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Depression Among Heart Attack Survivors Can Be Deadly, Yet Is Often Ignored

Kaiser Health News - Thu, 07/20/2017 - 7:49am

Clyde Boyce has been hospitalized 14 times in the past four years.

Boyce, 61, survived two strokes and five operations to unblock arteries around his heart, including three procedures in which doctors propped open his blood vessels with stents. He takes 18 pills a day and gets injections every two weeks with a powerful drug to lower cholesterol.

Yet the disease that came closest to taking Boyce’s life wasn’t a heart condition. It was depression, which led him to attempt suicide twice in the year after his first surgery.

One in 5 people hospitalized for heart attack or chest pain develop major depression — about four times the rate in the general population, according to the American Heart Association. One in 3 stroke survivors become depressed, along with up to half of those who undergo heart bypass surgery.

Heart disease patients who become depressed are twice as likely to die within the following decade as other patients, according to an unpublished study presented in March at the American College of Cardiology’s annual meeting.

This KHN story also ran on CNN.com. It can be republished for free (details).

Depression increased the risk of death more than any other risk factor in the study — even smoking, said lead author Heidi May, a cardiovascular epidemiologist at the Intermountain Medical Center Heart Institute in Salt Lake City.

Relatively few heart patients die from suicide.

Most often, depressed heart attack survivors die of physical causes, partly because they’re less motivated to take care of themselves and take medication as directed, said Dr. Martha Gulati, a spokeswoman for the American College of Cardiology.

People suffering from depression are also more likely to smoke but often less likely to exercise and follow a healthy diet than those who are not depressed, Gulati said.

“You may be told to change your diet, but if you’re depressed, you may think, ‘This is too overwhelming. I can’t even process this information right now,’ ” said Kim Smolderen, an assistant professor at the University of Missouri-Kansas City.

The American Heart Association has recommended that cardiologists screen all heart attack patients for depression, using a short questionnaire, since 2008.

Yet nearly a decade later, relatively few cardiologists screen patients for depression, Smolderen said. In May, she published a study in Circulation of younger heart attack survivors, most of whom were women, showing that only 42 percent of depressed heart attack patients received treatment.

Overall, only half of all Americans diagnosed with depression receive care, according to the National Institute of Mental Health.

Many cardiologists say they don’t have the time or the expertise to handle mental health care, Smolderen said. Critics note there’s little to no evidence that depression screening prevents additional heart attacks.

Yet many doctors also fail to refer patients to cardiac rehabilitation — a program of supervised exercise and education — which has been shown to both reduce depression and help prevent heart attacks and deaths, according to a 2015 study in JAMA Internal Medicine.

Although the American Heart Association strongly recommends cardiac rehab, doctors refer only 2 out of 3 heart attack survivors for the program, the study found.

A fraction of patients referred to the program — which involves three sessions a week for 12 weeks — actually show up. Due to cost and other barriers — such as long drives to hospital rehab centers — just 23 percent of patients attended one or more sessions, and 5 percent completed all 36 recommended sessions, the study found.

Cardiac rehab programs include stress management and teach relaxation techniques and coping skills similar to those used in some types of depression therapy. The programs can reduce the risks of heart attack more than standard rehab.

In a three-year study published in Circulation last year, which included heart patients ages 36 to 84, nearly half of patients who didn’t attend cardiac rehab died or had a heart attack, stroke or hospitalization due to chest pain, compared with 33 percent of those who attended rehab.

Among those whose rehab included stress management, only 18 percent suffered one of these heart-related complications, the study found.

Ignoring The Warning Signs

Boyce — who said depression sent him into rages that tested his marriage — said no one screened him for mental illness after his heart procedures, although he had suffered several debilitating depressions since adolescence.

He wasn’t prescribed antidepressants, Boyce said, until after his first suicide attempt.

“The system failed him,” said psychologist Barry Jacobs, a spokesman for the American Heart Association, when he heard Boyce’s story. “What you’re describing is not the way it’s supposed to work.”

After Boyce’s second heart procedure, he stopped taking his heart medications for five days — a move that his doctors viewed as a suicide attempt. His doctor committed him to a state psychiatric hospital for almost a week, prescribed medication and referred him to a psychiatrist.

Yet Boyce’s depression deepened as the bad health news piled up. Doctors diagnosed heart rhythm problems that required a pacemaker; congestive heart failure, caused when weakened heart muscle allows fluid to build up in the lungs; as well as asthmatic bronchitis, which affects the lungs. Boyce began to dread that he would suffer a fate similar to his mother, who died after six months in a coma, brought on by a long battle with heart disease.

A year after his first suicide attempt, Boyce tried to overdose on prescription medication. His wife found him and took him to the hospital, where doctors committed him to a psychiatric ward.

“Everything was happening so fast,” said Boyce, a former advertising executive from Murchison, Texas, who retired due to his health problems. “I was just convinced I was going to die. I thought to myself, ‘I’m going to end up on a ventilator, unconscious, just like my mother.’ ”

Boyce, 61, of Murchison, Texas, shows his smallest and largest pills — two of 18 he takes every day for various conditions. (Sarah A. Miller for KHN)

Boyce received help from a variety of sources: medication; counseling with a psychologist; a “mindfulness” stress reduction program, which borrows techniques used in meditation; and cardiac rehabilitation.

Exercise helped him feel stronger and less disabled, Boyce said.

“I do think the rehab raised my spirits … feeling like I could still do some things,” Boyce said.

What helped Boyce turn the corner, he said, was a conversation with God.

“It was the night before my third or fourth operation, and for some reason, I was sure I was not going to live through it,” Boyce said. “I said, ‘God, all I ask is that you give me one more day, and I will try to be a better man every day.’”

Boyce lost his fear of death. Although he occasionally still gets depressed, Boyce said, he’s able to manage his fears and anxieties better than in the past.

