Aging In Place- Pre-hospice Care Helps Patients Stay Home

Among the growing number of tools and resources aiding consumers to "age in place" is "pre-hospice." Kaiser Health News recently published an encouraging article, Pre-Hospice" Saves Money By Keeping People At Home Near The End Of Life, that well explains the concept and its promise. 

The article first discusses the practical impediments consumers face in an effort to age in place:

"Most aging people would choose to stay home in their last years of life. But for many, it doesn’t work out: They go in and out of hospitals, getting treated for flare-ups of various chronic illnesses. It’s a massive problem that costs the health care system billions of dollars and has galvanized health providers, hospital administrators and policymakers to search for solutions."

According to the article, Sharp HealthCare, a San Diego health system, devised the pre-hospice program called Transitions as a way to fulfill patients' desire to stay home, keep them out of the hospital, provide necessary care in their home, and reduce the costs of care. Social workers and nurses from Sharp regularly visit patients in their homes to explain what they can expect in their final years, help them make end-of-life plans, and teach them how to better manage their conditions, illnesses, and diseases. Physicians track their health, and eliminate unnecessary medications and treatments.  Unlike hospice care, patients don’t need to have a prognosis of six months or less to live, and they receiving curative treatment for their illnesses - not just relief from symptoms.

Transitions was among the first of its kind, but now there are several such "home-based palliative care" programs around the country. They are part of a broader push to improve people’s health and reduce spending through better coordination of care and more treatment outside of hospitals. Palliative care focuses on relieving patients’ stress and pain as their health declines, and aims to maintain quality of life. For people with serious illnesses, such as cancer, dementia, and pulmonary and heart failure, the plan is to provide patients palliative care and then transition naturally to hospice care when necessary.  The 2014 report “Dying in America,” by the Institute of Medicine, recommended that all people with serious advanced illness have access to palliative care. 

Transitions is one of the many good ideas that has come from Kaiser Permanente. Nearly 20 years ago, Kaiser created a home-based palliative care program in California and later in Hawaii and Colorado. Studies by Kaiser and others found that participants were far more likely to be satisfied with their care and more likely to die at home than those not in the program. One of the studies found that 36 percent of people receiving palliative care at home were hospitalized in their final months of life, compared with 59 percent of those getting standard care. The overall cost of care for those who participated in the program was a third less than for those who didn’t. A more recent study confirms these conclusions. 

The article also discusses that although the need for such services is increasing, "not enough trained providers are available. And some doctors are unfamiliar with the approach, and patients may be reluctant, especially those who haven’t clearly been told they have a terminal diagnosis." 

Of course hanging over ever the entire health care industry is what becomes of the Affordable Care Act.  The Affordable Care Act  established new rules and pilot programs that reward the quality rather than the quantity of care, such as “accountable care organizations,” networks of doctors and hospitals that share responsibility for providing care to patients. These organizations also share the savings when they rein in unnecessary spending by keeping people healthier. Innovations such as these are helping to make pre-hospice and home-based palliative care a more viable option.

Preparing for Medicare Open Enrollment

Oct. 15 marks the start of Medicare's seven-week annual election period, when current beneficiaries can add, drop or switch prescription-drug plans and make other coverage changes.

In Medicare, individuals must choose one of two paths: original fee-for-service Medicare, or a federally subsidized Medicare Advantage plan, which typically operates like a health-maintenance or preferred-provider organization. Many who opt for traditional Medicare also purchase a private "Medigap" policy, as well as a separate prescription-drug policy, to patch holes in their coverage.

In recent years, Medicare Advantage plans have gained in popularity, in part because, when compared with a Medigap policy, they generally cover a wider array of benefits, often including prescription drugs and dental care. Many also charge lower premiums, but require members to use the plan's network of providers.

The Affordable Care Act has sparked fears that Medicare Advantage plans, which cover about 30% of Medicare beneficiaries, will raise premiums, reduce benefits and pare their networks of doctors and hospitals. The reason: Under the law, Medicare will reduce payments to Medicare Advantage plans by some $156 billion by 2022, to bring per-person payments in line with those of traditional Medicare.

Citing the ACA, the nation's largest Medicare Advantage insurer, UnitedHealth Group, has cut an estimated 10% to 15% of the doctors and hospitals from its nationwide network. Consumer advocates say the insurer targeted providers with the sickest and most expensive patients, leaving patients in the middle of treatments in the lurch. The company says the changes enable it to better coordinate care and denies that patients in the middle of treatments are adversely affected, extending exceptions to members in active treatment.

