Doctors May Do a “Brexit” from Medicare

American physicians have already been declaring independence from Medicare, states the Association of American Physicians and Surgeons (AAPS), but the imposition of new payment methods may lead to a rush to imitate the British in exiting the regime of a remote, unelected, unaccountable bureaucracy. Almost four in 10 physicians in solo and small group practices predict an exodus from Medicare within their ranks because of the program’s new payment plan, according to a Medscape Medical News survey.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) includes complex system of bonuses and penalties. The Centers for Medicare and Medicaid Services (CMS) predicted that 87% of solo practice physicians would be penalized. AAPS says that a physician’s compliance score is tied to resource use. Physicians will be increasingly pressured to make decisions that save resources for Medicare instead of decisions that are in the best interest of their patients. Compliance is also tied to mandatory use of government-certified electronic health records, which AAPS says are harmful to patient medical privacy and detract from face-to-face patient care. The government would gain even greater ability to access patient medical records. The rules allow all insurance-based care, not just Medicare, to be phased in to these “harmful payment models, according to AAPS.

AAPS executive director Jane M. Orient, M.D. said, “It is impossible to practice medicine under this rule, for ethical and practical reasons. The rule makes it impossible to protect confidentiality, and one is in a constant conflict of interest: What is best for the patient may be bad for the financial viability of the practice. It would take a dedicated team of legal specialists to even attempt compliance. Full compliance is probably impossible even with such a team, which is beyond the means of a small practice. Physicians need to withdraw from Medicare or any other program that subjects them to this rule.” AAPS offers detailed instructions on how to opt out of Medicare, and regular workshops on building a successful practice to serve patients without third-party shackles.

Medicare to Enforce Profiteering at the Bedside

In the guise of “value pay” or “value purchasing,” the new Medicare payment system will reward doctors for not ordering services. This amounts to “a corporate or government agency profiteering, i.e., taking advantage of a situation to make a self-serving profit by corrupting the provision of care,” writes Robert Geist, M.D., in the spring issue of the Journal of American Physicians and Surgeons. The following is a summary of his comments:

            Advocates of managed care have long believed that cost control necessitated a switch of professional loyalty from patients to corporate populations. Previously forbidden and unethical, the corporate practice of medicine has been legalized. Federal laws against kickbacks and self-referrals have also been overridden. Medicare is turning doctors into bedside rationing agents..

The enabling act is the “doc fix,” the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which replaced the Sustained Growth Rate (SGR) formula and its yearly threats to drastically cut doctors’ pay.

MACRA’s Merit-Based Incentive Payment System (MIPS) hides its agenda to deny care behind euphemistic double-speak, such as “bonus opportunities”—meaning bribes to gatekeepers. As George Orwell wrote in 1946, “Political language…is designed to make lies…truthful and murder respectable.”

What happens to the ethical integrity of a nation and its professionals when leaders create a system where doctors are bribed to restrict care at the bedside for the benefit of third-party insurers?

“Value pay” conveys an image of social concern, but it actually gives enormous contracting power to insurers—the “power to transfer insurance risk and the black hat of profit-driven rationing of care to providers at the bedside.

The government regulator is supposed to guard against such consequences, but has been co-opted into collusion. The Obama Administration has winked at and abetted rotating chairs between the CMS regulator and the regulated HMO industry management. When former Medicare regulator Marilyn Tavenner became CEO of the industry trade association, President Obama promptly nominated Andrew Slavitt, an HMO (UnitedHealth Group) executive, as the new interim CMS regulator. The system is creating a conflict of interest between doctors and patients. Geist concludes that a good end, such as cost control never justifies corrupt means, a scandalous system of legalized profiteering at the bedside.

Medicaid and CHIP Beat Private Plans in Access to Pediatric Preventive Care

Children with Medicaid or the Children’s Health Insurance Program (CHIP) have greater access to preventive care than do children with private insurance, according to a survey by PolicyLab at the Children’s Hospital of Philadelphia. David Rubin, MD, MSCE, of PolicyLab suggests requiring private plans on the exchanges to match Medicaid’s mandatory benefit and cost-sharing provisions. He noted that some new insurance plans in the commercial market are tiering specialty providers as out-of-network, which blocks access for children with special healthcare needs.

Seventy-eight percent of caregivers of children with Medicaid and CHIP say the insurance always meets their needs compared to 73% of caregivers of children with private insurance. Eighty-eight percent of children with Medicaid or CHIP had access to preventive medical care compared to 83% of children with private insurance. Eighty percent of children with Medicaid have access to dental care compared to 77% of children CHIP and 73% of children with private insurance.

Getting specialty care is a challenge for children in all coverage types, with as many as one in four having difficulty seeing a specialist. However, these challenges are greatest for children with CHIP (28%) and for privately insured children with special health care needs (29%). Seventy-seven percent of caregivers of children with private insurance have out-of-pocket costs compared to 38% of those with CHIP, and 26% of those with Medicaid.

