Emeritus News-Mobile Home Page-Daily Updates on Issues and Public Policy

More from the Emeritus Newsroom- A requirement that female workers be granted birth control coverage in their employer health insurance plans was revised today by the Obama administration. Due to opposition from various religious organizations , the White House today announced the following revisions.

"Women will have free preventive care that includes contraceptive services no matter where she works. The policy also ensures that if a woman works for a religious employer with objections to providing contraceptive services as part of its health plan, the religious employer will not be required to provide, pay for or refer for contraception coverage, but her insurance company will be required to directly offer her contraceptive care free of charge".

"The new policy ensures women can get contraception without paying a co-pay and fully accommodates important concerns raised by religious groups by ensuring that objecting non-profit religious employers will not have to provide contraceptive coverage or refer women to organizations that provide contraception. Background on this policy is included below":

• Under Section 2713 of the Affordable Care Act, the Administration adopted new guidelines that will require most private health plans to cover preventive services for women without charging a co-pay starting on August 1, 2012. These preventive services include well women visits, domestic violence screening, and contraception, and all were recommended to the Secretary of Health and Human Services by the independent Institute of Medicine of the National Academy of Science.

• Today, the Obama Administration will publish final rules in the Federal Register that:

o Exempts churches, other houses of worship, and similar organizations from covering contraception on the basis of their religious objections.

o Establishes a one-year transition period for religious organizations while this policy is being implemented.

• The President will also announce that his Administration will propose and finalize a new regulation during this transition year to address the religious objections of the non-exempted non-profit religious organizations. The new regulation will require insurance companies to cover contraception if the religious organization chooses not to. Under the policy:

o Religious organizations will not have to provide contraceptive coverage or refer their employees to organizations that provide contraception.

o Religious organizations will not be required to subsidize the cost of contraception.

o Contraception coverage will be offered to women by their employers’ insurance companies directly, with no role for religious employers who oppose contraception.

o Insurance companies will be required to provide contraception coverage to these women free of charge.

o The new policy does not affect existing state requirements concerning contraception coverage.

Covering contraception is cost neutral since it saves money by keeping women healthy and preventing spending on other health services. For example, there was no increase in premiums when contraception was added to the Federal Employees Health Benefit System and required of non-religious employers in Hawaii. One study found that covering contraception saved employees $97 per year, per employee.

Also today, the Catholic Health Association, which represents over 1200 Catholic affiliated health facilities announced their support for President Obama's decision, saying it , "....Protects Religious Liberty and Conscience Rights". Their statement, posted online explains,

"The Catholic Health Association is very pleased with the White House announcement that a resolution has been reached that protects the religious liberty and conscience rights of Catholic institutions. The framework developed has responded to the issues we identified that needed to be fixed".

WILL TRADITIONAL HEALTH INSURANCE COMPANIES DISAPPEAR BY 2020?

VETERAN GETS $400,000 SETTLEMENT IN 60 YEAR BATTLE FOR DISABILITY BENEFITS

RISE IN FEDERAL HEALTH CARE SPENDING LOWEST IN 50 YEARS

More from the Emeritus Newsroom-The ultimate summary of federal spending on health care cites real progress in 2009 and 2010 to hold down costs. Prepared by the Center for Medicare Services, the compilation of the "National Health Expenditures" grade card offers hope.

Rather than growing at a rate almost double that of the rest of the economy, the report says federal spending on health care rose 3.8% in 2009 and 3.9% in 2010. The slower rate of spending increases also resulted in health care costs, as percentage of the gross domestic product, remained at 17.9%.

True, the recession did slow growth in health spending in 2009 and 2010 as consumers remained cautious about their spending—in part because of losses in private health insurance coverage, lower median household income, and future financial uncertainty. Slower growth in spending for hospital care and physician and clinical services, along with record low growth in spending for prescription drugs, reflected slower growth in the use of these goods and services.

From a payer perspective, according to the report, continued slow growth in private health insurance and out-of-pocket spending (which grew just 2.4 percent and 1.8 percent, respectively) and decelerations in Medicare and Medicaid spending growth (which slowed to 5.0 percent and 7.2 percent, respectively) contributed to overall low growth in 2010.

Although medical goods and services are generally viewed as necessities, the latest recession had a dramatic effect on their utilization. On average, between 2007 and 2009, growth in the use and intensity of health care goods and services contributed 1.4 percentage points to the annual growth in personal health care spending (5.0 percent). This was much lower than its average contribution of 3.3 percentage points between 2000 and 2006, when personal health care spending grew 7.6 percent, on average.

MASSACHUSETTS SUPREME COURT ORDERS IMMIGRANTS COVERAGE ON STATE HEALTH PLAN

More from the Emeritus Newsroom- Saying that restrictions against immigrants preventing them from being insured by "Commonwealth Care" health plans, the Massachusetts Supreme Court has ordered the state pick up the estimated 150+ million tab to insure the estimated 38,000 LEGAL immigrants who must wait five years to be eligible. the state has it's own subsidized plans for those with no coverage and separate plans for the poor, who cannot afford insurance.

A group called, Health Law Advocates, had taken the state to court over immigrants exclusion from the plans. Saying the immigrants paid taxes, were eligible for military service, and were entitled to equal protection, under the law. The Massachusetts Supreme Court agreed and ordered the state to include them.

In a statement after the ruling, Health Law Advocates of Boston said their victory in the case will immediately help tens of thousands of low-income Massachusetts legal immigrants, who were eliminated from access to Commonwealth Care because they had not been in the U-S for five years. the group claims that Massachusetts’ historic health reform law passed in 2006 allowed legal immigrants who met eligibility requirements to obtain health insurance through the Commonwealth Care program. Wendy Parmet, a Northeastern University School of Law professor who argued the case on behalf of the immigrants said “Our constitution prohibits the government from trying to solve its financial problems on the backs of a vulnerable class of people.”
“Massachusetts justifiably takes great pride in our ‘first in nation’ adoption of a health reform program that expanded access to quality healthcare to virtually all residents,” said Matt Selig, Executive Director of HLA. “It was critical that low-income immigrants, a group of already vulnerable, tax-paying residents, not be left behind.”
As a result of the ruling, the Massachusetts state legislature will likely need to allocate additional budgetary resources to the state’s Commonwealth Care program to meet its constitutional obligations. Once that occurs, legal immigrants will once again be afforded access to affordable health insurance.
“Fiscal considerations alone cannot justify a State's invidious discrimination against aliens,” notes the ruling. “The discrimination against legal immigrants that its limiting language embodies violates their rights to equal protection under the Massachusetts constitution.”

CALIFORNIA HOSPITAL CHAIN ACCUSED OF BILKING MILLIONS FROM MEDICARE (PBS NEWSHOUR VIDEO - 8 MINUTES)

PROBE OF MONEY TRAIL BETWEEN GINGRICH AND HEALTH CARE LOBBY REVEALS CONTRADICTIONS

CONSUMER WATCHDOG SAYS INSURANCE COMPANIES TRYING BACK DOOR METHOD TO PROTECT PROFITS

More from the Emeritus Newsroom- California based advocacy group Consumer Watchdog claims it and other consumer groups are demanding state insurance commissioners reject a proposal to increase health insurance industry sales commissions and profits at the expense of individuals struggling to pay for insurance. Consumer Watchdog called on state insurance regulators to allow the public to participate in a closed conference call scheduled for Tuesday to consider the insurance industry-sponsored resolution.The resolution would remove broker pay from the medical loss ratio rule of the federal health reform law and cost consumers nationwide an estimated $1.1 billion in premium rebates. It would render meaningless the requirement that companies spend 80% to 85% of health premiums on actual health care, not overhead, salaries and profit, said Consumer Watchdog.

