Category: Medicare

Access to care a serious problem in Medicaid managed care plans

A recent report by the HHS Office of the Inspector General reveals that private companies offering Medicaid managed care are failing to ensure adequate access to care to their enrollees. Each state has its own law regarding standards for access to care in managed care plans—both appointment availability and wait times for appointments—and different ways of determining compliance with standards.

Given that the federal government is paying the full cost or a significant part of the cost of these plans, the report makes a strong case for the federal government to step in and create a baseline standard with enforcement mechanisms for managed care plans in every state.

Disturbingly, the OIG found that appointments were not available from more than half of providers (51 percent) surveyed. More than one-third of providers (35 percent) surveyed were not even at the office listed by the plan. Another 8 percent were not in the plan’s network. And yet another 8 percent were simply not taking new patients.

Of the providers with whom appointments were available, the median wait time was two weeks and more than 25 percent of them required enrollees to wait more than a month for an appointment.The OIG surveyed 1,800 providers of care, both primary care physicians and specialists.

March 5, 2015
How Obama’s 2016 proposed budget hurts older Americans

The President’s 2016 proposed budget hurts older Americans with Medicare. While it contains many commendable proposals, it mistakenly buys into the philosophy that it’s OK to tax older Americans (make them pay more) and keep them from getting care if they are unable to afford the Medicare deductible or the copays. President Obama proposes to raise the Medicare deductible, impose a copay on home health care services and increase premiums for many older adults already at risk. If that’s not bad enough, he wants people to pay extra for a Medicare supplemental (Medigap) policy that ensures full coverage for their care.

Think again, Mr. President. High deductibles and copays are simply ways to ration care based on people’s ability to pay. They impede access to needed care for the most vulnerable Americans in two sinister ways. First, they keep many older adults from getting care altogether, essentially forcing them to endure a poor quality of life and possibly contributing to their premature death. Second, they undo the larger purpose of insurance, concentrating risk and costs among those who need a lot of care rather than spreading risk among everyone.

People with Medicare already typically spend a large chunk of their incomes on health care costs Medicare does not cover. The latest data from Kaiser Family Foundation reveals that in 2010 the typical person with Medicare spent almost $5000 out of pocket. People over 85 spent an average of nearly $6000. And, people with Alzheimer’s spent an average of $8305.

There’s a just and fair way to reduce Medicare spending further without shifting more costs onto older adults—insist the government negotiate with pharmaceutical and medical device companies on the prices we taxpayers pay for prescription drugs and devices, now the highest prices in the world. That would save Medicare billions of dollars. Yes, the President proposes giving the Department of Health and Human Services the authority to negotiate prices for biologics and select high-priced drugs. This is good but the authority needs to be comprehensive and include all drugs.

Imposing additional costs on America’s oldest generation, the overwhelming majority of whom live on small fixed incomes, is unconscionable. Look at the data. Isn’t it time we limited out-of-pocket costs for people with Medicare to ensure they receive needed care. Increasing their costs only guarantees that more of them will struggle to get by.

February 5, 2015
Medicare Trustees project Medicare Trust Fund to last until 2030

Medicare is in relatively good financial health for the moment. In their 2014 report, the Medicare Trustees project Medicare’s trust funds to last four years longer than projected a year ago. Medicare is succeeding at reining in health care costs. Medicare Part A, whose costs are covered by the Medicare trust fund, spent less per individual with Medicare in 2013 than in 2009.

Thanks in large part to lower than expected Medicare costs in 2013, the Trustees project that Medicare will continue to have adequate financing until 2030. Put differently, the Medicare trust fund, which covers Medicare Part A costs—primarily for hospital and nursing home services—is projected to last longer than ever before projected.

And, even if nothing changes between now and 2030, which is highly unlikely, the trust fund will still have funds to pay 85 percent of Medicare’s costs from people’s payroll taxes and other revenues after 2030.

Take Action to Protect Medicare

Note that Congress has always stepped in to shore up Medicare’s finances and guarantee older and disabled Americans health security. Since 1970, the Trustees have made annual projections regarding the Medicare trust fund’s financial health and either the growing economy has extended the life of the trust fund or Congress has stepped in to ensure Medicare remains strong.