An Expensive Problem To Ignore

Cardiologists are divided about whether to screen heart patients for depression, but many primary care doctors have embraced the idea, said Dr. Ken Duckworth, medical director for the National Alliance on Mental Illness.

Both the American Academy of Family Physicians and the U.S. Preventive Services Task Force, an expert panel that advises Congress on health care, now recommend that doctors screen all adults for depression. The family physician group also singles out heart attack survivors for depression screening.

Studies increasingly suggest that the most effective care comes from addressing physical and mental health conditions together, rather than forcing frail patients to make separate trips to a variety of specialists, Duckworth said.

Successful approaches have involved “packages of care,” rather than individual services, said Dr. Bruce Rollman, a professor at the University of Pittsburgh School of Medicine.

The team approach is key.

A mild decrease in depression led to a big decrease in cost.

Bruce Rollman, University of Pittsburgh School of Medicine

In an approach called collaborative care, mental health nurses or social workers serve as care managers, who reach out directly to patients, often by phone, to educate them about their disease, suggest ways to manage their depression and make sure that treatments are working, said Dr. Mary Whooley, director of cardiac rehabilitation at the San Francisco VA Health Care System.

Care managers work with primary care doctors to quickly adjust patients’ medications or other treatments as needed. They consult with a psychiatrist, often over the phone, Whooley said.

“You can’t stay home and get depressed … they won’t let you,” said Dr. Anita Everett, president of the American Psychiatric Association. “They reach out to you.”

A 2014 study in JAMA Internal Medicine found that collaborative care could be delivered over the phone. Patients in the study had blocked arteries, heart rhythm problems or heart failure.

Even on the phone, care managers “develop a trusted relationship with our patients,” said study co-author Dr. Bruce Rollman, a professor at the University of Pittsburgh School of Medicine.

An earlier study of collaborative care, which focused on patients who had undergone bypass surgery, found that telephone care not only improved depression, quality of life and patients’ physical functioning, it saved over $2,000 a year per patient. Rollman is now studying ways to treat depression and heart failure together.

Keeping depression under control can save money if patients stay healthy and spend less time in the hospital, Rollman said.

Depression costs the U.S. more than $210 billion a year, with much of the cost coming from reduced productivity at work, according to a 2015 study.

“There are very, very few things in health care that save money,” Rollman said. “A mild decrease in depression led to a big decrease in cost.”

Officials at the University of Pittsburgh Medical Center Health Plan were impressed enough by the results to include depression screening as part of a checklist of care for patients who are sent home after a heart attack.

Medicare, the federal health insurance program for Americans age 65 and older, began paying doctors to deliver collaborative care in January. Medicare has covered depression screenings in primary care settings since 2012.

In that time, Medicare payments for depression screening have grown from $1.7 million a year to $9.5 million a year, according to a Kaiser Health News analysis. While those screenings make a small fraction of Medicare’s annual budget of $646.2 billion, Duckworth called the services “a noteworthy trend in the right direction.”

Elizabeth Lucas contributed to this story.

Categories: Health Care

First Edition: July 20, 2017

Kaiser Health News - Thu, 07/20/2017 - 6:31am
Categories: Health Care

These Preventive Measures Might Help Delay Dementia Or Cognitive Decline

Kaiser Health News - Thu, 07/20/2017 - 5:00am

In a landmark report, scientists have endorsed three strategies for preventing dementia and cognitive decline associated with normal aging — being physically active, engaging in cognitive training and controlling high blood pressure.

This is the first time experts convened by the National Academies of Sciences, Engineering and Medicine have deemed scientific evidence strong enough to suggest that preventing dementia and age-related cognitive decline might be possible.

Seven years ago, in a separate report issued by the Agency for Healthcare Research and Quality, scientists said they couldn’t recommend any interventions to forestall or slow cognitive deterioration because state-of-the-art science at that time didn’t offer enough support.

Now there’s a considerably larger body of research to draw upon. And while findings are still far from definitive, “we found encouraging evidence that supports the value of several interventions,” said Story Landis, vice chair of the 17-member panel that prepared the report and director emeritus of the National Institute of Neurological Disorders and Stroke.

NAVIGATING AGING

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.

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That doesn’t mean the strategies are guaranteed to protect brain health. “You can do everything right and still get dementia in later life,” said Dr. Kenneth Langa, a panel member and professor of internal medicine, gerontology and health management and policy at the University of Michigan School of Public Health.

Nor does it mean these are the only interventions that offer promise. Managing depression, controlling diabetes and high cholesterol, engaging in social activities, getting adequate sleep, eating a healthful diet, taking disease-modifying treatments for dementia (if and when they become available) and getting enough vitamin B12 and folic acid also appear worthwhile, though more research is needed before those tactics can be formally recommended, the NAS report said.

Addressing lifestyle factors that raise the risk of cognitive impairment could help prevent more than one-third of dementia cases across the globe, according to a separate comprehensive analysis published in The Lancet on Thursday.

The NAS panel proposed that its findings be shared with the public and physicians, but stopped short of proposing a major public health campaign, citing the need for further research.

Here are insights from the report, based on interviews with panel members and outside experts:

Strategies Work In Some Cases, Not Others

As people age, mental processing becomes slower and memory becomes less reliable — a normal condition known as age-related cognitive decline.

Two of the interventions recommended in the NAS report — cognitive training and physical activity — appear to have the potential to delay age-related cognitive decline. But there’s no evidence that they can prevent dementia or mild cognitive impairment, an intermediate condition that sometimes progresses to dementia.

Managing high blood pressure is the only strategy thought to have the potential to prevent or delay the onset of Alzheimer’s disease. But it wasn’t shown to have an impact on age-related cognitive decline.

