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Congress and Obama Administration Seek Ways to Limit Increase in Medicare Premiums

Medicare -- New York Times - Tue, 10/06/2015 - 12:00am
White House officials have said they were considering administrative action to moderate the increase in premiums, $7.5 billion by some estimates, perhaps by using a Medicare contingency fund.
Categories: Elder, Medicare

Chronically Ill Pay More in Obamacare Plans Than Employer Coverage

Kaiser Health News - Mon, 10/05/2015 - 7:11pm

Chronically ill people enrolled in individual health plans sold on the Affordable Care Act insurance exchanges pay on average twice as much out-of-pocket for prescription drugs each year than people covered through their workplace, according to a study published Monday in the Health Affairs journal.

Patients with at least one chronic condition such as diabetes or asthma pay on average $621 out–of-pocket for prescription costs on the popular, mid-priced silver exchange plans compared to $304 for those with employer coverage, researchers at Emory University in Atlanta found.

The findings draw more attention to rising drug costs, now a hot button topic in the run-up to the 2016 presidential campaign.

An important reason why people on exchange plans pay more is they often must meet a deductible before their insurance coverage kicks in, the study said. Employer-sponsored plans usually exempt prescription drugs from their deductibles, but they still may have stiff co-pays.

As a result, the study said, patients in the most-popular silver plans pay 46 percent of their total drug spending on average, compared to 20 percent for patients in typical employer-sponsored plans.

Kenneth Thorpe, the study’s lead author and chair of the health policy department at Emory, said the report underscores the need for people to consider more than the premium when they compare health plans on an exchange. Health plans have been shifting more drug costs to consumers in part to hold down monthly premiums, he said. But studies have shown most people choose their health plan because it has the lowest premium.

Use Our Content This KHN story can be republished for free (details).

The risk of higher cost sharing for people with a chronic disease, Thorpe said, is that they won’t fill or renew prescriptions, leaving them sicker and in need of costly hospital care.

Insurers are required by law to offer many proven preventive services such as mammograms and colonoscopies without any cost sharing. The same should apply to prescription drugs known to prevent illnesses, such as Metformin for diabetics, Thorpe said. Health plans are shortsighted in saving money on drug costs by shifting expenses to consumers, he said. “It’s penny wise and pound foolish,” Thorpe added.

Larry Levitt, a senior vice president of the Kaiser Family Foundation, said most people buying exchange plans get subsidies to help reduce their out-of-pocket spending.

Levitt also said comparing employer-sponsored plans to those sold on exchanges has limited value because employer plans typically offer more generous benefits than the silver plans in the marketplaces, and employer plans also have higher premiums.

Some insurance exchanges this fall plan to offer software that allows comparisons of health plans’ costs based on consumers’ health status. The federal government has offered that ability for private Medicare drug and health plans for over a decade.

Cori Uccello, a senior health fellow at the American Academy of Actuaries, said health plans are shifting more costs to policyholders to manage their increased drug spending, which is rising faster than overall medical spending.

Mila Kofman, executive director of the Washington, D.C., health exchange, said officials there have been watching to make sure plans are not discriminating against sicker consumers — such as those with HIV– by putting all their drugs in the highest tier for out-of-pocket spending. Four Florida insurers agreed to lower their rates for HIV drugs after AIDS activists filed lawsuits last year accusing them of discrimination by making those drugs too expensive.

Categories: Health Care

California Gov. Brown Signs Aid-in-Dying Bill Into Law

Kaiser Health News - Mon, 10/05/2015 - 5:51pm

California Gov. Jerry Brown signed landmark legislation Monday, allowing terminally ill patients to obtain lethal medication to end their lives.

In a deeply personal statement, Brown wrote that he read opposition materials carefully, but in the end was left to reflect on what he would want in the face of his own death.

“I do not know what I would do if I were dying in prolonged and excruciating pain,” the former Jesuit seminarian wrote. “I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

Brown, who is a Democrat, had been silent on the issue before Monday’s signing statement. If he had not signed the bill, it would have become law later this week.

