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Nursing-home companies entering insurance business

By JORDAN RAU

For Kaiser Health News

Around the country, a handful of nursing-home companies have begun selling their own private Medicare insurance policies, pledging close coordination and promising to give clinicians more authority to decide what treatments they will cover for each patient.

These plans are recent additions to the Medicare Advantage market, where private plans have become an increasingly popular alternative to traditional fee-for-service coverage. Unlike other plans, these policies offered by long-term care companies often place a nurse in the skilled-nursing facility or retirement village, where they can talk directly to staff and assess patients’ conditions. Some provide primary-care doctors and nurses to residents in the homes or in affiliated assisted living facilities or retirement villages with the aim of staving off hospitalizations.

“The traditional model is making decisions based on paper, and in our model, these decisions are being made by clinicians who are really talking to the staff and seeing the patient,” said Angie Tolbert, a vice president of quality at PruittHealth, which began offering its plan to residents in 10 of its nursing homes in Georgia last year. “It’s a big shift in mindset.”).

Not everyone finds such plans superior. Some patients who are in disputes with the insurers have faulted the nursing home staff — who work for the same company — for not helping challenge decisions about coverage. They complain that the company holds an unfair advantage over Medicare beneficiaries.

“There’s a conflict there,” said Toby Edelman, a senior attorney with the Center for Medicare Advocacy.

In an Erickson Living retirement village in Silver Spring, Md., Faith Daiak signed up for an Erickson Advantage plan sold by a nurse whose office was in the main village building, according to her son, J.J. Daiak. After a bout with the flu last February weakened her enough to need a 10-day hospitalization, she was sent to her village’s skilled-nursing facility. There, the insurer repeatedly tried to cut short her stay.

Erickson Advantage first said it would stop paying for Daiak, 88, because she wasn’t getting healthier in the nursing facility. Her son appealed by pointing out that Medicare explicitly said as part of the 2014 settlement of a class-action lawsuit that patients do not have to be improving to qualify for skilled-nursing care.

Daiak’s appeal was denied, but the issue was sidelined in March when her rapid weight loss in the nursing home sent her back to the hospital, he said.

After Daiak returned to the nursing home with a feeding tube in her stomach, the insurer again tried to curtail her time there, saying she did not need that level of care. The family successfully appealed that decision after noting that Medicare’s manual said feeding-tube maintenance required the skilled care of a nursing facility.

In April, Erickson Advantage again said it would not continue paying for Daiak’s stay. It reversed that decision after Kaiser Health News asked the company about the case, J.J. Daiak said. He said the plan did not explain its turnaround.

Dolphine Williams (left) and Rita Coopersmith visit Faith Daiak in the Riderwood-ArborRidge Skilled Nursing Facility in Silver Spring, Md., on May 12, 2017. (Courtesy of the Daiak family)

While this Medicare Advantage plan touts its “team that knows you personally and wants to help,” J.J. Daiak said he found the registered nurse at Erickson’s Silver Spring community not helpful. “All I see is her trying to get Erickson out of having to pay for the nursing home,” he said. He subsequently switched his mother to traditional Medicare coverage with a supplemental Medigap policy, which she had until this year.

Erickson Living, the parent company of the nursing home and insurer, declined to discuss individual cases but noted that Medicare has given its insurance plans the best quality rating of five stars. In a written statement, the company said that “medical service determinations for Erickson Advantage members are based on reviews by licensed clinical staff and clinical guideline criteria. Our primary focus is always on ensuring that the healthcare being provided for our residents matches a patient’s needs and established clinical treatment protocols.”

Edelman said the dispute was particularly troubling because Erickson’s retirement villages are marketed on the promise that the company will care for seniors in all stages of aging. “They don’t tell you what they won’t pay for,” she said.

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There are nearly 18 million enrollees in the overall Medicare Advantage market. Medicare pays private insurers a set amount to care for each beneficiary. In theory, this payment method gives the insurers motivation to keep patients from needing costly medical services such as hospitalizations.

