Talking Health

The NYTimes has an op-ed today outlining discrepancies and gross abuse of Medicare Part D and Medicare. The author, a former presidential speechwriter (which means he’s a very clear writer, but not necessarily in a position of power in the health care reform movement), goes after the lack of caps on direct gov’t subsidies to insurers and the loopholes/flaws endemic to the 2003 drafting of legislation that allowed abuse.
It could serve as an intriguing and brief primer for common readers not versed on what exactly is wrong with Medicare’s current financing structure.

The fact that healthcare has become expensive and unequal in terms of who is covered and the services that are provided is a given. With the growth of umpteen insurance plans with neverending complex terminology, healthcare is a virtual mess of options. One plan, designed for the growing aged population, is Medicare. It is designed so that all Americans 65 or older receive basic healthcare. However, the reality is, as with most healthcare is that Medicare costs are ballooning out of control and the per state bill for Medicare depends on which part of the country you live in (Medicare Spending Still Varies By Region).

Furthermore, Medicare is plagued by what seems like the mantra of modern medicine. The more doctor to patients visits and costly procedures can be performed, the more that I can bill. Unfortunately, its not all the fault of patient care providers. The medical billing system trains patient caretakers to do work that can be somehow quantified. Doctors could spend countless hours and often do spend a lot of time with patients as health counselors but that is not billable beyond an office visit. So, maybe there needs to be a paradigm shift in medicine from seeing the patient as often as possible and referring for as many tests as possible to preventative therapy.  There should be an incentive for doctors to keep their patients out of their waiting rooms, hospitals, and off prescription medication.

Obama has a universal health plan not much unlike his Democratic predecessors Hillary Rodham Clinton and John Kerry that would provide Universal Health Care. The idea of universal health care, is great in theory, but unfortunately the dollars and cents just don’t add up. There are an estimated 46 million Americans without healthcare and that number is growing by the day. Obama hopes to free up around $600 billion dollars that would go in a health reform reserve that he hopes to create off more taxation from the wealthiest Americans and unnecessary payouts to the Medicare Advantage Plan (which would lessen the profits for insurance companies, drug companies. and healthcare providers). Unfortunately, this money is still not enough to cover uninsured Americans and Obama is leaving most of the details of his health plan as well as many others to Congress to flesh out. This, of course, will leave lobbyists, special interest groups, and the lawmakers that serve them in a bitter fight which could stall progress on any sweeping changes.

However, despite all of the money set aside for healthcare and Obama’s vow to keep Medicare honest by refusing to pay for medical mistakes and reducing payouts overall to cut down on unnecessary procedures and pill pushing, it appears that he glosses over one important detai. Healthcare is one of the costliest expenditures in America and it according to the New York Times article with the link “health reform reserve,” it is driving future projections of unsustainable deficits. In other words, there is no quick fix to making healthcare more efficent and cost-effective. The complexity of the healthcare system as well as the endless overhead make it virtually impossible to effectively track dollars and cents or lessen the overall cost of say, an emergency room visit, an inpatient visit, or an outpatient visit. Furthermore, the government only regulates to parts of insurance, Medicaid (for the low income) and Medicare (for the aged). Unfortunately, it seems that cutting costs cannot be selective. Either the government must regulate all of healthcare or none of it. As long as healthcare is left to private insurers on an individual basis, the urge to profit will never subside. Especially, in this economy, most things are thought of as a business. Healthcare is really a business and most of the insurance companies are run in such a way that they are sustainable even in tough times. This comes at great cost to the individual as well as the collective because a largely uninsured populous is disadvantageous to world development but, sadly, even one’s health and well-being (what seems a universal right), is reduced to whether the bottom line is black.

The NYT’s New Old Age blog often mentions Medicare. This post talks about the “comparative effectiveness research” proposed by the Obama administration.  The comments by readers are interesting – recent stories about elderly relatives and their experiences with Medicare, tied in with (possibly) unnecessary tests and procedures.

Medicare Part A
helps cover your inpatient care in hospitals, critical access hospitals and skilled nursing facilities. It also covers hospice care and some home health care.

