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RACIAL DISPARIETIES AMONGT MEDICARE BENEFICIARIES

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The Middle Class Cost of M-4-A

Medicare for All

By Rick Kahler MSFS CFP

The concept of “Medicare for All” is getting a lot of attention in the 2020 Presidential race. Senator Elizabeth Warren’s promise that it will not cost the middle-class “one penny” has much appeal.

While most Americans support providing free medical care to those who need it most, making it with no additional cost to the middle class would be something never before accomplished by any country that has universal health care. The middle class in those countries pay income taxes of up to 40% and a national sales tax equivalent of 15% to 25%.

Recently, Senator Warren revealed how she will finance her plan. She estimates the cost over a decade at $20 trillion in new federal spending. Estimates by six independent financial organizations are higher, ranging from $28 trillion to $36 trillion.

Here are some of the general provisions of her plan.

1.                            She would tax both employers and employees an amount equivalent to what they currently pay in health insurance premiums. This will bring in $11 trillion.

2.                            She would increase taxes on the top 1% of individuals and large corporations to generate $7 trillion.

3.                            The balance of the money needed, $2 to $18 trillion (depending on whether you believe Ms. Warren’s numbers or the other six independent estimates) would come from new-found efficiencies, tax enforcement, and reductions in wasteful spending. There is widespread doubt that this is even remotely possible.

A Forbes article describing the tax increases aimed at wealthy individuals caught my attention. These increases include:

·                                 Adding a wealth tax of 2% to 6% on household net worth above $50 million

·                                 Eliminating the favorable tax rate on capital gains

·                                 Increasing the “Obamacare” tax from 3.8% to 14.8% on net investment income above $250,000

·                                 Eliminating the step-up in basis for inheritors

·                                 Increasing the salary subject to Social Security from $132,900 to $250,000

·                                 Lowering the estate tax exemption from $12 million to $7 million

·                                 Establishing a financial transaction tax of 0.10%.

The capital gains tax increase, the step-up in basis, and the financial transaction tax will all affect middle class investors, potentially including anyone with a 401(k) or an IRA. The American Retirement Association estimates that the financial transaction tax alone will cost the average 401k and IRA investor over $1,500 a year.

Diann Howland, vice president of legislative affairs at the American Benefits Council, cited in an article in InvestmentNews, called the proposal “not a great thing to do to the middle class.”

The 0.1% financial transaction tax is more damaging than it might seem at first glance. It applies to all the securities sold and purchased within a mutual fund or ETF, as well as the purchase and sale of the funds by investors. By my calculations it can easily add a cost of 0.20% to 0.30% a year to every fund investment. Given that some index mutual funds only charge 0.10% in total expenses, that’s a cost increase of 200% to 300%.

Eliminating the step-up in basis on inheritances and the favorable capital gains tax rate will also affect the middle class. According to a 2013 survey by HSBC Bank, retirees expected to leave their heirs an average of $177,000. If the average basis is one-half of what’s inherited, the elimination of step-up in basis and capital gains tax will cost middle class inheritors $10,000 to $20,000 more in taxes.

Senator Warren’s proposed tax increases will affect the middle class as well as the wealthy. They also fall short of covering the estimated cost of her plan. Assuming, then, that Medicare for All could be implemented with no increase in federal income or sales taxes for the middle class may well be a pipe dream.

Conclusion

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Medicare for All?

Taxes for All?

[By Rick Kakler CFP®]

As the recent debates among the Democratic presidential candidates emphasized, the idea of government-managed health care is gaining popularity. “Medicare for all” or some form of “free” universal health care is certainly an appealing idea. Who among us wouldn’t appreciate someone else paying our medical bills?

I certainly would. My family’s personal health care costs, including premiums and out-of-pocket expenses, run just over $3,000 a month. If my health care were free, I could find a lot of uses for the savings.

But my skeptical side, and probably yours as well, knows that there is no such thing as a free medical procedure. Someone, by some means, has to pay for insurance coverage, doctor visits, hospitalizations, and other medical costs.

The tax tab for providing “Medicare for all,” as envisioned by Sen. Bernie Sanders, is $3 trillion a year, according to several analysts. Currently, the cost for Medicare is about one-sixth that amount, or $583 billion a year.

Sanders and other presidential candidates tell us the wealthy will pay this tab. The reality is that when we look at other countries that have similar universal health care plans, it isn’t just the wealthy that are paying for it.

Raising the more than $3 trillion needed annually to fund “Medicare for all” would require doubling all personal and corporate income taxes or tripling payroll taxes. This analysis comes from Marc Goldwein, a senior vice president at the non-partisan Committee for a Responsible Federal Budget. He was cited in a May 9, 2019, Bloomberg article by Laura Davison, “Tax hikes on wealthy alone can’t pay for Medicare for all plan.” “There is a lot of money out there, but there isn’t $30 trillion [over 10 years] sitting around from high earners,” Goldwein said. “It just doesn’t exist.”

I did a little investigating of the tax rates of European countries that have universal health care and found Goldwein’s statement to be true. For example, Denmark taxes income over $7,000, with rates starting at 40%. The US rate starts at 10%. This would indicate a doubling or tripling of income taxes or payroll taxes on the lowest earners is not a politically-skewed scare tactic, but an economic reality.

The top rate in Denmark is 56%, while the top rate in the US is 50% (37% federal and 13% state). This is just one of many examples I found in my searching that strongly indicate other countries that have universal health care haven’t found much room left to tax the wealthy. Based on their experience, the majority of the cost will need to come from lower income earners.

Sadly, this message is not being disseminated to voters by proponents of universal health care. While I am not advocating for or against universal health care here, I am advocating for full disclosure and transparency.

A topic as significant as this deserves a great deal of discussion based on clear, complete disclosure of facts and educated analysis. It requires the best available answers to questions like who will be covered, what will be covered, how much the program will cost, and who will pay for it.

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Assessment

Raising six times what we are currently spending for Medicare would be a huge task. Transferring one-eighth of the US economy from the private sector pocket to the public sector one would not be easy or painless. Making the transition to some form of tax-funded universal health care would be a major shift in direction for this country that would have a significant impact on all Americans. It is not a decision to make based on inadequate information, political rhetoric, or unreasonably optimistic assumptions.

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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More Changes to Medicare for Doctors

More Changes to Medicare

By Ira Nash MD

Conclusion

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On Medicare Bureaucratization

Isn’t limited to governments

By Rick Kahler MS CFP®

A client recently told me about her first medical checkup after becoming eligible for Medicare. “The doctor said things like, ‘They require us to fill out this form,’ and ‘This test is covered every three years, so we can’t do it this year,’ and ‘Medicare will pay for a baseline EKG even though you have no history of heart disease.’ I’ve gone to this doctor for ten years. I’m the same person I was a year ago. Yet it felt as if I had moved to a category where the appointment was all about the paperwork instead of my health. ”

A situation like this, where the paperwork seems more important than the person, demonstrates something I call the Principle of Bureaucratization: the idea that the more layers of decision-making are added to an organization, the less efficient it becomes in delivering its goods or services.

While this phenomenon affects organizations and governments of all sizes, the negative outcomes seem to increase the larger a company becomes or the further away the seat of government is from its constituents. Municipal services seem to be delivered more efficiently than state services. State services tend to be more efficient that those coming from the federal government. There are some exceptions, but not many.

One reason is that the further removed from you the decision-maker is, the less personal the services will be. Moving from the private health care system to the government-run health care system called Medicare is just one example. The same principle seems to apply in other countries. I have visited the UK numerous times, and it seems that every time I’ve read a newspaper article about some specific failing of the NHS (National Health Service). Just recently, at a workshop in Europe, a participant from the UK told me that the waiting list to see a psychiatrist was one year. “The NHS simply works against you,” she said with exasperation.

I think most Americans can agree that our healthcare system is badly flawed. We may disagree on the causes and cures. I see as one major problem that our federal government has created a regulatory structure which allows a select number of health insurance and pharmaceutical companies control over the health care system. These regulations have sent insurance costs soaring by almost eliminating competition. Third-party payment of medical bills means those receiving the services don’t have any incentive to even ask about costs.

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Bureaucratization isn’t limited to governments. It also affects large companies where the policies are made by people many layers away from the customers, and the employees dealing with customers don’t have the authority to make decisions or solve problems. Who hasn’t experienced having a seemingly easy problem to solve with a service provider, calling a customer service representative, and ending up on the phone for 45 minutes being passed from department to department and supervisor to supervisor?

Many employees of large firms and governments are equally frustrated by the bureaucracy created in their organizations. Bureaucratic organizations stagnate innovation and responsiveness. They are especially inefficient when those dealing directly with consumers don’t have any significant consequences riding on the quality of the goods or services provided. This is one reason why many, like Brian Robertson in his book Holacracy, believe the “best practices” governance model for organizations is a self-organizing structure that empowers employees closest to consumers to make decisions.

What’s the bottom line?

You’re ultimately responsible for your own well-being. Ask questions, be the squeaky wheel, and, above all, make connections with those working in the bureaucracies you deal with. Help them keep in mind that their purpose is to serve people, not paperwork. 

Conclusion

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Hospital Re-Admissions Trends

For Medicare

By http://www.MCOL.com

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Conclusion

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Financial “Planning” versus “Preparing”

Understanding the Difference

By Rick Kahler CFP®

Retirement planning is one of the issues that commonly lead clients to consult financial advisers.

One of its essential aspects is creating a plan to save and invest in order to provide a comfortable retirement income. Ideally, this starts many years ahead of retirement, even as early as your first paycheck.

As retirement comes closer, planning for it expands to take in a host of other considerations, such as deciding when to retire, where to live, and what kind of lifestyle you hope to have. When retirement becomes a reality, the focus shifts to carrying out the plan.

Preparing

All of this planning is crucial. Yet, for both financial advisers and clients, it’s good to keep in mind that planning has its limits. In the post-retirement years, it may be helpful to think in terms of preparing for old age rather than planning for it.

The older we get, the more important this distinction between planning and preparing becomes. Too many life-changing things can happen without regard to our best-laid plans. Often they occur unexpectedly, resulting in emergency situations where urgent decisions have to be made. A stroke or a fall, a diagnosis of terminal illness, a broken hip that leaves someone unable to go back to independent living—and suddenly, right now, the family needs to find an assisted living facility, arrange for live-in help, or sell a home.

What are some of the ways to prepare for these contingencies?

  1. Explore housing options well ahead of time. Find out what assisted living, home care, and nursing home services and facilities are available where you live and whether they have waiting lists. Have family conversations about possibilities like relocating or sharing households:
  2. Research the financial side of these options. Investigate the cost of hiring help at home, assisted living facilities, and nursing care centers. Find out what is and is not covered by Medicare and long-term care insurance. For example, people are sometimes surprised to learn that Medicare does not pay for nursing home care other than short-term medical stays.
  3. Designate someone to take over decision-making, and do the paperwork. Execute documents like a living will, medical power of attorney, and contingent power of attorney. Update them as necessary, and give copies to your doctors, your financial planner, and appropriate family members.
  4. Start relatively early to downsize. Well before you’re ready to let go of possessions or move into smaller housing, start considering what to do with your “stuff.” Focus on the decisions rather than the distribution. There’s no need to get rid of possessions prematurely, but decide what you want to do with them—and put in writing. Do this while it’s still your choice, rather than something your family members do while you’re in the hospital or nursing home
  5. Do your best to practice flexibility and acceptance. No matter how strongly you want to live in your own home until the end of your life, for example, it may not be possible. The physical limitations of aging can limit our choices, and even the best options available may not be what we would like them to be. It is a profound gift to yourself and your family members to accept these realities with as much grace as you can muster.