A subset of Medicare Advantage plans are designed exclusively for people who either require or are expected to require at least 90 days of skilled services from nursing homes, assisted living facilities or other long-term care institutions. UnitedHealthcare directly offers three-quarters of these plans with about 40,000 enrollees, far more than those offered by nursing-home companies. Matthew Burns, a UnitedHealth spokesman, said the majority of the company’s plans are rated four stars or better on Medicare’s five-star quality scale.

“Our plans offer members quality and peace of mind — and they are considered above average to excellent by CMS quality and performance standards,” he said in a statement.

United also underwrites Erickson’s policies, which have around 200 enrollees, and were the first Advantage plans offered by a long-term care operator. Under the arrangement, Erickson Advantage decides when a nursing home stay is covered.

Nick Williams, PruittHealth’s care integration officer, said its Medicare insurance plan has resulted in 30 percent fewer hospitalizations among residents since it began last year. The company intends to expand the insurance coverage to residents at 42 of its other nursing homes in Georgia. Other nursing-home chains are experimenting with this model in Missouri, South Carolina, Virginia and elsewhere.

Anne Tumlinson, a Washington healthcare industry consultant who specializes in long-term care, said that when a nursing home’s company is on the hook for the cost of hospitalizations of their patients, it is more likely to make efforts to prevent them.

“It gets them out of hospitalizing people at the drop of the hat,” she said. “If you live in a nursing home or are living in assisted living and they have one of these plans going, they’re going to be investing heavily in 24/7 access to primary care.”

She said big insurers have so many different types of enrollees that they are less focused on the particular needs of nursing-home patients. “They’re too big, they’re bureaucratic, and they are insurers, not providers,” she said.

The Costs Patients Face

In Hingham, Mass., Suzanne Carmick has been frustrated with the Erickson plan’s unwillingness to pay for most of her mother’s prolonged stay. Last October, 98-year-old Lorraine Carmick went into Erickson’s nursing home after a hospitalization. Eleven days later, Erickson Advantage notified Suzanne Carmick it would stop paying for the facility because it said her mother was strong enough to move with the help of a rolling walker. Under Medicare’s rules, nursing home stays are not covered if a patient does not need daily physical therapy. Erickson said two or three days was sufficient for Carmick.

Suzanne Carmick appealed the decision, saying Erickson exaggerated her mother’s recovery, noting that she had dementia, an infection and was wearing two stiff leg braces. She said getting therapy five days a week provided in the nursing home would help her mother recover faster.

“She still cannot stand up or sit down or go anywhere … without an aide helping her by pulling her up or setting her in a chair,” Carmick wrote. “She is improving but is now supposed to stop or decrease PT [physical therapy], and she must start paying out-of-pocket?”

After a week’s extension, the nursing home began billing her mother at its daily rate of $463, which rose to $483 this year as Lorraine Carmick remained in the nursing home. A Medicare appeals judge subsequently ruled Erickson’s action was justified, based on the testimony from the nursing-home staff — all Erickson employees. If the insurer had covered a maximum stay, Carmick would have avoided more than $30,000 in bills she now owes. Suzanne Carmick said her mother has been on a wait list for six months for a bed on a less expensive floor in the nursing facility.

“It is a closed system where the skilled-nursing facility, physicians and Medicare Advantage plan are all one and the same,” she said. “The Erickson Advantage plan is turning out to be quite a disadvantage at this point.”

 


Medicare Advantage doesn’t look all that good to some sicker seniors

By FRED SCHULTE

For Kaiser Health News

When Sol Shipotow enrolled in a new Medicare Advantage health plan earlier this year, he expected to keep the doctor who treats his serious eye condition.

“That turned out not to be so,” said Shipotow, 83, who lives in Bensalem, Pa.