How States Might Use Obamacare Waivers

State leaders face the quandary of losing federal funding if they act to control health care spending, according to an analysis from the National Institute for Health Care Reform (NIHCR). Section 1332 of the Affordable Care Act (ACA) allows states to request federal waivers of many key ACA provisions. The catch is that alternate state reforms must achieve the same or better health coverage and affordability for state residents and be budget-neutral for the federal government. The study by the RAND Corp., explores two approaches. The first approach is to enroll almost all state residents automatically into a universal coverage plan. The plan would be financed by a federal lump-sum payment to the state and a new state payroll tax. A key stumbling block would be the high tax rate required to fund a single-payer plan, particularly if it offers coverage that is more comprehensive than today’s norms.

The second approach involves a coordinated-waiver that would replace marketplace subsidies and the Medicaid and Children’s Health Insurance Program (CHIP) for lower-income children and non-disabled adults. Instead, there would be a voucher to purchase private insurance—an individual plan in the marketplaces or tax-preferred coverage from an employer. In some states, projected funding levels for Medicaid and the marketplaces could support a broad-based voucher program. In other states, a voucher-based approach would face challenges in meeting the ACA Section 1332 coverage and affordability standards. States pursuing a voucher approach could tap into additional federal funding if they agreed to implement the ACA Medicaid expansion as a base for the waiver. In general, states that develop a single-payer approach or a voucher approach would face an easier path if their waiver plans included substantial and effective cost-control components.

The two state-based waiver options outlined in the analysis are likely to appeal to polar opposites of the political spectrum. Nevertheless, they share key features. State-based plans would convert open-ended federal payments under the financing system into a lump-sum federal contribution. Such an approach would better position a state and its residents to reap the rewards of system-wide cost-containment efforts, according to the report.

CHIP renewal, court ruling affect coverage for nearly 2M children

An Urban Institute report predicts that 1.9 million children would lose coverage if Congress decides not to reauthorize the Children’s Health Insurance Program and if the Supreme Court rules against Affordable Care Act subsidies. “The combination of both policies would mean a lot of progress we’ve made over the last 20 years would be wiped out,” Urban Institute senior fellow Lisa Dubay said. The Hill (3/18), Modern Healthcare (tiered subscription model) (3/18)

Special Enrollment Period to Boost Insured Rate

Nationally, almost 7 million adults are likely to experience a qualifying event that triggers a special enrollment period, according to a report by Those who missed the March 31 enrollment deadline and are not eligible for Medicaid or the Children’s Health Insurance Program (CHIP) can still enroll in health insurance if they experience a qualifying event that triggers a Special Enrollment Period (SEP). Examples of qualifying life events include permanently moving to an area where different plans are available on the marketplace, getting married, having or adopting a child, and becoming a citizen, national, or “lawfully present individual.”

Medicaid Patients Use, Not Abuse Emergency Rooms

Medicaid enrollees visit the emergency department appropriately like most patients, but have more complex health needs and less access to primary care, according to a report from the Medicaid and CHIP Payment and Access Commission (MACPAC).  Non-urgent visits accounted for just 10% of Medicaid visits to the ER, which is very close to that of the general population – about 8%. Most have serious and complex medical problems that can only be addressed in the emergency department. Given Medicaid’s historically low reimbursement rates, the shortage of primary care physicians accepting these patients isn’t surprising. The lack of access to primary care is even more acute for Medicaid patients with disabilities who are disproportionately represented on Medicaid rolls. Alex Rosenau, DO, FACEP, president of the American College of Emergency Physicians  said, “The lack of access to primary care certainly contributes to Medicaid patients’ use of the ER, but for Medicaid patients with serious mental illness, multiple illnesses and homelessness, even having a primary care physician is no bar against appropriate emergency department use. In general, the combination of poverty and illness present challenges with few genuinely simple solutions, despite misplaced beliefs that significant health care costs could be saved by keeping patients out of the ER. Efforts by various states to deny payment for Medicaid visits to emergency departments are dangerous and wrong.” For more information, visit

ACA to Cost Government Less Than Expected

The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) estimate that the Affordable Care Act (ACA) will result in lower than expected net costs to the federal government. In July 2012, CBO and JCT estimated that the ACA’s effect would be to reduce federal deficits. The agencies now project a net cost of $36 billion for 2014, which is $5 billion less than the previous projection for the year; and $1,383 billion for the 2015 to 2024 period, which is $104 billion less than the previous projection.

The estimated net costs for 2014 stem almost entirely from spending for subsidies that are to be provided through insurance exchanges and from an increase in Medicaid spending. The following are projected net costs for the 2015 to 2024 period:
• Gross costs of $1,839 billion for subsidies and related spending for insurance through the exchanges, Medicaid, the Children’s Health Insurance Program (CHIP), and tax credits its for small employers.
• A partial offset of $456 billion in receipts from penalty payments, additional revenues resulting from the excise tax on high-premium insurance plans, and the effects on income and payroll tax revenues and associated outlays arising from projected changes in employer coverage.