“Health insurers are going after the only rule in health reform that could force them to cut wasteful bureaucracy and excessive profits. Exempting sales commissions from this key consumer protection would free health insurers from the rule, leaving brokers to demand higher pay and insurance companies to increase premiums at will,” said Carmen Balber, Washington Director for Consumer Watchdog. “Insurance commissioners considering this blatantly political move should remember that their responsibility is to protect citizens, not insurance industry profits.”

Florida Insurance Commissioner Kevin McCarty, who works for Gov. Rick Scott, an avowed opponent of federal health insurance reform, is leading the charge to gain support for the industry proposal.

The resolution, intended to revive legislation that is stalled in Congress, asks the Department of Health and Human Services to remove insurance sales commissions from industry administrative costs for purposes of calculating the medical loss ratio. It also suggests that HHS amend the rule to count much of the sales commission as “health care” instead of an overhead expense.

Backers assert that health reforms will drive brokers and agents out of business and leave consumers without “professional advisers” in choosing and dealing with insurance companies. However, all credible data says otherwise, said Consumer Watchdog. For instance:

A recent study by an industry lobby and trade group--the Independent Insurance Agents and Brokers of America--found that “organic [customer base] growth improved, albeit modestly, and profitability held constant across most of the study’s six [broker and agent] revenue groups.” The study credited more efficient business operations—exactly what the health reform legislation sought—for much of the recovery from an industry slump that began in 2006, long before federal health reform was even debated, said Consumer Watchdog. See the IIABA report.
The NAIC’s own staff report earlier this year found that removing broker compensation from the MLR calculation would mean a $1.19 billion loss in rebates for consumers in 2010. The same research failed to show that consumers will be harmed if broker pay remains in the MLR formula and some of the most excessive payments are reined in. In fact, of the eight states surveyed that have existing rules requiring MLR near or greater than the 80% federal standard, not a single state reported any consumer complaints about lack of access to insurance brokers, even though commissions are generally lower in such state. Download the report. Insurers are cutting back on some of the most excessive broker compensation schemes. One North Carolina insurer, Wellpath, reported that the MLR efficiency rule caused it to reduce first-year commissions for individual policies from 27% to 14%. The MLR standard was included in the health reform law specifically to eliminate that kind of waste. Download the letter.

 Such evidence indicates that the medical loss ratio rule is beginning to work, said Consumer Watchdog, and that insurance agents and brokers are holding their own--even improving profits in some cases. But these moves toward greater efficiency will be over before the first rebate check is issued if the NAIC embraces the insurance and broker industry demands, said Consumer Watchdog.

State insurance regulators backing consumer rights and opposing the broker resolution include: California, Connecticut, Minnesota, New York, Oregon and Washington.

State regulators that have publicly endorsed a version of the broker resolution include: Florida, Alabama, Arkansas, Georgia, Idaho, Kentucky, Louisiana, Indiana, Mississippi, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, South Carolina, Tennessee and Wisconsin.

A 2010 analysis by Consumer Watchdog found that more than half the state insurance commissioners had ties to the insurance industry, including commissioners that are former insurance executives and commissioners that have taken a combined $1 million in political contributions from insurers. The national lobbying groups for health insurance agents and brokers uniformly opposed federal health reform. See the analysis.

D-C APPEALS COURT SIDES WITH OBAMA ON HEALTH INSURANCE REFORM LAW

TRICARE PATIENTS TO GET CREDIT MONITORING AFTER DEFENSE DEPARTMENT COMPUTER HACKING

More from the Emeritus Newsroom- The Department of Defense announced today that the TRICARE Management Activity (TMA) has directed Science Applications International Corp. (SAIC) to provide one year of credit monitoring and restoration services to patients who express concern about their credit as a result of a data breach that occurred in Texas and was reported to TMA on Sept. 14, 2011. Approximately 4.9 million patients treated at military hospitals and clinics during the last 20 years may have been affected by the breach. Potentially affected patients are being notified by letter.

"These additional proactive security measures exceed the industry standard to protect against the risk of identity theft," said Brig. Gen. W. Bryan Gamble, TMA deputy director. "We take very seriously our responsibility to offer patients peace of mind that their credit and quality of life will be unaffected by this breach."

Immediately upon learning of the recent SAIC data breach TRICARE posted information about the data breach on their website at https://www.tricare.mil to inform their beneficiaries. There is no evidence any of the data has actually been accessed by a third party, and analysis shows the chance any data was actually compromised is low.Proactive measures are being taken to ensure potentially affected patients are kept informed and protected.

The data involved in the breach may contain names, Social Security numbers, addresses and phone numbers, and some personal health data such as clinical notes, laboratory tests and prescriptions. There is no financial data, such as credit card or bank account information, on the information that was taken.

Concerned individuals may contact the SAIC Incident Response Call Center, Monday through Friday, 9 a.m. to 6 p.m. Eastern time at 855-366-0140 (toll free) for U.S. callers and 952-556-8312 (collect) internationally.

MEDICARE PREMIUMS AND DEDUCTIBLES FOR 2012 LESS THAN EXPECTED

More from the Emeritus Newsroom- Officials of Health and Human Services have announced the amounts of Medicare premiums and deductibles for 2012. According to HHS, Medicare Part A premiums will be increasing by just $1 per month, and the deductible will increase by just $24. For Medicare Part A, which pays for inpatient hospital, skilled nursing facility, and some home health care, about 99 percent of Medicare beneficiaries do not pay a premium since they or their spouses have at least 40 quarters of Medicare-covered employment.

The standard Medicare Part B monthly premium will be $99.90 in 2012, a $15.50 decrease over the 2011 premium of $115.40. However, most Medicare beneficiaries were held harmless in 2011 and paid $96.40 per month. The 2012 premium represents a $3.50 increase for them. Medicare Part B covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items.

The estimate for the average 2012 Part D premium for basic coverage is $30. This is slightly lower than the actual average for 2011 of $30.76. The estimate for the average 2012 Part D premium for supplemental coverage is $8. The estimate for the average 2012 total Part D premium is $38.

On average, Medicare Advantage premiums will be 4 percent lower in 2012 than in 2011, and plans project enrollment to increase by 10 percent. Of people with Medicare, 99.7 percent continue to enjoy access to a Medicare Advantage plan, and benefits remain consistent with those offered in 2011.

FAMILY PREMIUMS FOR EMPLOYER HEALTH INSURANCE COVERAGE UP 9%

More from the Emeritus Newsroom- According to a Kaiser Health News survey, premiums for family coverage rose 9 percent this year, to an average of $15,073 a year. The employee share of that was $4,129. For employer-provided individual coverage, premiums rose 8 percent, with workers typically picking up $921 of the average $5,429 annual tab.

The price increases come as employees prepare to select their benefits for 2012. According to Kaiser Health News, premiums, deductibles and cost sharing continue to rise, sometimes even more steeply than in previous years. More employers are also moving to high-deductible plans that shift increasing expenses onto their employees, requiring them to pay more before benefits kick in. And companies are making it pricier to insure spouses and children.

OBAMA ADMINISTRATION GIVES UP ON "CLASS" INSURANCE FOR LONG TERM / NURSING HOME CARE

More from the Emeritus Newsroom- Health and Human Services Secretary Kathleen Sebelius admitted today that the Obama administration is giving up on part of the health reform act, called "CLASS". The program was designed to fund long term or nursing home care. However, intensive review of the plan by government actuaries reveals it will not work. The plan had been a magnet for criticism from Republicans, but an actuarial review from HHS auditors claims the rest of the reform plan will be able to stand on its own without "CLASS".

