States Can't Get Full Federal Funding for Partial Medicaid Expansion

Under the Affordable Care Act, states will be eligible for greatly increased federal-match payments beginning in 2014 if they expand their Medicaid programs to cover adults with incomes up to 133% of the Federal Poverty Level (FPL).  In a letter dated December 10, 2012, Secretary of Health and Human Services (HHS) Kathleen Sebelius said that states have "flexibility in Medicaid and the Children's Health Insurance Program (CHIP) to provide premium assistance for Exchange plans as well as to adopt 'bridge plans' that offer coverage through both Medicaid and Exchanges…"  The Secretary also noted, however, that flexibility is limited regarding federal funding for Medicaid expansion.  The Affordable Care Act, she stated, does not create an option for enhanced federal-match funding for a partial or phased-in Medicaid expansion.  In other words, states cannot partially expand their Medicaid programs and still receive 100% federal-match for two years, and 90% thereafter.

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2013 Medicare Cost-Sharing

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Hospital Deductible: $1,184 per spell of illness
Hospital Coinsurance:

• Days 0-60: $0
• Days 61-90: $296 / day
• Days 91-150: $592 / day

Skilled Nursing Facility Coinsurance

• Days 0-20: $0
• Days 21-100: $148 / day

Part A Premium (for voluntary enrollees only)

• With 30-39 quarters of Social Security coverage: $243 / month (no change)
• With 29 or fewer quarters of Social Security coverage: $441 / month

Part B

• Deductible: $147 / year
• Standard Premium: $104.90 / month

Part B Income-Related Premium

Beneficiaries who file an individual tax return with income:	Beneficiaries who file a joint tax return with income:	Beneficiaries who are married, but file a separate tax return with income:	Income-related monthly adjustment amount	Total monthly Part B premium amount
Less than or equal to $85,000	Less than or equal to $170,000	Less than or equal to $85,000	$0.00	$104.90
Greater than $85,000 and less than or equal to $107,000	Greater than $170,000 and less than or equal to $214,000		$42.00	$146.90
Greater than $107,000 and less than or equal to $160,000	Greater than $214,000 and less than or equal to $320,000		$104.90	$209.80
Greater than $160,000 and less than or equal to $214,000	Greater than $320,000 and less than or equal to $428,000	Greater than $85,000 and less than or equal to $129,000	$167.80	$272.70
Greater than $214,000	Greater than $428,000	Greater than $129,000	$230.80	$335.70

Part D Income-Related Premium Adjustment
Enrollees in Medicare Part D prescription drug plans pay premiums that vary from plan to plan.  Since 2011, Part D enrollees whose incomes exceed the same thresholds that apply to higher income Part B enrollees must also pay a monthly adjustment amount. The regular plan premium will be paid to their Part D plan, and the income-related adjustment will be paid to Medicare.  The base beneficiary premium for 2013 is $31.17.

Beneficiaries who file an individual tax return with income:	Beneficiaries who file a joint tax return with income:	Beneficiaries who are married, but file a separate tax return with income:	Part D Income-related monthly adjustment amount
Less than or equal to $85,000	Less than or equal to $170,000	Less than or equal to $85,000	$0
Greater than $85,000 and less than or equal to $107,000	Greater than $170,000 and less than or equal to $214,000		$11.60
Greater than $107,000 and less than or equal to $160,000	Greater than $214,000 and less than or equal to $320,000		$29.90
Greater than $160,000 and less than or equal to $214,000	Greater than $320,000 and less than or equal to $428,000	Greater than $85,000 and less than or equal to $129,000	$48.30
Greater than $214,000	Greater than $428,000	Greater than $129,000	$66.60

MRI May Tell Alzheimer's from Other Dementias

By Charles Bankhead, Staff Writer, MedPage Today

Published: December 27, 2012

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points

·         Three-fourths of patients in this study with Alzheimer's disease or frontal-lobe degeneration had MRI-detected biomarker levels that correlated with the diagnoses, suggesting MRI has potential as a screening tool for the conditions.

·         Note that the findings are consistent with previous in vivo and autopsy studies of CSF total tau and β-amyloid ratio (tt/Aβ).

Three-fourths of patients with Alzheimer's disease or frontal-lobe degeneration had MRI-detected biomarker levels that correlated with the diagnoses, suggesting MRI has potential as a screening tool for the conditions, investigators reported.

MRI-predicted values for total tau and β-amyloid ratio (tt/Aβ) in gray matter correctly pinpointed the diagnosis in 75% of patients with genetically or neuropathologically confirmed diagnoses, according to Corey McMillan, PhD, of the University of Pennsylvania in Philadelphia, and colleagues. Predicted values also had good correlation with actual tt/Aβ measured in cerebrospinal fluid (CSF), they said.