This story is part of a partnership that includes KQED, NPR and Kaiser Health News. It can be republished for free. (details)

The new law requires two different doctors to determine that a patient has six months or less to live before prescribing the drugs.  The patient must voluntarily submit two oral requests at least 15 days apart, as well as a written request to the attending physician. And patients must be physically able to swallow the medication themselves,  have the mental capacity to make medical decisions.

Brown’s signature concludes a hotly contested debate that elicited impassioned testimony from lawmakers, cancer patients who fear deaths marked by uncontrollable pain and suffering and religious and disability advocates who fear coercion and abuse.

The law will take effect in 2016, 91 days after the special legislative session concludes. At that time, California will become the fifth state to allow physician-assisted suicide. Oregon, Washington, Montana, and Vermont permit the practice. It was permitted in New Mexico until August, when the state supreme court ruled to outlaw the practice. Attorneys for the doctors and their patients vowed to appeal to the U.S. Supreme Court.

The California law is set to expire in ten years, unless the Legislature passes another law to extend it.

Brown’s decision on the bill provoked strong reactions on Monday from proponents and opponents alike.

Disability rights advocates said depression and incorrect prognoses could lead seriously disabled people to end their lives prematurely.

“We’re disappointed,” said Deborah Doctor, legislative advocate for Disability Rights California. “We opposed the bill because of the lack of safeguards in it.”

Doctor said that Gov. Brown’s responsibility is to look at the impact of a bill on all of California, not just on himself. “If the standard should be that the people of California get what the governor gets, we would be looking at a very different system of health care, benefits, wages and housing.”

Doctor said the governor is ensuring that people have access to “physician-assisted suicide” before guaranteeing they have access to palliative care.

Tim Rosales, spokesman for Californians Against Assisted Suicide, said that this is “a dark day for Californians.”

“Governor Brown was clear in his statement that this was based on his experience and his background,” he said. “As someone of wealth and access to the best medical care and doctors, the governor’s background is very different than millions of Californians living in health care poverty.”

Rosales said those are the people who are potentially hurt by giving doctors the “power to prescribe lethal overdoses to patients.”

But California Sen. Dianne Feinstein, a Democrat, said Brown made the  “absolutely correct” decision.

“I’ve seen firsthand the agony that accompanies prolonged illness, for both patients and loved ones, and this bill provides a compassionate, kind option,” Feinstein said in a prepared statement, which emphasized the bills safeguards.

Robert Liner, a retired obstetrician who is in remission from lymphoma, said he was thrilled with the governor’s action, having fought for this change for many years.

“It has been a long road,” Liner said. “I’m really glad Gov. Brown stepped up to the plate and signed it.”

Liner, 71, is part of a lawsuit seeking doctors’ right to avoid liability for prescribing lethal medication to terminally ill patients. Liner said he doesn’t know what he will do when he reaches the time to make a decision about his own life.

“But I really think it is important to have an option,”  he said. “I am delighted.”


Categories: Health Care

Challenges for Medicare at 50

Brookings Institute -- Medicare - Mon, 10/05/2015 - 5:00pm

Medicare will be under huge pressure in the next few years from the demographic bulge and rising per-enrollee spending. We see this challenge as an opportunity for the program to take more aggressive action to improve care delivery. As the largest payer for most U.S. health care providers, Medicare has the potential to improve the quality and efficiency of U.S. health care delivery overall — but it hasn't used this clout effectively in recent years. As the participants in a recent conference that we organized on “Strengthening Medicare for 2030” concluded, Medicare would be wise to accelerate the adoption of provider payment reforms in the traditional program and increase competition among the private health plans available to beneficiaries under Medicare Advantage. Doing both of these things effectively would improve results for Medicare and move the health care system toward higher quality and sustainable costs.   

In the past, Medicare has taken bold steps to reform provider payment. Inpatient hospital prospective payment, enacted in 1983, replaced a system of reimbursement of costs subject to increasingly tight caps with an almost completely prospective system, using national rates adjusted for local factors. The shift affected more than just Medicare; Medicaid programs and some private payers followed Medicare's lead. One result was that the length of hospital stays dropped dramatically. Subsequently, over many years, prospective payment was applied to outpatient hospital services, surgical centers, and other providers.