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Assessment

Finally, please don’t underestimate the importance of planning financially for retirement. Because the bottom line is that you can’t plan for all the things that might happen as you age, but you can prepare to deal with them. One of the most useful tools to cope with those contingencies is having enough money.

Conclusion

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PP-ACA Change or Repeal for 2017?

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Potential Component Changes

By http://www.MCOL.com

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infographic

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MORE: Podcast: Third Quarter Health Plan Financial Reports

Conclusion

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Tom Price for HHS Secretary & Seema Verma for CMMS

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Obamacare critic for HHS 

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112_price_ga06

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Trump nominates Rep. Tom Price for HHS secretary

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Trump picks Seema Verma to head Centers for Medicare and Medicaid Services

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Find Your Doctor’s Payments

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FBF300BA-321A-49FD-9289-0DE0AD63DCE5

 CMS’ Open Payments Program Posts 2015 Financial Data

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 The Centers for Medicare & Medicaid Services (CMS) has published the 2015 Open Payments (sometimes called the “Sunshine Act”) data, along with newly submitted and updated payment records for 2013 and 2014, at https://openpaymentsdata.cms.gov.
The Open Payments program requires that transfers of value by drug, device, biological, and medical supply manufacturers to physicians and teaching hospitals be published on a public website.
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physician investors

Portrait of two surgeons in a operating room viewing paper charts.

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Assessment
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In program year 2015, healthcare industry manufacturers reported $7.52 billion in payments and ownership and investment interests to physicians and teaching hospitals. This amount is comprised of 11.90 million total records attributable to 618,931 physicians and 1,116 teaching hospitals. To find out what any doctor received in 2015, click here.
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Conclusion
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Are you Being “Admitted” to the Hospital?

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OR … just “Observed”?

Brian J. Knabe MD

By Brian J. Knabe, MD, CMP©, CFP®

Savant Capital Management

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http://www.CertifiedMedicalPlanner.org

Much attention has been given in recent months to the unintended consequences of healthcare rules and laws.  Most of this has centered on the Affordable Care Act—employers discontinuing health plans for their employees, individuals being dropped from their privately purchased insurance, and other ill effects.  One subject that has not received much press, but which may affect many seniors, is changing rules for Medicare.

Medicare

Patients usually assume when they spend a night or more in a hospital that they have been “admitted.”  However, this is often not the case.  Medicare regulations and statutes require physicians and hospitals to predict at the time of initial hospitalization how long a patient will stay in the hospital.

A short stay—for a night or two– is classified as “observation,” while a longer stay can be classified as an “admission.”  While the difference between these may not be a primary concern for a sick patient wanting to receive necessary evaluation and treatment, it can make a significant difference for your pocketbook.

Observation status

Observation status is considered “outpatient” treatment, and as such can expose Medicare patients to unexpected expenses.  As outpatients, visits under observation status are not covered under Medicare Part A, which pays for hospital charges above a $1,184 deductible.  These outpatient services are billed under Medicare Part B, which requires patients to pay 20% of the cost and imposes no cap on their total out-of-pocket expenditures.

Moreover, observation patients must pay out of pocket for the medication they receive in the hospital.  Those with Medicare Part D prescription-drug plans can file claims for reimbursement, but they may receive little or no refund if their Part D plan doesn’t cover those specific medications.

SNF

Another unexpected consequence of hospital observation is subsequent nursing home coverage.  A stay in a Skilled Nursing Facility (SNF) is often covered by Medicare, as long as certain criteria are met.  One of those criteria is whether the SNF stay was preceded by a “qualifying hospital stay.”  An admission to a hospital might meet this criterion, but an observation stay will not, even if it extended for a number of days.  When a patient who meets Medicare’s admission requirement moves to a SNF, the program covers 100 percent of the first 20 days.  Patients are responsible for $152 daily co-pays for the next 80 days, if necessary.  On the other hand, patients leaving the hospital for a SNF after an observation stay pay the full cost out of pocket.

WSJ

According to a recent Wall Street Journal article, from 2004 to 2011 the number of observation services administered per Medicare beneficiary rose by almost 34%, while admissions per beneficiary declined 7.8%.  Why does this difference between admission and observation matter to hospitals?  It comes down to payment.  Hospitals are reimbursed less for outpatient services.  However, if it is determined after a hospitalization that a patient should have been kept under observation rather than admitted, Medicare will often deny payment to the hospital for the entire bill.  So hospitals are motivated to get it right, at least according to Medicare regulations.

hospital bills

What  to Do?

So, what can you do to protect yourself as a patient?  At the time of hospitalization, ask your physician whether you are being admitted or kept under observation.  Ask to speak to a case manager about the proper status of the hospital stay.  Ask your doctors if they suspect that rehabilitation services will be needed after the hospitalization, and if so, request their help in getting the decision to “observe” reversed prior to hospital discharge.

Assessment

For additional help, see the “Self Help Packet for Medicare Observation Status” at www.medicareadvocacy.org.

See more at: https://www.savantcapital.com/blog/are-you-being-admitted-to-the-hospital-or-just-observed/#sthash.EOOiPWOA.dpuf 

Conclusion

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Sherlock Health Administration Expense Benchmarks Invitation

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Sherlock Benchmarks – Participation and Licensing

By Douglas B. Sherlock CFA

sherlock@sherlockco.com

thoughtSherlockHello All ME-P Readers and Subscribers:

This email invites your participation and/or licensing of the Sherlock Benchmarks.

A central effect of the Affordable Care Act is to sharply increase the incentive for health plans to minimize their administrative expenses. The Sherlock Benchmarks can be a catalyst to respond to these incentives since they identify and prioritize cost variances.

Use of the Sherlock Benchmarks reflects this:

• At least 40 health plans serving at least 40 million people with health insurance are so far committed as participants in this year’s Sherlock Benchmarking study.

• Of the 36 U.S. – based Blue Cross Blue Shield primary licensees, one-half are participating in this year’s Sherlock Benchmarking Study, either as an enterprise or through a subsidiary.

• Of the 13 members of the Alliance of Community Health Plans that are not focused on public programs or are staff-model plans, 11 are participating in this year’s Sherlock Benchmarking Study for Independent / Provider – Sponsored Health Plans.

• Most of the largest members of the Health Plan Alliance that are not focused on public programs are participating in this year’s Sherlock Benchmarking Study for Independent / Provider – Sponsored Health Plans.

• Health plans serving at least one-half of all insured Americans are licensed users of Sherlock Benchmarks since January 1, 2015.

Licensing and participation is available to all health plans

We have recently launched the Independent / Provider – Sponsored and Blue Cross Blue Shield surveys. There is still time, but the financial metrics survey form must be returned to us by the end of April.

So please contact me immediately if you wish to join these robust panels.

Our universes of Medicaid and Medicare plans will launch in a few months to avoid conflict with your Medicare bid process. If a plurality of your members are in either Medicare or Medicaid, please contact us about participation. Note that all costs are segmented by product as well as by function to assure an apples-to-apples comparison between the plans.

Licensing is available without participation. Licensing costs more but it entails less effort.  The 2016 Sherlock Benchmarks for Blue Cross Blue Shield Plans and Independent / Provider – Sponsored plans will be available beginning in July. The 2016 Sherlock Benchmarks for Medicare plans and Medicaid plans will be available beginning in September. 

Assessment

We look forward to working with you.

Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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[HEALTH INSURANCE, MANAGED CARE, ECONOMICS, FINANCE AND HEALTH INFORMATION TECHNOLOGY COMPANION DICTIONARY SET]

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Medical Provider Billing Facts for 2014

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A Look at Medicare Spending

By http://www.MCOL.com

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billing

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Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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[HOSPITAL OPERATIONS, ORGANIZATIONAL BEHAVIOR AND FINANCIAL MANAGEMENT COMPANION TEXTBOOK SET]

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[Foreword Dr. Phillips MD JD MBA LLM] *** [Foreword Dr. Nash MD MBA FACP]

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CMS Home Health Agencies

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Star Ratings

By http://www.MCOL.com

MEDICARE @ 50 [1965-2015]

ImageProxy

More videos:

Conclusion

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David Belk MD Announces New Website [True Cost of Healthcare.net]

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A Site Re-Design

belk[By David Belk MD]

Here’s the new website with a whole new look that’s been redesigned by Modern Creations: http://truecostofhealthcare.org

There are three new sections:

The first is a study of the prices of brand name medications. It shows that the price pharmacies in the US pay for brand name drugs have gone up an average of 40% in 2 1/2 years. That’s about 18 times the rate of inflation.

The other two new pages examine Medicare supplemental policies as well as Part D and Advantage programs:

The page on supplemental policies is an expansion of the blog I wrote 2 years ago on the subject. It answers just about any question you might have about what Medicare covers and how much you would expect to pay if you have Medicare and need medical treatment

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 David Belk, M.D., Announces New Website

hospital bills

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Assessment

Feel free to tell me what you think of it. Also, I’m sending this message from my new email address – truecostofhealthcare@gmail.com

Conclusion

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“Navigating a course where sound organizational management is intertwined with financial acumen requires a strategy designed by subject-matter experts. Fortunately, Financial Management Strategies for Hospital and Healthcare Organizations: Tools, Techniques, Checklists and Case Studies provides that blueprint”

 —David B. Nash MD MBA Jefferson Medical College, Thomas Jefferson University, PA

On Medicare Advantage Plan[s] Enrollment

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Medicare Pre-Paid Enrollee Composition

By http://www.MCOL.com

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medicare advantage

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NOTE: CMS Releases 2013 Hospital, Physician Data

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The opening of this week’s Health Datapalooza conference in Washington was the setting for a new Medicare data dump on physician and hospital inpatient/outpatient payment and utilization rates. This is the third annual release of data as part of the Obama administration’s information transparency initiative to promote increased quality of care and more informed healthcare spending by consumers. A link to the inpatient dataset is here, the outpatient dataset is here, and the physician / supplier dataset is here.

Source: Joseph Goedert, Health Data Management [6/2/15]

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Conclusion

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How Much Did Your Doctor Receive From Medicare?

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From Medicare Part B in 2012

By http://www.nytimes.com

Use the form below to find a doctor or other medical professional among the more than 800,000 health care providers that received payments in 2012 from Medicare Part B, which covers doctor visits, tests and other treatments.

You will need to know the medical providers’ name, specialty and/or zip code.

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David MD MBA

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LINK:

http://www.nytimes.com/interactive/2014/04/09/health/medicare-doctor-database.html?_r=0

Source: The information presented here is from a database released by the Centers for Medicare and Medicaid Services. The database excluded, for privacy reasons, any procedures that a doctor performed on 11 or fewer patients. The total reimbursements for each doctor does not include those procedures either. Results shown above include only the individuals like doctors, nurses or technicians but not organizations like Walgreens. While some providers could have multiple offices, the address shown is the main address indicated in the database. Descriptions of the procedures are from the American Medical Association.

More:

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Hospital Information Systems and the PP-ACA

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Extension of Hospital Information Systems Beyond the Hospital

By Brent A. Metfessel MD

Dr. MetfesselThe Patient Protection and Affordable Care Act (ACA), affirmed after the November 7th 2012 presidential election, includes a number of policies and potential projects with the aim of improving quality of care while reducing costs – or at least greatly slowing increases in health care costs from year to year.