January 15, 2015
Medicare: Its Beginnings

On July 30, 1965, almost 50 years ago, Congress enacted Medicare to ensure that older adults had health insurance. Back then, almost half of Americans over 65 were uninsured, either no insurer was willing to cover them or the available insurance was unaffordable. Medicare offered them access to quality affordable health care. Medicare was designed to work—offering essentially automatic coverage for anyone who turned 65, deducting the premium from their Social Security check, and affording them access to doctors and hospitals anywhere in the United States. Medicare did not have a cap on out-of-pocket costs, nor did it cover long-term care or prescription drugs. But, health care costs were far lower then.

Thanks to Medicare, today just 2 percent of older adults lack health insurance coverage, while in 1962 48 percent of them lacked coverage. And, Americans’ life expectancy has increased significantly. Moreover, people with Medicare tend to rate it more highly than private insurance. According to the Commonwealth Fund, “people with Medicare indicate they are less likely to have problems getting needed care and to have burdensome medical bills and negative insurance experiences.”

Medicare today is in the forefront of insurers driving health care innovations throughout the health care system. Private insurers tend to keep their innovations confidential. Medicare therefore takes the lead in ensuring systemic improvements. According to the Commonwealth Fund, it is “developing models to promote high-quality, evidence-based care and reducing incentives to provide more services, regardless of their value to patients.” Could Medicare be stronger and better still? Of course. But, is it able to deliver better value than private insurance, in terms of cost and the ability to promote a better health care system? You bet. Check out this infographic on Medicare’s origins.

January 13, 2015
Medicare costs are dropping

This 2014 chart from The New York Times shows that, thanks to the Affordable Care Act, projected Medicare costs are dropping significantly. According to the NYT, “the reduced estimates mean that the federal government’s long-term budget deficit is considerably less severe than commonly thought just a few years ago.” In 2014 dollars, average costs per individual with Medicare is down to $11,300 from a Congressional Budget Office projection of $12,700.

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Medicare Trustees project Trust Fund to last until 2030

January 8, 2015
Medicare costs high for older adults and people with disabilities

No one should think that Medicare provides more than partial health care coverage. A new Kaiser Family Foundation report reveals high costs for people with Medicare. Average out-of-pocket spending was $4,734 in 2010, (the most recent year for which data was available), about 20 percent of the median income of people with Medicare, $23,500. (In 2014, it’s $24,150).

The ten percent of people with Medicare with the highest costs spent an average of $19,236 in 2010 on premiums, coinsurance and services that Medicare does not cover. People with costly conditions requiring multiple hospitalizations and long-term care incurred particularly high out-of-pocket costs.

The oldest Medicare recipients also spent significantly more out-of-pocket on health care. People over 85 spent about three times more out of pocket ($5962) than people between 65 and 74 ($1926).

Women spent more than men on average in 2010, $5036 and $4363 respectively. Higher health care spending by women with Medicare is largely attributable to women living longer and needing long-term care, which Medicare for the most part does not pay for.

Even with Medicare, people who were hospitalized and then admitted to nursing homes had the highest documented out-of-pocket costs, which amounted to $9508. Medicare does not cover most home care or nursing home care. People with Alzheimer’s also had particularly high out-of-pocket health care costs of $8305 on average.

But the people with the largest health care bills were the people living in long-term care facilities, paying $17,534. They spent nine times more than people with Medicare living in the community, whose average costs were $1858.

Here are three tips to plan for long-term care.

December 22, 2014
Most boomers and older adults live on small fixed incomes

Older adults and people with disabilities are often wrongly portrayed as well off and undeserving of the Medicare and Social Security benefits they have earned throughout a lifetime of work. What often is left unsaid is their overall low income and poor health status, putting them at serious health and financial risk.

In September 2014, the Kaiser Family Foundation released a paper illustrating characteristics of people with Medicare. Half of all people with Medicare have incomes under $23,500; half have savings less than $43,400. And, only one in five people with Medicare have incomes above $93,900.

