GOP 'Sabotaging' ACA Rollout, Dems Charge

Published: Aug 1, 2013

By David Pittman, Washington Correspondent, MedPage Today

WASHINGTON -- Republicans continue to undermine the Affordable Care Act by spreading misinformation and avoiding helping constituents learn about their benefits under the law, Democrats charged in a report Thursday.

Meanwhile, Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner told House lawmakers her agency was on track to have the law's health insurance exchanges operational when they begin open enrollment on Oct. 1.

"We are so ready; I just cannot wait for those 60 days," Tavenner told MedPage Today after a House Energy and Commerce Committee hearing on the ACA's implementation.

At that hearing, Democrats charged Republicans in a report of lying and generally being disingenuous at the eleventh hour of ACA implementation -- hindering "millions of their poorest constituents from receiving health insurance coverage."

"Nonpartisan analysts have accused Republicans of trying to 'sabotage' the law," their 14-page report said, outlining 10 ways Republicans have acted to undercut the ACA. These policies include:

·         Casting 40 votes to repeal the law, creating public confusion about the ACA's implementation

·         Refusing to expand Medicaid in 27 states and establishing state-based health insurance exchanges in 27 states

·         Not providing funding to implement the law

·         Attacking efforts to educate the public about the law

·         Denying basic constituent services requests from citizens who request help understanding or signing up for benefits

·         Misinforming citizens about the impact of reform on insurance premiums, leading many to believe prices will skyrocket

·          

Rep. Diana DeGette (D-Colo.) said at Thursday's hearing Democrats who opposed the creation of Medicare Part D were still helping their constituents understand their benefits and enroll in the program last decade. The Democrats' response then provides a contrast to Republican efforts today, she said.

"I think it's our job as elected representatives of our constituents to go out there and tell people that they can have these benefits, get the assurance they need, and save money," DeGette said.

Rep. John Shimkus (R-Ill.) disputed the notion that Democrats were helpful in the Medicare drug plan rollout.

"To make a claim about Medicare [Part] D how much you all were out there pushing that, I question the credibility of that," Shimkus said.

Republicans used Thursday's hearing to pepper Tavenner with questions about the raise in health insurance premiums and the Obama administration's preparation for and handling of the law's implementation.

"What assurances do we have that exchanges will be ready to enroll individuals in just 60 days?" Rep. Joe Pitts (R-Pa.) said in his opening statement. "My constituents want to know what to expect over the next couple of months."

Republicans have for some months said the ACA's changes to the insurance market will cause premiums in the individual and small group market to skyrocket. They've often used the term "rate shock."

The Obama administration says premiums will fall in many states as they have already in New York, Maryland, Washington, and others. They said last month premiums in the small group and individual markets will be 18% lower on average than what the Congressional Budget Office estimated.

Republicans counter that those states are the exception and not the norm.

"The president made a lot of promises to the American people both before and after the law's passage, and the promises to make healthcare more affordable and more accessible have fallen woefully short," Energy and Commerce Committee Chair Fred Upton said in his opening statement.

Tavenner, when asked about possible misinformation about the law's impact on premiums, said Republicans are just worried because they don't know what's coming, and Democrats are excited for what's a true game-changer in health insurance.

"Both sides have a valid argument, but we are ready to move ahead," Tavenner told MedPage Today.

She added she was most concerned about getting people enrolled in the exchanges once the 6-month enrollment process starts Oct. 1 -- not the information technology aspect of the exchanges.

Lawmakers -- for or against the law -- will have a chance to reach their constituents as Congress begins its long August recess next week. They won't return to Washington until Sept. 9.

Republicans have called for public forums with young adults and forums with members of the local healthcare community.