Included in this effort are CMS payment incentives for providers that can show care patterns that meet the goals of high quality, cost-efficient care.

HHS and ACOs 

On March 31, 2011, the Department of Health and Human Services (HHS) released a set of proposed new rules to aid clinicians, hospitals, and other health facilities and providers to improve coordination of care for Medicare patients using a model known as Accountable Care Organizations (ACOs). ACOs that are shown to lower health care cost growth while meeting CMS quality benchmarks, including measures of patient/caregiver experience of care, care coordination, patient safety, preventive health, and health of high-risk populations, will receive incentive payments as part of the Medicare Shared Savings Program.

But, in some proposed models ACOs may also be held accountable for shared losses.

Care Co-ordination

Coordination of care means that hospitals, physician offices, and other providers have a complete record of patients’ episodes of care, including diagnostic tests, procedures, and medication information.  This potentially would decrease extra costs from unnecessary duplication of services as well as reducing medical errors from incomplete understanding of the patients’ illness histories and medical care provided.

It is also believed that better coordination of care may prevent 30-day hospital readmissions (which occur for nearly one in five Medicare discharges), since needed post-discharge care would be more readily obtainable with more aggressive care coordination.

Medicare patients in ACOs, however, would still be allowed to see providers outside of the ACO, and proposals exist to prevent physicians in ACOs from being penalized for patients with a greater illness severity or complexity.

According to a CMS analysis, ACOs may result in Medicare savings of up to $960 million over three years.  Although the Affordable Care Act’s ACO provisions primarily target Medicare beneficiaries, private insurers are also beginning to create care models based on the accountable care paradigm.  Insurers could offer similar incentives to the ACO model described above, and which might include features such as performance based contracting or tiered benefit models that favor physicians who score highly on care quality and cost-efficiency measures.

Balance

Only the Beginning

ACOs and other implementations of the accountable care paradigm, however, are in their beginning stages, with a number of pilots around the country currently being conducted to more fully evaluate the concept, and there still is some controversy over the best way to achieve these goals. It is a continuing balancing act.

The critical point here is that in all likelihood, with the advent of the ACA and other initiatives, stemming the upward tide of medical cost increases becomes an even higher priority, and no matter what the final models will look like, the success of any of the models requires a high level of care coordination – requiring information systems that are fully compatible and allow seamless and errorless transmission of information between sites of service and the various providers that can be involved in patient care.

More:

  1. Ground Breaking Book Explains Why Accountable Care Organizations May Be the Answer the Health Care Industry Has Been Seeking!
  2. Evaluating ACOs at Mid-Launch
  3. How Using a ‘Scorecard’ Can Smooth Your Hospital’s Transition to a Population Health-Based Reimbursement Model
  4. Doubting the Accountable Care Organization B-Model

Assessment

Thus, wherever a patient goes for care, all the information needed to provide high-quality and cost-efficient care is immediately available.

References

Feds Take Critical Look at Meaningful Use Payments”, InformationWeek Healthcare, October 24, 2012.  http://www.informationweek.com/healthcare/policy/feds-take-critical-look-at-meaningful-us/240009661 [Accessed on November 2, 2012].

Conclusion

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How to Transition into Medicare?

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The Timing, Costs, and Factors to Know

By Lon Jefferies MBA CFP® http://www.NewWorthAdvice.com

Lon JeffriesDid you know that the choices you make during your first year of Medicare eligibility will have long-term financial consequences? Yes, it is true!

And unfortunately, most people and even medical professionals have to make these decisions at a time when they are only beginning to familiarize themselves with a complex program.

The Rules

If you don’t follow Medicare’s enrollment rules, you may pay lifelong penalties for coverage. You have a seven-month window to enroll in Medicare as you turn 65. This window begins three months before the month of your birthday, includes the month of your birthday, and continues for the following three months.

The Parts

Part A

In most cases, you should sign up for Medicare Part A, which covers hospital stays, when you turn 65, even if you have other health insurance coverage. There is no cost for this coverage as long as you have 40 quarters of work in which you paid FICA taxes.

However, be aware that you are not allowed to contribute to a health savings account (HSA) if you are receiving benefits from Medicare. Thus, you may want to defer beginning Part A to continue building up your HSA balance to help offset future healthcare costs not covered by Medicare.

Part B

Medicare Part B covers services and supplies that are needed to diagnose or treat medical conditions, and health care to prevent illness. The standard monthly premium for Part B in 2013 is $104.90, but individuals with a modified adjusted gross income (MAGI) more than $85,000 and couples with a MAGI more than $170,000 pay more.

The premium ranges from $146.90 to $335.70 for those with incomes above the thresholds. If you have group health insurance through your own or a spouse’s employer, you may want to delay beginning Part B.

However, for this to be done without penalty, be sure to enroll in Part B coverage within eight months of the time your employment ceases. Otherwise, for every 12-month period that you could have been enrolled in Medicare Part B but were not, you will pay a 10 percent penalty on your Part B premium for life.

Part D

Medicare Part D covers prescription drugs. This coverage is usually purchased at the same time as Part B.  Part D monthly premiums vary by plan. However, higher-income beneficiaries (singles with a MAGI over $85,000 and couples with a MAGI over $170,000) pay from $11.60 to $66.60 more each month.

There is also a late enrollment penalty for Part D that is one percent of the “national base beneficiary premium” ($31.17 in 2013) multiplied by the number of full months you went without drug coverage.

Part C

Note that Medicare Part C is not a separate benefit. Part C, sometimes referred to as a Medicare Advantage Plan [MAP], is the portion of Medicare that allows private health insurance companies to provide Medicare benefits.

Part C is an alternative method for obtaining the same coverage that Part A and Part B provide, but do so through private insurance providers with different rules, costs and coverage restrictions. You can also get Part D as part of the benefits package if you choose. Although significant research is required, determining whether Part C is a viable option for you is simply a matter of considering your health, the medical services you use regularly, your prescription drug medications, and your budget.

medicare

Assessment

Medicare is a complex program. Enrolling on time and making informed decisions about coverage can save you thousands of dollars each year during retirement.

Conclusion

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Some US Federal Budget Proposals

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Government Shutdown Hoopla for Retirees, Inheritors and Savers

By Rick Kahler CFP® http://www.KahlerFinancial.com

Rick Kahler CFPLost in the hoopla over the government shutdown, defunding Obamacare, and raising the debt ceiling are some proposals contained in President Obama’s budget that will have a significant impact on retirees, inheritors, and savers.

Most of the President’s proposals are aimed at enforcing higher taxes on savers who maximize their retirement plans. This is a way to raise revenue for government entitlement programs, like subsidies for health insurance, Medicare, and Social Security.

Retirement and Retirees

Back from last year is his proposal to cap contributions to IRA’s and 401(k)’s when the balance reaches a level determined by a set formula which is tied to interest rates. The proposal sets the cap at $3.4 million initially. As interest rates rise, the cap will lower. When a saver’s IRA balance hits the cap, he or she will not be allowed to make further contributions to any retirement plan.

This will mostly affect savers who terminate employment and roll large accumulations from profit-sharing plans and lump-sum distributions from defined benefit plans into their IRA’s. It will shut down their ability to save into the future.

Taxes and Inheritors

The President has yet another plan to end tax-deductible contributions for upper income earners. Only 28% of a contribution would be deductible for any taxpayer whose bracket exceeds 28%. For a taxpayer in the highest bracket, this means a tax increase of about 50%.

Another of the President’s proposals would end the ability of anyone other than a spouse to inherit a tax-deferred IRA. Under the proposal, all non-spouses inheriting an IRA would have five years to terminate the IRA and pay income taxes on the distributions. This proposal really impacts Roth IRA conversions, as most parents convert traditional IRA’s to Roths with the intention of leaving their children a non-taxable sum of money that can continue to grow tax free during their lifetime. If the President’s proposal passes, many older savers will discover that the intentions behind their Roth conversions have been nullified.

Forced Savings and Savers

While President Obama wants to cap what successful savers can stash away in retirement plans, he also wants to force employees to save for retirement. Employers will be required to open IRA’s for every employee and to fund the plan at a minimum of 3% of the employee’s pay, unless the employee specifically opts out. The employee can contribute more than 3%, up to the $5,000 cap for those under 50 and $6,000 for those over 50.

Of course, savvy savers and ME-P readers know most of us need to be saving 20% to 50% of our salaries, depending on our ages, so saving just 3% of pay won’t amount to much in the way of retirement income.

Good News

On the positive side, the President wants to end required minimum distributions on IRA balances under $75,000. This will reduce some paperwork for savers with smaller IRA’s who are not making withdrawals.

Typically, most retirees with small IRA’s are those with less savings anyway, who need to take withdrawals from their IRA’s to make ends meet. So it’s doubtful this rule change will have much impact.

Finally, the President proposes letting inherited non-spousal IRA’s enjoy the same benefit of a 60-day rollover window on any distribution, similar to what they can do with a non-inherited IRA. This will simply eliminate a lot of confusion, as most people don’t understand the 60-day rollover provision does not include inherited IRA’s.

Shutdown[US Federal Government Shut-Down]

Assessment

Of course, whether any or all of these proposals make it into law is anyone’s guess. Anyone whose retirement and estate planning includes saving in IRA’s will want to keep an eye on these provisions as the budget moves through Congress.

Conclusion

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Doubting the Accountable Care Organization B-Model

New Healthcare Business Model or Edsel Model?

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By David Edward Marcinko MBA http://www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

Dr. Marcinko with ME-P FansDefined by Professor Michael Porter at Harvard Business School, value is defined as a function of outcomes and costs. Therefore to achieve high value we must deliver the best possible outcomes in the most efficient way, outcomes which matter from the perspective of the individual receiving healthcare and not provider process measures or targets.

Sir Muir Gray expanded on the idea of technical value (outcomes/costs) to specifically describe ‘personal value’ and ‘allocative value’, encouraging us to focus also on shared decision making, individual preferences for care and ensuring that resources are allocated for maximum value.

Healthcare Value and ACOs

According to our Medical Executive-Post Health Dictionary Series of administrative terms http://www.HealthDictionarySeries.org  and health economist and colleague Robert James Cimasi MHA, ASA, AVA CMP™ of www.HealthCapital.com; an ACO is a healthcare organization in which a set of providers, usually large physician groups and hospitals, are held accountable for the cost and quality of care delivered to a specific local population.

ACOs aim to affect provider’s patient expenditures and outcomes by integrating clinical and administrative departments to coordinate care and share financial risk.

ACO Launch

Since their four-page introduction in the PP-ACA of 2010, ACOs have been implemented in both the Federal and commercial healthcare markets, with 32 Pioneer ACOs selected (on December 19, 2011), 116 Federal applications accepted (on April 10, 2012 and July 9, 2012), and at least 160 or more Commercial ACOs in existence today.

Federal Contracts

Federal ACO contracts are established between an ACO and CMS, and are regulated under the CMS Medicare Shared Savings Program (MSSP) Final Rule, published November 2, 2011.  ACOs participating in the MSSP are accountable for the health outcomes, represented by 33 quality metrics, and Medicare beneficiary expenditures of a prospectively assigned population of Medicare beneficiaries.

If a Federal ACO achieves Medicare beneficiary expenditures below a CMS established benchmark (and meets quality targets), they are eligible to receive a portion of the achieved Medicare beneficiary expenditure savings, in the form of a shared savings payment.