Once the hallmarks of Alzheimer’s are detected — notably amyloid beta plaques and tau tangles in the brain — some interventions might not be effective, said Dr. Ronald Petersen, a member of the NAS panel and director of the Mayo Clinic’s Alzheimer’s Disease Research Center.

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Start Early

It’s now known that biological changes associated with Alzheimer’s and related dementias begin a decade or more before any symptoms become evident. So it’s best to make recommended lifestyle changes early and sustain them over time.

“Prevention really needs to start in people who don’t show any sign of the disease — probably when people reach their 40s,” said Jeffrey Keller, director of the Institute for Dementia Research and Prevention at Louisiana State University, who was not involved in the NAS study.

Controlling high blood pressure, a strategy that helps preserve the health of blood vessels in the brain, is most effective if begun in middle age, the NAS report explained. But if you’ve reached age 65 and your blood pressure isn’t well managed, you’re still well advised to bring it under control, Landis said.

The same applies to physical activity: It’s best if you start in middle age, but becoming more active in later life is still good for your health. While it’s not yet known which type of activity is most effective, for what duration and how often it should be pursued for maximum brain benefit, walking briskly for 150 minutes a week or about 20 minutes a day is a good idea, Petersen said.

On Cognitive Training

Probably the best cognitive training you can get is a good education and ongoing mental stimulation. “There’s growing evidence that the ways in which your brain is challenged all through your life matter,” noted Langa, whose research has documented a decline in dementia rates in high-income countries over the past 25 years.

But the impact of education on brain health is very difficult to quantify. So the NAS panel endorsed cognitive training based largely on a randomized controlled trial known as Advanced Cognitive Training for Independent and Vital Elderly, which studied several thousand older adults over the course of 10 years.

ACTIVE had certified trainers work with seniors in small group sessions on various cognitive exercises for 10 sessions lasting an hour or more over five to six weeks. Feedback was an essential part of the intervention and booster sessions were offered. At 10 years, there was evidence of a positive effect on seniors’ independence and ability to perform daily tasks.

What was responsible for this effect? The training? Social interactions? Feedback? Booster sessions? All or some of the above? It’s not yet clear.

It’s important to note that the panel insisted that commercially sold computer-based brain games can’t be assumed to have the same effect. So far, research about brain games has failed to prove that this type of training improves broad-based cognitive functioning and people’s ability to function independently.

“The data supporting their efficacy just isn’t there,” said Petersen of the Mayo Clinic.

Try Several Things, Not Just One

When scientists examine the brains of people with Alzheimer’s disease, they find amyloid beta plaques and tangles, but also changes in blood vessels, evidence of microbleeds, and lesions in the brain’s white matter. “It’s mixed dementia, due to multiple factors — not just one thing,” Landis said.

The corollary: Mix it up and try several ways to reduce age-related cognitive decline or dementia, not just one.

“If we think of Alzheimer’s as a multifactorial disease, it makes sense to reduce multiple risk factors simultaneously,” said Rong Zhang, associate professor of neurology and neurotherapeutics at University of Texas Southwestern Medical Center. Zhang is also the principal investigator for a five-year study investigating whether aerobic exercise combined with intensive control of hypertension and cholesterol can help prevent Alzheimer’s. That study, the Risk Reduction for Alzheimer’s Disease trial, is currently enrolling participants at six medical centers.

“The brain is complicated and its response to interventions is complex,” Langa said. “Therefore, the more strategies that you use to try to improve the brain’s health long term, the more likely they’re going to work.”

Don’t Bother

The NAS report found no evidence supporting the use of ginkgo biloba and vitamin E, which are widely marketed to people concerned about brain health. And it questioned the value of other supplements, noting that overall dietary patterns appear more important than any single substance.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Categories: Health Care

Cruz Plan Gets Thumbs Up From HHS But Thumbs Down From Most Everyone Else

Kaiser Health News - Wed, 07/19/2017 - 8:02pm

Contradicting the opinion of most policy experts, a draft report from the Trump administration forecasts better enrollment and lower premiums for everyone who buys their own health insurance if a controversial amendment proposed by Sen. Ted Cruz of Texas were to become law.

The draft surfaced just as Republican senators were lunching with President Donald Trump on Wednesday to talk about the next steps in the health care debate.

“The Republicans never discuss how good their healthcare bill is, & it will get even better at lunchtime,” tweeted Trump, before the group convened.

But findings from the draft report drew immediate criticism from health policy experts as opaque and misleading.

“The details get a bit dicey,” said Craig Garthwaite, director of the health care program at Northwestern University’s Kellogg School of Management. “No one I’ve talked to thinks [the analysis] is well done.”

The forecasts in a 22draft analysis by the Department of Health and Human Services are exactly opposite from what many experts forecast.

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Still, the HHS analysis did provide some insight into how HHS envisioned that the Cruz plan, part of the Senate bill that appeared to die this week, could have worked. Particularly notable: The analysis assumes annual deductibles of $12,000, which means consumers would have to pay that amount — which is far higher than allowed under the ACA — before most benefits are covered.

On Wednesday, health care developments continued to unfold at a breakneck pace, and with a zigzagging trajectory, when the Senate Budget Committee posted on its website yet another bill. This one is an updated version of the 2015 “repeal and delay” bill, which is likely the measure the Senate will consider next week if a vote to start debate succeeds.

It would repeal all of the taxes that paid for the Affordable Care Act’s benefits, roll back the expansion of Medicaid (but not cap the underlying program), nullify the requirement for most people to have insurance and rescind the financial aid for low- and moderate-income Americans.

Late in the afternoon, the Congressional Budget Office released an updated estimate of an earlier analysis concluding that the new “repeal and delay” measure could result in 32 million fewer Americans having coverage and premiums doubling by 2026. By 2020, according to CBO, “about half the nation’s population would live in areas having no insurer participating in the non-group market.” The new bill does not include the Cruz amendment, the subject of the HHS report.