Explanation of Medicare Part A

Medicare has several parts to consider when making your health care insurance choices. Understanding Medicare and how it works will allow you to choose the best plan to fit your needs. One part of the Medicare program is called Part A. Most people do not have to pay a premium for Part A because the individual or their spouse paid Medicare taxes while working. Others can buy Part A if they meet certain criteria. Below is an explanation of Medicare Part A and the coverage received under this plan. Use this information to decide if Part A is for you.
What is Part A?

Medicare Part A is a type of hospital insurance provided by Medicare. The coverage provided by Part A includes inpatient care in hospitals, nursing homes, skilled nursing facilities, and critical access hospitals. Part A does not include long-term or custodial care. If you meet specific requirements, then you may also be eligible for hospice or home health care.

Fiscal Intermediaries handle the claims for the Medicare Part A plan. These are private insurance companies that act as agents for the federal government in processing and paying Medicare claims.
What does Part A Cover?

Before learning about what Part A covers, you should also know that Medicare does not cover everything, nor does it cover the total cost for many of the covered services or medical supplies. Coverage amounts are based on which Medicare plan you have. Part A helps cover only the medically necessary services below:
Blood Transfusions

This is blood (pints) that you receive during a covered stay in a hospital, critical access hospital, or a skilled nursing facility.
Hospital Stays

Part A covers hospital stays, which includes a semi-private room, meals, general nursing, and miscellaneous hospital services and supplies. Inpatient care in critical access hospitals and mental health care (up to 190 lifetime maximum) are also covered. Hospital stays must be at least 3 days (72 hours). The time begins the first midnight after admission and does not include any hours on the discharge date.
Nursing Home or Skilled Nursing Facility

Nursing home or skilled nursing facility stays must be related to diagnosis during a hospital stay. For instance, your hospital stay was for a stroke. Then, a nursing home or skilled nursing facility stay for rehabilitation would be covered. A nursing home or skilled nursing facility stay includes a semi-private room, meals, and rehabilitative and skilled nursing services and care.

The coverage is limited to a maximum of 100 days in a benefit period. The first 20 days are paid in full, and the remaining 80 days will require a co-payment. Medicare Part A will not cover long-term care, non-skilled, daily living, or custodial activities.
Home Health Services

Home health services include limited reasonable and only medically necessary part-time care and services such as skilled nursing care, physical or occupational therapy, home health aide service, speech language pathology, and medical social services. It also includes certain home-use medical equipment (wheelchairs, hospital beds, walkers, oxygen), and other medical supplies.
Hospice Care

Hospice care is for the terminally ill who have six months or less to live. Coverage includes pain relief and symptom control drugs, medical and support services, grief counseling, and other services. Care is provided by a nearby, Medicare-approved Hospice caregiver who will visit you at your home. Medicare also provides additional care for a Hospice patient so that the usual caregiver can take a time of rest. Medicare does not cover many of the services that are provided to patients who receive Hospice assistance.

Medicare Part B
Medicare Part B helps cover your doctors’ services, outpatient hospital care, and some other medical services that Medicare Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Medicare Part B helps pay for these covered services and supplies when they are medically necessary.

Explanation of Medicare Part B

Medicare has several parts to consider when making your health care insurance choices. Understanding Medicare and how it works will allow you to choose the best plan to fit your needs. One part of the Medicare program is called Part B.
Part B Premiums

Most people have to pay a premium for Part B. You can check to see if you are qualified to receive help from your state to pay for premiums or deductibles. Otherwise, the premium is usually deducted from a Social Security, Railroad Retirement or Civil Service Retirement check. The Part B premium can also be paid every quarter or through the electronic payment option, or Medicare Easy Pay. Premiums will be based on income beginning January of 2007.
What is Part B?

Medicare Part B is a medical insurance provided by the federal government to eligible beneficiaries. The coverage provided by Part B includes medically necessary doctor’s services, outpatient care, and most other services that Part A does not cover such as some physical or occupational therapies and some home health care services. Part B covers preventive services as well.
What does Part B Cover?