Shipotow said he had to scramble to get back on a health plan he could afford and that his longtime eye specialist would accept. “You have to really understand your policy,” he said. “I thought it was the same coverage.”

Boosters say that privately run Medicare Advantage plans, which enroll about one-third of all people eligible for Medicare, offer good value. They strive to keep patients healthy by coordinating their medical care through cost-conscious networks of doctors and hospitals.

But some critics argue the plans can prove risky for seniors in poor or declining health, or those like Shipotow who need to see specialists, because they often face hurdles getting access.ils).

A recent report by the Government Accountability Office, the auditing arm of Congress, adds new weight to criticisms that some health plans may leave sicker patients worse off.

The GAO report, released this spring, reviewed 126 Medicare Advantage plans and found that 35 of them had disproportionately high numbers of sicker people dropping out. Patients cited difficulty with access to “preferred doctors and hospitals” or other medical care, as the leading reasons for leaving.

“People who are sicker are much more likely to leave (Medicare Advantage plans) than people who are healthier,” James Cosgrove, director of the GAO’s health care analysis, said in explaining the research.

David Lipschutz, an attorney at the Center for Medicare Advocacy, says the GAO findings were alarming and should prompt tighter government oversight.

“A Medicare Advantage plan sponsor does not have an evergreen right to participate in and profit from the Medicare program, particularly if it is providing poor care,” Lipschutz says.

The GAO did not name the 35 health plans, though it urged federal health officials to consider a large exodus from a plan as a possible sign of substandard care. Most of the 35 health plans were relatively small, with 15,000 members or fewer, and had received poor scores on other government quality measures, the report said. Two dozen plans saw 1 in 5 patients leave in 2014, much higher turnover than normal, the GAO found.

Medicare Advantage plans now treat more than 19 million patients, and are expected to grow as record numbers of baby boomers reach retirement age.

Kristine Grow, a spokeswoman for America’s Health Insurance Plans, an industry trade group, says Medicare Advantage keeps expanding because most people who sign up are satisfied with the care they receive.

She says that patients in the GAO study mostly switched from one health plan to another because they got a better deal, either through cheaper or more inclusive coverage.

Grow says many Medicare Advantage plans offer members extra benefits not covered by standard Medicare, such as fitness club memberships or vision or dental care, and do a better job of coordinating medical care to keep people active and out of hospitals.

“We have to remember these are plans working hard to deliver the best care they can,” Grow says. Insurers compete vigorously for business and “want to keep members for the long term,” she adds.

Some seniors, wary of problems ahead, are choosing to go with traditional Medicare coverage. Pittsburgh resident Marcy Grupp says she mulled over proposals from Medicare Advantage plans but worried she might need orthopedic or other specialized health care and wanted the freedom to go to any doctor or hospital. She’s decided on standard Medicare coverage and paid for a “Medigap” policy to pick up any uncovered charges.

“Everything is already in place,” says Grupp, a former administrative assistant who turns 65 this month.

The GAO report on Medicare Advantage comes as federal officials are ramping up fines and other penalties against errant health plans.

In the first two months of this year, for instance, the federal Centers for Medicare & Medicaid Services fined 10 Medicare Advantage health plans a total of more than $4.1 million for alleged misconduct that “delayed or denied access” to covered benefits, mostly prescription drugs.

In some of these cases, health plans charged patients too much for drugs or failed to advise them of their right to appeal denials of medical services, according to government records. Industry watchers predict more penalties are to come.

Last month, CMS officials ended a 16-month ban on enrollment in Cigna Corp.’s Medicare Advantage plans. CMS took the action after citing Cigna for “widespread and systematic failures” to provide necessary medical care and prescription drugs, policies officials called a “serious threat to enrollee health and safety.”

A flurry of whistleblower lawsuits have surfaced, too. In late May, Freedom Health, a Florida Medicare Advantage insurer, agreed to pay nearly $32 million to settle allegations that it exaggerated how sick some patients were to boost profits, while getting rid of others who cost a lot to treat.


