Today's Datapoint

6.3% ... of the U.S. gross domestic product is projected to be spent on Medicare, Medicaid and the Children’s Health Insurance Program by 2020, according to a Congressional Budget Office report released on November 8.

Affordable Hearing Aids Now Available to US Veterans Through New Program From hi HealthInnovations

Minnetonka, Minn. (Nov. 9, 2012) – hi HealthInnovations, a UnitedHealth Group [NYSE: UNH] company and Optum business, has launched a new program to make hearing aids more affordable for U.S. veterans and their spouses.

The new program offers veterans and their spouses high-quality, custom-programmed digital hearing aids for as little as $649 to $849 each, depending on the model chosen. That compares to some hearing aids that retail for as much as $4,000 each.

Hearing loss is a growing health concern for some veterans, in part because of their history of noise exposure experienced during their time of service. Hearing loss is the second most common health condition among veterans, affecting more than 670,000 members of the armed forces nationwide, according to The Hearing Journal.

To access the discount program, veterans work with a health professional, such as an audiologist, hearing aid dispenser or primary care physician, to get their hearing tested. Those results, along with a copy of the veteran’s military ID card or discharge papers, can then be submitted by either fax or mail:

• Fax test results to: 1-877-955-4336
• Mail test results to: hi HealthInnovations, 3033 Momentum Place, Chicago, IL 60689.

hi HealthInnovations will then review the test results and follow up by phone to recommend an appropriate hearing device.

“Hearing aids can improve the quality of life for hundreds of thousands of veterans nationwide suffering from hearing loss,” said Lisa Tseng, M.D., CEO, hi HealthInnovations. “Providing this discount for our military veterans and their spouses is a way to thank them for their courageous service to our country.”

Untreated hearing loss can affect a person’s ability to stay connected to friends and family, contributing to social isolation, depression and lower income. While 90 percent of people with hearing loss can benefit from hearing aids, fewer than 20 percent currently use them, according to the U.S. Department of Health and Human Services. The high cost of most hearing aids is often a barrier for people to use them.

The discount for veterans is an expansion of an affordable hearing aid program already available to people enrolled in UnitedHealthcare individual and employer-sponsored health benefits. Many UnitedHealthcare Medicare Advantage and Part D plan members also already enjoy a deep discount on hearing aids, with some of them paying no out-of-pocket costs for the devices. The general public also has access to the devices at $749 to $949 per device, which represents a deep discount compared to most competitor prices.

“Cost is a significant barrier for millions of Americans suffering from hearing loss, and this new discount will help make hearing aids more accessible and affordable for veterans and their spouses,” Tseng said.

Each hearing aid comes with free batteries and ear tubes/wax guards that will last most users six months, as well as a 70-day money-back guarantee and free programming adjustments. hi HealthInnovations audiologists and hearing specialists offer education, counseling and support over the phone, online and in person.

For more information on product and pricing, visit hihealthinnovations.com.

About Optum
Optum (www.optum.com) is a leading information and technology-enabled health services business dedicated to helping make the health system work better for everyone. Optum comprises three companies – OptumHealth, OptumInsight and OptumRx – representing more than 35,000 employees worldwide who collaborate to deliver integrated, intelligent solutions that work to modernize the health system and improve overall population health.

About UnitedHealth Group
UnitedHealth Group (NYSE: UNH) is a diversified health and well-being company dedicated to helping people live healthier lives and making health care work better. With headquarters in Minnetonka, Minn., UnitedHealth Group offers a broad spectrum of products and services through two distinct platforms: UnitedHealthcare, which provides health care coverage and benefits services; and Optum, which provides information and technology-enabled health services. Through its businesses, UnitedHealth Group serves more than 75 million people worldwide. Visit UnitedHealth Group at www.unitedhealthgroup.com for more information.

