek to mimic the body’s inter-connectivity.

Collette Manning, RN, CCM, ONC is the Clinical Integration Strategy and Planning Director for Specialty Businesses at Anthem Blue Cross where she works with a team to identify and implement opportunities designed to deliver a fully integrated healthcare experience among health, vision, dental, disability, life and voluntary products for Anthem Blue Cross members. Collette has more than 30 years of Care Management experience in the provider and insurance setting. Anthem’s integrated care program is called the “Anthem Whole Health Connection.”

Do Wellness Programs Actually Help People Manage Chronic Conditions?

Forty-four percent of consumers enrolled in wellness programs have a diagnosed chronic condition, according to a HealthMine report. But just 14% say that their wellness program helps them manage their disease. Only 29% say their wellness program offers a disease management program. Only 11% participate in disease management through their wellness program. And just 6% have connected a disease management application/tool to their wellness program. Bryce Williams, CEO and president of HealthMine says, “Health plans and wellness programs need to have real time analytics that guide each member on health actions. We are loaded with health data including lab results, insurance claims and more, but we are not analyzing the data or offering recommendations consistently enough. Programs that do will close gaps in care, thus helping members manage their chronic conditions and minimize costly co-morbidities and utilization.”

H.R.5659 Would Open Medicare Advantage to End-Stage Renal Patients

Dialysis Patient Citizens (DPC) hailed the introduction of H.R. 5659 as the latest milestone toward opening Medicare Advantage enrollment to end-stage renal disease (ESRD) patients. Stephen Anderson, a patient advocate from Indianapolis said, “As a dialysis patient of five years, I am fortunate to have secondary insurance to cover what Medicare does not. However, I know many patients in my facility don’t have that luxury. Providing dialysis patients access to Medicare Advantage will greatly help to reduce our out-of-pocket costs while improving our health with care coordination measures,” said. A study comparing outcomes of dialysis patients grandfathered into Medicare Advantage plans found that they have lower mortality rates than id their peers in fee-for-service plans. For more information, visit

Medicare’s Competitive Bidding Program Drives Up Costs

Medicare’s competitive bidding program is driving up costs for diabetic patients, according a study by the National Minority Quality Forum. The study found that the competitive-bidding program disrupted beneficiaries’ ability to get diabetes testing supplies. Not having access to these supplies is associated with increased mortality, hospitalization rates, and inpatient costs. The Centers for Medicare and Medicaid Services (CMS) claims that the competitive-bidding program poses no health threat. However, the Government Accountability Office (GAO) says that CMS statistics did not reveal whether beneficiaries got the durable medical equipment they needed on time or whether they experienced health problems due to problems accessing the equipment. Jaime Davidson, M.D. of the University of Texas said, “We are particularly concerned about the disruption we detected in our analysis given the predominant use of rapid- and short-acting insulin by Medicare beneficiaries who are at significantly greater risk for hypoglycemia than younger individuals with insulin-treated diabetes.”

Californians with the Top Chronic Conditions: 11 Million and Counting

Chronic conditions are the leading cause of death and disability in the United States, and are the biggest contributor to health care costs. But there is wide variation in their incidence. Major differences depend on age, income, race and ethnicity, and insurance status, according to a report by the California HealthCare Foundation. The report finds that many Californians with chronic conditions are delaying needed care because of cost. The following are key findings:

  • About 40% of adults have at least one of the five chronic conditions studied.
  • High blood pressure is the most common chronic condition, affecting about one in four, or 7.6 million, adults in California.
  • The prevalence of chronic conditions falls as income rises. Fourteen percent of adults living under 138% of the federal poverty level have two or more chronic conditions compared to 8% of adults in the range of 400% or more of the federal poverty level.
  • 34% of Californians with psychological distress delayed getting needed medical care, and 27% delayed filling prescriptions. Cost or lack of insurance was frequently cited as the reason for these delays.
  • 70% of Californians who are 65 or older have at least one chronic condition, compared to 26% of those  18 to 39.

CMS Proposes Updates to Part D

The Centers for Medicare and Medicaid Services (CMS) released proposed changes to the Medicare Advantage (MA) and Part D Prescription Drug Programs. CMS says that the proposal would provide fair payments to plans while rewarding high-quality care. CMS is proposing to continue to refine the star rating system to encourage improved quality. CMS proposes to modify the system to ensure that plans are not penalized unfairly for enrolling dual eligible or low-income beneficiaries.

The proposal also enhances the value of in-home assessments to support care planning and care coordination and improve enrollee health outcomes. The Advance Rate Notice proposes changes in payments. On average, the expected revenue change would be positive growth of 1.05% when combined with expected growth in plan risk scores due to coding. Plans that have shown quality improvement and have demonstrated a focus on customer satisfaction would see additional growth. Plan payment levels will continue to be somewhat higher than the equivalent payments in fee for service.

The 2016 Draft Call Letter proposes steps to ensure that plans maintain accurate provider directories and make those directories widely available, helping enrollees better understand the providers available to them. In addition, CMS proposes to work with Part D sponsors that offer limited access to preferred cost sharing pharmacies in their networks to ensure all beneficiaries have access to affordable coverage.

CMS says that enrollment and quality in the Medicare Advantage and Part D Prescription Drug program has grown since the Affordable Care Act. Medicare Advantage has reached record high enrollment each year since 2010. That trend continues in 2015 with an increase of more than 40% since passage of the Affordable Care Act. Also, premiums have fallen nearly 6% from 2010 to 2015. More than 90% of Medicare beneficiaries have access to a $0 premium Medicare Advantage plan.

According to CMS, the continued popularity of the program reflects a clear signal that Medicare Advantage and the Prescription Drug Program are attractive to health plans and beneficiaries. In 2015, CMS estimates that 60% of Medicare Advantage enrollees will be in four- or five-star plans – an increase of 43 percent since 2009.

Addressing Growing Cost of Diabetes

As diabetes cases increase worldwide, curbing the personal and financial toll will become a high priority, according to the American Academy of Actuaries. Diabetes is expected to become more common globally, increasing from 8.3% prevalence in adults in 2011, to 9.9% in 2030, according to data from the International Diabetes Federation. At the same time, spending on diabetes varies widely. In 2010, the United States spent $197.8 billion, accounting for 53% of global spending on diabetes, whereas India, with the largest population of diabetics, spent $2.8 billion, less than 1% of the global total. An issue brief developed by the Academy examines the projected future global prevalence and costs associated with diabetes. It also examines efforts in seven different countries (Australia, Canada, Israel, Singapore, South Africa, the United Kingdom, and the United States) to develop better ways to measure, prevent, treat, and slow the cost of, the disease. The results are cautionary yet hopeful. For more information, visit

Patients Are in Denial About Diabetes Risks

Nearly 80% of patients who are at elevated risk for Type 2 Diabetes seem to be deluding themselves by assuming that they are in excellent or very good health, according to a survey from the American Diabetes Association (ADA). “These findings suggest it is critical for providers to connect the dots with patients between risk factors and disease development,” said Virginia Peragallo-Dittko, R.N., C.D.E., incoming chair of the ADA’s Prevention Committee. For more information, visit

Last Updated 10/10/2018

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