New Medicare Payment Model Puts People Who Need Home Care in Jeopardy

BY 

Several decades ago, it was standard practice to keep patients in the hospital for days, or even weeks after the most routine procedures. For patients with chronic conditions the situation was even worse, often involving frequent, long stays in the hospital. Thanks to advances in home health care, older Americans now have the choice to age at home, while receiving quality health care.

Most home care for older adults is paid for through Medicare, which covered nearly 3.5 million people last year. This makes it all the more important that the Medicare home health benefit be strengthened – to promote quality, accessibility, and cost effectiveness. Regrettably, a new proposal does just the opposite.

Recent regulations issued by the Centers for Medicare & Medicaid Services, which propose a new home health payment system, are alarming. The proposed payment system, known as the Home Health Groupings Model, would radically disrupt the home health care landscape. HHGM and associated payments would discriminate against patients with chronic conditions, threaten access care in rural and undeserved areas, and cut hundreds of millions of dollars from the Medicare home health program.

Proposed to roll out as early as 2019, the HHGM is an untested model that would have significant, wide-ranging effects on access to home care for the most vulnerable older and disabled Medicare beneficiaries. Among its many provisions, HHGM would cut the standard episode of care from 30 to 60 days, which will favor beneficiaries who have the ability to recover quickly, while diminishing access for people who are clinically complex and have longer term, chronic illnesses and impairments.

The HHGM discriminates against those living with chronic conditions – who typically need care for longer periods of time – by assigning lower payment weights for cases with longer lengths of stay. Thus, those with the greatest need would be assigned the fewest resources, despite the fact that these are the very people who need the most intensive care. Further, beneficiaries who require care for longer than 30 days and have not been admitted to home care from a hospital or other institution will find it harder to obtain, and retain, home care. Payment under the proposed rule would be lower for this population.

Finally, it is unclear that the proposed payment rules are lawful as they conflict with Medicare coverage rules, which define the scope of the Medicare home health benefit. They also conflict with the settlement in Jimmo v. Sebelius, which reiterates that Medicare can cover long-term home care for people who need skilled care to maintain or slow deterioration of their conditions.

Fortunately, the administration still has an opportunity to change course before this harm occurs. CMS should pull the proposed payment rule and work with beneficiaries, advocates, providers and other stakeholders to develop a payment model that protects the integrity of the Medicare home health benefit – and ensures access to home care for all who qualify, including people with chronic conditions. The health and welfare of millions of older and disabled people are at stake.

November 2, 2017 at 3:11 pm Leave a comment

Looking to Medicare as a Model for Health Care Coverage? Improve Medicare First.

In a September 2017 editorial, the New York Times reviewed proposals to improve health care coverage as efforts to repeal the Affordable Care Act (ACA) are stalled – at least for now. As noted in the editorial, “[t]he Republican campaign to repeal Obamacare, for all its waste of time and energy, has at least gotten people to talk seriously about proposals to improve the health care system.”

When looking to expand access to health care coverage, it’s natural to look to Medicare, the country’s well-tested, flagship health insurance program. Medicare is not only more cost-effective than private insurance, it’s also beloved by beneficiaries, their families, and the general public.  Thus, proposals presented by some would aggregate our current, multi-pronged coverage system into a single-payer model, which some call “Medicare-for-All.” Other proposals would allow people under age 65 to buy-into Medicare.

Considering several of these proposals, a recent article in the New Republic asked: “[i]f the plan is to transition to something like Medicare-for-All, shouldn’t the strategy begin with making Medicare great?”

Yes! We agree, before moving more people into Medicare, it needs to be improved and simplified. With all of its virtues, Medicare also has flaws. There are still significant gaps in coverage – vision, hearing and routine dental, not to mention long-term care.  Traditional Medicare does not include a cap on out-of-pocket expenses or its own prescription drug benefit.  Medicare Advantage adds costs to the system and significantly limits enrollees’ provider choices. Assistance for low-income individuals is limited.  And, all too often, payment and quality measures lead many providers to prematurely terminate, or avoid providing medically necessary care entirely, for people with longer-term, chronic and debilitating conditions.