Déjà Vu All Over Again: CMS Decides (Again) Not to Decide About Observation Status

On July 30, 2012, as part of proposed rulemaking on the outpatient prospective payment system, the Centers for Medicare & Medicaid Services (CMS) asked for public comment on potential policy options related to "observation status."[1]

What is Observation Status?
Observation status refers to the classification of a patient in an acute care hospital as an outpatient, even though the person is placed in a bed in the hospital, stays overnight (or, often, many nights), and receives medically necessary nursing and medical care, diagnostic tests, treatments, therapy, prescription and over-the-counter medications, and food.  Although outpatients may be intermingled with, and indistinguishable from, inpatients, the distinction between inpatient and outpatient status is significant.  Inpatients pay a large deductible ($1156 in 2012), after which Medicare Part A covers all care and services received in the hospital.  They are eligible for Medicare coverage of their subsequent stay in a skilled nursing facility (SNF) if they have three days of inpatient status in the hospital (not counting the day of discharge).[2]  Outpatients, on the other hand, pay co-payments for each hospital service billed under Medicare Part B, pay for medications, and, if they should need subsequent care in a SNF, Medicare will not pay for it. 

Final Rules Published November 15, 2012
In final rules published November 15, 2012, CMS declines to make any changes to observation status at this time, promising that "[w]e will take all of the public comments that we received into consideration as we consider future actions that we could potentially undertake to provide more clarity and consensus regarding patient status for purposes of Medicare payment."[3]

CMS' response is disappointing both because hospitals' use of observation status is increasing and adversely affecting tens of thousands of Medicare beneficiaries nationwide[4] and because CMS previously solicited public comment on observation status in 2005 and decided, at that time, that it wanted to consider the issue further.[5]
Despite refusing to address the observation status issues in regulations at present, CMS reported that the number of hospital patients in observation for more than 48 hours increased from 3% of hospital claims in 2006 to 7.5% in 2010 and that the financial consequences for patients may be significant – Part B copayments and drug costs for outpatients in observation may exceed the Part A inpatient deductible, and subsequent care in a SNF may not be covered by Medicare.[6]

CMS summarized the 350 comments it received on various options to revise its observation status policy, but provided no responses in the final rule to the comments that it received. 

 CMS' rationale for not providing responses is that while it requested comment, it did not propose any specific changes.[7]

Policy Options Discussed by CMS

• Clarifying current admission instructions or establishing specified clinical criteria for inpatient status.  Commenters expressed concerns about the need to give primacy to the clinical judgment of the treating physician and about the use of proprietary screening tools to make decisions about a patient's status as inpatient or outpatient  (some commenters supported their use, others opposed them);
• Using hospital utilization review procedure for making appropriate decision about inpatient-outpatient status.  Some commenters supported requiring hospitals to maintain utilization review staff 24 hours per day, seven days per week; others supported eliminating utilization review entirely.
• Using a prior authorization process for inpatient admission.  Some commenters supported prior authorization; others saw it as a barrier to urgently needed care.
• Using time-based criteria for inpatient admission, such as strictly limiting outpatient observation to 24 or 48 hours.
• Aligning payment to match payment rates more closely to resources spent by a hospital for a patient in outpatient status.
• Public comments received on other topics, such as establishing rules for the external review of inpatient claims (many commenters expressed concerns that external reviewers' criteria are not the same as Medicare's and that external reviewers making medical necessity decisions may not be physicians), improving beneficiary protections (such as clarifying and strengthening rules when patients' status is changed from inpatient to outpatient),  and revising the qualifying criteria for SNF coverage (such as counting all time in the hospital toward meeting the qualifying inpatient requirement for SNF coverage).