Opposition to the Cruz amendment from powerful health care sectors, like the insurance industry, is cited as one reason why the Senate was unable to muster enough votes to move the whole Senate bill forward for debate this week.

Last Friday, the insurance industry trade lobby sent a harsh warning to Congress, saying the Cruz amendment “is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage.”

Today, the HHS report took a very different view.

First reported in the right-leaning Washington Examiner, it forecasts far more people covered by insurance in 2024 if the Cruz plan were adopted, as compared with how many would be insured under the Affordable Care Act.

It also projects premiums would fall, both in plans that meet all the rules of the ACA, and in plans Cruz proposes, which would not have to follow the rules. The Cruz plans would have lower premiums, however, because they could come with far fewer benefits — and could reject people with medical problems or charge them more.

Insurers and actuaries said the Cruz proposal would result in a segmented market, with younger and healthier people drawn to the skimpier, less expensive plans. That, in turn, would leave older or sicker enrollees in the ACA-compliant plans, causing their premiums to spiral upward.

But the analysis by HHS shows premium costs for ACA-compliant plans would go down by more than $250 a month in 2024 when compared with what they would be under current law. The Cruz plans would be super cheap, at under $200 a month under the rosiest scenario outlined.

Experts today immediately pounced on the department’s methods — in as much as they could be determined, since the full report was not released.

(HHS did not respond to requests for comment or for the release of the full report.)

For starters, the draft report, they say, compares premiums for a 40-year-old with the “weighted average” of all people of all ages purchasing ACA plans now.

“It’s not apples to apples,” said Matt Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Innovation in Health Policy.

It cited its own “proprietary model” used to determine how many people would switch from ACA plans to the new Cruz plans, without spelling out its assumptions. Not including such details is highly unusual and makes the results difficult to analyze, said Garthwaite, adding: “There’s nothing in this that gives me any hope that the entire report will be any more accurate, complete or unbiased.”

Meanwhile, over lunch at the White House, President Trump asked senators to skip all or part of their August recess in order to work on another proposal to repeal and replace the ACA. He promised premiums that would be significantly lower, without citing details on how that would occur.

Categories: Health Care

Postcard From Capitol Hill: Lawmakers Put Women’s Health Care In Its Place

Kaiser Health News - Wed, 07/19/2017 - 7:13pm

The atmosphere at a House Appropriations Committee lunch meeting on women’s health midday Wednesday was predictably charged.

The Trump administration has proposed to defund Planned Parenthood and make severe cuts in other women’s health programs, such as Title X, a 40-year-old program that provides grants for family planning, and grants for teen pregnancy prevention.

Much of the male-dominated debate — over chili dogs and orange juice — was nominally about where women prefer to seek health care. But the central character was abortion.

Democratic representatives introduced several amendments related to women’s health, including one restoring teen pregnancy prevention grants and another striking language that would allow employers to exclude certain procedures from their health plans if they found them morally objectionable. All of the amendments failed in the Republican-controlled body.

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“No taxpayer dollars should be used to fund abortion, and I’ll fight any effort to dilute or get around that,” declared Rep. Martha Roby (R-Ala.), who prefaced her comments by calling herself “proudly pro-life.”

Federal funds are already prohibited for abortions under the Hyde Amendment, passed in 1976.

So the question of where women should be able to obtain health care has become an odd proxy for the abortion issue. According to Planned Parenthood, 60 percent of women who use their clinics consider it their main source for medical attention.

“We see community health centers as a more appropriate provider, and those are funded in the bill,” said Rep. Tom Cole (R-Okla.).

Rep. Evan Jenkins (R-W.Va.) agreed, saying women in his state — home to only one Planned Parenthood clinic — prefer to get their care at community health centers. “When we have an opportunity to defund Planned Parenthood and invest in community health centers, that’s good for West Virginia,” Jenkins said.

But money saved by defunding Planned Parenthood isn’t slated for community health centers, whose funding isn’t changing under the Trump administration’s proposed budget.

Rep. Barbara Lee (D-Calif.) pointed out: “We may disagree in terms of a woman’s right to choose abortions, but I hope we can agree that women should be able to make their own health care decisions.”

Categories: Health Care

Read CBO Score Of Repeal-Only Bill

Kaiser Health News - Wed, 07/19/2017 - 5:58pm

The Congressional Budget Office releases July 19 its estimates on an amendment to H.R. 1628 that would repeal the Affordable Care Act outright.

This is the CBO’s fourth review of repeal-and-replace related legislative drafts. Below are the past scores from the Senate’s Better Care Reconciliation Act, released June 26, and the House-passed American Health Care Act, released May 24.

Categories: Health Care

Fraud And Billing Mistakes Cost Medicare — And Taxpayers — Tens Of Billions Last Year

Kaiser Health News - Wed, 07/19/2017 - 4:24pm

Federal health officials made more than $16 billion in improper payments to private Medicare Advantage health plans last year and need to crack down on billing errors by the insurers, a top congressional auditor testified Wednesday.

James Cosgrove, who directs health care reviews for the Government Accountability Office, told the House Ways and Means oversight subcommittee that the Medicare Advantage improper payment rate was 10 percent in 2016, which comes to $16.2 billion.

Adding in the overpayments for standard Medicare programs, the tally for last year approached $60 billion — which is almost twice as much as the National Institutes of Health spends on medical research each year.

“Fundamental changes are necessary” to improve how the federal Centers for Medicare and Medicaid Services ferrets out billing mistakes and recoups overpayments from health insurers, he said.

Medicare serves about 56 million people, both those 65 and older and disabled people of any age. About 19 million have chosen to enroll in Medicare Advantage plans as an alternative to standard Medicare.

Federal officials predict the Medicare Advantage option will grow further as massive numbers of baby boomers retire in coming years.