Geisinger dramatically expanding geographical reach of its insurance

 

Danville, Pa.-based Geisinger Health System and Bethlehem, Pa.-based St. Luke’s University Health Network have agreed to extend Geisinger health plans to almost 50 Pennsylvania counties.

“The systems will share population and value-based payment model data and create a sponsored Medicare Advantage product to provide recipients access to services not covered under traditional Medicare and Medigap plans. In addition, more than 10,000 St. Luke’s employees will be placed on Geisinger’s health plan, effective Jan. 1,” reported Becker’s Hospital Review.

The development is one of the more dramatic demonstrations of hospital systems expanding insurance offerings to achieve the  cost efficiencies and customer loyalty that some systems see  as needed in the developing value-based world of healthcare.

“When you get to the heart of it, we are two organizations focused on taking the best care of patients and we’re excited to partner with a healthcare system that aligns with our vision and values,” said David Feinberg, M.D., Geisinger president and CEO. “Geisinger is thrilled to expand the scope of our relationship with St. Luke’s to advance population health, improve quality and provide better access to care.”

 

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But what does ‘single payer’ really mean?

By JULIE ROVNER

For Kaiser Health News

Healthcare has emerged as one of the flash points in the Democratic presidential race.

Vermont Sen. Bernie Sanders has been a longtime supporter of a concept he calls “Medicare for All,” a health system that falls under the heading of “single-payer.”

Sanders released more details about his proposal shortly before the Democratic debate in South Carolina Sunday night. “What a Medicare-for-All program does is finally provide in this country health care for every man, woman and child as a right,” he said in Charleston.

Sanders’s main rival for the nomination, former Secretary of State Hillary Clinton, has criticized the plan for raising taxes on the middle class and said it is politically unattainable.  “I don’t want to see us start over again with a contentious debate” about health care, she said Sunday night.

Some of the details of Sanders’s plan are still to be released. But his proposal has renewed questions about what a single-payer health care system is and how it works. Here are some quick answers.

What Is Single-Payer?

Single-payer refers to a system in which one entity (usually the government) pays all the medical bills for a specific population. And usually (though again, not always) that entity sets the prices for medical procedures.

Single-payer is not the same thing as socialized medicine. In a truly socialized medicine system, the government not only pays the bills but owns the health care facilities and employs the professionals who work there.

The Veterans Health Administration (VA) is an example of a socialized health system run by the government. It owns the hospitals and clinics and pays the doctors, nurses and other health providers.

Medicare, on the other hand, is a single-payer system in which the federal government pays the bills for those who qualify, but hospitals and other providers remain private.

Which Countries Have Single-Payer Health Systems?

Fewer than many people think. Most European countries either never had or no longer have single-payer systems. “Most are basically what we call social-insurance systems,” said Gerard Anderson, a professor at Johns Hopkins Bloomberg School of Public Health, who has studied international health systems. Social insurance programs ensure that almost everyone is covered. They are taxpayer-funded but are not necessarily run by the government.

Germany, for example, has 135 “sickness funds,” which are essentially private, nonprofit insurance plans that negotiate prices with healthcare providers. “So you have 135 funds to choose from,” Anderson said.

Nearby, Switzerland and the Netherlands require their residents to have private insurance (just like the Affordable Care Act does), with subsidies to help those who cannot otherwise afford coverage.

And while conservatives in the United States often use Britain’s National Health Service as the poster child for a socialized system, there are many private insurance options available to residents there, too.

Among the countries that have true single-payer systems, Anderson lists only two — Canada and Taiwan.

Are Single-Payer Plans Less Expensive Than Other Health Coverage Systems?

Not necessarily. True, eliminating the profits and duplicative administrative costs associated with hundreds of different private insurance plans would reduce spending, perhaps as much as 10 percent of the nation’s $3 trillion annual health care bill, Anderson said. But, he noted, once that savings is achieved, there won’t be further reductions in following years.