Those estimates only address the insurance coverage provisions of the ACA, which do not generate all of the act’s budgetary effects. Many other provisions are expected to reduce budget deficits. For more information, visit

3M more Americans gain Medicaid, CHIP coverage

More than 3 million additional people across 46 states had signed up for Medicaid and the Children’s Health Insurance Program by Feb. 28 compared with October of last year, bringing the total to about 61 million, according to a CMS report released Friday. “The increase in Medicaid enrollments across the country is encouraging, but more work is left to do to ensure that the millions of uninsured Americans eligible for these programs gain coverage,” HHS Secretary Kathleen Sebelius said. The Washington Post (tiered subscription model) (4/4), The Wall Street Journal (tiered subscription model) (4/4), Politico (Washington, D.C.) (4/4)

CMS Issues Proposed Rule on Exchanges

CMS issued a proposed rule on Jan. 14 describing how states should handle eligibility determinations for Medicaid and other income assistance programs on state-based health insurance exchanges, beginning in January 2014. The proposed rule would lay out a structure and options for coordinating Medicaid, CHIP, and Exchange eligibility notices and appeals; provide additional benefits and cost-sharing flexibility for state Medicaid programs; and codify several provisions included in the Affordable Care Act and Children’s Health Insurance Program Reauthorization Act (CHIPRA). The proposed rule includes the following Key Provisions:

Process for Appeals of Eligibility Determinations
The rule proposes a coordinated Exchange and Medicaid appeals process. The rule proposes that enrollees have the opportunity for a preliminary case review by appeals staff, referred to as “informal resolution.”  If the enrollee is satisfied by the outcome, the decision stands as an official appeal decision. Enrollees who are not satisfied would have rights to a full appeal. As required by statute, a federally managed appeals process would be available to all enrollees in the individual market. State-based exchanges could implement their own appeals processes in accordance with the Notice of Proposed Rulemaking standards, with people retaining the right to a federal appeal at HHS after exhausting the state-based appeals process.

The proposed rule provides options for states to coordinate appeals of eligibility decisions across Medicaid, CHIP, and the Exchange. Specifically, states could choose between the following options:
• A state Medicaid or CHIP agency could delegate the authority to make final determinations in Medicaid and CHIP eligibility appeals to an Exchange appeals entity subject to standards.

• A state could retain the Medicaid and CHIP appeals functions, consistent with the choice offered to states with respect to permitting the Federally-facilitated Exchange to make Medicaid and CHIP eligibility determinations or assessments.

Notices to applicants and beneficiaries would include combined, clear, and accurate information about eligibility for all insurance affordability programs, including Medicaid, CHIP, advance payments of the premium tax credit and cost-sharing reductions, as well as eligibility to enroll in a qualified health plan through the Exchange.  The final combined notice would be generated by the agency that completed the last step in making the eligibility determination (which could be the Exchange or the Medicaid or CHIP agency).  This coordinated process would not have to be in place until January 1, 2015.

Medicaid Benefits
The proposed rule modifies existing “benchmark” regulations applicable to Medicaid programs to implement the benefit options available to low-income adults beginning January 1, 2014.  The Notice of Proposed Rulemaking provides guidance on the use of section 1937 benchmark and benchmark-equivalent plans (now known as Alternative Benefit Plans) for the new eligibility group for low-income adults; the relationship between Alternative Benefit Plans and Essential Health Benefits; and the relationship between section 1937 and other Title XIX provisions.

Medicaid Cost Sharing
The rule proposes to update the maximum allowable cost-sharing levels and to consolidate redundant provisions. The goal is to create one streamlined set of rules for all Medicaid premiums and cost sharing.  States could establish higher cost sharing for non-preferred drugs and impose higher cost sharing for non-emergency use of the emergency department.

Streamlining Eligibility Categories
The proposed rule would do the following:
• Define the range of eligibility groups for Medicaid and eliminate obsolete categories to reflect the existing federal statute and use of the Modified Adjusted Gross Income (MAGI) methodology to determine eligibility with most populations.
• Codify eligibility categories authorized in CHIPRA and the Affordable Care Act, such as new coverage for former foster care children up to age 26.
• Simplify and align the citizenship documentation process across Medicaid, CHIP, and the Exchange.

Verification of Employer-sponsored Coverage
The proposed rule includes detail on the procedures for the Exchange to verify access to employer-sponsored coverage.  An Exchange relying on HHS to fulfill the employer-sponsored coverage verification process.

Application Counselors
Application counselors play a key role in helping people apply for and maintain coverage in a qualified health plan through the Exchange and through insurance affordability programs. This rule proposes standards for certifying those who want to become application counselors.

You can submit comments to the proposed rule by 5:00 p.m. on February 13 at To read the proposed rule, visit

Last Updated 10/20/2021

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