Standard Medicare has a similar problem making accurate payments to doctors, hospitals and other health care providers, according to statistics presented at the hearing. Standard Medicare’s payment error rate was cited at 11 percent, or $41 billion for 2016.

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Last week, Attorney General Jeff Sessions announced the arrest of 412 people, some 100 doctors among them, in a scattershot of health care fraud schemes that allegedly ripped off the government for about $1.3 billion, mostly from Medicare.

CMS official Jonathan Morse said that the “largest contributors” to billing mistakes in standard Medicare were claims from home health care and inpatient rehabilitation facilities.

Some lawmakers appeared frustrated that CMS cannot say for sure how much of the “improper payments” in both Medicare options are caused by fraud. The agency uses the term broadly to cover billing fraud, waste and abuse, as well as simply overcharges and underpayments.

“When trying to understand how much fraud is in Medicare, the answer is simply we don’t know,” subcommittee Chairman Vern Buchanan (R-Fla.) said.

Yet he added that “it doesn’t take a big percentage [of fraud] to get a giant number” of dollars.

CMS official Morse did little to clear up any confusion over billing mistakes. In his written testimony, he said that improper payments are “most often payments for which there is no or insufficient supporting documentation to determine whether the service … was medically necessary.”

In his testimony, GAO official Cosgrove focused on the Medicare Advantage program. He took aim at a little-known government audit process called Risk Adjustment Data Validation, or RADV. These audits require health plans to submit a sample of patient records for review.

Cosgrove said that the RADV audits take too long to complete and failed to focus on health plans with the greatest potential for recovery of overcharges. He also said that CMS officials had not done enough to make sure the payment data they use are accurate. As a result, “the soundness of billions of dollars in Medicare expenditures remains unsubstantiated,” according to written testimony.

The GAO, the watchdog arm of Congress, has previously criticized CMS for its failure to ferret out overcharges in Medicare Advantage. In an April report, GAO found that CMS has spent about $117 million on the Medicare Advantage audits since 2010 but recouped just under $14 million in total.

Payment errors and overcharges by Medicare Advantage plans were the subject of a lengthy investigation by Kaiser Health News and the Center for Public Integrity. Federal officials have struggled for years to weed out billing irregularities by Medicare Advantage plans, according to CMS records obtained through a Freedom of Information Act lawsuit filed by the Center for Public Integrity.

The investigation found that Medicare Advantage payment errors result mostly from flaws in a billing formula called a risk score. Congress expected risk scores would pay higher amounts for sicker patients and less for people in good health when it began phasing in the billing scales in 2004.

But since then, a wide range of CMS audits and other reviews have found that Medicare wastes billions of tax dollars annually because some health plans inflate risk scores by exaggerating how sick their patients are. One CMS memo made public through the FOIA lawsuit referred to risk-based payments as essentially an “honor system,” with few audits to curtail fraud and abuse.

Even when RADV audits have detected widespread overpayments, CMS officials have failed to recoup money after years of haggling with the health plans.

In January, Kaiser Health News reported that Medicare had potentially overpaid five Medicare Advantage health plans by $128 million in 2007, but under pressure from the insurance industry collected just $3.4 million and settled the cases.

Morse testified on Wednesday that CMS is still in the process of completing appeals of RADV audits from 2007. He said that payment errors have been calculated for 2011 and that reviews for 2012 and 2013 were underway.

These results are years behind schedule, according to CMS documents, which show the results were expected in early 2014. In the past, officials have said that they expected to collect as much as $370 million from the 2011 audits.

Morse said on Wednesday he didn’t know when the 2011 audit results would be released. “Hopefully soon,” he said after the hearing. “I actually don’t know.”

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Categories: Health Care

SNAP Caseloads Falling More Quickly in 2017

Center on Budget and Policy Priorities - Wed, 07/19/2017 - 4:19pm

SNAP (formerly food stamp) caseloads and spending continue to fall in 2017, the latest Agriculture and Treasury Department data show. (See graph.) These drops counter some policymakers’ assertions that they need to cut SNAP deeply to curb its growth.

Categories: Benefits, Poverty

Senate Health Bill Waivers Would Undermine Key Consumer Protections for People with Pre-Existing Conditions

Center on Budget and Policy Priorities - Wed, 07/19/2017 - 3:41pm

The bill would cut coverage and raise costs even without the Cruz amendment.

Categories: Benefits, Poverty

House Budget Would Cut Non-Defense Programs to Historic Lows

Center on Budget and Policy Priorities - Wed, 07/19/2017 - 1:52pm

In her budget plan, House Budget Committee Chair Diane Black directed some of her most draconian cuts at non-defense discretionary (NDD) programs, which promote opportunity, provide building blocks for economic growth, and fund basic public services, among many other things.   These programs have been squeezed considerably since 2010 under the 2011 Budget Control Act (BCA), but the House budget would shrink them to historic lows.  By 2027, the budget plan’s final year, NDD spending would:

Categories: Benefits, Poverty

Gov. Baker, If You Met My Immigrant Patients, You'd Support 'Safe Communities Act'

CommonHealth (WBUR) - Wed, 07/19/2017 - 1:40pm
A primary care doctor describes the fear she sees among her immigrant patients and wishes the governor could see it as well, in hopes it would persuade him to support a "sanctuary state" bill.
Categories: Health Care

Cinco poderosas razones por las que fracasó el proyecto de salud republicano

Kaiser Health News - Wed, 07/19/2017 - 12:59pm

Siete años de votos republicanos para “derogar y reemplazar” la Ley de Cuidado de Salud Asequible (ACA) se desmoronaron el martes 18 de junio, cuando quedó claro que el Senado no podría reunir los votos necesarios para ninguna de las tres propuestas separadas que se estaban considerando.