Medicare Part B covers many services, tests, preventive treatments, etc. that are common among health care patients, but are not covered in the Part A plan. Though many services and products are covered, keep in mind that Part B is still not a 100% insurance coverage plan. So, as with any other insurance policy, you should understand the plan and coverage completely upon enrolling. Part B helps cover only the medically necessary services listed below:

* Tests, Labs and Screenings
* Preventive services include exams, lab tests, or screening inoculations that will help prevent, manage, or diagnose a medical problem.
* Glaucoma tests are covered once per year if performed by a legally authorized eye examiner.
* Bone mass measurement is covered every two years (or as medically necessary). This is to see if you are at risk for broken bones.
* Lab Services such as blood tests or urinalysis are covered.
* Colorectal cancer screenings to find any pre-cancerous growths. Tests may include (a) annual fecal occult blood test, (b) flexible sigmoidoscopy (every four years), (c) screening colonoscopy (every ten years), or (d) barium enema (every four years).
* Diabetic screenings are covered if you have high blood pressure, dyslipidemia, obesity, or high blood sugar.
* Diabetic supplies covered include monitors, test strips, lancet devices, and therapeutic shoes.
* Diabetic self-management training is covered if prescribed by your doctor
* Cardiovascular screenings to help prevent heart attack or stroke are covered. A screening consists of testing your triglyceride, lipid, and cholesterol levels every five years.

Doctor, Hospital and Home Health Care

* Home health services include limited reasonable and only medically necessary part-time care and services such as skilled nursing care, physical or occupational therapy, home health aide service, speech language pathology, and medical social services. It also includes certain home use medical equipment such as wheelchairs, hospital beds, walkers, oxygen equipment, and other medical supplies.
* Chiropractic services will be covered if it is to correct one or more of the bones that has moved out of place in your spine subluxation).
* Ambulance services are covered if any other form of transportation would endanger your health.
* Blood (pints) that you receive during an outpatient visit or another Part B covered service.
* Clinical trials may be covered if it will help to diagnose, prevent, or treat diseases.
* Ambulatory surgery center fees are covered for approved services.
* Emergency room services for bad injuries, severe illness, or any time you believe your life is in danger
* Doctor services do not include routine physical exams except the one time “Welcome to Medicare” exam.
* Eyeglass coverage is limited to one pair of glasses and standard frames after cataract surgery.

Medicare Part C
Explanation of Medicare Part C

When considering your Medicare options, it is easy to get confused and overwhelmed. Relax and take one section at a time to gain an overall understanding. Knowing what Medicare is and how it works will help you to make the best decision. One option is called Part C, or Medicare Advantage Plan (like HMO or PPO).
What is Part C?

Medicare Part C combines your Part A and Part B options and must cover all medically needed services. The difference is that private insurance companies that are approved by Medicare provide this type of coverage. In most cases, Part C is a lower-cost alternative to the Original Medicare Plan, and providers usually offer extra benefits and include prescription drug coverage (Part D).

Part C plans often have networks, and you must use the doctors or hospitals that belong to the plan. These plans help you coordinate and manage your overall care. Part C includes specialized care for people who need a large amount of health care services. If you find yourself needing medical attention while traveling out of your plan coverage area, you will still be covered for emergency or urgent care services.
What Medicare Advantage (Part C) Plans are available?

There are several plans available for Medicare Advantage. The Part C plans include the following:

*Medicare Preferred Provider Organization (PPO) – You are able to see any doctor or specialist that you choose. If they are not in your PPO network, your cost will increase. You usually can see a specialist without a referral.

*Medicare Health Maintenance Organizations (HMO) – You are able to visit doctors in the HMO network only. In most cases, you will be required to have a referral to visit a specialist.

*Medicare Private Fee-for-Service (PFFS) – You are able to see any doctor or specialist, but they must be willing to accept the PFFS’s fees, terms, and conditions. You do not have to have a referral to see a specialist.

*Medicare Special Needs – These plans are designed for people with certain chronic diseases or other special health needs. These plans must include Part A, Part B, and Part D coverage.

*Medicare Medical Savings Account (MSA) – There are two parts to this plan:

(1) A high-deductible plan with which coverage won’t begin until the annual deductible is met.

(2) A savings account plan where Medicare deposits money for you to use for health care costs.
Do You Need Prescription Drug Coverage?