The HHS report says, "While the designated CLASS Plan is operational, solvency or legal problems may prevent the CLASS Program from continuing to implement the p lan. The Secretary might determine that the CLASS plan could no longer be reasonably expected to remain solvent, even if she were to make statutorily authorized changes to the plan, or a court might conclude that the designated CLASS Benefit Plan violates the CLASS Act. In those circumstances, there is substantial uncertainty about both what the Secretary would have authority to do and what a court would require. If such a circumstance occurred, there is a risk that the CLASS program would have to be entirely shut down, rather than simply closed to future enrollment, and then-existing enrollees or eligible beneficiaries would have no opportunity to receive the anticipated benefits, although it is possible—though by no means guaranteed—that they may be able to recoup some portion of their paid premiums".

The authors of the HHS report conclude, "....there is substantial uncertainty about what would follow if solvency or legal problems prevented the CLASS program, once operational, from continuing to implement the plan. We cannot with any confidence predict that the CLASS program would be able to honor its commitments to individuals who had already enrolled or entered beneficiary status in the program, or avoid leaving them worse off, or that such individuals would be able to recoup their paid premiums".

INSURANCE COMPANIES BATTLE PUBLIC RELEASE OF DOCUMENTS SUPPORTING RATE INCREASES

PENTAGON CLAIMS TRICARE PATIENT MEDICAL RECORDS HACKED BY DATA THIEVES / LATEST IN STRING OF DEFENSE DEPARTMENT BREACHES

WASHINGTON, Oct. 7, 2011 – The TRICARE Management Activity is reviewing its data protection policies and procedures in the wake of a data breach involving personal health information of an estimated 4.9 million military clinic and hospital patients.

The breach potentially affects patients who received care or filled pharmacy prescriptions in San Antonio-area military treatment facilities from 1992 through Sept. 7, 2011, TRICARE spokesman Austin Camacho reported.

Other beneficiaries who received care elsewhere, but whose laboratory workups were processed in San Antonio military treatment facilities, also could be affected, he said.

Science Applications International Corp., a TRICARE contractor, reported the data breach Sept. 14. Backup tapes from an electronic health care record the military health system used to capture patient data since 1992 were lost, Camacho reported.

The exact circumstances of the loss are part of TRICARE’s investigation, he said. Those results are expected to be published as soon as possible.

The tapes may include Social Security numbers, addresses and phone numbers, as well as personal health data such as clinical notes, laboratory tests and prescriptions, he said. No financial data such as credit card or bank account information is included.

Despite the information involved, TRICARE officials estimate the risk of harm to patients to be relatively low.

“Reading the tapes takes special machinery. Moreover, it takes a highly skilled individual to interpret the data on the tapes,” Camacho said. “Since we do not believe the tapes were taken with malicious intent, we believe the risk to beneficiaries is low.”

As TRICARE officials investigate the incident, they plan to notify everyone whose personal information may have been involved in the breach, Camacho said.

TRICARE and SAIC are working together to come up with that list of names, but because of the number of people potentially affected and the need to review multiple databases, Camacho said, individual notifications could take four to six weeks.

In the meantime, TRICARE officials encourage people who suspect they were affected by this incident to take steps outlined on the Federal Trade Commission website to protect their personal information. They also can monitor their credit and place a free fraud alert on their credit for 90 days using the FTC website.

Concerned patients may contact the SAIC Incident Response Call Center at no charge, Monday through Friday from 9 a.m. to 6 p.m. Eastern time. Stateside, patients may call toll-free to 855-366-0140. Overseas, patients can make collect calls to 952-556-8312. 10/11/2011

170,000 MEDICARE PATIENTS SUSPECTED PAIN KILLER DRUG FRAUD / GAO SAYS

More from the Emeritus Newsroom- The Government Accountability Office (GAO) says there is a rising toll of those addicted and those attempting to profit from abusive prescription filling practices in the Medicare Part "D" program.

During testimony before a congressional committee today, Gregory D. Kutz Director, Forensic Audits and Special Investigations, GAO said, "...analysis found that about 170,000 Medicare beneficiaries received prescriptions from five or more medical practitioners for the 12 classes of frequently abused controlled substances and 2 classes of frequently abused non controlled substances in calendar year 2008. This represented about 1.8 percent of the Medicare Part D beneficiaries who received prescriptions for these 14 classes of drugs during the same calendar year. These individuals incurred approximately $148 million in prescription drug costs for these drugs, much of which is paid by the Medicare program. We also found the following: (1) Most of these 170,000 Medicare beneficiaries who were prescribed prescriptions from five or more practitioners were eligible for Medicare Part D benefits based on a disability. Specifically, approximately 120,000 Medicare beneficiaries (about 71 percent) were eligible for Medicare Part D benefits based on a disability. (2) Of these 170,000 beneficiaries, approximately 122,000 beneficiaries (72 percent) received a Medicare Low-Income Cost-Sharing (LICS) subsidy".

The GAO obtained additional information on 10 of the Medicare Part D beneficiaries that showed indications of doctor shopping. In each of the 10 cases, they found evidence that the beneficiary was acquiring highly abused drugs through doctor shopping. Also, physicians were not aware that their patients were receiving drugs prescribed by other prescribers. According to the Drug Enforcement Administration, the definition of doctor shopping specifies an individual receiving more of a drug than intended by any single physician. In several examples physicians stated that they would not have prescribed the drugs if they were aware that the patient was receiving the same class of drugs from other sources.

GAO says more scrutiny of prescription claims data will help the drug plans identify individuals who are likely obtaining excessive amounts of highly abused drugs or potentially seeking such drugs from multiple medical practitioners.

The complication comes as federal law does not authorize Part D plans to restrict the access of these individuals, leaving little recourse for preventing known doctor shoppers from obtaining hydrocodone, oxycodone, and other highly abused drugs.

GAO suggests the Administrator of CMS should review our findings, evaluate and consider additional steps, such as a restricted recipient program for Medicare Part D that would limit identified doctor shoppers to one prescriber, one pharmacy, or both for receiving prescriptions. GAO says Medicare and Medicaid supervision through the Centers for Medicare and Medicaid Services, should consider sharing information on identified doctor shoppers among the Part D drug plan sponsors so that those beneficiaries cannot circumvent the program by switching prescription drug plans.

OBAMA APPEALS TO SUPREME COURT TO RULE ON REQUIREMENT FOR HEALTH INSURANCE IN REFORM ACT

More from the Emeritus Newsroom- The Obama administration today asked the U-S Supreme Court to take up the mandatory insurance requirement embedded in the health insurance reform laws. At issue is a case brought by the State of Florida, which contested the federal government's right to require all Americans have health insurance from the private sector or subsidized coverage from the government or face a tax penalty. This despite the fact that most states use the same requirement to obtain a driver's license, states argue they can legally do that, while the federal government cannot, as written in the reform laws.

The appeal arises from a decision from the Eleventh Circuit Court of Appeals in Atlanta, which ruled in favor of the State of Florida, that the mandatory provision for insurance, was unconstitutional.

In the appeal filing to the U-S Supreme Court, attorneys for the Department of Health and Human Services claim,

"The minimum coverage provision is squarely within Congress’s power to regulate interstate commerce, lay and collect taxes, and enact legislation that is necessary and proper to effectuate its enumerated powers.The court of appeals’ contrary decision is fundamentally flawed and denies Congress the broad deference it is due in enacting laws to address the Nation’s most pressing economic problems and set tax policy. The importance of the decision below—which strikes down “central piece of a comprehensive economic regulatory scheme enacted by Congress,” App. 189a (Marcus, J.,dissenting), on a ground that has no basis in the Constitution’s text or this Court’s precedents—is manifest. Moreover, the court of appeals’ conclusion that the mini-mum coverage provision lies outside Congress’s commerce authority directly conflicts with a recent decision of the Sixth Circuit (Cincinnati)" (page23).