Commercial Contracts

Commercial ACO contracts are not limited by any specific legislation, only by the contract between the ACO and a commercial payor.

In addition to shared savings models, Commercial ACOs may incentivize lower costs and improved patient outcomes through reimbursement models that share risk between the payor and the providers, i.e., pay for performance compensation arrangements and/or partial to full capitation.

Although commercial ACOs experience a greater degree of flexibility in their structure and reimbursement, the principals for success for both Federal ACOs and Commercial ACOs are similar.

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Eidsel

Dr. David E. Marcinko with 1960 Ford Edsel

[© iMBA, Inc. All rights reserved, USA.]

[The Edsel was an automobile marque that was planned, developed, and manufactured by the Ford Motor Company during the 1958, 1959, and 1960 model years. With the Edsel, Ford had expected to make significant inroads into the market share of both General Motors and Chrysler and close the gap between itself and GM in the domestic American automotive market. But, contrary to Ford’s internal plans and projections, the Edsel never gained popularity with contemporary American car buyers and sold poorly. The Ford Motor Company lost millions of dollars on the Edsel’s development, manufacturing and marketing].

More:

 

Update

Junking the Merit-Based Incentive Payment System (MIPS) would undoubtedly let the proverbial air out of the MACRA balloon, dealing a significant blow to the value-based reimbursement shift; right?

Assessment

Although nearly any healthcare enterprise can integrate and become an ACO, larger enterprises, may be best suited for ACO status.

Larger organizations are more able to accommodate the significant capital requirements of ACO development, implementation, and operation (e.g., healthcare information technology), and sustain the sufficient number of beneficiaries to have a significant impact on quality and cost metrics.

Conclusion

But, will this new B-Model work? Isn’t leading doctors in a shared collaborative effort a bit like herding cats? And, what about patients, HIEs, outcomes management, data analytics and … Population Health via our colleague David B. Nash MD MBA of Thomas Jefferson University, often considered the “father” of Pop Health?

OR, what about the developing IRS scandal and full PP-ACA launch in 2014? Will it affect federal funding, full roll-out, or even repeal of the entire Act?

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Medicare Inpatient Profitability in US Hospitals

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The Impending Need for Cost-Efficiency

[By Objective Health]

Medicare patients often account for the largest proportion of inpatient volume for an average US hospital. With the exception of outlier cases, Medicare inpatient services are adjusted for wage rates and reimbursed as a single predetermined payment across the country.

Over the next few years, Medicare is expected to substantially reduce growth in payment rates, thereby pressuring hospitals to become more cost-efficient.

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Medicare OH

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Assessment

This infographic highlights the need for hospitals to manage costs, showing that there is a wide variation in Medicare inpatient profit across US hospitals, which is primarily driven by differences in Medicare cost per case.

Conclusion

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How the Affordable Care Act Affects Taxpayers Now? [Audio-Link]

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Sound Medicine –  How does the Affordable Care Act affect taxpayers now?

By Ann Miller RN MHA

Sound Medicine is a radio show produced by the Indiana University School of Medicine and WFYI Public Radio.

In the last few years Aaron Carroll MS MD associate professor of pediatrics at the Indiana University School of Medicine, has been their go-to guy on health policy.

Audio Link

So, for those of you who would find your day brightened by the sound of his voice, enjoy the following from www.theIncidentalEconomist.com

Assessment

Dr. Carroll discusses how the Affordable Care Act will affect taxpayers in the coming months. The Affordable Care Act officially takes effect in January 2014, but several provisions are being implemented this year. These provisions specifically affect Medicare and Medicaid recipients, caregivers and all taxpayers.

Conclusion

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A Financial eMR “Got-Ya” from Uncle Sam?

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CMS and the Feds Want to Verify Docs eMR Info Before Meaningful Use Payment

By ME-P Staff Reporters

The conversion to electronic medical records [eMRs] is “vulnerable” to fraud and abuse because of the failure of Medicare and CMS officials to develop appropriate safeguards, according to a sharply critical report just issued by federal investigators.

###

[mobile eMR in clincal use]

###

Full Report: https://oig.hhs.gov/oei/reports/oei-05-11-00250.pdf

Assessment

Requiring an audit before paying hospitals and doctors could  significantly delay payments to providers.

Ya think!

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Understanding Modern Healthcare Market Competition

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Updating Competitive Strategy Theory in Healthcare

By Robert James Cimasi; MHA ASA FRICs MCBA AVA CM&AA
By Todd A. Zigrang; MBA MHA ASA FACHE
By Anne P. Sharamitaro; Esq.

www.HealthCapital.com

Michael Porter[i] is considered by many to be one of the world’s leading authorities on competitive strategy and international competitiveness.  In 1980, he published Competitive Strategy: Techniques for Analyzing Industries and Competitors,[ii] in which he argues that all businesses must respond to five competitive forces.

(1) The Threat of New Market Entrants

This force may be defined as the risk of a similar company entering the marketplace and winning business.  There are many barriers to entry of new market entrants in healthcare including: the high cost of equipment, licensure, requirement for physicians and other highly trained technicians, development of physician referral networks and provider contracts, and other significant regulatory requirements.

Certificate of Need (CON) laws, which require governmental approval for new healthcare facilities, equipment, and services have been in place since they were federally mandated in 1974.  State CON laws create a regulatory barrier to entry.  New medical provider entrants commonly face substantial political opposition by established interests, which is manifested in the CON review process.

(2) The Bargaining Power of Suppliers

A supplier can be defined as any business relationship upon which a business relies to deliver a product, service, or outcome.  Healthcare equipment is a highly technical product produced by a limited number of manufacturers. This reduces the range of choices for providers and can increase costs.

(3) Threats from Substitute Products or Services

Substitute products or services are those that are sufficiently equivalent in function or utility to offer consumers an alternate choice of product or service.  An illustration of this in healthcare would be diagnostic imaging as a substitute for surgery, which is often a more costly and risky option for patients. The threat of less invasive or less expensive diagnostic tests other than diagnostic imaging is relatively small for the near term future.

(4) The Bargaining Power of Buyers

This force is the degree of negotiating leverage of an industry’s buyers or customers.  The buyers of healthcare services are ultimately the patients. However, the competitive force of buyers is manifested through healthcare insurers including the U.S. and state governments through the Medicare, Medicaid, TRICARE, and other programs; managed care payors (e.g., Blue Cross/Blue Shield affiliates); workers’ compensation insurers; and, others.  In addition to the government, many of these healthcare insurers are large, national companies, often publicly traded, commanding significant bargaining power over healthcare provider reimbursement.

(5) Rivalry Amongst Existing Firms

This is ongoing competition between existing firms without consideration of the other competitive forces which define industries. Healthcare providers face pressure from other existing providers to obtain favorable provider contracts; maintain the latest technology; increase efficiencies; and, lower prices.

References:

[i]  A professor of Business Administration at the Harvard Business School, Michael Porter serves as an advisor to heads of state, governors, mayors, and CEOs throughout the world.  The recipient of the Wells Prize in Economics, the Adam Smith Award, three McKinsey Awards, and honorary doctorates from the Stockholm School of Economics and six other universities, Porter is the author of fourteen books, among them Competitive Advantage, The Competitive Advantage of Nations, and Cases in Competitive Strategy.

[ii]  Porter, M.E. Competitive Strategy: Techniques for Analyzing Industries and Competitors. The Free Press, 1980.

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Where the Presidential Candidates Stand on Medicare and Medicaid

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The Big Picture View

By Suevon Lee ProPublica, Sept. 14, 2012, 2:26 p.m.

Medicare and Medicaid, which provide medical coverage for seniors, the poor and the disabled, together [1]make up nearly a quarter [1] of all federal spending. With total Medicare spending projected to cost [2] $7.7 trillion over the next 10 years, there is consensus that changes are in order. But what those changes should entail has, of course, been one of the hot-button issues [3] of the campaign.

With the candidates slinging charges [4], we thought we’d lay out the facts. Here’s a rundown of where the two candidates stand on Medicare and Medicaid:

THE CANDIDATES ON MEDICARE

Big Picture

Earlier this year, the Medicare Board of Trustees estimated [5] that the Medicare hospital trust fund would remain fully funded only until 2024. Medicare would not go bankrupt or disappear, but it wouldn’t have enough money to cover all hospital costs.

Under traditional government-run Medicare, seniors 65 and over and people with disabilities are given health insurance for a fixed set of benefits, in what’s known as fee-for-service [6] coverage. Medicare also offers a subset of private health plans known as Medicare Advantage, in which roughly one-quarter [7] of Medicare beneficiaries are currently enrolled. Obama retains this structure.

The Obama administration has also made moves that it says would keep Medicare afloat. It says the Affordable Care Act would extend solvency [8] by eight years, mainly by imposing tighter spending controls on Medicare payments to private insurers and hospitals.

In contrast, Rep. Paul Ryan, Mitt Romney’s running mate, has proposed a more fundamental overhaul of Medicare, which he says [9] is on an “unsustainable path.” On his campaign website [10], Romney says that Ryan’s proposals “almost precisely mirrors” his ideas on Medicare. But he’s been fuzzy on other aspects of the plan.

A Romney-Ryan administration would replace a defined benefits system with a defined contribution system [11] in which seniors are given federal vouchers to purchase health insurance in a newly created private marketplace known as Medicare Exchange. In this marketplace, private health plans, along with traditional Medicare, would compete for enrollees’ business. These changes wouldn’t start until 2023, meaning current beneficiaries aren’t affected – just those under 55.

Under the Romney-Ryan, the vouchers would be valued [12] at the second-cheapest private plan or traditional Medicare, whichever costs less. Seniors who opt for a more expensive plan would pay the difference. If they choose a cheaper plan, they keep the savings.

Who’s Covered

In the current system, people 65 and over are eligible for Medicare, which Obama has said he would keep [13] for now.

Romney has proposed [14]raising the eligibility age for Medicare beneficiaries from 65 to 67 in 2022, then increasing it by a month each year after that. In the long run, he would index [15] eligibility levels to “longevity.” Ryan’s budget plan proposes [16] raising Medicare eligibility age by two months a year starting in 2023, until it reaches 67 by 2034.

Many others looking to keep Medicare solvent have also proposed [17]raising the age of eligibility.

The Congressional Budget Office estimates [18]that raising the minimum age from 65 to 67 would reduce annual federal spending by 5 percent.But it would also result in higher premiums and out-of-pocket costs for seniors who would lose access to Medicare.

Obama’s health care law also adds [19] some benefits for seniors, such as annual wellness visits without co-pays, preventive services like free cancer screenings and prescription drug savings.

Proposed Savings

The Affordable Care Act is projected to reduce Medicare spending by $716 billion over the next 10 years. These reductions, as detailed [20] by Washington Post’s Wonkblog, will come mostly from reducing payments to hospitals, nursing homes and private health care providers.

While Ryan criticized [21] such spending cuts in his speech at the Republican National Convention, his own budget proposed [22] keeping these reductions.

“The ACA grows the trust fund by giving more general revenue to the Treasury, which then gives the trust fund bonds. But it then uses the money from those bonds to expand coverage for low- and middle-income people,” explains [23] Dylan Matthews on Washington Post’s Wonkblog.

Romney hasn’t really come up with a solid answer: he previously said he would restore [24] the $716 billion savings that the health care law imposes. Per this New York Times story [24], the American Institutes for Research calculates this would increase premiums and co-payments for Medicare beneficiaries by $342 a year on average over the next 10 years.

