Employers, Insurers Push To Make Virtual Visits Regular Care

The Associated Press
Source: Associated Press, by Tom Murphy

Make telemedicine your first choice for most doctor visits. That’s the message some U.S. employers and insurers are sending with a new wave of care options.

Amazon and several insurers have started or expanded virtual-first care plans to get people to use telemedicine routinely, even for planned visits like annual checkups. They’re trying to make it easier for patients to connect with regular help by using remote care that grew explosively during the COVID-19 pandemic.

Advocates say this can keep patients healthy and out of expensive hospitals, which makes insurers and employers that pay most of the bill happy.

But some doctors worry that it might create an over-reliance on virtual visits.

“There is a lot lost when there is no personal touch, at least once in a while,” said Dr. Andrew Carroll, an Arizona-based family doctor and board member of the American Academy of Family Physicians.

Telemedicine involves seeing a doctor or nurse from afar, often through a secure video connection. It has been around for years and was growing even before the pandemic. But patients often had a tough time connecting with a regular doctor who knew them.

Virtual-first primary care attempts to smooth that complication.

The particulars of these programs can vary, but the basic idea is to give people regular access to a care team that knows them. That team may include a doctor, nurse or physician assistant, who may not be in the same state as the patient. Patients can also message or email the caregivers with a quick question in addition to connecting on a video call.

People who choose this option may have to give up a doctor they’ve been seeing in person. They also will need a smartphone, tablet or computer paired with a fast internet hookup.

The goal of the virtual-first approach is to make patients feel more connected to their health and less reliant on Google searches for advice or the nearest urgent care center to treat something minor.

“We have a large portion of the population that is avoiding going to a primary care doctor because they don’t have time or they think they can’t afford it, even though its generally covered under their benefits,” said Arielle Trzcinski, a health care analyst with Forrester who works with insurers.

Amazon Care pairs patients with a regular care team and in some markets also sends providers like nurses to them if they need in-person care. The retailer developed the program for its employees but said in March that it would expand it to other employers nationwide.

Insurers like Oscar Health, UnitedHealthcare and Kaiser Permanente also have started or expanded virtual-first care plans this year. Priority Health in Michigan began selling a plan for people without employer-sponsored coverage after the insurer noticed that customers weren’t visiting doctors as much as they expected.

A vice president, Carrie Kincaid, said Priority Health found that some customers didn’t have time to leave work for appointments. Another group, early retirees, travels frequently and isn’t able to make it back to Michigan for in-person visits.

She said the new plan, run with virtual care provider Doctor on Demand, blew past enrollment projections and had more than 5,000 people signed up on the first day.

“When members get exposed to virtual care in general, they really, really like it,” she said.

Wendy Katje signed up for a Priority Health virtual-first primary care plan by accident online, but she plans to stick with it.

The 60-year-old multiple sclerosis patient said the doctor she got through the program has helped adjust her cholesterol medications and made sure she stays connected with a neurologist she usually sees in person.

Katje said the virtual-first approach makes sense during the pandemic, when she wants to avoid waiting rooms.

“It’s not quite as personal as sitting in an office with someone, but for what I’ve needed to have done it was perfectly adequate,” the Otsego, Michigan, resident said.

Walter Woodberry, of Albuquerque, New Mexico, signed up for a virtual-first plan through his employer, ABF Freight, after he tried telehealth and grew used to its convenience.

He said he doesn’t have to leave work early for an appointment, and he feels more comfortable giving medical information to someone who knows him.

“I’m not trying to schedule my life around a doctor’s appointment,” he said.

Consumers have grown used to shopping for clothes, gifts or groceries online. But Carroll, the family physician, noted that patients sometimes need an in-person visit.

He said he once had a patient diagnosed virtually with pink eye. In person, Carroll could see that the patient actually had a form of glaucoma and was in danger of blindness.

Doctors are still sorting out what can be treated virtually and what demands in-person care. These new plans generally reserve those visits for emergencies or if the doctor or patient requests them.

Virtual-first proponents say they aren’t trying to eliminate in-person visits. They are focused on improving health.

Patients are more likely to follow a doctor’s orders, get laboratory tests or take prescribed medicine when they receive care from someone they’ve gotten to know and trust, said Doctor on Demand CEO Hill Ferguson.

“That’s what we need to get back to in this country,” he said.

Stanford University’s Dr. Megan Mahoney estimates that about half of primary care visits can be done virtually, depending on whether insurers and other payers reimburse for the care.

The family physician says her practice still does 30% to 40% of its visits virtually, months after reopening its offices. The pandemic has changed how patients view care, she said.

“We had made assumptions about consumers’ willingness to adopt telehealth, yet we see 89-year-olds who are on video visits with their providers every other week with no problem now,” she said.