The proposed and final rules also describe the Medicare Part A to Part B Rebilling Demonstration, which allows hospitals to receive 90% of the allowable Part B payment when payment under Part A is denied.  Hospitals voluntarily participating in the Demonstration must waive their appeal rights and do not receive any reimbursement for "observation hours," which they could have billed to Medicare if they had originally described the patient's status as "outpatient."[8]  This month, the American Hospital Association (AHA) sued the Department of Health and Human Services over a related issue – CMS's practice of disallowing any Medicare reimbursement to hospitals whose decision to admit a patient to inpatient status is later overturned by a Recovery Audit Contractor, even when the patient received medically necessary services in the hospital as an "outpatient."[9]

Conclusion
Observation status remains a significant issue for Medicare beneficiaries across the country.  The Center for Medicare Advocacy is pursuing litigation[10] challenging the practice and wants to hear from you.  The Center also hopes that  legislation now pending in Congress – the "Improving Access to Medicare Coverage Act of 2011," H.R. 1543 (introduced by Congressman Joe Courtney, D, CT,  and 37 co-sponsors) and S.818 (introduced by Senator John Kerry, D, MA, and six co-sponsors) – will be reintroduced in the next Congress.  The identically worded bipartisan bills would count all time in the hospital, whether called inpatient or outpatient, toward meeting the three-day qualifying hospital stay.

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.

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[1] 77 Fed. Reg. 45,061, at 45,155 (July 30, 2012).  See Center for Medicare Advocacy, “CMS Invites Public Comment on Observation Status” (Weekly Alert, Aug. 9, 2012), http://www.medicareadvocacy.org/2012/08/09/3805/.[2] 42 C.F.R. §409.30(a)(1).[3] 77 Fed. Reg. 68,209, at 68,433 (Nov. 15, 2012).[4] See Center for Medicare Advocacy, “Brown University Confirms Observation Continues to Replace Hospital Admission Status,” (June 7, 2012), http://www.medicareadvocacy.org/2012/06/07/brown-university-confirms-observation-continues-to-replace-hospital-admission-status-2/  (discussing study confirming increases in the number and length of outpatient observation stays).[5] In proposed rules updating prospective payment rates for skilled nursing facilities under Medicare published in 2005, CMS asked if observation time should be counted towards meeting the three-day qualifying hospital stay requirement for subsequent Medicare coverage of care in a SNF.  70 Fed. Reg. 29,069, at 29,098 (May 19, 2005).  In the final rules, while acknowledging that most commenters supported such a change, CMS declined to change its policy, saying it was “continuing to review this policy.”  70 Fed. Reg. 45,025, at 45,050 (Aug. 4, 2005).[6] 77 Fed. Reg., at 68,427.[7] 77 Fed. Reg., at 68,428.[8] 77 Fed. Reg. 45,061, at 45,155 (July 30, 2012); 77 Fed. Reg. 68,209, at 68,428-429 (Nov. 15, 2012).[9] The American Hospital Association v.Sebelius, Case No. 1:12-cv-1770 (D.D.C. filed Nov. 1, 2012), http://www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf.[10] Bagnall v. Sebelius, No. 11-1703 (D. Conn., filed Nov. 3, 2011), http://www.medicareadvocacy.org/2012/08/17/bagnall-v-sebelius-no-11-1703-d-conn-filed-november-3-2011/.

Repeat testing common among Medicare patients

By Genevra Pittman

NEW YORK | Mon Nov 19, 2012 4:07pm EST

NEW YORK (Reuters Health) - In a new study, up to half - or more - of older adults on Medicare who had a heart, lung, stomach or bladder test had the same procedure repeated within three years.

Those tests typically aren't supposed to be routinely repeated, researchers said. For some of them, such as echocardiography and stress tests for heart function, there are recommendations specifically against routine testing.

"What we were struck by is just how commonly these tests are being repeated," said Dr. H. Gilbert Welch, lead author of the report from the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, New Hampshire.

"Either these patients continually develop new problems or there are doctors who routinely repeat tests."

Extra testing can burden the health care system with costs and may lead to incidental findings and unnecessary treatment for patients, Welch told Reuters Health.

He and his colleagues looked at the use of six kinds of test - echocardiography (ultrasound of the heart), stress tests, lung function tests, chest CT scan, cystoscopy (examination of the bladder with a scope) and upper endoscopy (examination of the upper GI tract) - among 743,478 older adults with fee-for-service Medicare coverage.