For more on where the candidates stand on the $716 billion, the private health policy Commonwealth Fund offers this helpful explanation [25].

Caps on Spending

Both Obama and Ryan have set an identical target rate [26] that would cap Medicare spending at one-half a percentage point above the nation’s gross domestic product.

But they have different ideas on mechanisms to achieve it.

The Affordable Care Act establishes a 15-member Independent Payment Advisory Board [27] that, starting in 2015, would make binding recommendations to reduce spending rates. As Jonathan Cohn points out [28] in the New Republic, the commission is prohibited from making any changes that would affect beneficiaries.

Ryan has proposed hard caps on spending and derided [29]this panel of appointed members as “unelected, unaccountable bureaucrats.” When laying out his plan in a 2011 memo [30], Ryan wrote that to control spending, “Congress would be required to intervene and could implement policies that change provider reimbursements, program overhead, and means-tested premiums.”

Romney hasn’t stated [31] clear proposals for imposing a cap on spending.

THE CANDIDATES ON MEDICAID

Big Picture

Though, it’s far less discussed [32] on the campaign trail, Medicaid actually covers more people than Medicare. The joint federal-state insurance program for the poor, the disabled, and elderly individuals in long-term nursing home care currently covers about 60 million Americans. The Affordable Care Act hasexpanded [33] Medicaid coverage further. Beginning 2014, Medicaid will include [34]people under 65 with income below 133 percent of the federal poverty level (roughly $15,000 for an individual, $30,000 for a family of four). This was estimated [35] to cover an additional 17 million Americans as eligible beneficiaries.

In June, however, the U.S. Supreme Court ruled [36] that states could opt out of the Medicaid expansion. A ProPublica analysis estimated [37] that the 26 states that challenged the health care law, and thus may possibly opt out, would account for up to 8.5 million of those new beneficiaries.

Romney and Ryan would overhaul this current system by turning Medicaid into a system of block grants [38]: the federal government would issue lump sum payments to the states, who would determine eligibility criteria and benefits for enrollees. These grants would begin in 2013.

Effects on spending

The Congressional Budget Office estimates [39] that Medicaid expansion under the new health care law would cost an additional $642 billion over the next 10 years.

Under the Ryan plan, federal Medicaid grants would be adjusted only for inflation, but not health care costs, which grow at a much higher rate. The CBO estimates [40] Ryan’s plan would save the federal government $800 billion over the next 10 years. Another study conducted by Bloomberg News shows that the block-grants could decrease Medicaid funding by as much as $1.26 trillion [41] over the next nine years.

Actual Impact

The New York Times points out [42] that more than half of Medicaid spending goes toward the elderly and disabled. An Urban Institute analysis estimates [43] the Ryan plan would result in 14 million to 27 million fewer people receiving Medicaid coverage by 2021.

Assessment

Though rarely mentioned by any of the candidates, Medicaid costs are soaring to cover the elderly who require long-term nursing care. As the Times’ details [44] how, states saddled by high Medicaid costs have begun turning to private managed care plans to blunt the cost.

Conclusion

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How Americans Embrace Medicare Reform

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The 2012 Elections … and Medigap

[By Staff Reporters]

Americans are spending more on Medicare than is coming in.

In fact, Rand Paul states, “It’s your grandparents’ fault for having too many kids and then your fault for not having enough kids. It’s a demographic problem.”

Source: www.mostmedicare.com

Conclusion

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May Patients Privately Contract with their Doctors?

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Ask-An-Advisor

QUESTION: A question to ME-P readers and subscribers.

Medicare may disallow private contracting by federal law. But, can private insurances, whether PPO or managed care, legally prevent a patient from privately contracting with their doctor for services or goods above the contracted rates, as long as informed consent and appropriate waivers are executed in advance of the service?

IOWs: Do private managed care insurance companies have the legal  right to limit a person’s liberty to seek care above the constraints of the health insurers contract, if the patient so desires?  I understand that an insurer by contract with provider and patient is obligated to pay only a negotiated fee for a specific service or good, but if the patient desires a more accommodating service or extra features to a durable good, do they have the right to privately contract for such services beyond the contract payment or benefit restraints. I believe that this goes into state law safeguards for patient welfare in as much as most non-federal or non-ERISA health insurances are guided by state law.

Assessment

This is not a naïve question for I have posed it to various plan medical directors in our area and have had surprisingly varied responses.

I welcome your crowd-sourced comments with thanks in advance.

Dr. Mark D. Dollard

Loudoun Foot and Ankle Center

46440 Benedict Drive

Suite #111  – Sterling, VA 20164

703 444-9555 [ph] 703 444-1190 [fax]

mdollard@erols.com

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Controlling Health Care Spending [An NIHCM Foundation Webinar]

The Imperative to Act and Diverse Views of the Road Forward

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The U.S.now spends $2.5 trillion annually on health care, accounting for well over 17 percent of GDP and growing rapidly with challenging fiscal consequences. Despite the imperative to control spending, we face much uncertainty about how to move to a more sustainable path.

Political opposition threatens implementation of the Affordable Care Act, and many of its cost-control measures are still unproven. A long-term fix for Medicare physician payment remains elusive. The trigger mechanism activated by the failure of the Super Committee is poised to affect myriad health programs, but decisions on the specific cuts await sure-to-be intense congressional negotiations.

And, the many ideas for entitlement reform that were advanced during deficit reduction talks continue to generate much debate but little consensus.

Topics

To shed light on these complex issues, this webinar will feature leading health policy experts discussing topics including:

  • health spending growth and the implications for government budgets, employers and individuals
  • the societal trade-offs we face as health spending grows and as we think about ways to control spending
  • alternative viewpoints on the viability of cost control approaches now being tried and the most promising options for the future.

Assessment

Visit NIHCM Foundation’s website to view an agenda and additional resources on health care spending. And, please register by noon (EST) on February 1st.

Conclusion        

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Snarky Example of a Medical Practice RAC Audit

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RAC Repayment Demand – Query

I just received a demand for payment from the RAC program for $32.46. I treated a patient with a non-displaced fibula fracture with a BK CAM boot and crutches. I coded 99212-25 and 27786,73610 on 1-29-09.  The audit claims the evaluation and management is part of the fracture care.

Should I appeal for $32.46?

Back then (3 years ago), my records were hand-written and not as comprehensive as they are now with EHR. Am I exposing myself to further inquiry by sending my admitedly inadequate records?

Doctor Name Withheld

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How Lifetime Benefits and Contributions Point the Way Toward Reforming Our Senior Entitlement Programs

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From Expert Voices

By C. Eugene Steuerle PhD [Institute Fellow and Richard B. Fisher Chair, The Urban Institute]
By Stephanie Rennane [University of Maryland]

For August 2011

Reforms to Medicare and Social Security will likely be debated over the next few months as the new “super committee” formed by the debt ceiling agreement works to develop its long-term deficit reduction plan.

The Essay

In this essay, Dr. Eugene Steuerle and Stephanie Rennane help to inform this debate by presenting findings from their newly updated analysis showing that seniors retiring today can expect to receive dramatically more in entitlement program benefits during retirement than they contributed to the programs while working.

For example, the average Medicare beneficiary can expect $3 in benefits for every $1 paid in payroll taxes.

Link: http://nihcm.org/images/stories/EV-Steuerle-Rennane-FINAL.pdf

Assessment

The authors posit that the magnitude of the resources involved when viewing these programs in tandem over a lifetime gives policymakers new impetus and flexibility to develop coordinated entitlement reforms that promote a coherent, equitable and sustainable support system for current and future generations of seniors.

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Medicare and the Budget Control Act’s Joint Select Committee

Creating Spending Reductions for the Next Decade?

By Children’s Home Society of Florida Foundation

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Under the compromise between President Obama and leaders of the House and Senate, the Budget Control Act of 2011 created spending reductions of over $900 billion during the next decade. The bill also requires leaders of the House and Senate to appoint members to a Joint Select Committee. The committee has three Republican, three Democratic Senators, three Republican and three Democratic Representatives.

House and Senate leaders have now appointed the committee members. The 12 committee members are tasked with creating a $1.5 trillion budget solution by Thanksgiving. Their bill will be voted on without amendments by December 23, 2011.

If the committee is not able to develop and pass a bill by Dec. 23, there will be $1.2 trillion in budget cuts. Half of the cuts will come from the Department of Defense and one-half will be reductions in payments to Medicare providers.

Majority Leader Harry Reid (D-NV) appointed three Senators. The Co-Chair of the Joint Select Committee will be Sen. Patty Murray (D-WA). His other two appointees are Sen. John Kerry (D-MA) and Sen. Max Baucus (D-MT). Sen. Kerry is Chair of the Senate Foreign Relations Committee and Sen. Baucus is Chair of the Senate Finance Committee.

Republican Leader Mitch McConnell (R-KY) appointed Sen. John Kyl (R-AZ), Sen. Pat Toomey (R-PA) and Sen. Rob Portman (R-OH). Sen. Kyl is the Republican Whip and a senior member of the Finance Committee. Sen. Toomey is a member of the Budget Committee. Sen. Portman was previously Director of the Office of Management and Budget.

Speaker John Boehner (R-OH) appointed Rep. Jeb Hensarling (R-TX) as Co-Chair of the committee. His other appointments are Rep. Dave Camp (R-MI) and Rep. Fred Upton (R-MI). Rep. Camp is Chairman of the Ways and Means Committee and Rep. Upton chairs the Energy and Commerce Committee.

Democratic Leader Nancy Pelosi (D-CA) appointed Rep. James Clyburn (D-SC), House Ways and Means Member Xavier Becerra (D-CA) and Budget Committee Member Chris Van Hollen (D-MD).

The Joint Select Committee is expected to initiate meetings in September after Congress returns from the August recess.

Editor’s Note: There will undoubtedly be a spirited debate. All of the twelve committee members will want to avoid drastic budget cuts for the Department of Defense or Medicare providers. The group will need to discuss potential cuts in discretionary expenditures, defense and entitlements. With the appointments of key taxwriters Baucus and Camp, it is clear that taxes will also be a part of the discussion. Whether or not there are tax increases as part of the budget solution remains to be seen.

Conclusion

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To PAR or Not to PAR?

The Essential Question for Most Medical Providers

By Staff Reporters

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Ever since 1992, doctors are paid per resource-based relative value unit (RBRVU) and according to the lesser of the actual billed charges or the fee schedule amount. But, there are two types of providers. 

  • Those who accept Medicare assignment only bill the patient for the co-payment, which is usually 20%. 
  • Those who do not accept Medicare assignment are offered a lower fee schedule of 95% of the approved schedule, which is a 115% maximum fee limit of the approved schedule.

So, how does this work in real life?

Example:

A participating physician’s approved fee schedule charge of $100 would yield $80 from Medicare and $20 from the patient.

A non-participating (Non-Par) doctor with charges of $200, and with an approved fee schedule of $100, would yield: $109.25 = (.95 X $100) X 1.15 entirely from the patient. If the Non-Par doctor selects payment type on a case-by-case basis, Medicare will pay its portion of the bill directly to the physician, but the doctor must accept the Non-Par fee schedule.

Assessment

Continuing our example yields: (.8 X $95) plus the patient’s co-payment of (.2 X $95), OR $76 plus $19 = $95.00.