Because some of the cuts occurred at times of the year when patients are unable to switch plans, Sen. Sherrod Brown (D., Ohio) and Rep. Rosa DeLauro (D., Conn.) recently introduced legislation that would bar insurers from dropping providers outside of Medicare's annual open-enrollment period.

Because Medicare Advantage can change annually, it's important to examine your options during open enrollment, from Oct. 15 to Dec. 7.  You should call your providers to make sure they still participate in your plan.  You can also use the "Plan Finder" tool at medicare.gov to compare premiums, copayments and deductibles for Part D prescription-drug plans in your area.

During open enrollment, you can switch to either a Medicare Advantage plan or to traditional Medicare, which allows you to see any doctor who takes Medicare. From Jan. 1 to Feb. 14, Medicare Advantage participants may switch to traditional Medicare.

Medicare beneficiaries whose claims are denied should also know that, despite rising backlogs in Medicare's appeals system, two recent lawsuits indicate that those who press their cases have a good chance of success. The procedure differs depending on whether you're in traditional Medicare, a Medicare Advantage plan or a Part D prescription-drug plan. Typically, each appeal can be heard five times, the last time in a federal court.

Since 2010, success rates in the first two rounds of appeals of denied claims for home health-care coverage have plunged to 5% or less, according to a class-action lawsuit the nonprofit Center for Medicare Advocacy in Willimantic, Conn., filed on June 4 in the U.S. District Court in Connecticut against the Department of Health and Human Services, which oversees the agency that administers Medicare.

The center's director of litigation, Gill Deford, told the Wall Street Journal that consumers who want a "meaningful review of their Medicare claims" should continue to the third round of appeal—before an administrative law judge—where odds of success jump to 40% or more.

The average wait for a decision from an administrative law judge is 398 days, up from 95 days in 2009, according to HHS. In a federal lawsuit filed Aug. 26, also in Connecticut, the Center for Medicare Advocacy seeks to force the government to take steps so that appeals can be decided within the 90 days the Medicare statute requires.

When appealing, ask your doctor for a letter explaining why you need the treatment in question. Those who go before an administrative law judge may benefit from retaining a medical or legal advocate. Most State Health Insurance Assistance Programs provide free counseling.

This post is based upon a Wall Street Journal article which can be read here.

Is Health Care Reform Hazardous To Your Health?

Regardless of your position on the Affordable Health Care Act, it is at one time both fascinating, and troubling, to witness the scope and pace of the major transformations taking place in the medical system. The transition to greater utilization of Skilled Nursing Facilities for rehabilitation following expiration of Medicare Benefits has caused much concern, for example.

Now,  John C. Goodman, one of the nation’s leading thinkers on health policy suggests bluntly that some of these changes are hazardous to your health.  Mr. Goodman's opinions are worthy of consideration. He is a Senior Fellow at the Independent Institute and author of the widely acclaimed book, Priceless: Curing the Healthcare Crisis. The Wall Street Journal calls Dr. Goodman "the father of Health Savings Accounts."

Dr Goodman, in an article entitled, "Is Obamacare Hazardous to Your Health," and published 8/15/2014 in Forbes, writes:

The Obama administration wants to change the practice of medicine.  Marcus Welby is out. Working in teams is in – especially in large practices owned by hospitals. Along the way, doctors are being subjected to pay-for-performance protocols and other forms of managed/integrated/coordinated care. 

How is all that working?  Not well at all.

A new study, which will soon appear in Health Affairs, showed these unexpected results: Practices with 1-2 physicians had 33 percent fewer preventable hospital admissions than practices with 10-19 physicians. 

I say “unexpected” because virtually everyone in the health policy community has bought into the idea that good medicine is medicine practiced in teams – rather than solo – and it is medicine that centers on medical homes  and follows protocols where physicians are rewarded for the “value they create” not the number of things they do. “Value” of course is determined by some bureaucracy somewhere. 

When I say “everybody” has bought into this idea I really mean everybody who is anybody except for … well … except for doctors who actually treat real patients. Whereas two thirds of doctors worked in private practice a few years ago, more than half of all doctors work for hospitals today. Medicare pays doctors more for the same procedures if billed as a hospital employee than if billed directly by a solo practitioner, perhaps to encourage the demise of private practice. 

Yet the Health Affairs study couldn’t be clearer. Practices owned by hospitals had 50 percent more preventable admissions than practices owned by physicians (regardless of size). 

The larger practices as well as hospital-based practices made greater use of medical homes, were more likely to be rewarded by pay-for-performance formulas and did better on performance measures that focused on inputs, not outputs. So why were the results so bad?

For the full article, click here.