"To highlight the negative effects of the president's healthcare law, the member will engage with local businesses and employees that have been impacted by job cuts, furloughs, or the loss of health insurance," the GOP plan read. "This event will promote local businesses and emphasize the need to repeal Obamacare to protect employees, small businesses, and jobs."

http://www.medpagetoday.com/Washington-Watch/Reform/40794?xid=nl_mpt_DHE_2013-08-02&utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&eun=g350341d0r&userid=350341&email=john@thebrokerageinc.com&mu_id=5344066

Observation Status: Morphed Into Madness

Although a large and increasing number of Senators and Representatives now support bipartisan legislation to solve the problem of Observation Status, many beneficiaries and their families continue to face this outpatient status as a barrier to Medicare coverage of care in a skilled nursing facility.  This Alert describes the continuing problem, Congressional legislation, a survey of members of the National Association of Geriatric Care Managers, several recent studies and articles, and a hearing by the Senate Finance Committee on the Recovery Audit Contractor program.
The Problem
Observation Status refers to the classification of a hospital patient as an outpatient, even though the patient is placed in a hospital bed, stays overnight (and often for multiple days and nights), and receives nursing and medical care, diagnostic tests, treatments, therapy, prescription and over-the-counter medications, and food.  The classification of Observation Status as an outpatient status means that the patient is ineligible for Medicare coverage of a subsequent stay in a skilled nursing facility (SNF) because Medicare limits SNF coverage to patients who have had an inpatient hospital stay of at least three consecutive days, not counting the day of discharge.[1]  The Center for Medicare Advocacy hears daily from families of beneficiaries who are hospitalized for more than three days, all called outpatient days, who then must pay  thousands of dollars out of pocket for their SNF stay.  Beneficiaries who cannot afford to pay privately (or who do not have another source of payment, such as Medicaid) forego SNF care.  Also hugely problematic is the fact that there is no apparent appeals system to challenge an Observation Status classification.
Federal Legislation
Identical bipartisan legislation pending in Congress – H.R. 1179 and S.569 – the "Improving Access to Medicare Coverage Act of 2013" – would count the time in Observation Status towards meeting the requirement for a three-day qualifying inpatient hospital stay.   The number of co-sponsors for both bills has increased dramatically in the last few months.  As of August 1, 2013, H.R.1179, introduced by Congressman Joseph Courtney (D, CT), has 91 House co-sponsors (an increase from 18 co-sponsors in April) and S.569, introduced by Senator Sherrod Brown (D, OH), has 16 Senate co-sponsors (an increase from one co-sponsor in April).
The legislation is supported by an ad hoc coalition of 14 national organizations (see the joint Fact Sheet[2]) and there is no organized opposition.
You can contact your Senators and Representatives about this crucial legislation at http://org.salsalabs.com/o/777/p/dia/action/public/?action_KEY=8514.
Administrative Developments
On July 29, 2013, the Office of Inspector General (OIG) issued a report about Observation Status that included the following statement in its Conclusion, "CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access to and cost-sharing for SNF services."[3]  OIG suggested that federal legislation might be necessary.  (The Center for Medicare Advocacy will discuss the OIG report in detail in a future Alert.)
The New England Journal of Medicine
Writing in The New England Journal of Medicine, two physicians from the Department of Emergency Medicine at Brigham and Women's Hospital in Boston support the federal legislation discussed above.  Although they appear to support the use of distinct observation units, they view Observation Status in inpatient units as problematic: "When observation is used as a billing status in inpatient areas without changes in care delivery, it's largely a cost-shifting exercise – relieving the hospital of the risk of adverse action by the RAC [Recovery Audit Contractor] but increasing the patient's financial burden."[4]  (Emphasis added)  With a hypothetical three-day hospital stay, the physicians demonstrate how Observation Status shifts costs from the Medicare program to beneficiaries and hospitals.
National Association of Professional Geriatric Care Managers survey
More than 80% of geriatric care managers across the United States who were surveyed by the National Association of Professional Geriatric Care Managers (NAPGCM) between July 1 and July 16, 2013 reported that "inappropriate hospital Observation Status determinations" were a significant problem in their communities and 75% noted that the problem was growing worse.[5] 
As a result of Observation Status:

• 81% of care managers reported that beneficiaries do not receive the rehabilitation services they need;
• 79% of care managers reported financial hardship on beneficiaries and their families; and
• 75% of care managers reported "emotional stress" for beneficiaries and their families.