Traditional Medicare must include the same benefits and the same limits on cost-sharing as private Medicare Advantage. People who choose traditional Medicare ought to have the same cap on out-of-pocket costs and the same “one-stop-shopping” opportunities as people in private Medicare Advantage. Like their counter-parts in Medicare Advantage, people who choose traditional Medicare should be able to obtain prescription drug coverage without having to purchase a separate Part D plan. If supplemental, Medigap insurance continues to be necessary to help with cost-sharing, it should be available and affordable for all people with Medicare, including people with disabilities and pre-existing conditions, which it is not the case in many states.

As health policy discussions (hopefully) turn towards expanding, rather than contracting, health coverage, the Center for Medicare Advocacy will work to improve Medicare for all those it currently serves, and may serve in the future. This is a critical first step before adopting Medicare as a basis for health coverage expansion.

September 18, 2017 at 2:00 pm Leave a comment

Time to Renew, Not Repeal or Retreat!

Last week, an older adult wrote the Center for Medicare Advocacy:

“I will be on the streets at 66 years old without Medicare and Medicaid.  It’s as simple as that.  My money has all gone raising 3 granddaughters after their mother died.  There are millions of stories like mine everywhere.  We must help the least of us that had bad luck or are sick etc.” J.D., Medicare Beneficiary, Michigan

This week, on its first day, Congress passed a Resolution that begins the process to repeal the Affordable Care Act (ACA). Repealing ACA threatens access to health coverage and Medicaid for 20 million people. It would also reduce Medicare prescription drug coverage, reduce Medicare preventive benefits, and decrease the long-term solvency of the Medicare program.

ACA, Medicare and Medicaid are intertwined. Repealing the Affordable Care Act would also harm Medicare and Medicaid. It would harm the people, like Mrs. D, who raised her own family and is now raising her grandchildren.

Policy-makers need to know how their decisions impact real people. If you know someone who has benefited from the Affordable Care Act, Medicare and/or Medicaid –  Tell Your Story!

January 4, 2017 at 11:26 pm Leave a comment

Medicare: Es El Momento Para Renovar y No Retroceder!

Si, Medicare importa! Abrio sus puertas al cuidado medico al proporcionar cobertura que el mercado privado no querria ofrecer. Hoy dia 55 millones de personas viejas y personas incapacidadas disfrutan de atencion medica gracias a Medicare. El programa alivia familias de preocupacion y mejora la calidad de sus vidas, su tranquilidad, salud y seguridad economica. Sin embargo, en 2017 todo esto esta a riesgo.

Tenemos que mantener Medicare al dia, con salud oral, audiologia y cobertura de vision. Deberiamos pagar solamante el mejor precio por medicamentos de receta, y poner fin al derrame de los dolares  de Medicare a las ganacias de las companias de seguros. Medicare tiene que quedar vital y relevante. Pero esto solamente puede ocurrir si Medicare se renueva y no se retrocede de su promesa.

Desafortunadamente, muchas de las personas entrando en ls escena nacional que van a establecer nuevas politicas estan dedicadas a convertir Medicare de un programa de beneficios definidos a un programa de contribuciones definidas que ayudaria a pagar por primas de seguros individuales y privadas.  Este resultado seria el fin de Medicare tal como lo conocemos, con sus multiples objectivos de proporcionar cubertura de la mas alta calidad y con los precios mas justos. En cambio, cada persona recibiria un comprobante en la forma de un pago parcial para buscar y comprar un seguro medico en el mercado privado.

Por mas de 50 anos Medicare ha servido las nececidades de familias individuales y al mismo tiempo el programa ha ayudado a unir nuestra familia nacional. Las informaciones aqui incluidas, comentarios y historias veridicas demuestran lo que esta al riesgo si deshacemos este tesoro nacional- y como podemos renovarlo por las generaciones por venir.

“Antes de que eramos eligibles para Medicare nuestras finanzas casi fueron destruidas por primas de seguros altas…Medicare ha hecho una diferencia enorme en nuestra capacidad de disfrutar de una cobertura adequada, especialmente desde que la crisis economica resulto en la disminucion severa de nuestros fondos de jubilacion.”