El fracaso, al menos por ahora, rompe una de las promesas clave que los republicanos vienen haciendo a sus votantes desde 2010, cuando ACA se convirtió en ley.

“Esta ha sido una experiencia muy desafiante para todos nosotros”, dijo el líder de la mayoría del Senado Mitch McConnell (republicano de Kentucky) a periodistas el martes a la tarde. “Está bastante claro que no hay 50 republicanos en este momento para votar por un reemplazo del Obamacare”.

La declaración de oposición que hicieron el lunes los senadores republicanos conservadores Mike Lee (Utah) y Jerry Moran (Kansas) desterró incluso la oportunidad de iniciar el debate sobre la versión de un proyecto de ley presentado la semana anterior.

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McConnell agregó que el Senado votaría a principios de la próxima semana sobre un plan, originalmente aprobado en 2015 y vetado por el presidente Barack Obama, que derogaría partes de la ley de salud. Ese enfoque retrasaría la fecha efectiva de votación por dos años para dar a los legisladores el tiempo para proponer un reemplazo.

Sin embargo, la oposición de los republicanos moderados Susan Collins (Maine), Shelley Moore Capito (West Virginia) y Lisa Murkowski (Alaska), garantiza que esta votación también fracasará.

“Sólo para decir “derogamos la ley y confíe en nosotros, que vamos a arreglar esto en un par de años’, eso no va a proporcionar consuelo a la ansiedad que muchas familias de Alaska están sintiendo en este momento”, dijo Murkowski a periodistas.

En retrospectiva, la incapacidad de los republicanos para reemplazar la ley de salud no debería ser una sorpresa. Estas son algunas de las razones:

1. Es difícil quitarle las cosas a la gente

Una vez lanzados, los programas federales que proporcionan a las personas beneficios que consideran importantes y valiosos son muy difíciles de quitar. En el caso de la atención de salud, la vida de las personas puede estar en juego. En el debate actual, los pacientes que temían lo que sucedería con su cobertura de salud si se derogaba el Obamacare le hicieron saber sus preocupaciones a los legisladores, en voz bien alta.

2. Los republicanos están divididos desde hace tiempo en el tema de la atención médica

El recóndito secreto que los republicanos guardaron estos últimos siete años es que, fundamentalmente, en lo único que acordaron sobre la atención de salud fue en el eslogan “derogar y reemplazar”. Hay una razón por la cual no tuvieron un plan cuando Donald Trump fue elegido presidente. Hasta ahora, todos los esfuerzos por lograr un consenso fracasaron.

“No vine a Washington para herir a la gente”, dijo Capito en un comunicado. “Tengo serias preocupaciones acerca de cómo seguimos proporcionando atención asequible a aquellos que se han beneficiado de la decisión de West Virginia de ampliar el Medicaid”.

Pero los miembros más conservadores, en particular el senador Rand Paul (republicano de Kentucky), tienen otras prioridades. “Todos nosotros prometimos que derogaríamos al Obamacare”, dijo Paul a periodistas el martes. “Si no está dispuesto a votar de la manera en que votó en 2015, entonces necesita regresar a casa y necesita explicarles a los republicanos por qué ya no apoya la revocación del Obamacare”.

3. El liderazgo presidencial en asuntos difíciles es importante

El presidente Trump dejó claro en todas partes lo que quería de un proyecto de ley de salud. Fue su insistencia original sobre que el “revocar y reemplazar” sucediera simultáneamente lo que alejó al Congreso de su estrategia de 2015 de derogar primero y reemplazar más tarde. Durante una celebración en el Jardín de las Rosas de la Casa Blanca, Trump aplaudió cuando la Cámara aprobó su proyecto de ley, pero luego lo llamó “maldito” durante una reunión de estrategia con senadores.

Cuando se hizo claro el lunes por la noche que el esfuerzo del Senado se estaba hundiendo, Trump twitteó: “Los republicanos deberían simplemente rechazar el Obamacare que está fracasando ahora y trabajar en un nuevo plan de salud desde cero”. “Como siempre han dicho, dejar que Obamacare fracase y luego diseñar un gran plan de salud”, agregó.

El presidente “les dio una tarea imposible con sus promesas (más, mejor, más barato para todos). Pero ni las políticas ni el púlpito bully ayudan en el momento crucial”, dijo Len Nichols, profesor de política de salud en la Universidad George Mason. “Y ahora los culpará por fracasar”.

Thomas Miller, del conservador American Enterprise Institute, agregó: “Ahora tenemos un ensayo clínico aleatorio que demuestra que uno no puede dirigir y gobernar a través de Twitter”.

4. El cuidado de la salud es complicado. De verdad

La atención de salud no ha sido tradicionalmente un tema de votación importante para los republicanos, y por lo tanto ha sido una prioridad menor -en comparación con cuestiones como los impuestos y el comercio- a la hora de elegir a sus representantes.

Agrega complejidad el hecho de que el conocimiento de los republicanos no es tan profundo como el de los demócratas cuando se trata de experiencia en políticas de salud. Los demócratas han trabajado en estos temas durante años. Incluso antes de la Ley de Cuidado de Salud Asequible, muchos ya habían servido en el Congreso durante décadas y habían aprendido de los errores que se cometieron en esfuerzos como el fracasado proyecto de ley de salud del presidente Bill Clinton.

5. Algunas partes del Obamacare son realmente populares, incluso entre los republicanos

El requisito de que la mayoría de las personas tengan un seguro a riesgo de pagar una multa -conocido como mandato individual- ha sido muy poco popular entre los votantes de todos los signos políticos. Pero muchas otras disposiciones importantes de la ley de salud, como garantizar la cobertura para las personas con condiciones preexistentes, siguen siendo ampliamente populares.