The findings are consistent with previous in vivo and autopsy studies of CSF tt/Aβ, the group reported in the Jan. 8 issue of Neurology.

"Specifically, MRI-predicted and actual CSF tt/Aβ values are highly correlated, predicted tt/Aβ accurately defines the anatomic distribution in Alzheimer's disease and frontotemporal lobar degeneration (FTLD), and predicted tt/Aβ values are reasonably accurate for classifying individual patients as having Alzheimer's disease or FTLD pathology," they wrote.

"This study establishes empirical evidence that an MRI-based technique can predict a single, biologically valid level of CSF tt/Aβ. This may contribute to diagnosis and treatment trials of neurodegenerative conditions by screening for individuals requiring a more invasive diagnostic lumbar puncture," they added.

Measurement of tt/Aβ in CSF has demonstrated diagnostic accuracy for distinguishing between Alzheimer's disease and FTLD. However, the measurement requires lumbar puncture, which is invasive and problematic in situations that require repeated measurements, such as a clinical trial. An accurate, non-invasive alternative is needed, the authors noted.

Volumetric MRI has shown potential as an alternative to assessment of CSF tt/Aβ because of its ability to capture neuroanatomical features that distinguish Alzheimer's disease from FTLD.

The authors performed a prospective study to compare MRI-predicted versus actual CSF tt/Aβ in 185 patients with clinically diagnosed neurodegenerative disease. All patients underwent lumbar puncture, and CSF tt/Aβ showed a profile consistent with Alzheimer disease in 88 cases and other conditions in the remaining 97 patients.

The patients underwent volumetric MRI an average of 5 months after lumbar puncture.

The authors estimated MRI-predicted CSF tt/Aβ on the basis of the extent of gray matter atrophy. Comparison of predicted and actual CSF tt/Aβ showed significant correlation between the two measures (P<0.0001).

Next, investigators examined neuroanatomic features of the patients' gray matter to develop profiles associated with measured CSF tt/Aβ. Lower actual values for CSF tt/Aβ, indicative of FTLD, were associated with reduced gray matter density in the ventromedial prefrontal cortex, orbital frontal cortex, insula, thalamus, and anterior temporal cortex.

Higher CSF tt/Aβ values, associated with Alzheimer's disease, were associated with reduced gray matter density in posterior regions, including superior parietal cortex, precuneus, and occipital association cortex.

"A regression revealed a very similar distribution of reduced gray matter density associated with tt/Aβ levels predicted by MRI," the authors wrote. "Lower predicted tt/Aβ values, consistent with FTLD, were related to reduced gray matter density in frontal regions ... by comparison, higher predicted tt/Aβ values, consistent with Alzheimer's disease, were related to reduced density in posterior gray matter regions."

The investigators compared the predicted and actual tt/Aβ in a subset of 32 patients with known pathology (21 with FTLD, 11 with Alzheimer's), as determined by genetic mutations or detailed neuropathologic studies. Using a cutoff of -1.38 for actual tt/Aβ resulted in 91% sensitivity and 81% specificity for Alzheimer's disease and overall classification accuracy of 84%.

The authors reported that 17 patients were correctly identified as having FTLD, and 10 patients with Alzheimer's disease were classified correctly on the basis of actual tt/Aβ.

Using the same cutoff value, investigators repeated the calculations for MRI and found 75% overall accuracy for classification of the patients: 17 of 21 patients with FTLD and seven of 11 with Alzheimer's disease.

McMillan's group cautioned that the trajectory of disease may be a limiting factor for MRI-based CSF screening.

"While we demonstrate that the distribution of gray matter atrophy in Alzheimer's disease and FTLD is highly related to a distinct range of CSF tt/Aβ values, these biological changes may occur at different stages in the disease course," they said.

The authors of an accompanying editorial praised the work as another step forward in defining MRI's role in pathologic diagnosis.

"The results of McMillan et al are impressive," wrote Christian Habeck, PhD, of Columbia University in New York City and Jennifer Whitwell, PhD, of the Mayo Clinic in Rochester, Minn. "The clinical diagnoses of the patients with Alzheimer's disease and FTLD overlapped substantially, demonstrating utility for predicting pathology in clinically atypical patients in which diagnosis is the most challenging."

The study was supported by the Wyncote Foundation and NIH.

The authors reported no conflicts of interest.

The editorialists reported no conflicts of interest.

Primary source: Neurology
Source reference:
McMillan CT, et al "Can MRI screen for CSF biomarkers in neurodegenerative disease?" Neurology 2013; 80: 132-138.