All of those tests are diagnostic, meaning they would typically be done on people with symptoms to help doctors make a diagnosis. They range in price from about $200 to over $1,000.

Between 2004 and 2006, anywhere from seven percent (cystoscopy) to 29 percent (echocardiography) of the Medicare beneficiaries in the study had each of those tests at least once.

And those exams were all commonly repeated: 35 percent of the people who had an upper endoscopy had another within three years. Of those who had an echocardiogram, 55 percent had a repeat echocardiogram. Repeat rates for the other tests fell somewhere in between.

The average time between multiple tests was anywhere from four to 14 months, according to findings published Monday in the Archives of Internal Medicine.

Welch said the only time repeat tests make good medical sense is when patients develop a new set of symptoms that doctors want to check out after the first test. But for physicians, financial incentives typically support more frequent testing, no matter what the purpose.

With an echocardiogram, for example, "If the cardiologist is the one that's ordering and going to interpret it… there probably is a financial incentive to overuse that test," said Dr. Rachel Werner, a health policy researcher from the University of Pennsylvania in Philadelphia.

"The fact is, we are paid more to do more," Welch said. And that's not always the best thing for the people getting tested.

"Patients have understood the importance of not having unnecessary medications. But I think the general sense is, ‘Well, a diagnostic test can never hurt you,'" Welch said.

But, he added, "Whenever we do a diagnostic test, we're at risk to be distracted by an incidental finding." Those findings can lead to more tests and possibly unnecessary treatments.

"Patients get in this cascade of events of new things to worry about and subsequent procedures," Welch said.

His team also found that metropolitan areas that did more of the initial diagnostic tests to begin with also had higher rates of re-testing.

Werner, who was not involved in the new study, said policies written into the Affordable Care Act will emphasize outcomes over number of procedures, in an attempt to balance quality and cost.

In the meantime, she recommended the Choosing Wisely initiative website (), which has lists compiled by medical specialist societies of particular tests that patients should question.

"You should always speak up to your physician," Werner told Reuters Health. "It's very hard often for patients to do that, because of the dynamics of the relationship, but they should always feel that that's part of their right, to be able to question what their physician is doing."

SOURCE: bit.ly/MbBLbb Archives of Internal Medicine, online November 19, 2012.

DOJ Seeks Coventry Health Bid Info Amid Industry Consolidation

Fri, Nov 09 2012 00:00:00 E 00_WEBBy James Detar, Investor's Business Daily

 Posted 11/09/2012 07:05 PM ET

Aetna (AET) said Friday its proposed $5.6 billion acquisition of Coventry Health Care (CVH) has come under increased scrutiny by Justice Department antitrust regulators, who asked the companies for more information related to their deal.

The country's third-largest health insurer, with 18.2 million members, Aetna is seeking to add Coventry's nearly 1 million members in its Medicaid business and about 250,000 in Medicare Advantage.

With the election settled, ObamaCare is expected to continue to roll out, bringing millions more people under the government-funded Medicare and Medicaid programs that provide medical care to older people and those without funds.

Aetna still expects to close the deal in mid-2013.

Neither Aetna nor Coventry were immediately available to comment.

Aetna shares fell less than 1% Friday to 42.12. Coventry dipped fractionally, to 42.91.

Elsewhere in the Medical-Managed Care group, ranked No. 18 on the list of 197 industry groups IBD tracks, giant WellPoint (WLP), with more than 34 million members, edged up 0.3% to 56.16.

WellPoint is also in the midst of a proposed acquisition, seeking to buy health insurer Amerigroup (AGP). It received a request from antitrust regulators in September for additional information related to the deal. It said it would sell its managed care operations in Virginia as part of the purchase.

WellPoint reported Wednesday that third-quarter profit grew 18% to $2.09 a share, beating forecasts by 25 cents. Revenue slid 2% to $15.13 billion, falling short of Wall Street's outlook for $15.31 billion.