Most Part C plans already include prescription drug coverage (Part D). If your plan offers drug coverage, you have to take it. If you have a stand-alone drug plan, and your Medicare Advantage Plan already has one, you will not be able to keep the Part C coverage. If you already have a prescription drug coverage, then you may choose a plan that does not have the drug plan included.
Eligibility for Part C

If you join Part C, you will still be in the Medicare Program and will have complete Part A and B coverage. You will continue to have Medicare rights and protection and in most cases, you will have prescription drug coverage (Part D) included as well.

You can join Part C if you reside in the service area where you wish to join, if you already have Medicare Part A and B, and if you do not have End-Stage Renal Disease (with minor exceptions).
Medicare Part D
Explanation of Medicare Part D

After reading about Medicare plans A, B and C, you might still be wondering where prescription drug coverage comes in, or how can you insure coverage for your medications. You’ll find the answer in this next Medicare plan, or the final plan offered through Medicare, called Part D.
What is Part D (Medicare Prescription Drug Coverage)?

Part D is prescription drug coverage insurance that is provided by private companies approved by Medicare. You need to enroll when you first become eligible to keep from paying a penalty cost later. Part D was designed to help people with Medicare to lower their prescription drug costs and to protect against future costs. A prescription drug plan will also enable you to have greater access to medically necessary drugs.
How Can You Get Part D Coverage?

There are two ways to join the Medicare prescription drug coverage plan. The first is by adding it to your Original Medicare Plan or some Medicare cost plans, private fee-for-service plans, and Medical savings account plans. The second way is to join an HMO or PPO plan that includes Part D coverage. You will usually have to pay a monthly premium that will vary according to the plan you choose.
Adding Part D to the Original Medicare Plan

If you are in the Original Medicare Plan, you may add Part D coverage. Generally, you will pay a separate premium or yearly deductible.
Adding Part D to the Medicare Advantage Plan

If you are in the Medicare Advantage Plan, then chances are you already have Part D coverage. However, a few plans do not include a drug plan; therefore, you may add Part D to those plans.
How Part D Works

After you join, you will receive a membership card and materials via mail. You will pay a co-pay, co-insurance, or deductible when you use your card.

Some Part D plans have a “coverage gap.” A coverage gap means when you have spent a certain amount of money, you are responsible for paying the entire cost of prescriptions while you are in the gap until you reach the out-of-pocket limit. After you meet the out-of-pocket obligation, you will only have to pay a small co-pay or co-insurance for the remainder of the calendar year.
If you can’t afford Part D costs, you may qualify for additional help. Several programs are available to assist with covering additional costs such as Medigap or Medicaid if you meet the income and resource requirements.

If you already have coverage through a previous or current employer or union, you must contact your benefits administrator before you add or change your drug coverage. Joining Part D could result in the loss of your employer or union health or prescription coverage.

Long-term care

A Quick Overview of Hospice

When you or a loved one becomes a Hospice patient, the last thing you’ll want to worry about is insurance coverage. The final stages of a fatal disease can devastate a family mentally, emotionally, physically, and financially. Hospice care is available under Medicare Part A to help ease the burden for a family in all four of the above areas.

It is critical that a family has this coverage when a loved one reaches the final stages of cancer, kidney disease, or other similar life-threatening diseases. The patient will usually need around-the-clock care at home during this time, and Hospice workers can help relieve the family of some of the care-giving burdens as well as provide proper health care assistance that only a medical professional could provide.

What is Hospice Care?

Hospice is a Medicare program designed to provide care in a person’s home for a person who has a terminal disease. A Medicare-approved Hospice will administer reasonable non-curative medical services and support for patients with a terminal illness. All services are designed to have a plan of care coordinated by the attending physician and the Hospice team.

Home and inpatient care are provided through Part A in addition to other services that are not otherwise covered by Medicare. A Hospice patient will no longer receive treatment to cure the illness. The Hospice program is designed to provide care and make the patient as comfortable and pain free as possible. The focus is to maximize the quality of life for each day the patient has remaining.