When you take into account that one in four people with Medicare spend more than $11,500 a year on their care, it becomes crystal clear that large numbers of them are struggling to make ends meet.

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Even with Medicare, many people spend over $11,500 on care that is not covered.

November 20, 2014
Medicare Advantage plan “prior approval” rules could stick you with huge medical bills

The Medicare Rights Center just released a report illustrating how people with Medicare who are enrolled in Medicare Advantage plans can get stuck with huge bills even when they use in-network doctors. They didn’t understand Medicare Advantage plan “prior approval” rules.

Medicare Rights Center’s client thought he was following his health plan’s rules when he received surgery from an in-network doctor. The health plan had told him he did not need a referral from his primary care doctor to be covered. But, because his health plan requires “prior approval” for surgery–an OK from the health plan to go ahead with the procedure, which is different from a referral–and he had not secured it–he was stuck with a $12,000 bill.

People with Medicare have appeal rights, and most people who know how to appeal win. Had the client understood how to appeal the denial properly, he most likely would have won on appeal because the health plan did not tell him he needed prior approval, and the in-network doctor did not secure prior approval as he should have known to do.

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A crash course in five important insurance terms

November 12, 2014
Medicaid, Medicare and long-term care
Long-term care can cost a lot. Medicare sometimes picks up a small piece of the cost. Medicaid can cover a lot of the cost. Paying out-of-pocket for long-term care tends to be extremely expensive. Here are some key facts on Medicaid, Medicare and long-term care:
- Fact: Medicaid covers about two-thirds of all long-term care spending, about $131 billion in 2011. 87% of Medicaid spending on older adults is for long-term care. One in three older adults with Medicaid receive long-term care through Medicaid.
- Fact: 43% of people with Medicaid needing long-term care are under the age of 65.
- Fact: Medicare does not cover long-term custodial care, nor does standard health insurance. Medicare contributed 21% to long-term care in 2011, because it covers skilled nursing care and skilled therapy services for a limited time post-hospitalization.
Here’s more from Just Care on aging in place and long-term care services and supports:
Click here to learn more about long-term services and supports from the Robert Wood Johnson Foundation and here to learn more about long-term care from JAMA.

Photo Credit: RWJF
October 15, 2014
Evidence suggests cutting Medicare will hurt kids
Benefits to kids tend to go hand in hand with benefits to older adults. And, evidence suggests that cutting Medicare will hurt kids. If you analyze the data, countries that spend a greater share of their income benefiting older adults, also spend a greater share of their income benefiting kids, report Shawn Fremstad and Dean Baker, Center for Economic Policy and Research. The evidence further suggests that cutting Medicare will not mean more money for kids. Congress has never made financial trade-offs between older adults and kids.
- Fact: Jonathan Bradshaw and Emese Mayhew report that “Nations make choices about the level of resources they commit to children and the elderly, and the countries that are most generous to children also tend to be most generous to the elderly.”
- Fact: The U.S., for the most part, spends less than other OECD countries on retirement benefits. Indeed, they are relatively moderate, says Fremstad, relying on data from Jonathan Bradshaw and Emese Mayhew.
- Fact: There is no evident tradeoff between government benefits to kids and benefits to older adults, according to sociologist David Brady. In Rich Democracies, Poor People: How Politics Explains Poverty, Brady looks at poverty data in 18 OECD countries to show that in countries with high poverty rates among elderly, there are high poverty rates among kids and vice versa.
- Fact: As the U.S. has created programs for older adults, such as Medicare, we have also created programs for the young, such as Head Start. And, funding has increased at the national, state and local levels for both older Americans and the young, according to Baker.
Fremstad and Baker believe that the economic security of kids in America, both today and in the future, depends in good part on their parents’ and grandparents’ economic security, because families take care of one another across the generations. If we give their parents and grandparents greater security, working-class kids will be better off as well.

To learn more about how countries that spend more on seniors also spend more on children from the Center for Economic and Policy Rights (CEPR), click here. CEPR also has this post, explaining that our parents are not stealing from our kids. And, yet another showing the fallacy of the argument that spending on older adults in any takes money from kids.
October 15, 2014