Meanwhile, however, a poorly conceived approach for physician payment, the sustainable growth rate formula (SGR), stymied physician payment reform for more than a decade. The SGR controlled physician reimbursement rates so stringently (without controlling service volume) that Congress repeatedly postponed its effects before finally dropping it this year. Moreover, while private payers were increasing patient cost sharing to limit premium increases, Medicare left its benefit structure essentially unchanged from 1965 on and failed to address the subsidy to private supplemental coverage, which often eliminates all cost sharing at the point of service.

Further payment reform is now clearly in order. As the population ages, patients with multiple chronic diseases account for a growing share of health spending — which increases the need to provide more effective care at lower cost. Both public and private payers are now experimenting with alternative payment models (APMs) that encourage all providers participating in an enrollee's care to work together to deliver care tailored to that patient's needs. These models include accountable care organizations (ACOs), bundled payment for episodes of care, and patient-centered medical homes for primary care.

The secretary of health and human services has set the ambitious goal of moving half of Medicare payments to APMs by the end of 2018, but we argue that Medicare is not currently pursuing a course that will achieve this goal — let alone with APMs that successfully improve value. The shortcomings of Medicare's efforts often reflect limitations on the authority that Congress has granted to the Centers for Medicare and Medicaid Services (CMS), but Congress may prove more supportive now that it has taken bipartisan action to replace the SGR and encourage payment reform.

If APMs are to be broadly adopted, Medicare models need to be attractive to providers, whose active support and participation are essential to the success of any payment system. To date, many providers have found participating in APMs to be dauntingly complex and to require up-front investments that are unlikely to be justified by small and uncertain rewards. Some have joined the Medicare APM pilot projects only to later withdraw from them.

Part of the difficulty involves provider-specific benchmarks that reward improvement rather than the level of performance. Frequent updating of these benchmarks undermines the business case for investments by providers to improve the effectiveness of care delivery. If Medicare committed to avoiding the use of provider-specific spending trends to update benchmarks and shifted as quickly as possible to benchmarks reflecting regional or national standards, we believe it would have more success. The recently passed Medicare Access and CHIP Reauthorization Act (MACRA), which replaced the SGR with a merit-based incentive payment system (MIPS), opens the way for better benchmarks by providing a strong incentive for physicians to participate in APMs.2 Where evidence of their effectiveness is strong, bundled payments can be mandated. The recent proposal by Medicare to mandate bundled payment for joint replacement and transition to a regional benchmark is encouraging, although many aspects of that proposal are problematic.3

The quality measures used for APMs can also be improved and simplified, and quality data can be made available to beneficiaries in user-friendly form. Lack of alignment among Medicare, private payers, and Medicaid programs on quality measures has burdened providers and limited their incentives for improving quality. Better alignment requires expanded discussion among payers, provider associations, professional societies, and quality-measurement experts.

Medicare APMs also do not support provider's efforts to engage beneficiaries in their care. To coordinate care effectively, providers need to be able to engage patients actively in their care, especially in chronic disease management, and steer them to other providers on their team. But under Medicare, an ACO may not even be able to identify the patients for whom it's responsible until after the contract year ends. Shifting from an attribution model to an enrollment model — in which beneficiaries choose to participate in an ACO and have incentives to do so and to use specialists that are cooperating with their ACO — is the most effective way of engaging beneficiaries.

Medicare has offered private-plan options to beneficiaries since the 1980s, primarily to expand their choices rather than to contain costs. Indeed, Medicare has actually subsidized Medicare Advantage plans, although these subsidies were reduced by the Affordable Care Act (ACA). Medicare could reduce program spending by introducing competitive bidding by Medicare Advantage plans, requiring each plan to submit a bid reflecting the price at which it would agree to deliver the Medicare package of benefits in a given geographic area and either setting the Medicare contribution on the basis of the second-lowest bid or choosing a percentile in the distribution of bids. This approach, along with other practices used in the insurance exchanges created by the ACA, would probably lead to lower Medicare payments and make it easier for beneficiaries to compare the available Medicare Advantage alternatives.