The Sixth Circuit Court of Appeals, had rejected challenges to the mandatory insurance provision. A win for the Obama administration.

A ruling on the appeal could come next June during the height of the presidential campaign, however, in view of various provisions of the new health insurance laws, which take effect next year through 2014, the court could expedite a hearing and a decision.

HEALTH INSURANCE PREMIUMS UP BY 9% / PARTIALLY DUE TO INCREASING COVERAGE FROM REFORM ACT

More from the Emeritus Newsroom- A survey of employers by the Kaiser Family foundation has found small companies especially hard hit by premium increases for their health insurance.

According to Kaiser, annual premiums for employer-sponsored family health coverage increased to $15,073 this year, up 9 percent from last year. On average, workers pay $4,129 and employers pay $10,944 toward those annual premiums.

Premiums increased significantly faster than workers’ wages (2.1 percent) and general inflation (3.2 percent). Since 2001, family premiums have increased 113 percent, compared with 34 percent for workers’ wages and 27 percent for inflation.

"This year’s nine percent increase in premiums is especially painful for workers and employers struggling through a weak recovery," Kaiser President and CEO Drew Altman, Ph.D. said.

According to Maulik Joshi, Dr.P.H., president of HRET and senior vice president for research at the American Hospital Association, "survey findings related to the impact of early provisions in health reform provide valuable insight for employers, providers, consumers, and policymakers as they prepare for additional provisions to take effect by 2014."

The 13th annual Kaiser/HRET survey of small and large employers provides a detailed picture of trends in private health insurance costs and coverage. This year’s survey also looked at employers’ experiences with several already implemented provisions of the 2010 health reform law affecting employer coverage.

In particular, the survey estimates that employers added 2.3 million young adults to their parents’ family health insurance policies as a result of the health reform provision that allows young adults up to age 26 without employer coverage on their own to be covered as dependents on their parents’ plan. Young adults historically are more likely to be uninsured than any other age group.

"The law is helping millions of young adults to obtain health coverage. In the past, many of these young adults would have lost coverage when they left home or graduated college," said study lead author Gary Claxton, a Kaiser vice president and co-executive director of the Kaiser Initiative on Health Reform and Private Insurance.

The study also finds 31 percent of covered workers are in high-deductible health plans, facing deductibles for single coverage of at least $1,000, including 12 percent facing deductibles of at least $2,000. Covered workers in smaller firms (3-199 workers) are more likely to face such high deductibles, with half of workers in smaller firms facing deductibles of at least $1,000, including 28 percent facing deductibles of $2,000 or more.

MORE 18-26 YEAR OLDS GETTING HEALTH INSURANCE DUE TO REFORM ACT

More from the Emeritus Newsroom- Different surveys show different results. Regardless of the true number, the health insurance reforms passed over the last two years have helped those, ages 18-26, get health insurance coverage.

A survey from the Census Bureau shows more than 500,000, in that age group, were able to get coverage, mostly by being attached to a parent or guardian's plan, mandated by the reform laws.

Also, according to a Center for Disease Control survey, released earlier this month, among adults aged 19–25, the percentage uninsured at the time of interview decreased from 33.9% (10 million) in 2010 to 30.4% (9.1 million) in the first 3 months of 2011.

And in a Gallop survey, released today, fewer young adults in the U.S. reported lacking health insurance coverage in each of the three quarters since the new healthcare law in September 2010 began allowing young adults to stay on their parents' plans up to age 26. About one in four (24.2%) 18- to 25-year-olds reported being uninsured in the second quarter of this year, down from 28% in the third quarter of 2010, and nearly the lowest Gallup has measured at any point since it began tracking health insurance coverage rates in 2008.

OBAMA / LAWMAKERS EYE CUTS TO ARMED FORCES MEDICAL AND BENEFIT PLANS

ARMED FORCES ACCUSE WALGREENS OF FEAR CAMPAIGN ON PRECRIPTION DRUG BENEFIT TALKS

WASHINGTON, Sept. 15, 2011 - A dispute between Walgreens and a TRICARE contractor will not stop beneficiaries from getting their prescriptions filled, despite a Walgreen's ad campaign to the contrary, a TRICARE official said today.

Don't let that advertising, letter and Internet outreach campaign scare you, Navy Rear Adm. Christine Hunter, deputy director of the TRICARE Management Agency, said. Even if contract renewal negotiations fall through and Walgreens drops out of TRICARE's retail pharmacy network on Jan. 1, beneficiaries still will have plenty of other options for getting their prescriptions filled.

Hunter called the dispute between Walgreens and Express Scripts, Inc., the contractor for TRICARE's retail pharmacy and pharmacy home delivery programs "a business matter" between the two companies.

A similar impasse between the two companies in 2008 ultimately was resolved by mid-November, about six weeks before the new contract was to take effect, she noted.

Walgreens is a big player in the TRICARE pharmacy network, with about 7,000 participating outlets that Hunter said have filled prescriptions for one in 10 TRICARE beneficiaries at one time or another.

Concerned about a campaign that has alarmed some TRICARE beneficiaries, Hunter offered assurance today that regardless of how this year's negotiations go, patients will always have access to the medications they need.

"If Walgreens does drop out or fail to renew their relationship with ESI so they are not included in the network, patients will still have 56,000 other pharmacies to obtain their medications at retail," she said. "We have a very, very broad network" that, for the vast
majority of beneficiaries, ensures them access to a participating pharmacy within two miles of their homes.

Meanwhile, Hunter emphasized other options TRICARE beneficiaries can use to get their medications: a TRICARE military treatment facility or the increasingly popular mail- order and home-delivery plans.

Hunter is a big proponent of the mail-order and home-delivery program, helping boost participation by 9.9 percent this year alone as retail pharmacy use grew by just 1.6 percent. Delivering medications directly to the beneficiary's home assures an uninterrupted supply of medication, she said, while saving money for beneficiaries as well as the Defense Department.

"I would recommend that this is a great time to consider TRICARE [Pharmacy] Home Delivery for chronic medications," Hunter said.

But with more than three months left on Walgreen's current contract with ESI, she emphasized, "There is no emergency, and there is time for people to understand and consider their options."

Those who elect to stay with the retail pharmacy option but are concerned that Walgreens could drop out of the TRICARE pharmacy network also have the option of moving their prescriptions to another pharmacy in the TRICARE network now.

"We are not taking a position about whether patients should move their prescriptions," Hunter said. "We are allowing this issue to play itself out, but those who want to can do so, and that will absolutely be honored."

Because all prescription information is centralized, the only thing patients need to do to move their prescriptions is to take their medication bottle or tube to another pharmacy. "They don't need another prescription or visit to a doctor," Hunter said.

Beneficiaries also can elect to use pharmacies not included in the TRICARE network. However, Hunter offered a reminder that these users will receive only partial reimbursement for their out-of-pocket costs and could have to file their own insurance claim, where network pharmacies do that automatically.

"Our focus is on ensuring patients have access to the care they need," including reliable access to their prescription medications, she said. "Our goal is to be sure people have the information they need so that they get their medications in a timely fashion."

"We offered to lower our current rates with Express Scripts for prescriptions filled on behalf of TRICARE beneficiaries. In fact, under our proposal, the payment rates for TRICARE would have been lower than under Walgreens commercial rates. In addition, Walgreens offered to separate its contract with Express Scripts for TRICARE beneficiaries from all commercial business with Express Scripts so that we would be in a position to continue providing services for all active and retired military personnel. We do not wish for military beneficiaries to be “in the middle” of this issue".