Study of University of Wisconsin's Use of Observation Status
A retrospective descriptive study looked at all Observation Status and inpatient stays at the University of Wisconsin Hospital and Clinics, an academic medical center that does not have a dedicated observation unit, from July 1, 2010 to December 31, 2011.[6]  The study found that:

• 4,578 of the total 43,853 hospital stays (10.4%) were observation stays
• 756  observation stays (16.5%) exceeded 48 hours; 1,791 observation stays (39.1%) were 24-48 hours; 2,031 observation stays (44.4%) were less than 24 hours
• 25.4% of patients in observation had longer lengths of stay and were more likely to be discharged to a SNF, to have more acute/unscheduled admissions, to have more "avoidable days" (days not accounted for by medical need), and to have more "repeat encounters."

The study found that "many observation stays did not meet the CMS definition of observation." Many patients stayed longer than 48 hours and 1,141 distinctly billed observation codes were used for their stays.  It concluded, "observation care in clinical practice is very different than what CMS initially envisioned and creates insurance loopholes that adversely affect patients, health care providers, and hospitals." (Emphasis added)
In an Invited Commentary on the Wisconsin study, Robert M. Wachter, MD, of the Department of Medicine at the University of California, San Francisco, was more blunt.  He described "Observation Status" as having "morphed into madness"[7] and wrote, "[I]n fact, if one was charged with coming up with a policy whose purpose was to confuse and enrage physicians and nearly everyone else, one could hardly have done better than Observation Status." 
Senate Finance Committee Hearing
The Senate Finance Committee held a hearing on June 25, 2013, "Program Integrity: Oversight of Recovery Audit Contractors,"[8] which focused on the impact on hospitals of the Recovery Audit Contractor (RAC) program.  Although the RAC is intended to assure that Medicare payments to health care providers are appropriate, hospital witnesses from Montana and Utah testified about the burdensome nature of RAC review, the amount of money hospitals spend responding to RAC reviews (Intermountain Health's Vice President of Business Ethics & Compliance estimated that most of the 22 full-time employees it hired are devoted to RAC issues[9]), and hospitals' successful appeals of RAC denials of inpatient status.  Many of the RAC reviews involve inpatient status and RACs' claim that patients should have been classified as outpatients in observation.  The Center for Medicare Advocacy submitted a statement for the record describing the impact of Observation Status on beneficiaries.[10]
Conclusion
Observation Status continues to grow as a significant problem facing Medicare beneficiaries and their families.  Studies and articles identify the need to change the system and to assure that beneficiaries get Medicare coverage for their SNF care following their hospital stays.  Members of Congress increasingly support pending legislation.   Pending litigation brought by the Center for Medicare Advocacy, Bagnall v. Sebelius, challenges the use of Observation Status as violating the Medicare Act, the Freedom of Information Act, the Administrative Procedure Act, and the Due Process Clause of the Fifth Amendment to the Constitution.[11] The time has come to end the "madness."

For more information, contact attorney Toby S. Edelman (tedelman@medicareadvocacy.org) in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760. 

---

[1] 42 C.F.R. §409.30(a)(1).
[2] http://www.medicareadvocacy.org/fact-sheet-observation-stays-deny-medicare-beneficiaries-access-to-skilled-nursing-facility-care/.
[3] Office of Inspector General, "Memorandum Report: Hospitals' Use of Observation Stays and Short Inpatient Stays for Medicare Beneficiaries," OEI-02-12-00040, page 15 (July 29, 2013), http://oig.hhs.gov/oei/reports/oei-02-12-00040.asp.
[4] Christopher W. Baugh, M.D., M.B.A., and Jeremiah D. Schuur, M.D., M.H.S., "Observation Care – High Value Care or a Cost-Shifting Loophole?" N Engl J Med 369:4 (July 25, 2013), http://www.nejm.org/doi/full/10.1056/NEJMp1304493#.UfK2Z1RRcYo.twitter.
[5] "Seniors Increasingly Victims of Medicare's 'Observation Status' Trap Says Survey of Aging Experts; Congress Considers Changes" (July 24, 2013), http://www.prweb.com/releases/2013/7/prweb10958752.htm.
[6] Ann M. Sheehy, MD, MS, et al., "Hospitalized but Not Admitted: Characteristics of Patients With 'Observation Status' at an Academic Medical Center," JAMA Intern Med. 2013; ():-. doi:10.1001/jamainternmed.2013.7306.  (abstract published online July 8, 2013), http://archinte.jamanetwork.com/article.aspx?articleid=1710122.
[7] Robert M. Wachter, MD, "Observation Status for Hospitalized Patients," JAMA Intern Med (published online July 8, 2013), http://archinte.jamanetwork.com/article.aspx?articleid=1710118.
[8] http://www.finance.senate.gov/hearings/hearing/?id=7b79eddd-5056-a032-52de-e9f0d4ce8ed0
[9] http://www.finance.senate.gov/imo/media/doc/S.Draper-Senate%20Finance-Written%20submission-Final(1).pdf.
[10] http://www.medicareadvocacy.org/senate-hearing-on-oversight-of-recovery-audit-contractors-centers-statement-regarding-beneficiary-impact/
[11] No. 3:11-cv-01703 (D. Ct., filed Nov. 3, 2011), http://www.medicareadvocacy.org/medicare-info/observation-status/.