At least for the immediate future, we would favor limiting competitive bidding to Medicare Advantage plans so that Medicare gains experience with the bidding process and can improve risk adjustment to avert favorable risk selection. If this experience is successful, we would favor including the cost of traditional Medicare as another bid and applying the resulting Medicare contribution to the traditional program as well. The federal contribution to Medicare would then be the competitively determined cost of providing the Medicare benefit package in the area (perhaps the second-lowest bid or an average of the bids) — a policy often referred to as “premium support.” We acknowledge the political difficulties of taking this step but believe it would result in higher-quality care at lower cost.4

Another area for reform involves simplifying and improving the Medicare benefit structure. A unified benefit structure with one deductible for Parts A and B and an out-of-pocket maximum would make sense, especially if some physician office visits were exempted from the deductible to avoid discouraging early treatment. Supplemental plans could also be required to leave some cost sharing for beneficiaries to pay at the point of service; MACRA took an initial step in this direction. These changes would have modest effects on Medicare spending but would remove a barrier to engagement of beneficiaries in the payment reforms discussed above.

Medicare is in a position to lead the health system toward more efficient delivery of care. To meet this challenge, we believe that CMS needs to step up the vigor of its pursuit of payment reform in the traditional Medicare program and competition in Medicare Advantage.

Authors Publication: New England Journal of Medicine Image Source: © Lucy Nicholson / Reuters         
Categories: Elder

An Interview with Debbie Shrager, Legal Reference Librarian

In Custodia Legis - Mon, 10/05/2015 - 3:15pm

This week’s interview is with Debbie Shrager, a legal reference librarian with the Public Services Division of the Law Library of Congress.

Debbie Shrager is a legal reference librarian with the Public Services Division of the Law Library of Congress.  Photo by Donna Sokol.

Describe your background.

I grew up in the Philadelphia area and still love cheesesteaks, hoagies, and “the shore.” I’ve also lived in New York, Chicago, and EdinburghScotland. Northern Virginia has been home for more than 20 years.

What is your academic/professional history?

I stayed in my hometown for college and received a BA in history from the University of Pennsylvania. I spent my junior year at the University of Edinburgh. Following a brief stint in the retail industry, I moved to Chicago to attend Northwestern School of Law. After graduation, I clerked for a U.S. District Court judge and then moved to the D.C. area to work in the Division of Enforcement Litigation, Appellate Court Branch, of the National Labor Relations Board  (NLRB). It was a great job for a new attorney because I immediately had primary briefing and argument responsibility for cases in the U.S. Courts of Appeals. I argued in the First Circuit after only three months on the job! I spent close to 8 years at the NLRB and then took a break from law to spend time at home with my children.

When I was ready to start thinking about going back to work, I decided to make a career change. I received my MLS from Catholic University in 2010. My favorite experience during library school was doing a practicum at the U.S. Supreme Court Library. After getting my library degree, I worked as a reference librarian at George Mason Law Library before joining the Law Library of Congress public services staff.

 How would you describe your job to other people?

I get to help people every day. They give me puzzles, and I try to solve them.

Why did you want to work at the Law Library of Congress?

It’s the ultimate library for anyone interested in legal research. It is also a wonderful place to learn about the documentary history of Congress.

What’s something most of your co-workers do not know about you?

I am the director of a small family foundation that supports arts and humanities programs for disadvantaged children. My father, who was a trial lawyer in Philadelphia, created the foundation before he died in 2005. I care a great deal about the availability and quality of arts education in our community. I benefited tremendously from the performing arts and other educational experiences I had growing up, and it is incredibly rewarding to help others have these opportunities.

Categories: Research & Litigation

You’re Not Lazy, You Just Quickly Minimize Exertion, Study Suggests

CommonHealth (WBUR) - Mon, 10/05/2015 - 1:52pm

(A new study finds we quickly change our gait for greater efficiency. (Photo:Peter Mooney/Flickr Creative Commons)

By Josh Eibelman
CommonHealth intern

If you’re feeling guilty and blaming yourself for being lazy, take heart: We evolved to minimize how much we move, and new research suggests we adjust our bodies quickly to expend the least possible energy.

In a new study, “Humans Can Continuously Optimize Energetic Cost During Walking,” published in the journal Current Biology, researchers found that people optimize their gaits — the manner in which they walk — in real time in order to expend less energy.

Subjects in the study were fitted with exoskeletons that forced them to walk in abnormal ways. The scientists found that participants automatically fine-tuned their manners of walking to more energetically efficient ones in response to the exoskeletons.