RULES SET FOR NEW HEALTH INSURANCE PLANS TO OFFER PREVENTIVE CARE FOR WOMEN NO ADDITIONAL COST

More from the Emeritus Newsroom- Historic new guidelines that will ensure women receive preventive health services at no additional cost were announced today by the U.S. Department of Health and Human Services (HHS). Developed by the independent Institute of Medicine, the new guidelines require new health insurance plans to cover women’s preventive services such as well-woman visits, breastfeeding support, domestic violence screening, and contraception without charging a co-payment, co-insurance or a deductible.

“The Affordable Care Act helps stop health problems before they start,” said HHS Secretary Kathleen Sebelius. “These historic guidelines are based on science and existing literature and will help ensure women get the preventive health benefits they need.”

Before health reform, too many Americans didn’t get the preventive health care they need to stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce health care costs. Often because of cost, Americans used preventive services at about half the recommended rate.

Last summer, HHS released new insurance market rules under the Affordable Care Act requiring all new private health plans to cover several evidence-based preventive services like mammograms, colonoscopies, blood pressure checks, and childhood immunizations without charging a copayment, deductible or coinsurance. The Affordable Care Act also made recommended preventive services free for people on Medicare.

Today’s announcement builds on that progress by making sure women have access to a full range of recommended preventive services without cost sharing, including:

well-woman visits;
screening for gestational diabetes;
human papillomavirus (HPV) DNA testing for women 30 years and older;
sexually-transmitted infection counseling;
human immunodeficiency virus (HIV) screening and counseling;
FDA-approved contraception methods and contraceptive counseling;
breastfeeding support, supplies, and counseling; and
domestic violence screening and counseling.

New health plans will need to include these services without cost sharing for insurance policies with plan years beginning on or after August 1, 2012. The rules governing coverage of preventive services which allow plans to use reasonable medical management to help define the nature of the covered service apply to women’s preventive services. Plans will retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost-sharing for branded drugs if a generic version is available and is just as effective and safe for the patient to use.

The administration also released an amendment to the prevention regulation that allows religious institutions that offer insurance to their employees the choice of whether or not to cover contraception services. This regulation is modeled on the most common accommodation for churches available in the majority of the 28 states that already require insurance companies to cover contraception. HHS welcomes comment on this policy.

Previously, preventive services for women had been recommended one-by-one or as part of guidelines targeted at men as well. As such, the HHS directed the independent Institute of Medicine to, for the first time ever, conduct a scientific review and provide recommendations on specific preventive measures that meet women’s unique health needs and help keep women healthy. HHS’ Health Resources and Services Administration (HRSA) used the IOM report issued July 19, when developing the guidelines that are being issued today. The IOM’s report relied on independent physicians, nurses, scientists, and other experts to make these determinations based on scientific evidence.

LIKE IT OR NOT, THE FEDERAL GOVERNMENT WILL BE PAYING HALF OF ALL HEALTH CARE COSTS BY 2020

More from the Emeritus Newsroom- With financial projections increasingly pointing to the federal government paying a larger share of America's medical bills, it is difficult to understand why there is so much opposition to a single payer health care system such as Canada's. More statistics released today by the Centers for Medicare and Medicaid Services show the federal government will be paying half of all medical care by the year 2020, even with private insurance companies still doing business.

The information comes from an article in "Health Affairs", a publication of Project Hope. The article state, in 2010, US health spending is estimated to have grown at a historic low of 3.9 percent, due in part to the effects of the recently ended recession. In 2014, national health spending growth is expected to reach 8.3 percent when major coverage expansions from the Affordable Care Act of 2010 begin. The expanded Medicaid and private insurance coverage are expected to increase demand for health care significantly, particularly for prescription drugs and physician and clinical services. Robust growth in Medicare enrollment, expanded Medicaid coverage, and premium and cost-sharing subsidies for exchange plans are projected to increase the federal government share of health spending, IN THOSE PROGRAMS, from 27 percent in 2009 to 31 percent by 2020. HOWEVER, by 2020, governments' total health care spending for ALL PROGRAMS, COUNTING THOSE IN NEW HEALTH REFORM LAWS, "... is projected to be 49 percent of national health spending, up from 47 percent in 2014, reaching a total of $2.3 trillion; it is expected that the federal government will pay almost two-thirds of this amount. During this period, projected increases in the government’s share of health care financing is largely associated with the robust projected Medicare enrollment growth, the Medicaid expansion, and federal costs associated with the exchange premium and cost-sharing subsidies (but offset somewhat by the lower Medicare expenditures resulting from Affordable Care Act provisions). As the government share of spending rises, the projected share for private businesses declines (from 20 percent in 2014 to 18 percent by 2020), and the share for households remains at 26 percent", according to the report.

The report also shows, while total health care costs as Gross Domestic Product will rise, the increase will be more controlled, from the current 17.6% to 20% of GDP, from 2010-2020, even with 23 million more consumers added to the rolls of the insured through health care reform.

10 STATES GET FEDERAL REVIEW OF HEALTH INSURANCE RATE INCREASES

PHARMACY BENEFITS GIANTS MEDCO AND EXPRESS SCRIPTS PLAN MERGER

More from the Emeritus Newsroom- Prescription benefit companies Medco and Express Scripts today announced Express Scripts, Inc. (NASDAQ: ESRX) and Medco Health Solutions, Inc. (NYSE: MHS) today announced that they have entered into a definitive merger agreement. Under the agreement, Medco shareholders will receive $71.36 per share in cash and stock, or $29.1 billion, based on yesterday's closing price. Medco shareholders will receive $28.80 in cash and 0.81 shares for each Medco share they own upon closing of the transaction. The agreement has been unanimously approved by the boards of directors of both companies. Both companies will be operated by Express Scripts Holdings.

The joint press release from both companies says the merger will combine the expertise of two complementary pharmacy benefit managers (PBMs) to accelerate efforts to lower the cost of prescription drugs and improve the quality of care for Americans.

"The cost and quality of healthcare is a great concern to all Americans; this is the right deal at the right time for the right reasons," said George Paz, chairman and CEO of Express Scripts. "Companies like ours have a responsibility to provide the leadership and resources required to drive out waste in healthcare and provide the best care in the world. The merger with Medco will accelerate our efforts to create greater efficiencies in the healthcare system and better protect American families from the rising costs of prescription medicine while improving health outcomes.

"This continues Express Scripts' commitment to strong growth, both organically and through strategic mergers and acquisitions. The opportunity with Medco represents an attractive strategic combination which will provide the opportunity to move forward with a wide array of tools and resources to accomplish our goals."

David Snow, chairman and CEO of Medco, commented: "Our organizations represent two great success stories in American business. We have each been successful in creating shareholder value because we are both passionate about driving value to our customers through service, innovation and a focus on cost and quality. We have a shared desire to improve the way healthcare is delivered in this country and I believe this creates a strong best-of-breed foundation, culturally, for a very successful merger.

"We continue to have great confidence in moving forward as a stand-alone business, however, the incremental benefits of combining with Express Scripts are both logical and compelling."

GOVERNMENT ACCOUNTABILITY OFFICE URGES STEPPED UP ENFORECEMENT ON MEDICAID AND MEDICARE FRAUD

More from the Emeritus Newsroom- The Government Accountability Office today presented an erratic picture of federal efforts to catch those who defraud Medicare and Medicaid and made recommendations for improvements. The GAO report was introduced during a hearing today before the House Sub-Committes on Oversight and Health.

As an example, the GAO report stated, a CMS contractor identified overpayments in excess of $9 million after interviewing physicians who had referred beneficiaries with high home health costs. The physicians indicated that their signatures had been forged or that they had not realized the amount of care they had authorized. We recommended that CMS require that physicians receive a statement of services beneficiaries received based on the physicians’ certification, but to date, the agency has not taken action.