K.M., Beneficiaria de Medicare, Minnesota                                                                           

#SalvarMedicareAhora

December 29, 2016 at 8:50 pm Leave a comment

Medicare Beneficiary Costs Will Rise if Affordable Care Act is Repealed (And Private Medicare plans will be paid more)

With all the talk about repealing the Affordable Care Act (ACA/Obamacare), many people miss the impact repeal would have on Medicare, older and disabled adults, and their families. ACA added preventive benefits to Medicare, decreased Part D cost-sharing for prescription drugs, and increased the long-term solvency of Medicare by about 11 years.

According to the Kaiser Family Foundation:

” Full repeal would increase spending primarily by restoring higher payments to health care providers and Medicare Advantage plans. The increase in Medicare spending would likely lead to higher Medicare premiums, deductibles, and cost sharing for beneficiaries, and accelerate the insolvency of the Medicare Part A trust fund. Policymakers will confront decisions about the Medicare provisions in the ACA in their efforts to repeal and replace the law.”

http://kff.org/health-reform/issue-brief/what-are-the-implications-of-repealing-the-affordable-care-act-for-medicare-spending-and-beneficiaries/

Policy-makers and people who rely on Medicare should think twice before supporting legislation that will give windfalls to private insurance companies, while reducing coverage and increasing costs for older and disabled people.

December 13, 2016 at 5:20 pm Leave a comment

The Rush to Destroy Medicare as We Know It

November 29, 2016 – Despite statements during the campaign that he would protect Medicare, the President-Elect is indicating otherwise with his selections of Rep. Tom Price (R-GA) to head the Department of Health & Human Services, and health consultant Seema Verma to head the Centers for Medicare & Medicaid Services.

Price is an ardent foe of the Affordable Care Act, although it has extended the solvency of the Medicare Part A Trust Fund, closed gaps in prescription drug coverage, and expanded preventive benefits under Medicare.

Particularly threatening to Medicare and Medicare beneficiaries, says Center for Medicare Advocacy Executive Director, Judith Stein, “Rep. Price favors letting people opt-out of Medicare. Allowing beneficiaries – most likely the healthiest beneficiaries – to opt out of Medicare is an example of what Newt Gingrich in 1995 called letting the program ‘wither on the vine.’ The key to future solvency is a larger coverage pool, not a smaller one. That’s just how insurance works.”

In addition, Mr. Price’s proposals to rely on tax credits as incentives to purchase insurance ignore the fact that a huge number of families don’t make enough income for such credits to be worthwhile. Further, CMS nominee Verma favors Health Savings Accounts – another private option that would break up the Medicare community. “All of these proposals,” continued Ms. Stein, “will be sold to Medicare beneficiaries as ‘preserving’ and ‘protecting’ Medicare. In fact, they will end Medicare and turn it over to the private insurance industry.”

 

November 29, 2016 at 5:44 pm Leave a comment

Medicare Is Withering on the Vine

In 1995 Newt Gingrich predicted that privatization efforts would lead Medicare to wither on the vine. He said it was unwise to get rid of Medicare right away, but envisioned a time when it would no longer exist because beneficiaries would move to private insurance plans.

Well … that’s what’s happening.  Not just by happenstance, but rather according to a determined, strategic plan. The plan has included the following:

  1. Government subsidies to private plans, renamed “Medicare Advantage,” ranging from 14% –  2% above traditional Medicare per-beneficiary costs;
  2. Additional benefits added to private Medicare Advantage, benefits that weren’t added, and aren’t allowed, in  traditional Medicare;
  3. Part D prescription drug coverage wrapped into Medicare Advantage, but not into traditional Medicare;
  4. Increases in traditional Medicare Part B premiums, especially for the middle class;
  5. Limits on access to Medigap insurance to supplement traditional Medicare and on benefits for those who can obtain a Medigap policy.

It didn’t take a crystal ball.  It took a vision, planning and persistence.

The Center for Medicare Advocacy also has vision, planning and persistence. We do all we can to keep Medicare focused on the needs of older and disabled people, not the insurance industry. We speak out with expertise and with  the stories of real people.

With your support, we’ll keep insisting that Medicare is fully present for the families that rely on it – now and in the future. We’re ready to keep Medicare from withering on the vine.

Will you help?

November 28, 2016 at 4:48 pm Leave a comment

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