Ten States with Highest 2012 Medical Loss Ratio Average Rebate per Family in All Markets

1.    WA - $512
2.    DE - $495
3.    MA - $457
4.   MN - $303
5.   WY - $284
6.    AL - $248
7.   OR - $206
8.    AK - $190
9.   MT - $173
10. CT - $168
Source: Centers for Medicare & Medicaid Services, The Center for Consumer Information & Insurance Oversight

White House delays employer mandate until 2015

July 3, 2013 | By Dina Overland

In a shocking move, the White House announced Tuesday it is delaying the reform law's mandate that employers provide health insurance coverage for their workers.    

The decision to postpone the mandate, which requires companies with at least 50 employees offer health plans or pay fines, by one additional year to 2015 is a major concession to business groups and employers and could have a rippling effect on the health insurance industry.

"We have heard concerns about the complexity of the requirements and the need for more time to implement them effectively," Mark Mazur, an assistant secretary for the U.S. Department of Treasury, wrote in a blog post announcing the delay. "We recognize that the vast majority of businesses that will need to do this reporting already provide health insurance to their workers, and we want to make sure it is easy for others to do so."

Postponing the mandate, however, could mean more people will enroll in health insurance exchanges if employers stop offering health coverage, even if only temporarily. "Essentially for calendar 2014 the act of dropping coverage and dumping employees into the exchanges is on sale," Douglas Holtz-Eakin, president of American Action Forum, told Politico. "Drop and dump, but no penalty."

The Treasury Department, which is responsible for implementing the employer portion of the reform law, will publish guidance on the delay within the next week and will propose official rules later this summer, according to the blog post.

To learn more:
- here's the Treasury blog post
- read the Politico article

White House delays employer mandate until 2015 - FierceHealthPayer http://www.fiercehealthpayer.com/story/white-house-delays-employer-mandate-until-2015/2013-07-03#ixzz2ajY2SeQc

Today's Datapoint

91,661 … was the increase in Medicare Advantage enrollment for the month of July, which dwarfed the 65,000 gain for the prior month and clobbered the 14,400 member gain from April to May, according to data from CMS.

Quote of the Day

“If I were to say what the two top risk areas out there are for any [HIPAA] covered entity, it’s they haven’t conducted a thorough risk analysis, so they don’t know where their risks are. And the second one is [employees] bringing their own mobile devices. That’s one of the big headlines you see a lot: Somebody lost their USB drive and it wasn’t encrypted, they lost their tablet and it wasn’t encrypted.”

— Chris Apgar, CEO and president of Apgar & Associates, LLC, told AIS’s Health Plan Week.

Connections with Community and Family – Not Money – Most Important for Seniors' Quality of Life

• Healthy living another key indicator of happiness in old age
• Women, African Americans most optimistic about growing older
• National Council on Aging, UnitedHealthcare release results of the second annual United States of Aging Survey

LOUISVILLE, Ky.--(BUSINESS WIRE)--Relationships with friends and family outweigh financial concerns among older Americans seeking fulfillment in their senior years, according to the second annual United States of Aging Survey. When asked what is most important to maintaining a high quality of life in their senior years, staying connected to friends and family was the top choice of 4 in 10 seniors, ahead of having financial means (30 percent).