1. Strengthening provider enrollment process and standards. Checking the background of providers at the time they apply to become Medicare providers is a crucial step to reduce the risk of enrolling providers intent on defrauding or abusing the program. In particular, GAO has recommended stricter scrutiny of providers identified as particularly vulnerable to improper payments to ensure they are legitimate businesses.

2. Improving pre-payment review of claims. Pre-payment reviews of claims are essential to helping ensure that Medicare pays correctly the first time. GAO has recommended that CMS further enhance its ability to identify improper claims through additional automated pre-payment claim review before they are paid.

3. Focusing post-payment claims review on most vulnerable areas. Post payment reviews are critical to identifying payment errors and recouping overpayments. GAO has recommended that CMS better target claims for post payment review on the most vulnerable areas.

4. Improving oversight of contractors. Because Medicare is administered by contractors, overseeing their activities to address fraud, waste, and abuse is critical. GAO found that CMS’s oversight of prescription drug plan sponsors’ compliance programs has been limited. However, partly in response to GAO’s recommendation, CMS oversight of these programs is expanding.

5. Developing a robust process for addressing identified vulnerabilities. Having mechanisms in place to resolve vulnerabilities that lead to improper payment is vital to program management, but CMS has not developed a robust process to specifically address these. GAO has recommended that CMS establish an adequate process to ensure prompt resolution of identified improper payment vulnerabilities.

RESEARCH FINDS INSURANCE IMPROVES MEDICAL OUTCOMES FOR THE POOR / CUTS LONGTERM COSTS

More from the Emeritus Newsroom- A 2008 lottery by the state of Oregon to determine which low income adult residents would qualify for Medicaid, provided the ideal sampling pool for research. The concept was to see what result access to insurance would have on medical care and outcomes for those who were selected in the lottery. The results were published today by MIT and the National Bureau of Economic Research, both based in Cambridge, Massachusetts. According to a press release from MIT, the research shows that Medicaid recipients are far more likely to receive health care than the uninsured. Citizens with Medicaid are 30 percent more likely to have a hospital stay, 35 percent more likely to have an outpatient visit to a doctor, and 15 percent more likely to take prescription drugs, compared to similar low-income citizens not enrolled in the program.

“There has been a lot of genuine uncertainty about whether it makes a difference when you give people Medicaid,” says Amy Finkelstein, a professor in MIT’s Department of Economics and one of the principal investigators of the study. “The short answer from our study is that it does.”

The study, titled, "The Oregon Health Insurance Experiment: Evidence from the First Year", also found people enrolled in Medicaid also see improvements in their finances: They are 35 percent less likely to experience out-of-pocket medical expenses, and see a 25 percent decline in unpaid medical bills sent to collection agencies. The program also reduces the number of unpaid bills owed to health care providers.

OBAMA ADMINISTRATION LOWERS PAYMENTS FOR "HIGH RISK" PATIENT HEALTH INSURANCE

More from the Emeritus Newsroom- Depending on the state, "high risk" patients who cannot get or afford health insurance on the open market, will pay lesss than aniticipated on most government run alternative health insurance policies. Effective July 1st, the Department of Health and Human Services began changing rate and filing requirements to simplify applications for those plans.

According to HHS, premiums for the Federally-administered Pre-Existing Condition Insurance Plan (PCIP) will drop as much as 40 percent in 18 States, and eligibility standards will be eased in 23 States and the District of Columbia to ensure more Americans with pre-existing conditions have access to affordable health insurance. The Pre-Existing Condition Insurance Plan was created under the Affordable Care Act and serves as a bridge to 2014 when insurers will no longer be allowed to deny coverage to people with any pre-existing condition, like cancer, diabetes, and asthma. “The Pre-Existing Condition Insurance Plan changes lives, and in many cases, literally saves lives,” said HHS Secretary Kathleen Sebelius. “These changes will decrease costs and help insure more Americans". In 23 States and the District of Columbia, the PCIP program is Federally-administered. The remaining States operate their own PCIP programs using Federal funds provided by the Affordable Care Act. Under the changes announced today, PCIP premiums will drop as much as 40 percent in 18 States where the Federally administered PCIP operates. These premium decreases help bring PCIP premiums closer to the rates in each State’s individual insurance market; in the six States where PCIP premiums were already well-aligned with State premiums, premiums will remain the same. The changes announced today will make enrolling in the Federally-administered PCIP in 23 States and the District of Columbia easier. Starting July 1, 2011, people applying for coverage can simply provide a letter from a doctor, physician assistant, or nurse practitioner dated within the past 12 months stating that they have or, at any time in the past, had a medical condition, disability, or illness. Applicants will no longer have to wait on an insurance company to send them a denial letter. This option became available to children under age 19 in February, and this pathway is being extended to all applicants regardless of age. Applicants will still need to meet other eligibility criteria, including that they are U.S. citizens or residing in the U.S. legally and that they have been without health coverage for six months.HHS also sent letters today to the 27 States running their own programs to inform them of the opportunity to modify their current PCIP premiums. Beginning this fall, HHS will begin paying agents and brokers for successfully connecting eligible people with the PCIP program. This step will help reach those who are eligible but un-enrolled. Several States have experimented with such payments with good success. This is a part of continuing HHS outreach efforts with States, insurers, providers, and agents and brokers to reach more eligible people and let them know that coverage is available. HHS is also working with insurers to notify people about the PCIP option in their State when their application for health insurance is denied.Congress created the temporary PCIP program as part of the Affordable Care Act to help uninsured Americans with a variety of medical conditions get affordable coverage rather than be locked out of the system by insurance companies. In 2014 and beyond, insurers will be prohibited from denying coverage to anyone with a pre-existing condition and new competitive marketplaces called Health Insurance Exchanges will give people the opportunity to shop for the policy that best suits their needs. Millions of Americans also will receive tax credits to help cut the cost. Enrollment in PCIP programs has begun to grow rapidly, according to HHS. In the period between November 2010 and March 2011, enrollment in all programs rose 129 percent to more than 18,000 Americans enrolled in PCIP.

APPEALS COURT UPHOLDS MANDATORY COVERAGE PROVISION OF HEALTH INSURANCE REFORM

More from the Emeritus Newsroom- Health insurance reform legislation which passed in the first two years of the Obama presidency, has scored a victory in a federal appeals court. The case, referred to as, "Thomas More Law Center, et al. v. Barack Hussein Obama, President of the United States", challenged the the mandatory coverage requirement as being unconstitutional.

The Thomas More Law Center had filed an an appeal of a lower court ruling, with the 6th Circuit Court of Appeals in Cincinnati.

The appeals court wrote in its decision, "For now, whatever else may be said about plaintiffs’ activity/inactivity theory of commerce power, they have not shown that the individual mandate exceeds that power in all of its applications. Congress may apply the mandate in at least four settings: (1) to individuals who already have purchased insurance voluntarily and who want to maintain coverage, but who will be required to obtain more insurance in order to comply with the minimum-essential-coverage requirement; (2) to individuals who voluntarily obtained coverage but do not wish to be forced (at some indeterminate point in the future) to maintain it; (3) to individuals who live in States that already require them to obtain insurance and who may have to obtain more coverage to comply with the mandate or abide by other requirements of the Affordable Care Act; and (4) to individuals under 30, no matter where they live and no matter whether they have purchased health care before, who may satisfy the law by obtaining only catastrophic-care coverage. The valid application of the law to these groups of people suffices to uphold the law against this
facial challenge.