Biden Says He Wants to Go Big On Health Care. But He Left Major Reforms Out of His Latest Plan

U.S. President Joe Biden speaks during a joint session of Congress at the U.S. Capitol in Washington, D.C., U.S., on Wednesday, April 28, 2021.

Source: Time, by Abigail Abrams

During President Joe Biden’s speech to Congress on Wednesday, he called for an ambitious health agenda that would allow the federal government to negotiate prescription drug prices, expand Medicare coverage, build on the Affordable Care Act and lower deductibles. All of these ideas would transform the way Americans pay for health care—but most of them are not actually in the legislative plan the President has put forward.

“Let’s give Medicare the power to save hundreds of billions of dollars by negotiating lower drug prescription prices. And, by the way, that won’t just help people on Medicare. It will lower prescription drug costs for everyone,” Biden said. “We’ve talked about it long enough. Democrats and Republicans, let’s get it done this year.”

Despite his strong rhetoric, Biden’s American Families Plan, also unveiled on Wednesday, does not include the proposals to cut prescription drug costs or lower the Medicare eligibility age, which congressional Democrats had pressured him to include in recent weeks. His $4 trillion package comprised of the American Families Plan and the American Jobs Plan has been praised by progressives as a huge investment in the country’s economy and social safety net. But the omission of these larger health care policies has raised questions for progressives about the President’s commitment to the ideas in the face of opposition from Republicans, moderate Democrats and pharmaceutical companies.

“While [lowering drug prices and expanding Medicare] is a focused priority of Congress, it’s clear it’s not as much so for the White House,” says Alex Lawson, executive director of Social Security Works, which supports the drug pricing and Medicare reforms.

Biden’s plan does include $200 billion to make permanent the increased premium subsidies for people who buy health coverage on the Affordable Care Act (ACA) marketplace, which were passed in the American Rescue Plan earlier this year. The expanded subsidies mean that millions of Americans are eligible for cheaper or free health coverage. But the Congressional Budget Office has estimated that the subsidies will get just 1.3 million uninsured people to buy coverage over two years, a small portion of the total uninsured. “In terms of federal dollars, subsidizing private insurance is the most expensive way you can go about getting people covered. Whereas doing it through a public option or Medicaid or Medicare is much lower cost on a per person basis,” says Cynthia Cox, a vice president at the nonpartisan Kaiser Family Foundation.

That is a main reason why many congressional Democrats have been pushing Biden to do more than shore up the ACA. Vermont Sen. Bernie Sanders and 16 other Senators sent a letter to Biden on April 25 calling for the President to address drug pricing, lower the Medicare eligibility age, cap out-of-pocket expenses for Medicare and expand Medicare benefits to cover hearing, dental and vision care. Another group of more than 80 House members, including progressives like Washington Rep. Pramila Jayapal and moderates like Rep. Conor Lamb of Pennsylvania and Rep. Jared Golden of Maine, wrote a similar letter advocating for the government to negotiate drug prices and expand Medicare.

A new set of analyses from the Kaiser Family Foundation this week indicate that lowering the Medicare eligibility age from 65 to 60 or even lower could bring down U.S. health spending overall. The foundation’s first analysis showed that when people turn 65, their health care spending drops significantly from the period between age 60 to 64 despite the fact that most people use more health care as they age. The reason? Medicare pays lower prices for health care services than private insurers. Employers also benefit. The foundation’s second analysis showed that if people ages 60-64 were no longer enrolled in employer-sponsored insurance, the cost for employer plans could drop by 15%. Even if Medicare expanded to include dental, vision and hearing coverage as Sanders and some Democrats want, Kaiser Family Foundation’s Cox says health spending could still drop.

Polling has shown that both of these policies are popular, even among Republican voters. And congressional Democrats say that is especially true after the COVID-19 pandemic disproportionately affected older Americans. But by far the most popular item that Democrats are pushing is the proposal to allow the U.S. government to negotiate with manufacturers over drug prices—something that most other developed countries already do. A new government study commissioned by Sanders and released this week shows that the U.S. pays two to four times more for prescription drugs than other wealthy countries, adding to the evidence supporting the Democrats’ position.

Even though these policies are popular among voters, the political reality for Biden is more difficult. Republicans oppose most of Biden’s spending on the social safety net, so the legislation will likely need to pass through the budget reconciliation process, which would allow Democrats to push it through along party lines. But with an evenly-divided Senate, they can’t afford to lose any votes. The ACA subsidies that Biden has included in his plan face no opposition from Democrats or the health insurance industry, but both the drug pricing reform and Medicare changes will face intense pushback from pharmaceutical companies, hospitals and medical providers, as well as more moderate Democrats.

Health care has been a winning topic for Democrats in recent election cycles and bringing down drug prices could be particularly helpful ahead of the next midterms, says Robert Blendon, a Harvard professor of health policy and political analysis who studies public opinion about health care. If Biden isn’t prioritizing that, “it must be because there’s one or two votes in the Senate who have an interest that’s more worried about the pharmaceutical industry than what it’s going to look like in the 2022 election,” he says.