More important, as many analysts have noted, is how much health services cost and how those prices are determined. In most other developed countries, even those with private insurance, writes Princeton Health Economist Uwe Reinhardt, prices “either are set by government or negotiated between associations of insurers and providers of care on a regional, state or national basis.” By contrast, in the U.S., “the payment side of the health care market in the private sector is fragmented, weakening the bargaining power of individual insurers.”

Would Medicare For All Be Just Like The Existing Medicare Program?

No, at least not as Sanders envisions it. Medicare is not nearly as generous as many people think. Between premiums (for doctor and drug coverage), cost-sharing (deductibles and coinsurance) and items Medicare does not cover at all (most dental, hearing and eye care), the average Medicare beneficiary still devotes an estimated 14 percent of all household spending to health care.

Sanders’s plan would be far more generous, including dental, vision, hearing, mental health and long-term care, all without copays or deductibles (which has given rise to a lively debate about how to pay for it and whether middle-class families will save money or pay more).

Would Private Insurance Companies Really Disappear Under Sanders’s Plan?

Probably not. Private insurers are fully integrated into Medicare, handling most of the claims processing and providing supplemental coverage through “Medigap” plans. In addition, nearly a third of Medicare beneficiaries are enrolled in private managed care plans as part of the Medicare Advantage program.

Creating an entirely new federal claims processing structure would in all likelihood be more expensive than continuing to contract with private insurance companies. However, Sanders makes it clear  that insurers in the future would no longer be the risk-bearing entities they are today, but more like regulated utilities.


What’s in the House Medicare ‘doc fix’

By MARY AGNES CAREY, for Kaiser Health News

 

It’s make-or-break time for a Medicare “doc fix” replacement.

The House is likely to vote this week on a proposal to scrap Medicare’s troubled physician payment formula, just days before a March 31 deadline when doctors who treat Medicare patients will see a 21 percent payment cut. Senate action could come this week as well, but probably not until the chamber completes a lengthy series of votes on the GOP’s fiscal 2016 budget package.

After negotiating behind closed doors for more than a week,  Republican and Democratic leaders of two key House committees that handle Medicare unveiled details of the package late Friday. According to a summary of the deal, the current system would be scrapped and replaced with payment increases for doctors for the next five years as Medicare transitions to a new system focused “on quality, value and accountability.”

 

There’s enough in the wide-ranging deal for both sides to love or hate.

Senate Democrats have pressed to add to the proposal four years of funding for an unrelated program, the Children’s Health Insurance Program, or CHIP. The House package extends CHIP for two years. In a statement Saturday, Senate Finance Democrats said they were “united by the necessity of extending CHIP funding for another four years.”

Their statement also signaled other potential problems for the package in the Senate, including concerns about asking Medicare beneficiaries to pay for more of their medical care, the impact of the package on women’s health services and cuts to Medicare providers.

Still some Democratic allies said the CHIP disagreement should not undermine the proposal. Shortly after the package was unveiled Friday, Ron Pollack, executive director of the consumers group Families USA, said in a statement that “while we would have preferred a four-year extension, the House bill has our full support.”

Some GOP conservatives and Democrats will balk that the package isn’t fully paid for, with policy changes governing Medicare beneficiaries and providers paying for only about $70 billion of the approximately $200 billion package.

For doctors, the package offers an end to a familiar but frustrating rite. Lawmakers have invariably deferred the cuts prescribed by a 1997 reimbursement formula, which everyone agrees is broken beyond repair. But the deferrals have always been temporary because Congress has not agreed to offsetting cuts to pay for a permanent fix. In 2010, Congress delayed scheduled cuts five times. In a statement Sunday, the American Medical Association urged Congress “to seize the moment” to enact the changes.

Here are some answers to frequently asked questions about the proposal and the congressional ritual known as the doc fix. 