In a partial dissent against the majority opinion, which also partially agreed with, United States District Judge James L. Graham (Southern District of Ohio) wrote, "Section 1501 of the Patient Protection and Affordable Care Act of
2010 requires most Americans to buy a minimum level of medical insurance and, if they do not, to pay a monetary penalty instead. Today’s “question” about the “extent of the powers” granted to Congress goes primarily to its commerce power to compel individuals to buy something they do not want (medical insurance) as part of a regulatory
system that a majority of elected representatives do want (national health care)."Congress’s legislative finding that the “individual responsibility requirement . . . substantially affects interstate commerce” turns the analysis on its head. ACA § 1501(a)(1). Without question, forcing all individuals to purchase a product that not everyone would otherwise purchase will have an effect on commerce. But Congress cannot be tolerated to justify its exercise of power by creating its own substantial effects. In determining whether the substantial effects test is satisfied, the focus must be on the existing economic activity Congress seeks to regulate, not on the impact the regulation would have. See Wickard v. Filburn, 317 U.S. 111, 125 (1942) (examining whether “appellee’s activity,” together with the activities of those similarly situated, “exerts a substantial economic effect on interstate commerce”); Lopez, 514 U.S. at 558-59 (holding that Congress may regulate an activity that substantially affects interstate commerce). The inquiry then is whether plaintiffs’ “activity,” as it were, substantially affects interstate commerce. Much has been made in this litigation of the distinction between No. 10-2388 Thomas More Law Center, et al. v. Obama, et al. Page 58 activity and inactivity. The Supreme Court has often employed the word “activity” to describe the regulatory subjects of Congress’s power over interstate commerce. See Wickard, 317 U.S. at 125; Lopez, 514 U.S. at 559; Morrison, 529 U.S. at 609-10; Raich, 545 U.S. at 17. Yet I do not interpret those cases as drawing a constitutional line between activity and inactivity. That distinction would suffer from the same failings as the “direct” and “indirect” effects test of prior Commerce Clause jurisprudence. See
NLRB v. Jones & Laughlin Steel Corp., 301 U.S. 1, 36-38 (1937) (rejecting the direct/indirect distinction and stating that the question of Congress’s authority is “necessarily one of degree”); Lopez, 514 U.S. at 579 (Kennedy, J., concurring) (noting that questions of constitutional law are often “not susceptible to the mechanical application of bright and clear lines”). Imposing an activity/inactivity line could hinder Congress in future cases from removing burdens on commerce that certain classes of individuals have passively enabled. See United States v. Faasse, 265 F.3d 475, 487 (6th Cir. 2001) (upholding the constitutionality of the Child Support Recovery Act and rejecting the argument that the willful failure to make a court-ordered, out-of-state child support payment from California to Michigan was insufficient for Commerce Clause purposes). The inquiry should start by considering the “economic nature of the regulated activity.” Morrison, 529 U.S. at 610; see also Lopez, 514 U.S. at 559-61 (finding that
possession of a gun in a school zone was not an economic activity).

STUDY: VETS DISABILITY CLAIM BACKLOG WORSE / LABELED BY CRITICS AS "RESEARCH FRAUD"

More from the Emeritus Newsroom- A survey , released this month, conducted by the Transactional Research Action Clearing House, refutes reports from federal officials that progress is being made on the backlog of claims from the nation's veterans. According to TRAC, based at Syracuse University, more than 728,000 Americans are waiting for an appeal hearing on their Social Security disability benefits claims that have been initially denied. This shows a 5 percent increase in pending cases over the last year.Wait times for appeals cases peaked in 2008 at 514 days. The Social Security administration has stated that its goal is to reduce the average wait time for appeals from 367 days, where the SSA claim the backlog presently stands, to 270 days by 2013. The TRAC reports provides fodder for those suspicious of SSA backlog estimates.

According to TRAC, in addition to documenting the recent overall surge in the number of pending matters, TRAC's analysis also found sharp variations in the growth and decline in backlogs depending on where the claimants live. In the last 12 months, for example, the change in state-by-state pending case backlogs varied from an increase of 86 percent in Nevada to a decline of 25 percent in Connecticut. The reasons why some states were up and others were down sometimes were hard to discern, with Iowa experiencing a 23.5 percent increase, while next door in Nebraska the backlog dropped by 14.8 percent. Table 1 shows the 10 states with the largest backlog growth and the 10 states with the largest declines over the last 12 months. Details for every state can be obtained from the interactive "app" accompanying this report.

" (TRAC) “analysis” of our hearing backlog reduction efforts is sloppy and irresponsible. It focuses on the wrong measures, ignores the tremendous progress we have made in addressing the disability hearing backlog, and reaches the incorrect conclusion that we are “faltering.” What matters most to someone waiting for a decision is how quickly we decide their case, not how many other people are waiting for a hearing. We have made significant progress in reducing that time. In August 2008, the average wait time for a decision peaked at 532 days. In May 2011, the average processing time for a hearing decision was less than a year at 354 days -- the lowest monthly figure since October 2003. The agency’s published benchmark for processing hearing cases is 270 days, and we established it in consultation with Congress and the disability advocacy community. In 2008, nearly half of the people waiting for a decision waited more than 270 days. As of May 2011, only 29 percent of pending hearings were over 270 days. TRAC misrepresents the facts by failing to note this standard and the data that relate to it".

EXTRA FED PAYMENTS ENDING AS MEDICAID FACES FINANCIAL TRAIN WRECK / STATES PUSH FOR MORE

More from the Emeritus Newsroom- The warnings have long come from the hardest hit states, where unemployment and the uninsured have consumed billions in state and federal assistance. The so far, "Boiling under the must deal with now" crisis level, will advance to the "We're in over our heads" level, starting next month, as extra federal dollars that were part of the American Recovery & Reinvestment Act of 2009 (ARRA), as a federal match for state paid Medicaid claims . It runs out at the end of this month. At least half the states around the country will be boosting patient co-pays and/or cutting payments to providers. The amounts, in many states, have not even been decided , as their legislatures try to get a better handle on Medicaid budgets.

As a bargaining chip, The National Association of Medicaid Directors is pushing the Obama Administration to compensate the states for state payments made on SSI benefits, which should have been processed under federal SSI disability payments instead. In a letter to HHS Secretary Kathleen Sebelius, Andy Allison, Executive Director, Kansas Health Policy Authority and President of NAMD, along with the NAMD Vice President, Darin J. Gordon
TennCare Director, State of Tennessee, Department of Finance and Administration, are asking for federal payments to settle this issue and thereby give states a way of heading off an almost certain financial onslaught in view of expanding needs. Allison and Gordon state in their letter,

"As you know, for nearly 40 years, the Social Security Administration (SSA) erroneously enrolled hundreds of thousands of people in the program for Supplemental Security Income for the Aged, Blind, and Disabled (SSI), when they should have been enrolled in the Social Security Disability Insurance (SSDI) program. This error resulted in states making payments under their Medicaid program that legally should have been paid for by Medicare. The error has been acknowledged by SSA, and over the past ten years the agency has implemented the SDW project to correct the error and restore the cash benefits that were wrongfully withheld from those who qualified for them.
SSA has stated that it is near completion of this project. To date the federal agencies and states lack a reasonable, mutually agreed-upon process to reconcile payments originally made by the state Medicaid programs which federal agencies acknowledge are the legal responsibility of the Medicare program. According to one analysis, based on SSA’s eligibility determinations, outlays by state Medicaid agencies for Medicaid coverage, net of the federal share of those outlays, has been over $4.3 billion. While this issue is primarily about resolving a long-acknowledged debt, it has taken on a much greater urgency, due to the fact that states are facing unprecedented revenue shortfalls which challenge our ability to continue financing the Medicaid program. We ask that you use your authority under the Medicare and Medicaid statutes to authorize demonstration projects that would pay for the services provided by the SDW cases. States have experience working with your Department to develop waivers to address unique and complex situations. For example we collaborated with the Centers for Medicare and Medicaid Services to develop disaster relief templates for states affected by Hurricane Katrina, to address challenges during implementation of Medicare Part D, and to promote coverage expansions using HIFA waivers. A similar approach should be employed to develop a template to resolve the SDW liability. Under such a proposal states would be reimbursed for their share of the payments made by their Medicaid programs to service providers, which in turn would help preserve program solvency. States would also release Medicare from any claims the state has against that program arising out of its payments to providers of care to SDW cases. The waiver demonstration proposal would allow for a vastly more efficient, expeditious and reasonable solution compared to the previously discussed process that would be more laborious and expensive for the federal government and states. We look forward to working with you to rectify this liability owed states in a timely manner, and we thank you for your consideration of our request".