Democrats can still fight to add the drug pricing proposal and Medicare changes into the spending package once it gets to Congress. Sanders told reporters on Tuesday that the provisions would be in the legislation “if I have anything to say about it,” while Senate Finance Committee Chair Ron Wyden of Oregon said he would “look at every possible vehicle” to get drug pricing done. House Energy and Commerce Committee Chair Frank Pallone of New Jersey said drug pricing would be one of his top priorities as the plan makes its way through the House.

House Democrats passed their signature drug pricing legislation, known as H.R. 3, back in 2019, and the bill was recently reintroduced and has a hearing scheduled in Pallone’s committee. Advocates believe that lawmakers can negotiate to put measures like this into the American Families Plan. “We have a container that can fit what we want in there,” said Lawson of Social Security Works.

Still, Biden’s speech Wednesday hinted at how difficult these big health care changes can be. “We know how to do this. The last president had that as an objective,” he said, referencing former President Donald Trump’s failed push to lower prescription drug prices.

Now Biden has left it up to Democratic lawmakers to get their own colleagues on board and make the changes happen.

Dem Senators Urge Biden To Expand Medicare In American Families Plan

Dem senators urge Biden to expand Medicare in next big spending bill | Fox  BusinessSource: Fox Business, by Megan Henney

A coalition of 17 senators is calling on President Biden to expand Medicare as part of his next massive economic spending bill.

In a Sunday letter addressed to the White House, the group of mostly Democrats – led by Sen. Bernie Sanders, I-Vt. – urged Biden to lower the Medicare eligibility age, expand Medicare benefits to include vision, dental and hearing coverage, allow the program to negotiate lower drug prices and establish a limit on out-of-pocket expenses under traditional Medicare.

“We have an historic opportunity to make the most significant expansion of Medicare since it was signed into law,” the lawmakers wrote. “We look forward to working with you to make this a reality and, in the process, substantially improve the lives of millions of older Americans and persons with disabilities.”

In addition to Sanders, letter signatories included: Sens. Debbie Stabenow of Michigan, Ben Cardin of Maryland, Elizabeth Warren of Massachusetts, Tammy Baldwin of Wisconsin, Dick Durbin of Illinois, Chris Van Hollen of Maryland, Ed Markey of Massachusetts, Cory Booker of New Jersey, Kirsten Gillibrand of New York, Jeff Merkley of Oregon, Richard Blumenthal of Connecticut, Tina Smith of Minnesota, Sherrod Brown of Ohio, Tammy Duckworth of Illinois, Sheldon Whitehouse of Rhode Island and Alex Padilla of California.

Biden is expected to release details of the second part of his Build Back Better agenda, dubbed the American Families Plan, ahead of his address to a joint session of Congress on Wednesday.

The proposal could cost as much as $1.5 trillion and will focus on child care, paid family leave and other domestic priorities. It’s unclear whether the administration plans to address health care in the tax and spending plan.

Biden is also facing pressure from Democrats in the House who want the White House to use the American Families Plan to include three Medicare-related provisions: allow Medicare to negotiate drug prices, expand Medicare by lowering the eligibility age from 65 to 60 and extend Medicare to include dental, vision and hearing care.

Over 20 Democrats sent a letter to Biden on Monday asking the White House to include those provisions in the forthcoming plan. Signatories included representatives from across the party’s ideological spectrum, including Reps. Conor Lamb, D-Pa., and Jared Golden, D-Maine, as well as Pramila Jayapal, D-Wash.

“Now is a historic opportunity to also make an important expansion of Medicare that will guarantee health care for millions of older adults and people with disabilities struggling with the health and economic realities of the COVID-19 pandemic,” the lawmakers wrote, in a letter first obtained by Politico. “Therefore, we are asking for you to prioritize the expansion and improvement of Medicare in the American Families Plan.”

Although details remain in flux, the measure will likely be fully paid for with new tax increases aimed at wealthy Americans and and investors. Some tax increases currently under consideration include restoring the top marginal tax rate to 39.6%, where it sat before Republicans’ 2017 tax overhaul, taxing capital gains as ordinary income above a certain threshold and eliminating the stepped-up basis at death.

Lyft Pass For Healthcare Lets Patients Book Their Own Rides To The Doctor

Source: Fierce Healthcare, by Dave Muoio

Ride-sharing company Lyft is letting patients schedule nonemergency medical transport (NEMT) on health organization’s dime with the launch of Lyft Pass for Healthcare.

The latest healthcare offering falls in line with the initial Lyft Pass service launched in July 2020, which allows business organizations to monitor and cover the cost of employees’ transportation. Now, the company is extending those capabilities to healthcare organizations—commercial health plans as well as Medicare or Medicaid—and their members.