De hecho, en los últimos meses, el Obamacare ha ido creciendo en popularidad. La mayoría de las encuestas muestran que es más de dos veces más popular que el esfuerzo republicano por cambiarlo.

“Los republicanos tienen que admitir que realmente nos gustan algunas de las cosas de ACA”, dijo Murkowski.

Eso abrió una gran brecha entre los republicanos que querían mantener los beneficios populares y los que querían derogar la ley por completo. Una brecha que, hasta ahora, los republicanos han sido incapaces de zanjar.

Rachel Bluth contribuyó a esta historia.

Categories: Health Care

UK Supreme Court rules “Deport first, appeal later” power is unlawful

In Custodia Legis - Wed, 07/19/2017 - 9:57am

The following is a guest post by Conleth Burns, a foreign law intern working this summer in the Global Legal Research Directorate of the Law Library of Congress.

Supreme Court of the United Kingdom, January 2017. [photo by Conleth Burns]

Recently, in the R (Kiarie) v Secretary of State for the Home Department [2017] UKSC 17 case, the United Kingdom (U.K) Supreme Court issued a decision concerning the ability to make human rights-based appeals, against the Home Secretary’s deportation orders to foreign criminals. Section 94B of the Nationality, Immigration and Asylum Act 2002 (as amended by s. 17 (3) of the Immigration Act 2014 and s.63 of the Immigration Act 2016) created the ‘deport first, appeal later’ deportation power. Section 94B(2) states that: “despite the appeals process not having been begun or…exhausted, refusing P entry to, removing P from or requiring P to leave the United Kingdomwould not be unlawful.” (Home Office, Certification under section 94B of the Nationality, Immigration and Asylum Act 2002, Version 8.0 at 5)

In practical terms, under §94B any appeal against deportation of a foreign criminal (since July 2014) and any appeal against deportation of someone who has overstayed their leave to remain in the U.K. (since December 2016) has to be appealed from outside the U.K. The U.K Supreme Court in R (Kiarie) v Secretary of State for the Home Department [2017] UKSC 17  ruled that deportation certifications by the Home Secretary to foreign criminals were unlawful; they had not achieved the fair balance between the rights of the appellants under Article 8 Human Rights Act 1998 (Right to Private and Family Life) and the public interest. The Supreme Court only considered the effect of §94B for foreign criminals in this judgement. 

The ‘Deport first, appeal later’ policy was first implemented in 2014 under then Home Secretary Theresa May. At the Conservative Party Conference 2013 she stated: “where there is no risk of serious and irreversible harm, we should deport foreign criminals first and hear their appeal later.” (Theresa May, Home Secretary Speech to 2013 Conservative Party Conference, UKPOL, 12/3/15). The Supreme Court took the opinion that an inability to appeal deportation certifications was equally harmful. Since the amendment’s inception in July 2014 through December 2016, 1,175 certificates were issued. Only 72 of these were subject to appeal, and not a single one has been successful. (R (Kiarie) v Secretary of State for the Home Department ¶ 77, supra.). These statistics form the backdrop for the Supreme Court’s reasoning.

The Supreme Court has faced two questions: whether an appellant was likely to be legally represented when an appeal is brought from abroad; and whether the appellant has a worthwhile chance of winning his/her appeal.  Lord Wilson (leading the majority opinion) answered that an effective appeal requires the appellants to be afforded the opportunity to give live evidence. The judgement added that financial and logistical barriers to giving evidence on screen from abroad are almost insurmountable (R (Kiarie) v Secretary of State for the Home Department ¶ 76, supra.). The Supreme Court held that leaving the appellant without effective means of appeal was imbalanced, unfair and unlawful.

As a result of the appeal, it is anticipated that the Home Secretary’s usage of ‘deport first, appeal later’ certifications will be scaled back. Manjit S Gill QC, leading counsel for one of the appellants, indicated that this decision will: “heavily limit, if not entirely curtail, the home secretary’s use of the controversial ‘deport first, appeal later’ power (for those) who wish to challenge deportation decisions on the basis that deportation will infringe the right to family or private life.” (Supreme Court Rules UK System for Deporting Foreign Criminals Unlawful, The Guardian, June 14, 2017). Clive Coleman, legal affairs correspondent with the BBC, characterized the ruling as a “hammer blow to the Home Office.” (‘Deport First, Appeal Later’ Policy Ruled Unlawful, BBC News, June 14, 2017).

As the Brexit negotiations begin, this question may be raised again.  Under the Immigration (European Economic Area) Regulations 2006, SI 2006/1003, an appellant can apply for an interim order to suspend enforcement of the removal decision or return temporarily to the U.K. (Regs. 21AA (4) and 29AA). As the U.K. processes its separation from the European Union over the next two years, and the case for special rules around European Economic Area immigration becomes weaker, the issue of deporting individuals first and appealing later will likely become a subject of legal challenge again.

Brandon Lewis, the U.K.’s Government Immigration Minister, expressed the government’s disappointment with the judgment of the Supreme Court, adding that the government is “…carefully considering the implications.” (Id.) The true implications of this decision are, as yet, uncertain. Sonali Naik and Bijan Hoshi, Counsel for Bail for Immigration Detainees, contend that this ruling raises “very significant questions as to the future viability of the §94B certification.” (Supreme Court Rules ‘Deport First, Appeal Later’ System Unlawful, Garden Court Chambers, June 14, 2017).   

Categories: Research & Litigation

Obamacare Exchanges In Limbo

Kaiser Health News - Wed, 07/19/2017 - 9:44am

California’s Obamacare exchange scrubbed its annual rate announcement this week, the latest sign of how the ongoing political drama over the Affordable Care Act is roiling insurance markets nationwide.

The exchange, Covered California, might not wrap up negotiations with insurers and announce 2018 premiums for its 1.4 million customers until mid-August — about a month later than usual. Similar scenarios are playing out across the country as state officials and insurers demand clarity on health care rules and funding, with deadlines fast approaching for the start of open enrollment this fall.