Hospice Eligibility

Not everyone is eligible for Hospice care. Certain requirements are laid out to ensure that only the patients and families who truly need Hospice services will receive them. The Hospice eligibility requirements are listed below.

• The patient must be eligible for Medicare Part A.
• A physician must certify that a person is terminally ill with a six-months or less life expectancy.
• The patient is required to sign a statement acknowledging that they want Hospice care instead of standard Medicare benefits.
  • Biologicals or Drugs – 5% of prescription cost with a $5.00 maximum.
  • Respite Care (inpatient)- 5% and may vary slightly with a five-day maximum stay.

How Long Can a Person Receive Hospice Care?

Hospice care receives a special benefit period. The benefit period does not have to be consecutive. You can choose care for two three-month periods followed by unlimited two-month periods. The only requirement is that the patient is certified as a Hospice patient at the beginning of each period.Hospice care can be altered once each benefit period. Hospice care may be cancelled at any time, and the patient may return to the standard Medicare benefits; however, any days remaining in that period will be lost. If later the patient wants to return to the Hospice care program, he/she may do so during the next benefit period. The exception to this is if the patient keeps the Medicare Part B plan. Part B may in this case be used for other services as long as they do not relate to the terminal illness.

What Does the Medicare Hospice Program Cover?

The Hospice program covered by Medicare includes physician services, intermittent 24-hour, on-call nursing care, any illness related medical appliances or supplies, and pain and symptom management outpatient drugs. The program also includes acute short-term and respite care, homemaker and home health aide services. Other services provided are physical and occupational therapy, speech-language pathology, medical social services, and counseling. Any and all services related to the treatment of the terminal illness have to be covered as well.

What the Medicare Hospice Program Does NOT Cover

There are some limitations to Hospice coverage. The treatments Medicare will not pay for include any treatment that is not for pain or symptom management. It also will not pay if the patient has an additional health care provider that covers the same services that Hospice provides.

What Are the Patient’s Out-of-Pocket Expenses?

Your Medicare plan will pay the Hospice expenses. Costs will vary depending upon the care required. The patient will be responsible for the following:

Since the start of Hospice services many years ago, families all over the United States have benefited tremendously from the program. It’s well worth looking into if you or a family member has been diagnosed with a terminal illness. It’s good to understand your eligibility status and how Hospice works beforehand so you will be prepared if tragedy strikes your family.

ALL INFORMATION COURTESY OF:

http://www.medicareconsumerguide.com/

The article in Newsday highlighting “Medicare for All” is intriguing, at least because it proposes an idea I’d never heard broached before as feasible. Saul Friedman sounds confident and the case he makes for HR 676 seems compelling. But I still feel like I’m missing – as in not grasping – something.
Firstly, how does an expanded Medicare program not equate with so-called “socialism”? The rhetoric means nothing to me and inspires no passionate anger and such, so I’m honestly, non-biasedly curious about the difference. 
Secondly, this proposal (HR676), as described by Mr. Friedman, would restrict the influence of private insurers so in the current political climate – in this country for that matter – is such a proposal even viable? How can it be made even a topic of discussion? 
Also, what reasons could there be for health care resources like the Kaiser Family Foundation to not have covered this proposal? Because it probably doesn’t stand a chance of passing? Or because they hadn’t heard of it? Or something I’m missing altogether?

On another note, I’m glad to have the difference between Medicare and Medicaid cleared up in my mind. It’s sad that I didn’t realize the difference earlier.

What kind of premiums might someone have to pay? How do these premiums compare to those charged by private insurance?

There is a lot of talk that Medicare fraud is a growing problem. How real and significant is Medicare fraud?

1.) Is there a measure to determine whether the average person 65 or older understands the coverage that he/she receives from Medicare?

2.) What kinds of claims does Medicare deny?

3.) There was a recent push to minimize the number of repeat and mistake procedures that Medicare pays for…has this been successful?

4.) Is Medicare considered a good insurance payer?

5.) Who came up with Medicare and why was it devised?

6.) How much more money would it take to expand Medicare to cover all age groups?

7.) How much money does Medicare cost per taxpayer?

8.) What are the major differences between Medicare and Medicaid besides the fact that Medicaid is for the very poor and Medicare is for the old?