Through the app, users who need a ride to their medical appointments, vaccinations, prescription pickups or other destinations request a ride. This process is similar to ordering a pickup as a consumer, except that patients will need to select an in-app branded Lyft Pass provided via phone number, access code or a direct link.

Healthcare organizations sponsoring the pass, meanwhile, are able to customize the program’s budgets, approved locations and scheduling windows. The organizations are able to monitor usage and manage spend while allowing members to be more autonomous with their NEMT scheduling.

“By leveraging our superpower in consumer tech, we’ve automated an important piece of health access that allows patients to be self-sufficient and in control, while allowing our partners to focus on the services they provide, rather than on administrative processes,” Megan Callahan, vice president of Lyft Healthcare, said in a statement.

Inadequate transportation is a persistent roadblock to care for low income, elderly and other underserved patients.

A study published in 2019, for instance, found that a program that provided unlimited Lyft rides to older patients with transportation barriers helped these individuals reach their medical appointments and improved their self-reported quality of life.

Organizations also weather the cost of patient transportation issues. Millions of patients in the U.S. don’t receiving medical care due to transportation issues, with no-shows contributing to more than $150 billion in annual costs across the entire U.S. health system.

Lyft said in the announcement that the product is compliant with healthcare regulations. It’s the latest healthcare-focused effort from the company, which over the last couple of years has partnered with health organizations and coordination servicesintegrated with Epic’s electronic health record system and launched a campaign to provide rides to and from COVID-19 vaccination sites.

Uber, its primary rival in the ride-sharing space, has also had its eye on healthcare for some time.

Its Uber Health service launched in 2018, and it has since partnered with more than 1,000 healthcare organizations to provide NEMT. The service recently cut deals with NimbleRx and ScriptDrop to enable home prescription deliveries, but it also lost its leader, Dan Trigub, to home health startup MedArrive late last year.

Can You Add Your Parents to Your Health Plan? California Considers It

CA Considering Letting Kids Add Parents to Their Insurance Plans

Source: The National Law Review, by Katherine Anne Sullivan Morgan and Hannah R. Demsien

12% of parents in the United States with children under age 18 are also caring for another adult. The number of caregivers who provide unpaid care for a family member over the age of 50 has increased in the past five years, as has the percentage of caregivers who live in the same household as the individual who is receiving care. Children who care for a parent or parent-in-law are commonly involved in the management of their parent’s health, handling responsibilities such as communicating with health care providers and monitoring their parent’s health conditions.

Last week, the California Department of Insurance sponsored California State Assembly Member Miguel Santiago in introducing Assembly Bill 570 (the “Bill”), which would mandate that individual or group health care service plan contracts or health insurance policies cover dependent parents. Though the Bill does not limit the age of the dependent parent, Assembly Member Santiago noted an existing issue with seniors’ access to health care that has been exacerbated by COVID-19, and the Commissioner added that in the face of the high health risks to older adults due to the pandemic, the Bill could help reduce health insurance costs for California families by expanding health coverage. Additionally, the Bill would offer relief to immigrant families with younger working adults caring for older undocumented family members.

If passed, the Bill would require health coverage issued, amended, or renewed on or after January 1, 2022 that provides dependent coverage to make that coverage available to a qualified dependent parent or stepparent. The Bill would expand the definition of “dependent” under California law to include a parent or stepparent who meets the definition of a qualifying relative under 26 U.S.C. § 152(d). This connection to the federal definition of “qualifying relative” in the Internal Revenue Code means that in order to fall under the mandate, a parent or stepparent must have a gross annual income under a certain amount and must have more than one-half of their support for the year provided by the individual claiming them as a qualifying relative.

We will continue to monitor this bill and similar bills at the state and federal level.

House Votes to Avert Deep Medicare Cuts to Pay for $1.9 Trillion Stimulus Plan

House Votes to Avert Deep Medicare Cuts to Pay for $1.9 Trillion Stimulus  Plan - The New York Times

Source: The New York Times, by Emily Cochrane and Margot Sanger-Katz

The House voted on Friday to avert an estimated $36 billion in cuts to Medicare next year and tens of billions more from farm subsidies and other social safety net programs, moving to stave off deep spending reductions that would otherwise be made to pay for the $1.9 trillion stimulus bill enacted last week.

The action, opposed by the vast majority of Republicans, would effectively exempt President Biden’s pandemic aid package from a deficit-reduction law that requires that all spending be offset by automatic, across-the-board cuts to certain government programs. It passed by a vote of 246 to 175, with 29 Republicans joining Democrats to support it.

In passing the virus aid plan, Democrats used a fast-track budget process to push past Republican opposition, arguing that urgent needs brought on by the pandemic outweighed concerns about running up the national debt. But the maneuver meant that Congress had to act separately to prevent the automatic cuts, which would go into effect in January if lawmakers do not act.