Medicaid Expansion Signups Hindered By Fear of Estate Recovery

A fear that the government will seize their house after they die is causing some people to not sign up for expanded Medicaid under the Affordable Care Act (ACA). A long-standing provision in Medicaid law allows states to recoup Medicaid costs by putting a claim on the home or other assets of older deceased Medicaid recipients.

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In 1993, Congress passed a law requiring that states try to recover from the estates of deceased Medicaid recipients whatever benefits they paid for the recipient's long-term care. But the law allows states to go further and recover all Medicaid benefits from individuals over age 55, including costs for any medical care, not just long-term care benefits.

The ACA gives states the option of expanding Medicaid eligibility to individuals and families with incomes up to 133 percent of the poverty line, and so far 26 states have taken this option. Now that more people are becoming eligible for Medicaid under the ACA, there are potentially more people who may have their houses (or other valuable assets) sold after they die to pay off Medicaid debt. People subject to this estate recovery would have to live in one of the 26 states, and their state would have to be recovering the costs of all Medicaid benefits, not just long-term care. Still, there are protections: the state cannot take a house if there is a surviving spouse, a child under age 21 or a child of any age who is blind or disabled.

According to the Washington Post, the realization that their house might be subject to estate recovery is giving some with low incomes second thoughts about signing up for Medicaid, even though not doing so will likely mean going without any insurance at all. ACA plans bought in the regular marketplace are not subject to estate recovery, but individuals who qualify for expanded Medicaid coverage are not able to get a subsidy to buy coverage in the marketplace. If someone doesn't want to be subject to estate recovery, there are two options: buy a plan from the marketplace without a subsidy, or buy no insurance at all.

In order to encourage people to sign up for Medicaid, both Oregon and Washington have changed their rules to allow estate recovery only for long-term care debt. In addition, advocates are asking the federal government for clarification on whether Medicaid estate recovery will apply to people who purchase expanded Medicaid coverage.  A spokesman for the Centers for Medicare and Medicaid Services told the Post, "We recognize [the] importance of this issue and will provide states with additional guidance in this area soon." 

For the Washington Post article, click here.

For more on Medicaid's estate recovery rules, click here.

California Doctor Shortage Frustrates Affordable Care Act

According to the Los Angeles Times, as California moves to expand healthcare coverage to millions of Californians under the Affordable Care Act, it faces a major obstacle: There simply aren't enough doctors to treat a crush of newly insured patients.

The obstacle, while acute in California, is not unusual.  There exist regional doctor shortages throughout the United States (see map), and these are likely to worsen.  The Association of American Medical Colleges estimates that there will be a shortage of 63,000 doctors by 2015 and 130,600 by 2025. The tidal wave of newly insured patients has to be served somehow and US Medical Schools and Residency Programs cannot supply anywhere near these numbers of new physicians in such a short time frame.

Some lawmakers want to fill the gap by redefining who can provide healthcare.  They are working on proposals that would allow physician assistants to treat more patients and nurse practitioners to set up independent practices. Pharmacists and optometrists could act as primary care providers, diagnosing and managing some chronic illnesses, such as diabetes and high-blood pressure.

For the complete article, click here.

Affordable Health Care Act Tackles Tooth Decay in 2014

The following is an abstract from Kaiser Heath News: 

Tooth decay is the most common chronic health problem in children. By the time they enter kindergarten, more than a quarter of kids have decay in their baby teeth. The problem worsens with age, and nearly 68 percent of people age 16 to 19 have decay in their permanent teeth, according to the Centers for Disease Control and Prevention. 

Starting in 2014, the Affordable Care Act requires that individual and small-group health plans sold both on the state-based health insurance exchanges and outside them on the private market cover pediatric dental services. However, plans that have grandfathered status under the law are not required to offer this coverage.

The requirement also doesn't apply to health plans offered by large companies, although they are much more likely to offer dental benefits than small firms. Eighty-nine percent of firms with 200 or more workers offered dental benefits in 2012, compared with 53 percent of smaller firms, according to the Kaiser Family Foundation's annual survey of employer health plans. (Kaiser Health News is an independent project of KFF.).

The changes in the health law apply specifically to children who get coverage through private plans. Dental services are already part of the benefit package for children covered by Medicaid, the state-federal health program for low-income people. But many eligible kids aren't enrolled, and even if they are, their parents often run into hurdles finding dentists who speak their language and are willing to accept Medicaid payments.

The health law encourages states to expand Medicaid coverage for adults, which advocates say will have the added benefit of probably bringing more children into the system. Despite the challenges, advocates say they anticipate that many low-income children will gain dental coverage.

Dental health advocates say they're pleased that pediatric dental services (along with other pediatric care) were included among the 10 "essential health benefits" that new health plans must cover in the exchanges and the small-group and individual markets under the law.

Go here to read the entire article.