Additional source: Neurology
Source reference:
Habeck C, Whitwell JL "Structural brain imaging and multivariate analysis enable virtual lumbar punctures" Neurology 2013; 80: 126-127.

http://www.medpagetoday.com/Geriatrics/Dementia/36628?utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&xid=NL_DHE_2012-12-28&eun=g350341d0r&userid=350341&email=john@thebrokerageinc.com&mu_id=5344066

Medicare Benefits Still At Risk in Deficit Talks

Policymakers continue to negotiate deficit reduction terms, and Medicare sits squarely in the midst of the debate. Some policymakers demand higher revenues through increased taxes on the wealthiest Americans. Others insist on major changes to earned benefits, like Medicare and Social Security. So, what could proposed changes mean for older adults and people with disabilities?

Raising the eligibility age: Some policymakers suggest raising the Medicare eligibility age from 65 to 67 in an effort to cut federal spending. Yet, estimates suggest that raising the age would increase costs for older adults, communities of color, blue collar workers and employers—totaling $11.4 billion in 2014. That’s two times more cost shifting than the anticipated savings to the government of $5.7 billion.

Medigap cost sharing: Some members of Congress propose limiting or prohibiting “first dollar coverage” in Medigap plans—a widely used form of supplemental insurance to Medicare. This increased cost sharing for Medigap plans would bring the most harm to those beneficiaries who have the greatest need for supplemental coverage—the sickest individuals with moderate incomes. As a result, many beneficiaries forced to pay more would forgo needed health care, resulting in poor health outcomes.

Benefit redesign: The most discussed redesign proposals would combine the Medicare Part A and Part B deductibles, implement a single coinsurance rate for health services, and create an out-of-pocket spending cap for beneficiaries. The benefit redesign proposals currently under discussion would increase costs for Medicare beneficiaries, providers, and other insurers. Instead of reducing the costs of services, the most discussed among these proposals merely shift costs to people with Medicare.

Income-related premiums: Some policymakers propose higher cost sharing for the wealthiest 25 percent of Medicare beneficiaries (individuals with annual incomes of $47,000 or couples with incomes of $94,000). According to the Kaiser Family Foundation, such proposals could lead higher-income beneficiaries to drop out of Medicare Part B, resulting in higher premiums for poorer and sicker beneficiaries who remain on Medicare. Already the Medicare Part B and Part D premiums are higher for beneficiaries with annual incomes above $85,000, or couples with incomes over $170,000.

Medicare Rights Center supports proposals that address the real spending problem—rising health care costs in the system overall—not cost-shifting proposals that place the burden of reducing the deficit on Medicare beneficiaries, half of whom live on annual incomes of $22,000 or less and are in no position to pay even more for their health care. 

Visit the Medicare Rights deficit reduction webpage

For Duals Initiatives, Washington Politics Are Upside Down

By James Gutman - December 14, 2012

There were all sorts of strange things occurring yesterday when the Senate Finance Committee held a hearing on initiatives for Medicare-Medicaid dual eligibles, and they may be pretty revealing about both duals and Washington politics. For one thing, the power in the hearing room went off and on for extended periods at least three times, prompting numerous snide comments about congressional inability to get anything done. But more significantly, the hearing showed again that it is Republicans who are the strongest supporters of the Obama administration’s duals initiatives.

Duals initiatives represent an area “in which we can achieve bipartisan agreement,” unlike other things in Washington these days, said the committee’s ranking minority member, Sen. Orrin Hatch (R-Utah). He also went out of his way to praise the director of the CMS duals office, Melanie Bella, for her “pragmatic” approach and the quick pace of getting the big duals demonstration ready. Referring to the current climate in Washington, Hatch later added, “I don’t want to continue to praise you for fear it might hurt you.”

Contrast that with the comments of Sen. Jay Rockefeller (D-W. Va.), who was partly responsible for getting the duals demonstration provision included in the health reform law but now has become a critic of its scope and speed. One problem with enrolling as many duals in a state in the demonstration as the duals office seems to be intending, said Rockefeller, is when that happens, it ceases to be a demonstration and instead “it’s the inevitable formulation of policy.”

What do you think is the likely outcome of these upside-down assessments of the duals program? Will it get derailed because of Democrats’ misgivings? Should it? Or can Washington perhaps make duals “the start of a beautiful relationship”?

Six Weeks Early, 2012-13 Flu May Spike Medical Costs for Medicaid, MA Plans

Reprinted from HEALTH PLAN WEEK, the most reliable source of objective business, financial and regulatory news of the health insurance industry.

By Patrick Connole, Editor

December 10, 2012 Volume 22 Issue 43

Although all health insurers are vulnerable to higher flu-related medical costs, Medicaid managed care organizations are likely to experience the most cost pressure from higher medical utilization rates, if a late November government report showing the 2012-2013 flu season six weeks ahead of schedule portends a severe winter for the ailment, market observers say.

Centene Corp. is one of the insurers in the crosshairs of a possible severe flu period, since its busiest Medicaid markets are in the Southern states where the Centers for Disease Control and Prevention (CDC) has detected early flu activity. ”This is the earliest in the regular season that influenza activity has reached the national baseline level since the 2003-2004 season,” CDC said in its report. This fact has some worried the flu season could be severe and prolonged.