Democrats remained confident that, even though they opposed the stimulus package, Republican senators would eventually support legislation to avoid cutting Medicare, farm subsidies and social services block grants to pay for it. But the debate was a chance for members of both parties to make their dueling cases about the government’s spending priorities after the enactment of one of the most expansive federal rescue packages in modern times.

In remarks on the House floor, Representative John Yarmuth of Kentucky, the chairman of the Budget Committee, described the bill as “a loose end we have to tie up before our work is finished.” He argued that the legislation would place the stimulus law on equal footing with previous pandemic relief bills passed during the Trump administration. All of those bills were approved with overwhelming bipartisan majorities and waived the requirement for corresponding spending cuts.

The vote margin signaled that the waiver legislation could become the subject of negotiations later in the year, as lawmakers approach a deadline to address the debt ceiling and the dozen spending bills needed to keep the government funded. It is unclear when the measure will be taken up in the Senate, where 10 Republicans would have to join Democrats for it to become law. Similar waivers have repeatedly been approved regardless of party.

The politically unpopular specter of drastic Medicare cuts during a pandemic is likely to prod lawmakers to a deal before the year is out.

“Very few of them would actually want the pay-go sequester to hit,” said Marc Goldwein, a senior vice president at the Committee for a Responsible Federal Budget, a group that urges fiscal restraint. Mr. Goldwein predicted that Republicans were likely to eventually vote for a waiver, as part of a larger deal. “They may try to get something in return for it.”

The debate over paying for the stimulus stems from a 2010 law called the Statutory Pay-as-You-Go Act that requires certain deficit spending to be automatically offset by cuts to federal programs. Typically, when Congress has wanted to spend big, it has also voted to ignore that rule. But because the recent pandemic relief bill was passed using a special budget process known as reconciliation, a waiver could not be included.

The Congressional Progressive Caucus has called for the law to be ended to avoid the automatic cuts.

The Congressional Budget Office, in a letter to Representative Kevin McCarthy of California, the minority leader, estimated that without the waiver enacted before the end of the calendar year, $36 billion would be cut from Medicare spending — 4 percentage points — in 2022 alone and billions more from dozens of other federal programs. Many mandatory spending programs could be completely defunded, including social services block grants, a Justice Department program that provides aid to crime victims, and the Black Lung Disability Trust Fund.

Waiver bills of this sort have typically been passed in time to avoid major cuts. In 2017, after Republicans passed their $1.5 trillion tax cut, also using the budget reconciliation process, many Democrats voted to prevent automatic spending reductions as part of a year-end funding bill.

“We need to be working together, as we did for you when you were giving tax cuts to the wealthiest Americans,” Representative Jan Schakowsky, Democrat of Illinois, said in a comment directed at Republicans.

Republican lawmakers criticized Democrats for having created their own problem, arguing that there would be no need for a separate vote to avert the cuts if the stimulus plan had been bipartisan.

“We are here today because Democrats want to ‘fix’ one of the many problems caused by President Biden’s $1.9 trillion bailout bill,” said Representative Jason Smith of Missouri, the top Republican on the Budget Committee. “They want to do so by just erasing $1.9 trillion in spending from the nation’s books — pretending $1.9 trillion in spending is not going to happen.”

Conservatives see the confrontation as an opportunity to criticize overspending by the Democrats.

“I do think it would be irresponsible to not do something to address the level of overspending,” said Matthew Dickerson, the director of the Grover M. Hermann Center for the Federal Budget at the Heritage Foundation. He said Republicans should use the looming cuts as leverage to pressure Democrats to agree to new measures to reduce federal spending.

Under New Cost-Cutting Medicare Rule, Same Surgery, Same Place, Different Bill

Under New Cost-Cutting Medicare Rule, Same Surgery, Same Place, Different  Bill | Kaiser Health News

Source: Kaiser Health News, by Susan Jaffe

A cost-saving change in Medicare launched in the final days of the Trump administration will cut payments to hospitals for some surgical procedures while potentially raising costs and confusion for patients.

For years, the Centers for Medicare & Medicaid Services classified 1,740 surgeries and other services so risky for older adults that Medicare would pay for them only when they were admitted to the hospital as inpatients. Under the new rule, the agency is beginning to phase out that requirement and, on Jan. 1, 266 shoulder, spine and other musculoskeletal surgeries were crossed off what’s called the “inpatient-only list.” By the end of 2023, the list — which includes a variety of complicated procedures including brain and heart operations — is scheduled to be gone.

CMS officials said the change was designed to give patients and doctors more options and help lower costs by promoting more competition among hospitals and independent ambulatory surgical centers. But they forgot one thing.