“there’s no such thing as getting old”

For the 2013 edition of The United States of Aging Survey, the National Council on Aging (NCOA), UnitedHealthcare and USA TODAY surveyed 4,000 U.S. adults including a nationally representative sample of seniors ages 60 and older. This year, for the first time, the survey also included a nationally representative sample of adults ages 18-59 to provide contrasting perspectives on aging and explore how the country could better prepare for a booming senior population.

The results of the 2013 survey are being released today at the National Association of Area Agencies on Aging (n4a) 38th Annual Conference in Louisville, Ky., as part of a broader effort led by n4a, NCOA, UnitedHealthcare and USA TODAY to educate seniors and stakeholders in communities across the country and support further awareness and understanding of senior perspectives on aging.

“The United States of Aging Survey shows us that seniors are an optimistic group,” said Rhonda Randall, D.O., chief medical officer, UnitedHealthcare Medicare & Retirement. “By learning more about seniors’ priorities, successes and unmet needs, we hope to identify the services, programs and infrastructure that may best support older adults so that future generations of seniors can have this same sense of optimism as they age.”

The importance of connectivity
The survey finds that seniors are driven by a desire for connectedness. More than half of seniors (53 percent) nationally indicate that being close to friends and family is important and only 15 percent report occasional feelings of isolation. Eighty-four percent of seniors nationally cite technology as important to their ability to connect with the world around them.

Seniors who report experiencing feelings of isolation and depression express less optimism regarding their future health and quality of life compared with seniors nationally: 37 percent of isolated seniors believe their overall quality of life will get worse in the next five to 10 years (compared with 24 percent of all seniors), and 32 percent of isolated seniors believe their health will get worse, compared with 23 percent of all seniors.

Low-income seniors also face challenges. While they cite technology as important to staying in touch with family and friends (81 percent), issues of technology access persist, with 47 percent of low-income seniors reporting cost as a barrier to using more technology, and 48 percent indicating they have trouble understanding how to use technology.

Taking care of health associated with optimistic outlook
The 2013 United States of Aging Survey finds that seniors have maintained a positive outlook on their future and the aging process. Eighty-six percent of seniors say they are confident about their ability to maintain a high quality of life, and 60 percent expect their health to stay the same during the next five to 10 years (compared with 53 percent of adults ages 18-59).

The survey also finds that women and African Americans are among the most optimistic about growing older. Of the most optimistic seniors – those surveyed who expect their quality of life in the next five to 10 years to be “much better” or “somewhat better” – 65 percent are women and 18 percent are African American, compared with the national sample comprising 55 percent women and 8 percent African Americans.

Seniors focused on taking care of their health are more optimistic about aging. Nearly two-thirds (64 percent) of optimistic seniors have set one or more specific goals to manage their health in the past 12 months, compared with 47 percent of the overall senior population.

This and other findings reveal important opportunities to help seniors improve their health. While 65 percent of seniors report having at least two chronic health conditions, less than one in five has received guidance in the past year to develop an action plan for managing their health. Additionally, 26 percent of seniors nationally indicate they exercise less than once a week for 30 minutes or more. Low-income seniors face additional challenges, with 74 percent reporting at least one barrier to managing their health condition, such as lack of energy or money.

“This year’s survey points to the impact of health on an individual’s ability to age successfully,” said Richard Birkel, Ph.D., senior vice president, healthy aging, and director of the NCOA’s Self- Management Alliance. “But maintaining good health as we age requires being proactive, especially for people with chronic health conditions. We must seize opportunities across local communities to empower seniors with the skills they need to stay healthy.”

Communities responsive but not doing enough to support seniors
Most seniors (71 percent) feel the community they live in is responsive to their needs, but less than half (49 percent) believe their city or town is doing enough to prepare for the future needs of a growing senior population. Twenty-six percent say their city or town should invest in better public transportation, and 23 percent say their city or town should invest more in affordable health care services and housing.