Conclusion

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The Medicare Cost-Control Efficiency Paradox

Essay on the Eight-Hundred Pound Gorilla in the Medical Treatment Room

By Dr. David E. Marcinko MBA

[Editor-in-Chief]

According to economist Austin Frakt PhD, and others, there is a school of thought that says Congress is incapable of controlling costs in the Medicare and Medicaid System [CMS].

And, then there is the reality known by all practicing medical professionals regardless of specialty orientation or degree designation. That is to say, CMS really can control healthcare costs and with great ferocity and efficiency, and to non-public sectors as well …. PARADOXICAL?

On Getting What You Wish For

Blogger Ezra Klein opines that one of the dirty little secrets of the health-care system is that Medicare has done a much better job controlling costs than private health insurers.

http://voices.washingtonpost.com/ezra-klein/2010/11/what_happens_when_medicare_con.html

A Forehead-Palm Moment

Of course, we doctors know that the real problem is that Medicare seemingly [think Seinfeld’s character George Costanza] controls costs all too well; but not really. It is just that CMS pays doctors too little and thus it appears costs are controlled. What really is happening is that physician fees are being reduced carte’ blanche.

Nevertheless, and regardless of semantics, CMS will never control costs much more efficiently than private insurance companies or doctors will simply abandon Medicare for related payment models like direct reimbursement or concierge medicine. This is happening right now. Physicians, osteopaths and podiatrists etc, are opting out of Medicare in increasingly large numbers. In a world where there’s only Medicare and Medicare to control costs, doctors can either take the pay cut or stop seeing patients, and stop being doctors. “Taking what they are given – because they’re working for a livin.”

So sorry that this seems like a forehead-palm moment for Ezra, but not for healthcare practitioners or the ME-P!

Too Much Demand Elsewhere

And, as we see from other countries, many young bright folks want to be doctors, even if being a doctor doesn’t make one particularly wealthy [high demand and high eventual supply produces lower provider costs in the long term?]. Think medical tourism.

Not so much the case anymore in this country [lower demand and lower eventual supply produces higher reimbursement costs to the doctor survivors in the very long term?].

Our Domestic World

But, we are not elsewhere. In fact, in our present domestic healthcare ecosystem, when Medicare decides to control costs, many doctors can simply stop accepting Medicare patients, and the politicians will lose their jobs. One political party then declares that Medicare is rationing and will hurt senior citizens. The other party capitulates and pays MDs more [SGR]. Then, the federal budget looks bad as it does now. The circle is complete when one party asserts that Medicare actually can’t contain costs but the private insurance companies will.  It all fails, in an unending circular Boolean-like loop of illogic.

Listen Up!

So, listen up AARP, politicians, CMS and seniors as I admonish you to be careful what you wish for [medical cost controls]. It might just come true. As Ezra rightly says; rinse, repeat – rinse, repeat – ad nausea. You simply can’t have it both ways.  You either choose to spend less and offend certain cohorts, or spend more and offend different factions.  Either way, you’re going to piss someone off. A good healthcare reimbursement system would try to make that decision rationally [a-politically]. But, at least it would make an economics driven decision; wouldn’t it?

Assessment

Is CMS really the eight hundred pound cost-controlled gorilla in the increasingly large Medicare treatment room? Why or why not? Now, relative to the ACA of 2010, please read: The Case for Public Plan Choice in National Health Reform [Key to Cost Control and Quality Coverage], by Jacob S. Hacker, PhD. Link: Jacob Hacker Public Plan Choice

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Do we have a Medicare cost control efficiency paradox? Or, are the economists just reveling in the publication banal? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Price Adjustment Medical Costing

End of Life Care Programs

By Dean G. Smith PhD and the Accounting Workgroup

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An alternative to traditional medical resource costing is ‘price adjustment’.  In an international context, this method compares the monetary estimates of resource used, after adjustment for price level differences between countries and over time to standard current values.  In order to attempt comparisons of different cost estimates, analysts must be at least certain as to what items are included in costs and whether costs are being based on opportunity costs, charges, or average costs.

Medicare Cost-to-Charge Ratios

In the US context, the price adjustment approach underlies the use of Medicare Cost-to-Charge Ratios (CCR).  Costs are estimated using the CCR approach by multiplying the number of units of each procedure billed by its Medicare charge and CCR and then summing these costs.  Some health care organizations have begun to invest in sophisticated, computerized cost-accounting systems (CAS) that are capable of providing procedure-specific cost estimates, usually based on relative value units, but these systems often rely on billing data to obtain service units.

The Studies

A couple of studies have used a combination of CCR and CAS to estimate costs (costs to the institution – costs to Medicare are the Medicare charges). In both studies, the CAS was for hospital costs only, with Medicare reimbursement (not institution costs) being used for professional services by using relative value units and a conversion factor from the Medicare Fee Schedule.

Inaccuracy

To overcome the issues of inaccurately (or non-transparently) measuring resource units, it has become more common in clinical trials (a distinct sub-set of possible study methods) to develop case report forms to capture all study end points, including medical service use.  These studies then translate medical service use into costs using standard charges or costs, or a series of representative data sets of charges or costs, to the resource units. These methods have become so common that all submissions to the British Medical Journal are required to document methods using a 35-part form that includes items such as: part 16) Quantities of resources are reported separately from their unit costs; part 17) Methods for the estimation of quantities and unit costs are described; part 18) Currency and price data are recorded; and part 19) Details of currency of price adjustments for inflation or currency conversion are given.

Following these guidelines, a Michigan-based study is collecting data through a resource use data collection form and applying to standard costs per unit of service to produce costs for a RWJ-sponsored palliative care program.

Not the Usual Medical Care

There are a few studies on the costs and cost-effectiveness of end of life programs or the impact of serious illness on patient’s families.  Those studies that do evaluate end of life care programs are usually small in scope, compare the end of life program (e.g., as in hospice) to “usual care,” or have no comparison group, or do not evaluate the costs of the program.

Assessment

Criticisms of studies of only one medical resource/cost item often surround the total costs of care – suggesting that the use of focused studies may not be well received.  In fact, even studies that capture the total costs of medical care services are criticized for not capturing the indirect costs – family expenses on end of life care are substantial and are not factored into most cost-analysis studies. Very few studies try to capture all costs to enable adjustments of costs for selection processes that may influence resource use.

Editor’s Note: Accounting workgroup members:

1 Stephen Seninger PhD: Professor, Bureau of Business and Economic Research, University of Montana, Missoula, MT

2 Ira Byock, MD: Director, Promoting Excellence in End of Life Care, Practical Ethics Center, University of Montana, Missoula, MT

3 Carol D’Onofrio,DrPH: Research Director, Sutter Visiting Nurse Association & Hospice, Piedmont, CA

4 Jennifer Elston-Lafata PhD: Director, Center for Health Services Research, Henry Ford Health System, Detroit, MI 

5 Joe Engelhardt PhD: Research Coordinator, Life Institute VA Medical Center, Albany, NY

6 Carol A. Lockhart PhD: Project Director, Phoenix Care, Hospice of the Valley, Phoenix, AZ

7 Steven H. Miles MD: Professor of Medicine, Center for Bioethics, University of Minnesota, Minneapolis, MN

8 Herbert A. Rosefield: Corrections Care Consultant, Volunteers of America, Raleigh, NC

9 Anne M. Wilkinson PhD:Senior Health Policy Analyst, RAND, Arlington, VA

10 Barbara Volk-Craft RN, MBA  Program Manager: Phoenix Care, Hospice of the Valley, Phoenix, AZ

11 Dean G. Smith, PhD  Professor and Chair, Department of Health Management & Policy, University of Michigan, Ann Arbor, MI

Conclusion

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Update on Senior Donut Hole Rebate Checks

More Seniors to Receive One-Time Donut Hole Rebate Checks

By Staff Reports

Medicare Beneficiaries Whose High Prescription Drug Costs Have Put Them in the Medicare Part D Donut Hole to Receive $250 Rebate Checks as a Result of the Affordable Care Act

WASHINGTON – The next round of more than 300,000 eligible seniors who have entered the Medicare Part D “donut hole” this year have been mailed their tax-free, one time rebate check for $250, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced recently. These one-time rebate checks are the first step in closing the prescription drug coverage gap under the Affordable Care Act. The first round of checks were distributed in the middle of June. As qualifying Medicare recipients “fall into the donut hole,” they will be sent a rebate check by Medicare.

“Seniors and other Medicare recipients in the Medicare donut hole are struggling to afford the medications they need and their basic living expenses. Seventy percent of our first round of these $250 rebate checks were cashed within a week of eligible Medicare recipients receiving them; so, we know that folks really need some help,” said Secretary Sebelius. “The Affordable Care Act starts to close the donut hole this year, giving much-needed relief to millions of seniors. In 2011, the Affordable Care Act takes an additional step for Medicare beneficiaries in the donut hole by providing them with a 50 percent discount on their brand name medications. Every year from 2012 until 2020, the Affordable Care Act will take progressive steps to close the donut hole.” 

“Seniors also need to know that they will just receive their check at their usual address – they don’t have to take any extra steps,” said Centers for Medicare & Medicaid Services Deputy Administrator and Director for the Center for Medicare, Jonathan Blum. “And they should never give out their personal information. If someone asks for your personal Medicare information over the phone who isn’t a trusted resource like Medicare, please don’t provide it. Seniors or family members should contact us at 1-800-MEDICARE to report any of these types of calls or go to www.stopmedicarefraud.gov to learn more about efforts to fight fraud and scams against seniors.”

On Thursday, July 8th, at 2:00 p.m., HHS Secretary Kathleen Sebelius joined local officials in Manchester, N.H., for a forum with senior citizens to discuss the rebate checks and other benefits of the Affordable Care Act as well as efforts to fight Medicare fraud.

The $250 checks are being mailed to those Medicare beneficiaries who entered the Medicare Part D donut hole, also known as the coverage gap, in the second quarter of 2010 and are not eligible for Medicare Extra Help (also known as the low-income subsidy or LIS) or enrolled in a qualified retiree prescription drug plan. The donut hole is the period in the prescription drug benefit in which the beneficiary pays 100 percent of the cost of their drugs until they reach the catastrophic coverage phase.

About Medicare Extra Help

Medicare Extra Help provides assistance to seniors so they don’t face higher costs or a coverage gap in their prescription drug coverage. Qualifying Medicare beneficiaries who entered the donut hole in the first quarter of 2010 who were not eligible for Medicare Extra Help received a check in the first round of rebates mailed June 10th. Going forward, a check for qualifying beneficiaries newly reaching the donut hole in 2010 will be mailed monthly.

Assessment

More information about the “donut hole” rebate checks, please contact www.HealthCare.gov or 1-800-MEDICARE. For further questions about Extra Help (or the LIS) benefit under Part D, please contact the Social Security Administration at www.ssa.gov.

Conclusion

Doctors and FAs – how will this rebate assist your patients and clients? Feel free to comment and review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Health Plan Management Navigator

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July 2010 Edition

By Erin Sawchuk

erinsawchuk@sherlockco.com

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Dear ME-P Readers

Please find attached the early July 2010 Edition of our health Plan Management Navigator. In this month’s edition, we suggest an approach to quantifying best practice of administrative activities of health plans. Determining best practice for health plans is a knotty problem because of the complexity of the product and because some of what makes for best practice cannot be captured in the current year’s administrative expense line. We offer a solution that we hope to implement but we would be grateful for any insights you wish to share on this matter.