While removing the surgeries from the inpatient-only list, the government did not approve them to be performed anywhere else. So patients will still have to get the care at hospitals. But because the procedures have been reclassified, patients who have them in the hospital don’t have to be considered admitted patients. Instead, they can receive services on an outpatient basis.

CMS pays hospitals less for care provided to beneficiaries who are outpatients, so the new policy means the agency can pay less than it did last year for the same surgery at the same hospital and Medicare outpatients will usually pick up a bigger part of the tab.

“The impetus for this is for Medicare to save money,” said Dr. James Huddleston, a professor of orthopedic surgery at the Stanford University Medical Center and the chair of the American Association of Hip and Knee Surgeons’ Health Policy Council. “The oldest trick in the book is to say the patients don’t need to be cared for in an expensive hospital setting.”

But since seniors will still have to go to the hospital, “it’s sort of a distinction without a difference,” he added.

“This is not about a different care setting, or giving more choice to providers,” said Judith Stein, executive director of the Center for Medicare Advocacy. “It’s about Medicare billing practices that will further confuse hospital patients.”

When unveiling the final rule in December, then-CMS Administrator Seema Verma said the change would give seniors and their physicians more options for care “without micromanagement from Washington.” She promised the new policy would also let seniors avoid hospitals, especially during the covid-19 pandemic, and free up needed beds.

CMS did add services that it will cover when provided by ambulatory surgery centers this year, a spokesperson said last month, but those don’t include procedures that were on the inpatient-only list.

Dr. Catherine MacLean, chief value medical officer at New York City’s Hospital for Special Surgery, said CMS should have tested the change as a pilot project to be sure it’s safe for patients. “These are big procedures,” she said, with a lot of “cutting, sewing and bleeding” that require post-surgery monitoring due to a significant risk of complications, especially for patients with multiple health problems.

The change applies to adults who have government-run Medicare insurance, but some Medicare Advantage plans sold by private companies have similar policies.

CMS officials said the change was a response to numerous requests seeking assurance that payment requirements do not override physicians’ judgment and assessment of their patients’ conditions. But health care groups representing millions of providers opposed it.

Even though seniors getting this care will be considered outpatients, they may still stay in the hospital overnight or longer, often on the same floor as those who are admitted, getting the same nursing care, lab tests and drugs with one big difference: their bill.

Patients admitted to the hospital typically receive an all-inclusive package of services and pay only this year’s Medicare hospital deductible of $1,484 for a stay of up to 60 days. They also pay 20% of doctors’ charges. Medicare picks up the rest of the bill.

Outpatient services are charged differently, with the patient typically paying 20% of the Medicare-approved amount for each service. That’s one payment for the outpatient surgery plus, for example, a second payment for blood transfusions, and more payments depending on what may be included in the surgery charge and how many other separately billed items the patient needs. (And, like admitted patients, outpatients also pay 20% of doctors’ charges.)

As with other outpatient services, in most cases each charge cannot exceed $1,484. “However, your total copayment for all outpatient services may be more than the inpatient hospital deductible,” according to the federal government’s annual guide sent to all Medicare beneficiaries.

Patients will also be hit with a “facility fee” up to several thousand dollars to cover the hospital’s overhead costs, said Richard Gundling, senior vice president at the Healthcare Financial Management Association. After Medicare pays its portion, outpatients owe 20% of the facility fee. And because Medicare prescription drug plans don’t cover medication ordered for hospital patients, they’re treated as if they have no drug insurance and can be charged exorbitant amounts for drugs they routinely take at home.

Another item that can be tacked onto the bill for outpatients — but not admitted patients — is called “excess charges.” Providers who do not accept the Medicare-approved amount as full payment can charge up to an extra 15% of that amount. Medicare pays none of these extra charges.

These surprise expenses can add up even for people who buy supplementary or Medigap health insurance to cushion the sticker shock. These private policies cover some portion of the patient’s payments for Medicare-approved charges. Only the most expensive policies cover “excess charges.” Otherwise, when Medicare doesn’t cover something, Medigap doesn’t chip in, so the patient is on the hook for the total charge.

In addition, Stein warned that the new rule will “sometimes limit their Medicare coverage when they need care after leaving the hospital.” Medicare patients don’t qualify for nursing home coverage even if they stay in the hospital for the required three days. That time doesn’t count because they were not admitted to the hospital — something Medicare patients who are in the hospital for observation care have complained about for years, forcing some to sue the government for a change.

Outpatients may also find it more difficult to get home health care. Medicare pays home care agencies more for people after a hospital inpatient stay, but those who are not admitted may have trouble finding agencies willing to serve them at Medicare’s lower reimbursement, said Stein.

A procedure that was on the inpatient-only list can still be provided to an admitted hospital patient, if health care providers can justify the need based on their clinical judgment. But there’s no guarantee that CMS will agree the admission was necessary and cover it.

Since the Biden administration inherited the new policy, critics are hoping CMS will rescind it.