Next month's expiration of the extra federal aid for Medicaid will reduce the fed portion to 57% from the current 67%.

It remains to be seen how congress will eventually deal with this issue, as most of the oxygen on Capitol Hill has been invested in the current showdown over the federal debt ceiling.

AIR AMBULANCE BILL MAY MAKE YOU WISH YOU DIED ON THE WAY TO THE HOSPITAL / INSURANCE MAY PAY NOTHING

FOR PROFIT MEDICAID MANAGED CARE PLANS HAVE HIGHER ADMINISTRATIVE COSTS

GAO SAYS DISABILITY OVERPAYMENTS EXCEED $1.4 BILLION

More from the Emeritus Newsroom- The Social Security Administration says the exact total of overpaid disability benefits is unknown, however, it estimates that Disability Insurance overpayments detected by SSA increased from about $860 million in fiscal year 2001 to about $1.4 billion in fiscal year 2010. The problem is detailed in a Government Accountability Office review, released today. According to the GAO report, overpayments include those paid to recipients who have returned to work or who are no longer eligible due to medical improvement. SSA estimates about 72 percent of all projected DI overpayments were work related during fiscal years 2005 through 2009. While the agency collected, or recovered, $839 million in overpayments in fiscal year 2010, monies still owed by beneficiaries grew by $225 million that same year, and total DI overpayment debt reached $5.4 billion. SSA does not have agency-wide performance goals for debt collection, for example, the percent of outstanding debt collected annually. And while SSA does have a policy for full repayment within three years, 19 of the 60 continuing disability review (work CDR) cases we reviewed had repayment plans exceeding three years. SSA officials told lengthy repayment plans are often the result of an individual's limited income, but SSA does not review or approve repayment plans which exceed agency policy. During the course of our review, we also found a limitation in SSA's Recovery of Overpayments, Accounting and Reporting (ROAR) system. Used to track overpayments and collections, ROAR does not reflect debt due SSA past year 2049 so the total balance due the program is unknown, and likely larger than the agency is reporting. SSA officials acknowledged this issue, but are unable to determine the extent of the problem at this time. They told us they have a work group which will recommend action to correct the problem. But until this issue is addressed, SSA officials told us the agency can only track and report on overpayments scheduled to be repaid through 2049. Full text of GAO summary click here. Full GAO report, click here. 06/14/2011

ATLANTA FEDERAL APPEALS COURT JUDGES SUGGEST POSSIBLE DEFEAT FOR FED HEALTH REFORM LAW

STUDY FINDS MEDICARE PAYMENTS TO DOCTORS AND MEDICAL CENTERS "DEEPLY FLAWED"

More from the Emeritus Newsroom- A commission approved by the Obama Administration last year has blasted compensation formulas used to determine payments to doctors and medical centers. Released today by the National Academy of Sciences, the commission claims the fact that 40% of hospitals are granted exceptions to get higher payments from Medicare, is proof that the formulas for determining payments are not working. The report cites the total financial picture at stake for the Medicare program being more than $500 billion dollars for 2010 alone, based on Congressional Budget Office estimates.

Federal law requires geographic adjustments to be budget neutral, meaning any increase in the amount paid to one hospital or practitioner must be offset by a decrease to others. Salaries and benefits make up one of the largest costs of providing care. The Medicare program should use health sector data from the Bureau of Labor Statistics (BLS) to develop its indexes for calculating wage adjustments for hospitals and private practice health professionals, the report says. BLS data are a more accurate, independent, and appropriate source than the hospital cost reports, physician surveys, census data, and other information currently used, the committee said. Congress will have to revise a section of the Social Security Act to enable this change.

Medicare should take into account median wage data for all types of workers in private practice settings and hospitals to calculate payments, the report adds. Currently, regional wage differences are based on data for registered nurses, licensed practical nurses, health technicians, and administrative staff only, which does not reflect the full work force in many practices or hospitals.

Medicare also adjusts payments according to which labor market a hospital or practitioner operates in and competes for workers. Because hospitals and health professionals in a given area tend to function within the same local market, there is no reason for the program to use one set of 441 markets to determine hospital payments and a different set of 89 markets for practitioner adjustments, the report says. Instead, the program should employ the metropolitan statistical areas (MSAs) developed by the Office of Management and Budget for both. MSAs reflect information on where people live and work and decisions made by employers and employees that define labor markets' boundaries, the report notes.

OBAMA ADMINISTRATION INTRODUCES COVERAGE FOR THOSE WITHOUT HEALTH INSURANCE DUE TO PRE-EXISTING CONDITIONS

MEDICARE TO RATE HOSPITALS ON SPENDING PER PATIENT

UNINSURED PATIENTS GETTING FARTHER BEHIND PAYING MEDICAL BILLS

More from the Emeritus Newsroom- The Department of Health and Human Services claims few families without health insurance have the financial assets to pay potential hospital bills. According to a report the agency released today, on average, uninsured families can only afford to pay in full for approximately 12-percent of hospital stays they may experience – and even higher income uninsured families are unable to pay for most potential hospital stays. Hospital stays for which the uninsured cannot pay in full account for 95-percent of the total amount hospitals bill the uninsured. Other studies have estimated that the bills for all types of health care that the uninsured cannot pay – the uncompensated cost of care – is up to $73 billion a year, a significant portion of which is shifted into higher costs for Americans with insurance and their employers. Approximately 50 million Americans are uninsured. The report found that most uninsured people have virtually no savings. In fact, the median financial assets for all uninsured families are just $20. Even among higher income families, assets are low. Half of families with income at 400-percent of the Federal Poverty Level (FPL), or $89,400 a year for a family of four in 2011, have financial assets below $4,100.Every year, nearly 2 million uninsured Americans are hospitalized. With 58-percent of these hospital stays resulting in bills of more than $10,000, most uninsured people are unable to afford potential hospital bills. Even the top 10-percent of uninsured families with the most assets are estimated to be able to pay the full bill for only half of potential hospital stays. Uninsured families can, on average, afford to pay the full bills for only about 12-percent of the hospital stays they might experience, bills that account for just 5-percent of the total amount hospitals bill them.

“Health insurance is critical in helping protect families from unexpected hospital costs,” said Sherry Glied, HHS assistant secretary for planning and evaluation. “This report shows that even higher income uninsured families are struggling to meet the high costs of health care. No family should bear the burden of being one illness or accident away from bankruptcy.”

The high cost of hospitalization means that lacking health insurance poses a greater risk of financial catastrophe than lacking car insurance or homeowner’s insurance. Although people are 50-percent more likely to have car accident than to be hospitalized in a given year, the average bill for a hospital visit is over two and a half times higher than the average loss for a car accident. And, while the bill for a single hospitalization is about the same as the average loss from a house fire, a person is ten times more likely to be hospitalized than to experience a house fire.

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