Financial and Operating Results

Navigator also summarizes some of the May financial and operating results of health plans reporting in our Dashboard. Operating earnings are weak on soft revenues and compressing margins. Enrollment trends in Medicare, Medicaid and ASO products are relative bright spots. Plans are adapting by reducing staffing ratios.

Link: Early July 2010 Navigator[1]

Web Casts

Please save 2:00 on July 16, and 2:00 on August 5 for two important web conferences. The first will summarize the results of this year’s SEER benchmarks for Independent / Provider-Sponsored plans. The second will summarize this year’s SEER benchmarks for Blue Cross Blue Shield Plans.

The Plan Management Navigators containing the respective peer group data will be sent to you a day or so before the web conference. There is no charge to participate, but we would be grateful if you would let us know in advance. Please reply back to me.

Assessment

Erin Sawchuk [Sherlock Company]

P.O. Box 413

Gwynedd, PA 19436

www.sherlockco.com

215-628-2289 – Phone

Conclusion

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The PPACA and Physician’s Ability to Bill

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Failure of Physician Referral Sources to Enroll in Medicare’s Provider Enrollment, Chain and Ownership System [PECOS] May Affect their Ability to Bill

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By Garfunkel Wild, PC

In response to, among other things, the Patient Protection and Affordable Care Act that was signed into law earlier this year, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule on May 5, 2010 that requires all:

  • Physicians [1] and non-physician practitioners [2] who order or refer Medicare beneficiaries for, or furnish Medicare beneficiaries with, Part B covered items and services; and
  • Physicians who certify home health services be enrolled in PECOS as of July 6, 2010 in order for the billing provider to receive payment for the ordered, referred, or furnished items or services under Medicare Part B (and, in the case of home health services, Part A).  Some of the types of claims that will be affected by this new rule include:
  • Claims from laboratories for ordered tests;
  • Claims from imaging centers for ordered imaging procedures;
  • Claims from suppliers of DMEPOS for ordered DMEPOS;
  • Certification for Part A and Part B covered home health services; and
  • Claims from specialists or specialty groups for referred services (including, but not limited to, physical therapy services).

In addition to prohibiting payment for these services, the interim final rule also requires that the teaching physician — NOT the intern or resident — be identified on the claim for Part B services as the referring or ordering physician whenever an intern or resident orders or refers.  This is also effective as of July 6, 2010.

Physician Health

Assessment Therefore, all providers who bill for ordered, referred, or furnished items or services that are payable under Medicare Part B (and home health care providers who bill for Part A and/or Part B covered services) should check the “Ordering and Referring Report” maintained by CMS to confirm whether the ordering or referring provider has an enrollment record in PECOS before submitting a claim as of July 6, 2010.

This Report can be viewed at: www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp.

If the ordering or referring provider is not listed on the Report, there is confusion as to whether billing providers are entitled to submit claims for items and services ordered or referred by such providers.  While CMS has acknowledged that some providers have encountered problems getting their information into PECOS and announced that, for the time being, it will not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010, CMS has expressly declined to delay implementation of the interim final rule as of the date of this Alert.

References [1] This includes a doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry, and doctor of chiropractic medicine.

Conclusion

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How Physicians Select Risk Management Advisors

More Difficult than Ever Before

By Brian J. Knabe MD, Certified Medical Planner

www.SavantCapital.com

Historically, the term “risk management” has brought to mind one subject for the practicing physician – medical malpractice.  Unfortunately, physicians today face a multitude of other risks which may be more insidious and daunting than malpractice.  It is important to recognize these risks, and to have the appropriate procedures and policies in place to mitigate the risks.  These risks come from the federal government, state government, insurance companies, patients, employees, and even prospective employees.  Some risks, many unique to small businesses and medical practices, include the following:

  • Medicare recoupment risk – challenges to coding and subsequent billing by the physician.
  • Medicare fraud.  Numerous laws can be used by the federal government to go after the physician, including the Medicare and Medicaid Anti-Fraud and Abuse Statute, the RICO statute, and the Federal False Claims Act.  The recently enacted Patient Protection & Affordable Care Act aims to save money by increasing funding for anti-fraud efforts.
  • Insurance fraud.  An inquiry from Medicare to look for fraud in a physician’s practice is often followed by similar efforts by insurance companies.
  • The HIPPA Act of 1996 creates new definitions and penalties to use against the physician.
  • Self referral risks.  Federal regulations in this area include the Medicare Anti-Fraud and Abuse Statute, the Medicare Safe Harbor Regulations, and the Stark Amendment.
  • Federal agency risks.  These include regulations from the Occupational Health and Safety Agency (OSHA), Health and Human Services (HHS), the Drug Enforcement agency (DEA), and even the Environmental Protection Agency (EPA).
  • Anti-trust risks.  The Department of Justice (DOJ) and Federal Trade Commission (FTC) formulate regulations in this arena.
  • Managed care contractual risks.  Most managed care contracts require the individual physician rather than the professional corporation to sign the contract, thus placing the physician’s personal assets at risk.
  • Medical malpractice risks.  Although the vast majority of claims are paid by the insurance carrier, there can be other adverse consequences for the physician.  These include the risk of increased premiums, non-renewal of policies, and difficulty in getting replacement insurance.
  • Loss of income due to death or disability.  Most physicians recognize the importance of life insurance, but the medical professional is actually much more likely to lose income due to disability at some point in his or her career.

http://www.amazon.com/Insurance-Management-Strategies-Physicians-Advisors/dp/0763733423/ref=sr_1_6?ie=UTF8&qid=1375149801&sr=8-6&keywords=marcinko+david

The practicing physician should seek the advice of professionals with expertise in these areas.  Every practice should have an experienced attorney on retainer.  It is very important to seek advice from fiduciaries – experts who have no conflicts of interest and who can therefore act in the best interest of the client.  A Certified Medical Planner is such a fiduciary with training and expertise in these areas.

http://www.CertifiedMedicalPlanner.org

It can be particularly challenging to find an insurance advisor with no conflicts of interest, as this industry is built upon product sales and commissions.  One such insurance advisor is Scott Witt, a fee-only insurance advisor with Witt Actuarial Services (www.wittactuarialservices.com).

Others can be found with an internet search for “fee only insurance advisor”.

Assessment

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Conclusion

Your comments on this ME-P are appreciated. How do you select an advisor? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com 

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The DDS / Doctor [Salesman] will See [Up-Sell] you Now

Blurring the Line between Medical Professionalism … and Mercantilism

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Concerns and complaints about pushy dentists are apparently becoming more numerous among consumers, as elective cosmetic treatments and marginally effective tests and modalities are increasingly available from the same providers that patients formerly turned to for unbiased dental advice and oral healthcare. All for a price!

http://www.msnbc.msn.com/id/37198272/ns/health-oral_health

So, enter the cosmetic [rank-and-file] dentists and the elective renaissance of the profession – at least economically. An entire industry has even sprung up teaching dentists how to sell various products, and up-sell related services and procedures.

[picapp align=”none” wrap=”false” link=”term=dentists&iid=166771″ src=”0163/1731b859-b744-4a0e-b055-a9e985ad8673.jpg?adImageId=12959860&imageId=166771″ width=”372″ height=”459″ /]

Root-Cause [pun intended]  

Why is this happening? Economics of course! Dental profession success in eradicating cavities, caries and other common mouth disorders – which used to comprise 80% of dental procedures and income – is now a two-edge sword working against their financial self interests … damn!

In fact, I recall about three decades ago when the situation first became acute, as more than a few of our nation’s dental schools closed for lack of interest in matriculation. Right here in Atlanta, the prestigious Emory University School of Dentistry closed its doors while I myself was a patient there; and employed as a surgical resident at a nearby acute care hospital. Contemporaneous cocktail party talk and medical gossip centered on the “death of dentistry” as I exhaled a sigh of relief at my career choice.

Going forward, years later, far too many managed care contracts reimbursed so poorly that they became a loss-leader [access portal to a patient population] for dental practitioners. In other worlds, lose money or break-even on the covered services contract, but profit handsomely by offering [pushing] non-covered services to cohort contract members … and their sphere of influence.

One Word from Mrs. Robinson – Plastics

Plastic surgeons, of course, are still the doctors most commonly associated with non-covered and purely cosmetic and elective treatments such as Botox injections, facelifts and tummy tucks. But, similar elective procedures — which generally aren’t covered by insurance — are being offered by a wide variety of medical specialists.

For example, many dermatologists, who treat patients for skin cancer and other diseases, also promote treatments to smooth wrinkles, lighten age spots and remove hair. Otolarnygologists, who care for patients with conditions of the ear, nose and throat, commonly perform nose jobs, brow lifts and eyelid surgery. And, podiatrists, who are often experts at foot reconstructive, diabetic and ankle surgery, sell shoes, shoe-inserts, laser beam treatments for fungus toenails and various cosmetic and prosthetic devices for deformed toenails and crooked digits.

Medicare Limits – Privates Don’t

At least Medicare requires an ABN [advanced beneficiary notice] for non-covered medical services, and limits non-participating doctors to 115% of the Medicare fee schedule for all providers. Increasingly, some private health plans are doing and proposing, same.  

Practice Management Guru

Now, I have no issue with efficient medical practice management operations, for any specialty. In this era of managed care and health 2.0, governmental intervention is onerous, competition is fierce and patient empowerment is reversing the aging command-control medical establishment. Nor, do I have a problem with offering the entire range of therapeutic and/or elective options to any patient. This is a “good – better – best” elective marketing concept.

In fact, the third edition of our best-selling book, the Business of Medical Practice [Transformational Health 2.0 Skills for Doctors] will soon be released this autumn www.BusinessofMedicalPractice.com. In it, we seek to educate doctors about modern business, management and economics practices; as well as the emerging participatory health 2.0 philosophy and information technology skills. Our goal is enhancing the survival potential of the independent practicing medical professional.

But, the ever expanding menu of treatment options – promoted by a trusted medical professional – should include procedural risks and complications, period of recovery and alternatives, including benign neglect [watchful waiting], marginal benefit and marginal utility, as well as price transparency.

Call this new-wave litany, a type of “informed patient business consent”.

[picapp align=”none” wrap=”false” link=”term=doctor+money&iid=182012″ src=”0178/66353b45-9776-48b9-9bdd-2993a48f32bf.jpg?adImageId=12959922&imageId=182012″ width=”372″ height=”459″ /]

Aphorisms of the Past

Over the years, we have heard phrases like the following from all sorts of independent specialists. I know I have, and so have you. Many are the butt of “insider” jokes:

MD: I’m sure that appendix is hot – I have a car payment to make

DPM: Even the normal foot can be surgically improved

DO: Now, I can bill like a real MD

DDS: We can straighten out – the straightest teeth

DC: I’ll crack your back in only forty sessions … and I finance

But, these are aphorisms of the last-generation. Today we are responsible adults. Let’s grow up and become medical professionals and “DOCTORS” again … not healthcare merchants, sales sharks or equipment shills that offer strategic competitive advantages; but not real patient benefits.  