“The decision ought to be made by the surgeons in consultation with their patients,” said Dr. Joseph Bosco, a vice chair of NYU Langone Health’s department of orthopedic surgery and president of the American Academy of Orthopaedic Surgeons. “We don’t need the federal government or health insurance companies interfering in the doctor-patient relationship.”

Insurers Urge SCOTUS To Take A Look At Appeals Court Ruling On ACA Cost-Sharing Reduction Payments

Billions of Dollars on the Line as Insurers Await Obamacare Ruling - WSJ

Source: Fierce Healthcare, by Paige Minemyer

Two insurers are urging the Supreme Court to review a lower court decision that they say could prevent many plans from receiving the full amount in owed cost-sharing reduction payments.

In a filing with the court (PDF) this week, Maine Community Health Options and Community Health Choice argue that the decision allows the government to avoid paying out its full obligation in CSR payments under the Affordable Care Act.

In the August 2020 ruling, the Court of Appeals for the Federal Circuit says that the Supreme Court’s ruling that mandated the government pay back-owed risk corridor payments meant CSR payments were also mandatory.

However, the court said that plans that engaged in a practice known as “silver-loading” to mitigate the lost CSR payments should not be entitled to receive such payments in full. Following the Trump administration’s decision to cancel cost-sharing reduction payments in 2017, many insurers raised premiums on their benchmark silver plans, raising subsidies on its plans in tandem.

The insurers counter, however, that the Supreme Court decision on risk corridors sets a precedent that all of the back payments are owed regardless of how payers adjusted to deal with the decision to cut them off.

“The decision contradicts the simple principle that this Court set forth in Maine Community: When the government violates a clear statutory shall-pay obligation, the party who performed in full is entitled to a statutory shall-pay remedy,” they wrote in the filing.

The insurers petitioned the appeals court for a hearing on the issue in November but were denied.

Both cost-sharing reduction payments and the risk corridor program were efforts to incentivize health plans to participate on the nascent ACA exchanges. CSR subsidies help low-income Americans pay for coverage, while the risk corridors provide a boost to health plans that aren’t performing strongly on the exchanges.

No Hotter Health Care Issue Than Drug Pricing, Lobbyist Says

Why Prescription Drugs Cost So Much

Source: InsuranceNewsNet, by Susan Rupe

There is no health care issue hotter than drug pricing, Jonathon Jones told members of the National Association of Health Underwriters at their virtual Capitol Conference. Jones is a partner with the government relations consultant Peck Madigan Jones.

“It’s not just a Democratic priority – it has become a priority for both parties,” Jones said in looking ahead to what the Biden administration and the new Congress mean for health care.

Of the major health care issues in Washington, lowering the cost of prescription drugs is the issue that enjoys the most bipartisan support, at least ideologically, Jones said. “Everyone agrees on the idea that we need to do something to change the U.S. laws to reduce drug prices.”

In December 2019, the House of Representatives passed H.R.3, the Elijah E. Cummings Lower Drug Costs Now Act, but the bill did not come up for a Senate vote. Jones said he did not believe H.R. 3 will come up in the House again this year.

“I definitely don’t think it will become law,” he said. “I think with drug pricing, one of two things will happen. One is that in the Senate, if there is an outreach to Democrats from Republicans, there’s a growing recognition that the Senate could pass a bipartisan drug pricing bill. For the Biden administration, it could open an opportunity to do a big piece of health legislation with bipartisan support.

“The other option is that because a lot of the drug pricing policies generate revenue for the federal government, they could be paired with further expansions of the Affordable Care Act like we saw in this current COVID-19 relief package.”

What about the chances of Medicare for All or a public option becoming law anytime soon? Jones had some thoughts.

“President Biden wasn’t only unsupportive of Medicare for All but he campaigned against it and advocated building on the ACA instead. I think he has taken steps in this first COVID-19 bill to make good on that promise. The bill has a number of provisions that strengthen the current ACA system. I think he will continue to steer down that path. But the left wing of the Democratic party will continue to push for M4A and for public option.”

Jones said he believes “it’s virtually impossible that Medicare for All would pass” in Biden’s first two years in office. But a public option is a more likely possibility.

“I think it depends on what you consider to be a public option,” he said. “You could see some things that would quality as a modest public option, such as reducing the eligibility age for Medicare. There’s strong support in the Democratic party for a Medicare buy-in or public option. But I think it will be much more of a modest step and not a robust public option available to a really broad group of people.”

In health care, “you’re always straddling between the idea of adding something new and taking away something popular,” Jones said. “Republicans ran into this when they tried to repeal the ACA unsuccessfully in 2017. And I think Democrats are facing the same situation and they will go slow on this.”

Jones predicted that the nation “will continue to take more incremental steps toward government health care.”

“I’m not saying we will go to a single-payer system. But I think government will be more involved and public options will be available for more people.”