I spoke with Jessica Selinger, lead author of the study and a doctoral candidate at Simon Fraser University, to learn more.

How would you sum up your results?

What we found was that people quite readily will tune or change really fundamental characteristics of their gait –characteristics that have been established over millions of steps over the course of their lifetime — in order to move in a way that uses the least amount of energy.

That’s probably intuitive for a lot of us. We know that we like to do things that require the least effort and do them in the least effortful way. I might prefer to take a bus to work when I could walk or I might prefer to sit when I could stand. But what’s really interesting is that even when you make a conscious choice to exercise or spend energy, what our study shows is that your nervous system is optimizing and tuning behind-the-scenes your movements so that you’re burning the fewest calories possible.

What message do you want people to take away from these findings?

For one, it’s really remarkable that the body can do this. There are countless ways that someone could walk from point A to point B. We can choose different speeds, step rates, and even muscle activity patterns, yet we have very strong preferences for particular gaits — the energetically optimal gait. It’s really amazing that our body is able to home in on what is the most energetically optimal way to move. It’s a complex problem and an impressive feat. You have to be smart to be that lazy!

And the other really interesting thing was that that people would adapt their gait even in response to very small savings in energetic cost. We’re talking about just a few percent of the body’s total energy use. It seems that the body is really sensitive to this measure. Energetic cost is not just an outcome of our movement, it is continuously shaping the way me move.

Can people do anything to counteract this laziness?

Yes, absolutely. We can make conscious choices to override this wired laziness. As I said, we can choose to get off the couch or go out for a run. But when you do, your body is still going to be tuning your movements so that it’s doing it in the most efficient way possible. That can be viewed as a good thing or a bad thing, I suppose. If you are running just to lose weight, then maybe you wish you weren’t as efficient or your nervous system weren’t as clever. But when you’re running in a race or marathon, you want your body to be quite efficient and save some of that energy for the final push.

How do you think people became so good at optimizing movement?

Well, we’ve known for a long time that people do walk in the way that’s most energetically optimal. That’s not the new finding. We know that out of a whole range of gait parameters that someone can select — their speed, step frequency, or muscle coordination — they choose those that are metabolically efficient. But what we haven’t known, and what this study has added to the body of literature, is over what timescale this preference is formed.

You can imagine that this could have occurred over evolutionary time. We might have evolved to move this way. Or it might have occurred over the course of our lifetime. Perhaps this took years and years of walking to learn. But what we’ve shown is that it’s something we can continually optimize in real time, over quite short time scales. At the moment we are conducting experiments to try to figure out exactly how the body solves this very complex optimization problem so quickly.

In other words, the findings showed it was not evolutionary or it was both evolutionary and during the course of a lifetime?

What our study showed in particular is that this is something that happens continuously, in real time. It is still likely that we have evolved the ability to do this, but it’s not the case that our chosen gait is just hard-wired. We can adapt to our surroundings remarkably well and tune our movements to new environments and constraints.

That was the motivation behind using the exo-skeletons. We wanted to drop subjects into a totally new world where suddenly there are new rules around the optimal way to move. That way any walking strategies they may have learned over evolutionary or developmental timescales are obsolete. Instead, in order to move in an optimal manner in this new world, they have be able to sense and optimize energetic cost in real time. And, we found, this was indeed what they did.

Do you think these findings have practical considerations for someone who does exercise? Say someone who is running — should they change the way they’re thinking about running?

I don’t think our results suggest that someone should change the way they run, at least not if the goal is to improve economy. In some running circles, people advocate that athletes should run at a certain cadence or change their cadence so they are no longer at their preferred. Our results suggest that you probably can’t do much better than what your nervous system is already doing. Your body tends to pick the cadence that is optimal for you.

And that brings me to my last question: I saw that the U.S Army provided a grant for the study, and I was curious whether there was a specific reason for that.

Max [Donelan, the principal investigator of the research group] was awarded a grant from the U.S Army. The money from this grant has been used to explore fundamental research questions, aimed at understanding why people move the way they do. The army is also interested in the application of these principles in the design of exoskeletons or assistance devices, potentially to restore or even enhance movement.

Categories: Health Care


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