“Centene’s membership has the highest overlap with the five states reporting high flu activity this year. These five states are Alabama, Louisiana, Mississippi, Tennessee and Texas,” said Scott Fidel, a securities analyst for Deutsche Bank, in a Dec. 4 investor’s note. He added that Centene has 1.1 million members in Louisiana, Mississippi and Texas, accounting for 45% of total enrollment. “When also including the two states with moderate flu activity, Georgia and Missouri, almost 1.5 million or nearly 60% of Centene’s members reside in states that are reporting moderate or high flu activity,” Fidel added.

Requests for comment from Centene on Fidel’s analysis went unanswered by HPW press time.

Although Fidel and other industry analysts say it is too early to draw any meaningful conclusions from the early flu activity’s impact on medical costs for Medicaid and Medicare Advantage (MA) operators, there is concern. “We believe this heightened flu activity has a positive read through for hospitals, while it creates more of a headwind to managed care and Medicaid in particular, given the disproportionate impact,” said Ralph Giacobbe, securities analyst for Credit Suisse, in a Dec. 4 investor’s note.

Matthew Coffina, a health care industry analyst at Morningstar, Inc., tells HPW that while the markets tend to overreact to reports like the November CDC assessment, infectious diseases “are one of the few correlated risks that can affect managed care,” akin to a hurricane or other natural disaster for a property insurer. The issue for Medicaid plans is that regardless of any flu-caused utilization spike, the margins are tight to begin with. “It is a low-margin business with low control over premium rates. There is little ability to adjust,” Coffina says.

Medicaid plans’ heightened vulnerability stems from the fact the flu attacks the elderly and young children in higher proportions than the rest of the population. An outbreak, or even a pandemic like the H1N1 flu seen in 2009, results in more doctor visits, more prescription drug purchases and more hospital admissions for Medicaid recipients, many of whom are in managed care plans. MA plans have the same risk from their elderly membership, analysts say.

Flu Vaccine May Ease Fears

Molina Healthcare Inc., another major managed care operator, is both cautious and optimistic about what the flu season may bring to its members. Michael Siegel, M.D., corporate vice president/medical director, tells HPW that predictions for a more severe-than-normal flu outbreak mean people must counteract the threat.

“Creating awareness and providing access are crucial when preparing for a tough flu season. As we do each season to reduce the impact, we remind our providers and members of the importance of getting the annual flu vaccine and we share additional ways to prevent both contracting and spreading the infection,” he says.

Precaution may be especially helpful this season since the flu vaccine is expected to work well against the 2012-2013 strain of influenza. “We believe that the full impact of the epidemic may be blunted because of the excellent match between this year’s flu vaccine and the flu viruses as well as the public’s increased awareness of the importance of vaccination,” Siegel adds.

Humana Inc.’s Concentra Health Services, a chain of 320 health care clinics, attacks the seasonal flu threat by doing outreach early in the season, primarily in September and early October, to drive awareness and encourage people to get an annual flu shot, Concentra spokesperson Matt Longman tells HPW. “Given the latest report from the CDC and our own clinical data, we are increasing our efforts to communicate the importance of getting a flu shot, which are available at all Concentra locations nationwide. This new information gives many the opportunity to get vaccinated before the peak of the season hits, which is usually in late January. But we continue to see flu visits increase in select states experiencing high concentration, and will likely see more MA and Medicare patients seeking treatment for influenza.”

Quote of the Day

“Patients who choose a market basket of brand-name drugs instead of clinically equivalent generic alternatives are being charged a higher premium for this decision than ever before. That larger-than-necessary cost is being shared across the member and the plan sponsor. Both can realize savings when members choose lower-cost therapeutically equivalent generic drugs.”

— Sharon Frazee, Ph.D., VP for research and new solutions at Express Scripts, told AIS’s Drug Benefit News.

Factoid

Price Inflation for Most Highly Utilized Brand-Name Medications Greater Than Overall for Consumer Goods

According to the Express Scripts Prescription Price Index, prices on a market basket of the most highly utilized brand-name medications increased 13.3 percent from September 2011 to September 2012, far outpacing the overall economic inflation level of 2.0 percent. During the same timeframe, prices of generic medications declined 21.9 percent. This 35.2 percentage point net inflationary effect is the largest widening of brand and generic prices since Express Scripts began calculating its Prescription Price Index in 2008.

During the first three quarters of 2012, spending on traditional medications decreased 0.6 percent over the same period in 2011, primarily driven by lower prices brought on by increased use of generic medications.

Express Scripts 2012 Q3 Drug Trend Quarterly
http://phx.corporate-ir.net/phoenix.zhtml?c=69641&p=irol-newsArticle&ID=1762296&highlight=