“It’s insane,” said John Baackes, CEO of L.A. Care Health Plan, which has about 26,000 customers on the California exchange. “Here we are in the middle of July and we don’t even know what rules we will be operating under for open enrollment. It is not how you want to run a business.”

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

Consumers could face sharply higher premiums and fewer choices if more health insurers leave the insurance marketplaces due to lingering uncertainty. State and industry officials around the United States are concerned that the federal government could stop funding so-called cost-sharing subsidies that reduce out-of-pocket costs for low-income consumers. And they worry the Trump administration won’t enforce the individual mandate that requires people to purchase health coverage or pay a penalty.

Amid those concerns, there was a sense of relief Tuesday among many exchange officials and insurers after the U.S. Senate’s latest attempt to replace the Affordable Care Act failed.

Two large insurer trade groups bluntly warned last week that parts of the Senate plan were “unworkable” and could plunge the market into chaos. In a letter to the Senate, America’s Health Insurance Plans and the Blue Cross Blue Shield Association particularly objected to an amendment by Sen. Ted Cruz (R-Texas) that would have allowed insurers to sell bare-bones health plans to people who wanted cheaper premiums. That provision, the insurers said, would split the market between the healthy and the sick, driving up costs for people with preexisting conditions.

However, the Republicans’ failure to pass that ACA replacement plan did not resolve questions swirling around the current health law.

Tuesday, President Donald Trump expressed disappointment at the outcome in the Senate, telling reporters, “We’ll let Obamacare fail and then the Democrats are going to come to us and they’re going to say, ‘How do we fix it?’”

Some Senate Republicans struck a more conciliatory tone, suggesting that lawmakers should work on a bipartisan measure that would help stabilize the individual insurance markets.

Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Committee on Health, Education, Labor and Pensions, said he plans to hold hearings in the coming weeks on ways to shore up the individual insurance market. Lawmakers may look at creating a new stabilization fund that helps compensate insurers for higher-cost patients. Such a fund would be similar to one that existed during the first three years of the ACA exchanges.

Some insurance industry executives welcomed the talk of bipartisanship, but they said action must be taken quickly to resolve key issues affecting consumers.

“We are running out of time and we need a resolution on what we are charging for 2018,” said Gary Cohen, vice president of public affairs at Blue Shield of California in San Francisco, the largest Covered California insurer by enrollment.

Cohen, who helped launch the exchanges in 2014 as an official in the Obama administration, noted that the Republican bills in both the House and Senate included money for reinsurance that can help lower premiums industrywide. Those provisions are among the “immediate steps Congress and the Trump administration need to take in order for markets to provide coverage that is affordable.”

A federal reinsurance program helps compensate insurers for the high costs incurred by the sickest patients. That, in turn, allows health plans to keep their overall premiums lower and attract healthier customers into the insurance pool.

Lawmakers could also appropriate federal funds for the cost-sharing subsidies, which have a price tag of about $7 billion a year. Those payments, made directly to insurers, help reduce deductibles and other out-of-pocket costs for policyholders who earn up to 250 percent of the federal poverty level. This year, that’s up to about $29,000 for an individual or around $61,000 for a family of four. More than half of the people enrolled on exchanges nationwide qualify for this financial assistance.

Without it, many consumers would face annual deductibles of $2,000 or more when visiting the doctor or undergoing medical tests. That would make people far less likely to sign up with participating insurers.

Conservatives generally oppose the subsidies, calling them a bailout of the insurance industry and arguing that the Obama administration didn’t have the authority to pay them. Trump has repeatedly threatened to cut off those cost-sharing subsidies as well.

With their future up in the air, some states, including California and Pennsylvania, allowed insurers to submit two sets of proposed premiums. One filing reflects continued federal funding of those subsidies, and a separate one assumes they are eliminated and their cost is included in health plan premiums.

In Pennsylvania, premiums next year without the subsidies would increase by an average of 20 percent, compared with 9 percent if they remained intact.

Pennsylvania Insurance Commissioner Teresa Miller said the market in her state would be in good shape without the uncertainty over federal policy. “The only thing right now keeping everyone on edge is what’s going to happen in Washington, D.C.,” Miller said. “If things calm down in D.C. and if we don’t see further changes, then Pennsylvania’s market really is stabilizing.”

On Tuesday, Covered California said the two different rate filings its health plans submitted will be released Aug. 1. The exchange may announce that same day what the final premiums are, or it could postpone the decision for several more weeks if Congress has begun to pursue fixes to the ACA.

“This decision is based on the ongoing federal uncertainty around the repeal and replacement attempts of the Affordable Care Act and the dramatic potential impacts such uncertainty has on the rates and on California consumers,” the exchange said in a statement.

A recent analysis commissioned by Covered California estimated that premiums for silver-tier plans would jump by 16.6 percent if the federal government stopped paying for the cost-sharing subsidies. That would be in addition to normal increases meant to cover rising medical costs. An exchange spokeswoman declined to comment further Tuesday, citing the ongoing developments in Washington.

In the Florida exchange market, health insurers have sought an average rate increase of nearly 18 percent. But Florida Blue, the state’s largest health insurer, said those rates would go even higher if the cost-sharing reduction payments disappeared.

Robert Laszewski, an industry consultant in Virginia and a frequent ACA critic, said the exchange markets aren’t imploding, despite what the Trump administration has often said. But their premiums will continue to rise unless more young and healthy people are persuaded to buy coverage, he said.

“I think most insurance companies will at least break even, or even make a profit, in 2018,” Laszewski said. “Coverage will be ‘stable,’ but it will stabilize at a horrific premium rate level.”

Eric Whitney, Abe Aboraya and Ben Allen contributed to this story.

Categories: Health Care

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