Q: How did this become an issue?

Today’s problem is a result of efforts years ago to control federal spending – a 1997 deficit reduction law that called for setting Medicare physician payment rates through a formula based on economic growth, known as the “sustainable growth rate” (SGR). For the first few years, Medicare expenditures did not exceed the target and doctors received modest pay increases. But in 2002, doctors were furious when their payments were reduced 4.8 percent. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size of the fix needed the next time.

The Medicare Payment Advisory Commission (MedPAC), which advises Congress, says the SGR is “fundamentally flawed” and has called for its repeal. The SGR provides “no incentive for providers to restrain volume,” the agency said.

Q. Why haven’t lawmakers simply eliminated the formula before?

Money is the biggest problem. An earlier bipartisan, bicameral SGR overhaul plan produced jointly by three key congressional committees would cost $175 billion over the next decade, according to the Congressional Budget Office. While that’s far less than previous estimates for SGR repeal, it is difficult to find consensus on how to finance a fix.

For physicians, the prospect of facing big payment cuts is a source of mounting frustration. Some say the uncertainty has led them to quit the program, while others are threatening to do so. Still, defections have not been significant to date, according to MedPAC.

In a March 2014 report, the panel stated that beneficiaries’ access to physician services is “stable and similar to (or better than) access among privately insured individuals ages 50 to 64.” Those findings could change, however, if the full force of SGR cuts were ever implemented.

“The flawed Sustainable Growth Rate (SGR) formula and the cycle of patches to keep it from going into effect have created an unstable environment that hinders physicians’ ability to implement new models of care delivery that could improve care for patients,” said Dr. Robert M. Wah, president of the American Medical Association. “We support the policy to permanently eliminate the SGR and call on Congress to seize the moment and finally put in place reforms that will foster innovation and put us on a path towards a more sustainable Medicare program.”

Q: What are the options that Congress is looking at?

The House package would scrap the SGR and give doctors a 0.5 percent bump for each of the next five years as Medicare transitions to a payment system designed to reward physicians based on the quality of care provided, rather than the quantity of procedures performed, as the current payment formula does.

The measure, which builds upon last year’s legislation from the House Energy and Commerce and Ways and Means Committees and the Senate Finance Committee, would encourage better care coordination and chronic care management, ideas that experts have said are needed in the Medicare program. It would give a 5 percent payment bonus to providers who receive a “significant portion” of their revenue from an “alternative payment model” or patient-centered medical home. It would also allow broader use of Medicare data for “transparency and quality improvement” purposes.

“The SGR has generated repeated crises for nearly two decades,” Energy and Commerce Committee Chairman Fred Upton, R-Mich., one of the bill’s drafters, said in a statement. “We have a historic opportunity to finally move to a system that promotes quality over quantity and begins the important work of addressing Medicare’s structural issues.”

The package, which House Speaker John Boehner, R-Ohio, and Minority Leader Nancy Pelosi, D-Calif., began negotiating weeks ago, also includes an additional $7.2 billion for community health centers over the next two years.  NARAL Pro-Choice America denounced the deal because the health center funding would be subject to the Hyde Amendment, a common legislative provision that says federal money can be used for abortions only when a pregnancy is the result of rape, incest or to save the life of the mother.

In a letter to Democratic colleagues, Pelosi said the funding would occur “under the same terms that Members have previously supported and voted on almost every year since 1979.” In a statement, the National Association of Community Health Centers said the proposal “represents no change in current policy for Health Centers, and would not change anything about how Health Centers operate today.”

The “working summary” of the House plan says the package also includes other health measures – known as extenders – that Congress has renewed each year during the SGR debate. The list includes funding for therapy services, ambulance services and rural hospitals, as well as continuing a program that allows low-income people to keep their Medicaid coverage as they transition into employment and earn more money. The deal also would permanently extend the Qualifying Individual, or QI program, which helps low-income seniors pay their Medicare premiums.