Jones cautioned that government policies eventually will take more people away from the employer-sponsored health care model.

“What I worry about is over time and as the ACA plans get bigger and we allow more people to participate, we’ll take more people out of employer market. It will reach a point where it becomes harder to defend the system. We need to have more affordable options so we can compete with this idea that the government can give people everything they want without their having to pay for it. The ability of this industry to provide choices is critical.”

Public Option Would Be Destabilizing, NAHU Exec Says At CapCon

No Hotter Health Care Issue Than Drug Pricing, Lobbyist Says -  InsuranceNewsNet

Source: InsuranceNewsNet, by Susan Rupe

The public option would destabilize current insurance markets, while the cost of Medicare for All is not sustainable.

Those are among the talking points members of the National Association of Health Underwriters will discuss with their representatives in Washington during this week’s virtual NAHU Capital Conference. The conference kicked off Monday with a rundown of the legislative and regulatory issues foremost on NAHU members’ minds.

The association continues its opposition to a public option, which would establish a government-funded health plan to compete with private health insurance.  The public option “would destabilize current insurance markets by creating an unlevel playing field,” said Chris Hartmann, NAHU vice president of congressional affairs. “This would have the devastating effect of closing hospitals.”

A public option would destabilize the market by compelling providers to accept payments at much lower rates than private carriers can require them to accept, he said. More than 1,000 rural hospitals would be put at high risk of closure under a public option by using Medicare provider reimbursement rates. These hospitals depend on a mixture of patient payment methods to allow them to provide services.

In addition, Hartmann said, the public option raises the questions of how much it would cost and how it would be paid for.

Last week, U.S. Sens. Michael Bennett, D-Colo., and Tim Kaine, D-Va., reintroduced the Medicare-X Choice Act, which would create a public option by expanding on the Affordable Care Act and Medicare. Under Medicare-X, the public option would initially be available on the individual exchange in areas where there is a shortage of insurers or higher health care costs due to less competiton. By 2025, the Medicare Exchange plan would expand to every ZIP code in the country and be added as another option on the Small Business Health Options Program Marketplace.

President Joe Biden said he favors establishing a public option as well as permitting a Medicare buy-in at age 60.

The cost of Medicare for All is not sustainable, Hartmann said, adding that such a plan would carry a price tag of $32 trillion over 10 years and an average tax increase of $24,000 per household at a time when the financial viability of our current Medicare plan is already in question.

NAHU’s position on Medicare for All is that it would reduce standards of quality, eliminate choice, and create delays in treatment and access to care. This would be the result of doctors being unable to treat as many patients for the amount they would be paid, some doctors dropping out of the system, and continued financial pressure on hospitals.

Other health-related issues are on the NAHU conference agenda:

COVID-19 Relief

NAHU is urging Congress to continue the Paycheck Protection Program loans as needed throughout the pandemic to allow more Americans to maintain or obtain health insurance coverage both in the group and individual markets, and allow employers to stay in business and maintain employment.

The pandemic is affecting administrative compliance with employer-reporting rules. NAHU wants Congress to suspend enforcement during the pandemic for employer-reporting provisions such as responding to 226-J letters, calculating affordability requirements for 1095 forms and calculating ALE status with variable-hour employees.

Market Stabilization

NAHU is urging Congress to preserve the employer tax exclusion, noting that the employer-sponsored health insurance system provides private-sector, market-based coverage for more than 175 million Americans. Along with the mortgage interest tax benefit, the employer tax exclusion is the largest tax benefit in the U.S., Hartmann said. COVID-19 has proven how the employer-sponsored market is, and the failure to preserve the tax exclusion would put all of those covered lives in jeopardy.

The cost of prescription drugs is another issue NAHU members will discuss with their representatives. NAHU is calling for bringing down prescription drug costs by eliminating impediments to drugs getting to market, and considering methods used by other countries, such as an international pricing index.

NAHU also favors a new voluntary reporting system for employers, reducing the number of individuals and amount of information reported, eliminating the requirement to collect Social Security numbers of dependents enrolled in employer coverage, and easing reporting provisions.

The “family glitch” is the ACA rule that bases eligibility for a family’s premium subsidies on whether available employer-sponsored insurance is affordable for the employee only, even if it’s not actually affordable for the whole family. NAHU is asking Congress to clarify that employee eligibility for affordable coverage does not extend to family members if there is not an affordable employer contribution to dependent coverage.


NAHU wants COBRA coverage to count as creditable coverage for Medicare beneficiaries just as employer-sponsored coverage does. This will allow beneficiaries to have access to Part B on a timely basis without penalties for late entry into the program.

NAHU also has proposed Medicare allow observation stays to be counted toward the three-day mandatory inpatient stay for Medicare skilled-nursing coverage.

Last Updated 05/12/2021

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