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Assessment

The old practice management business adage of yesteryear – to work longer hours, see more patients quicker, up-sell marginally effective procedures, or do more treatments in order to realize more income – will not necessarily hold true in the modern era.

http://www.washingtonpost.com/wp-dyn/content/article/2010/05/17/AR2010051703034.html

According to colleague, financial advisor and ME-P thought leader Brian J. Knabe MD – a primary care physician and current www.CertifiedMedicalPlanner.com matriculant – and textbook chapter 27 co-author on physician compensation and salary:

In the environment of Healthcare 2.0, those doctors who embrace efficiency, innovation and appropriate business models will be better positioned to optimize their incomes. 

http://businessofmedicalpractice.com/chapter-27-salary-compensation-2/

Conclusion

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SOAP[IER] eMRs [Beware the Alphabet Soup Switcher-Roo]

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Medical Records not a Reflection of Reality – Are Reality Itself

[By Dr. David Edward Marcinko; MBA, CMP™]

[By Hope Rachel Hetico; RN, MHA, CMP™]

Now more than ever, inadequately documented medical charts can mean civil and criminal liability to the sloppy and/or unwary practitioner.

Medical records were previously used to aid in the quality of medical care. Today, they are also the basis for payment for services, not as a record or reflection of the care that was actually provided, but as a separate justification for billing.

History

As little as a hundred years ago, detailed medical records were likely to have been compiled by medical researchers such as Charcot and Hughlings-Jackson. The medical record was an “aide memoire” for detecting changes in patients’ conditions over time, solely for the benefit of the physician in treating the patient.  As health care became more institutionalized, medical records became a communications device among health care providers. A centralized record, theoretically, allowed all to know what each was doing.  The ideal was that if the doctor were unable to care for the patient, another physician could stand in his or her shoes and assume the patient’s care.

Payer Pressures

Then, according to our friend and colleague William “Duffy” LaCava PhD Esq, came pressure from third party payers. As insurance and government programs became larger players in the compensation game, they wanted to know if the care they were paying for was being delivered efficiently. Though the real push behind these questions was the desire to save money, utilization review also directly contributed to better patient care.

Utilization review however, was mainly retrospective; denial of compensation was rarely imposed, and suasion by peers was the main effector of change. Though “economic credentialing” was shouted about, it rarely showed itself in public. Even managed care which openly admitted economic incentives as one of its motivators, preferred to find some other reason for deciding not to admit Dr. Jones to its panel of providers or not renewing Dr. Smith’s contract with the MCO. The medical record remained essentially a record of patient care which was good or not, efficient or not. If the record wasn’t complete, the doctor could always supplement it with an affidavit, use information from somewhere else, or provide explanations.

A Paradigm Shift

This nearly complete change in function of the medical record had precious little to do with the quality of patient care. To illustrate the point, consider only an office visit in which the care was exactly correct, properly indicated and flawlessly delivered, but not recorded in the office chart. As far as the patient was concerned, everything was correct and beneficial. As far as the third-party payer is concerned, the bill for those services is completely unsupported by required documentation and could be the basis for a False Claims Act charge, a Medicare audit, or a criminal indictment.

IOW: We have left the realm of quality of patient care far behind in the current e-medical record debates.

An Attitude Shift

In this contemporary age [circa 2010 and beyond], medical practitioners must adjust their attitude to the present function of patient records. They must document as required under pain of punishment for failure to do so. This new reality is infuriating to many doctors since they still cling to the ideal of providing good quality care to their patients and disdain such requirements as hindrances to reaching that goal. They are also aware of the fact that full documentation can be provided without a reality underlying it.

So, in the modern era of eMRs; some doctors think … and frustratingly say outright: “Fine, you want documentation?  I’ll give you documentation!”  Hence e-MR diarrhea!

APSO needs to replace SOAP in eMRs?

But, according to Dr. Ed Pullen, writing for the Health Care Blog www.TheHealthCareBlog.com,

Consultants have known for years that their referring physicians do not want to look through the entire history and physical exam documentation to get to the assessment and plan. Most consultants make notes to their referring physicians with the Impression and Plan/Recommendations at the top. . 

So, now the entire legal world knows that referring physicians do not want to look through the entire history and physical examination documentation to get to the medical assessment and treatment plan. WOWSA! As the patient, how would you feel about this statement? Furthermore he states that:

When a physician reviews a prior progress note, the information they usually want to see the assessment and plan.  Much less often they need to know the details of the patient’s history, examination, review of systems, etc. In a paper chart it is just a movement of the eyes to find the desired part of the note, and it makes little difference whether the needed information is on the first few lines, or at the end of the note.  The traditional progress note format is the SOAP note: Subjective history first, Objective information like vital signs, physical exam and test results next, Assessment including the diagnosis and documentation of the thought process and decision making third, and the Plan of treatment last.  This reads in a logical fashion, and has become the standard format in most paper patient charts.  In an EMR note reviewed on a computer monitor, the traditional SOAP note simply does not work.  The history of present illness, past medical history, family, and social history, and review of systems, and physical exam more than take up the available space on a monitor. 

To which we agree as the traditional SOAP format of medical charting was developed by Dr. Lawrence Weed in 1968. More formally, it is known as the Problem Orientated Medical Record [POMR]. However, the concept was updated about 20 years ago by adding the extension SOAP[IER], which may work a bit better:

I = Intervention
E = Evaluation
R = Revision

Of course, nurses know this, but doctors still may not. Or; they know but do not execute – a much graver offense.

On the APSO Format

Ed further states that:

Simply making an APSO note instead of a SOAP note, i.e. putting the Assessment and Plan first, and the Subjective history and Objective information later can make reviewing notes much more efficient.  This simple change can be done easily in most eMRs, and just requires thinking about the different work process using a computer monitor to look at information.

Note: APSO = Assessment, Plan, Subjective and Objective

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So, Let’s Change the eMR – But Not Bad Physician Behavior?

Well maybe; maybe not! The thought process here seems to be that if the physician behavior is wrong [not reading the entirely legible e-note], let’s change the electronic algorithm instead. To which we say, let’s change bad physician behavior; or doctor – PLEASE READ THE DAMN NOTE.

eMRs – A Malpractice Litigator’s Dream

Regardless of the above, whether electronic medical records will be more helpful, or even read and reviewed in the future, is still not known. Nevertheless, it is at best naive and more frequently closer to a death wish to think that an unscrupulous practitioner can beat the system, with handwritten notes; computer generated records, or fabricated eMR documentation. And, we do politely disagree when Dr. Pullen opines that:

eMRs also can easily make a document that does a good job of producing a document that can stand up to legal scrutiny. Although there is little data to prove it, some experts believe use of an EMR can reduce liability.

In fact, after serving as expert medical witnesses thru three decades, beginning during the early digital medical records revolution, we believe that eMRs will actually increase medical liability as astute plaintiff attorneys and skilled litigators portray them as canned, automated and robotic notes – not at all relative to the real patient. We’ve seen it before, and it will successfully happen again, as sympathetic jurors buy the argument – en mass.

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For example, we can just imagine a sly attorney admonishing the lay jury–

“My client, Mrs. Smith, is a human being – a patient – she is not an electronic template. Like you, she exits in the real world, not the virtual world of manipulated bits and fabricated electronic bytes. And, by the way doctor, did you even read the notes. After all, according to Dr. Ed Pullen, consultants have known for years that their referring physicians do not want to look through the entire history and physical exam documentation to get to the assessment and plan.   

Of course, like some other experts, we also believe that eMRs actually hinder the patient-physician relationship and communication channel.

http://www.kevinmd.com/blog/2010/03/emr-conversion-physician-communication.html

Assessment

MD-TraderIn almost an ironic return to the original reason for medical records, False Claims Act suits have been maintained on the basis that the care actually provided to patients was not good enough in quality to justify the claims being submitted. In other words, if the care provided fell below the standard of care provided, not only did the practitioner commit medical malpractice, but he or she also submitted a false claim!

Therefore, always remember that medical records are not a reflection of reality – they are the new reality [personal communication “Duffy” LaCava].

Conclusion

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Understanding the Mental Healthcare Regulatory Environment

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Appreciating the Rules

[By Carol Miller; RN, MBA]

Carol S. MillerLocal counties and municipalities are the primary providers of state mental healthcare for patients who lack private insurance coverage for such care.

Both children and adults may be eligible to receive assistance.

These counties provide a wide range of psychiatric and counseling services to the residents in their community as well as other types of assistance such as:

  • treatment services related to substance abuse;
  • housing;
  • employment services;
  • information and education service;
  • referrals;
  • consultative services to schools, courts and other agencies;
  • after-care services; and other related activities.

mental

Rules and Regulations

Accordingly, regulations from federal, state, and county governments have an impact on the day-to-day operations, procedures and processes of a county mental health center. Traditionally, there are three main types of regulations.

Federal Regulations — The United States healthcare system is guided by programs such as those established under the Centers for Medicare and Medicaid (in the case of county mental health programs, Medicaid is especially important), Americans with Disabilities Act (ADA), Occupational Safety and Health Administration (OSHA), Health Insurance Portability and Accountability Act (HIPAA), and others.

State Regulations — These include general legislative guidelines, state management of benefits and reimbursement of the Medicaid program, and state allocations of budgets, which impact the centers’ operations.

County Regulations — Each county defines its own County Mental Health Program and decides which services will be provided or excluded.

Assessment

County facilities generally include outpatient clinics, county mental health programs, short-term psychiatric facilities, day-care centers, de-toxification centers, residential rehabilitation centers for substance abuse, long-term care psychiatric facilities, and Veterans Affairs (VA) psychiatric centers. The county centers may be co-located with other county services such as social services, occupational rehabilitation services, information technology services, human resources, maintenance services, and others or may be independently located.

Conclusion

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Events-Planner: March 2010

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Events-Planner: MARCH 2010

By Staff Writers

“Keeping track of important health economics and financial industry meetings, conferences and summits”

Welcome to this issue of the Medical Executive-Post and our Events-Planner. It contains the latest information on conferences, news, and relevant resources in healthcare finance, economics, research and development, business management, pharmaceutical pricing, and physician/entity reimbursement!  Watch for a new Events-Planner each month.

First, a little about us! The Medical Executive-Post is still a relative newcomer.  But today, we have almost 17,500 visitors and readers each month from all over the country, in addition to our growing subscriber base. We have been a successful collaborative effort, thanks to your contributions.  As a result, we are adding new resources daily.  And, we hope the website continues to provide the best place to go for journals, books, conferences, educational resources, tools, and other things you need to establish the value your healthcare consulting and financial advisory intervention. And so, enjoy the Medical Executive-Post and our monthly Events-Planner with our compliments. 

A Look Ahead this Month

March 1: Print Edition Healthcare Journalism: If you would like to “step-up-your-game” and be considered as a peer-reviewed contributor to the third print edition of: The Business of Medical Practice [Health 2.0 Profit Maximizing Techniques for Savvy Doctors]; contact Ann at: MarcinkoAdvisors@msn.com. There are several chapter topics still available. Now, the important dates:

  • March 1-4: HIMSS-10 Conference, Atlanta, GA
  • March 4-5: Medicare RAC Summit, Washington, DC 
  • March 6-9: BISA Annual Convention, Westin Diplomat, Hollywood, FLA
  • March 7-9: ABA Wealth Management and Trust Conference, Biltmore, AZ
  • March 11: Health Plan Innovations Conference, Orlando, FLA
  • March 13: AORN Congress, Denver, CO
  • March 14: Health Facility Planning, San Diego, CA
  • March 25: World Healthcare Congress on HI-TECH, Washington, DC
  • March 29: HIT and the Future of Managed Care Industry Forum, NY 

Please send in your meetings and dates for listing in the next issue of our ME-P Events-Planner: MarcinkoAdvisors@msn.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com 

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