Q. What is the plan for CHIP?

The House plan would add two years of funding for CHIP, a federal-state program that provides insurance for low-income children whose families earned too much money to qualify for Medicaid. While the health law continues CHIP authorization through 2019, funding for the program has not been extended beyond the end of September.

The length of the proposed extension could cause strains with Senate Democrats beyond those on the Finance panel who have raised objections to the House package. Last month, the Senate Democratic caucus signed on to legislation from Sen. Sherrod Brown, D-Ohio, calling for a four-year extension of the current CHIP program.

Q: How would Congress pay for all of that?

It might not. That would be a major departure from the GOP’s mantra that all legislation must be financed. Tired of the yearly SGR battle, veteran members in both chambers may be willing to repeal the SGR on the basis that it’s a budget gimmick – the cuts are never made – and therefore financing is unnecessary. But that strategy could run into stiff opposition from Republican lawmakers and some Democrats

Most lawmakers are expected to feel the need to find financing for the Medicare extenders, the CHIP extension and any increase in physician payments over the current pay schedule. Those items would account for about $70 billion of financing in an approximately $200 billion package.

Conservative groups are urging Republicans to fully finance any SGR repeal. “Americans didn’t hand Republicans a historic House majority to engage in more deficit spending and budget gimmickry,” Dan Holler, communications director for Heritage Action for America, said earlier this month.

Q. Will seniors and Medicare providers have to help pay for the plan?

Starting in 2018, wealthier Medicare beneficiaries (individuals with incomes between $133,500 to $214,000, with thresholds likely higher for couples) would pay more for their Medicare coverage, a provision impacting just 2 percent of beneficiaries, according to the summary.

Starting in 2020,   “first-dollar” supplemental Medicare insurance known as “Medigap”  would not be able to cover the Part B deductible for new beneficiaries, which is currently$147 per year but has increased in past years.

But the effect of that change may be mitigated, according to one analysis.

“Because Medigap policies would no longer pay the Part B deductible, Medigap premiums for the affected policies would go down. Most affected beneficiaries would come out ahead — the drop in their Medigap premiums would exceed the increase in their cost sharing for health services,” according to an analysis from the Center on Budget and Policy Priorities, a left-leaning think tank. “Some others would come out behind. In both cases, the effect would be small — generally no more than $100 a year.”

Experts contend that the “first-dollar” plans, which cover nearly all deductibles and co-payments, keep beneficiaries from being judicious when making medical decisions. According to lobbyists and aides, an earlier version of the “doc fix” legislation that negotiators considered would have prohibited “first dollar” plans from covering the first $250 in costs for new beneficiaries.

Post-acute providers, such as long-term care and inpatient rehabilitation hospitals, skilled nursing facilities and home health and hospice organizations, would help finance the repeal, receiving base pay increases of 1 percent in 2018, about half of what was previously expected.

Other changes include phasing in a one-time 3.2 percentage-point boost in the base payment rate for hospitals currently scheduled to take effect in fiscal 2018. The number of years of the phase-in isn’t specified in the bill summary.

Scheduled reductions in Medicaid “disproportionate share” payments to hospitals that care for large numbers of people who are uninsured or covered by Medicaid would be delayed by one year to fiscal 2018 but extended for an additional year to fiscal 2025.

Q. How quickly could Congress act?

Legislation to repeal the SGR is expected to move in the House this week. The House is scheduled to begin a two-week recess March 27.

Senate Democrats and Republicans may want to offer amendments to the emerging House package, which could mean that the chamber does not resolve the SGR issue before the Senate’s two-week break, which is scheduled to begin starting March 30.

If the SGR issue can’t be resolved by March 31, Congress could pass a temporary patch as negotiations continue or ask the Centers for Medicare and Medicaid Services, which oversees Medicare, to hold the claims in order to avoid physicians seeing their payments cut 21 percent.

 


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