Seniors give low ratings to the quality of public transportation and job opportunities in their city or town: just 16 percent and 10 percent, respectively, rate their community’s transit and employment offerings as “excellent” or “very good.”

Compared with seniors, adults ages 18-59 are less likely to believe that the community they live in is doing enough to prepare for the needs of a growing senior population (41 percent).

The changing economics of retirement and concerns of living longer
Nearly half (47 percent) of retired seniors have access to pensions, and among seniors that are not yet retired, 41 percent plan to rely on Social Security as their primary source of retirement income. In contrast, just 23 percent of adults ages 18-59 plan to rely primarily on Social Security. Forty-eight percent of adults ages 18-59 say they will live mostly off of their personal savings and investments in their senior years.

While most seniors are able to pay their monthly expenses, many express concern about the financial impact of living longer. Though two-thirds (66 percent) of seniors believe it to be very easy or somewhat easy to pay their monthly living expenses, more than half (53 percent) are somewhat to very concerned that their savings and income will not be sufficient to last them for the rest of their life.

Getting the most from more golden years
With life expectancies on the rise and the centenarian population set to boom, the survey reveals what seniors are most looking forward to in their “bonus years” – the years they may live beyond the average U.S. life expectancy of 78. More than 4 in 10 (41 percent) say seeing their children and grandchildren grow up is the most exciting prospect of living a longer life. One-fifth say spending time with friends and family will be the best part of their bonus years, and 18 percent say they are excited to have more time to do the things they enjoy.

The survey finds that seniors themselves are casting doubt on the famous adage, “The older you get, the wiser you become.” While 19 percent of adults ages 18-59 believe aging means becoming wiser, only 9 percent of those ages 60 and older agree.

Perhaps that’s because both seniors and younger adults share the belief that “there’s no such thing as getting old” because “age is a state of mind,” statements with which 28 percent of seniors and 27 percent of adults aged 18-59 agree.

For complete survey results, visit ncoa.org/UnitedStatesofAging. To watch live as the survey is presented at the n4a Annual Conference in Louisville, including an interview with featured keynote speaker Dr. Nancy Snyderman, visit USofAging.USATODAY.com on July 30 from 4-5:30 pm, EDT. Join the conversation on Twitter at #USofAging.

About The United States of Aging Survey
The United States of Aging Survey is an annual survey conducted by the National Council on Aging, UnitedHealthcare and USA TODAY. For the 2013 survey, Penn Schoen Berland completed 4,000 telephone interviews from April 4, 2013, to May 3, 2013, including nationally representative samples of Americans ages 60 and older and adults ages 18-59. The margin of error for the national samples is +/-3.1 percent and between 3.7 percent and 5 percent for oversampled subpopulations. Data from general population samples, the regional oversampled audiences and the oversampled audience of seniors ages 80 and older are weighted to U.S. Census Bureau demographic statistics in terms of age, ethnicity, gender, income and marital status.

About the National Council on Aging
The National Council on Aging is a nonprofit service and advocacy organization headquartered in Washington, D.C. NCOA is a national voice for millions of older adults – especially those who are vulnerable and disadvantaged – and the community organizations that serve them. It brings together nonprofit organizations, businesses, and government to develop creative solutions that improve the lives of all older adults. NCOA works with thousands of organizations across the country to help seniors find jobs and benefits, improve their health, live independently, and remain active in their communities. For more information, please visit: www.ncoa.org |www.facebook.com/NCOAging | www.twitter.com/NCOAging

About UnitedHealthcare
UnitedHealthcare is dedicated to helping people nationwide live healthier lives by simplifying the health care experience, meeting consumer health and wellness needs, and sustaining trusted relationships with care providers. The company offers the full spectrum of health benefit programs for individuals, employers and Medicare and Medicaid beneficiaries, and contracts directly with 780,000 physicians and other care professionals and 5,900 hospitals and other care facilities nationwide. UnitedHealthcare serves more than 40 million people in health benefits and is one of the businesses of UnitedHealth Group (NYSE: UNH), a diversified Fortune 50 health and well-being company.