Humana (HUM), which was downgraded by Goldman Sachs this week, fell 0.6% Friday to 68.77.

UnitedHealth Group (UNH) slid 1% to 52.90 and Cigna (CI) closed down 1.1% at 51.65

Today's Datapoint

More than
$500 billion … in U.S. health care costs over the next two decades will result from the 40% of Americans who are expected to be obese by 2030, according to the CDC.

Stay Focused on the Big Picture

by Harvey Mackay

A reader once sent me an email thanking me for a column I had written on getting outside the box. She told me how she had lost focus for a while, but had turned things around. She encouraged me to write a column on staying focused.

I immediately thought of my varsity golfing days at the University of Minnesota many years ago. Back then The Saint Paul Open was one of the top tournaments on the men’s professional golf circuit. Prior to the tournament, I had a chance to meet Gary Player when he was taking a lesson from our team coach, Les Bolstad. Later that evening I went to dinner with the world’s future No. 1 player when he was still an unknown.

The following day at The Saint Paul Open, I saw Gary after he teed off the first hole and ran up to him to say hi. I wanted to tell him what a great time I had the night before. His steely eyes remained focused on the fairway ahead and he never broke stride. “Harvey, please don’t talk to me. I must concentrate. I will see you when I’m finished.”

I remember how devastated I felt, but I learned a valuable lesson on focus. Many years later, when he was world famous, my wife, Carol Ann, and I ran into Gary and his wife in South Africa. I reintroduced myself and reminded him of what happened on the golf course. Gary’s wife told me, “Don’t feel bad. He doesn’t even talk to me on the golf course.”

That’s the focus that it takes to do your best. If you have the ability to focus fully on the task at hand, and shut out everything else, you can accomplish amazing things.

Arnold Palmer, another golfing legend, recalled a tough lesson he learned about focus in Carol Mann’s book The 19th Hole:

It was the final hole of the 1961 Masters tournament, and I had a one-stroke lead and had just hit a very satisfying tee shot. I felt I was in pretty good shape. As I approached my ball, I saw an old friend standing at the edge of the gallery. He motioned me over, stuck out his hand and said, “Congratulations.” I took his hand and shook it, but as soon as I did, I knew I had lost my focus. On my next two shots, I hit the ball into a sand trap, then put it over the edge of the green. I missed a putt and lost the Masters. You don’t forget a mistake like that; you just learn from it and become determined that you will never do that again. Trust me, your friends will understand!

A response Babe Ruth once gave to a reporter sticks in my mind: “How is it,” the Babe was asked, “that you always come through in the clutch? How is it you can come up to bat in the bottom of the 9th, in a key game with the score tied, with thousands of fans screaming in the stadium, with millions listening on the radio, the entire game on the line and deliver the game winning hit?” His answer, “I don’t know. I just keep my eye on the ball.”

In other words: Focus.

How many times have you heard an athlete talk about focus? It’s a topic I also hear about frequently in business. The most common complaints?

Too many irons in the fire. Too many projects spinning at one time. Too many interruptions. Too many phone calls. Too many emails. Too many things to do. Too little time.

The late Peter Drucker, management consultant and author, observed, “When you have 186 objectives nothing gets done. I always ask, ‘What’s the one thing you want to do?’ In Mexico they call me Senor Una Cosa.” (Translation: Mister One Thing)

Decide what’s most important. Make a list every day or every week and prioritize your activities. Scale back the amount of time you spend on meetings; they can be the biggest time-wasters of all. Learn to delegate, and make sure all members of your team follow through on assigned tasks.

Set aside a specific time of day to return phone calls and emails, and keep distractions to a minimum. In other words, set rules about how others use your time. And if you’re not the boss, work with your supervisor to make sure you agree on priorities.

Stay focused as best you can, and don’t let things happen to you—not when you can make things happen.

Mackay’s Moral: The person who is everywhere is nowhere.