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The new Medicare law, highlighed by the democrats, reversed scheuduled payment cuts to physicians, however, what is being quietly overshadowed are the cuts in payments to the Medicare Advantage Plans and how this will affect them and the seniors enrolled in them.  2.3 million medicare beneficiaries are enrolled in Medicare PFFS plans up from 209,000 since  2005.  Since many of the 2009 plan benefits have been filed with CMS for 2009, Medicare beneficiaries will likely see the effect of these changes beginning in 2010 coverage. 

Insurance companies have not fully evaluated how this will affect the benefits they offer but it can be assured we will likely see costs of these plans increase, copays or coinsurance increase, or additional benefits such as vision care phased out.  In addition, most PFFS plans effective in 2011 will be required to set up provider networks.  That has been a very important attribute to PFFS as seniors had freedom of choice to use any provider that was willing to bill the insurance company for the service provided.   

 What is ironic is how the democrats have praised this change as a “great day for Medicare and a great day for seniors.”  However, seniors utilizing these PFFS plans tend to be fixed income Medicare beneficiaries that would otherwise have just traditional medicare.  Fixed income seniors often view traditional Medicare supplements or Medigap plans to expensive or unaffordable despite the more comprehensive coverage - and there in lies the problem.  These cuts to Medicare Advantage Plans mean that the population of seniors that will be affected the most are the ones slightly above the poverty line surviving on fixed income often times only social security.

 Many seniors in this segment of Medicare beneficiaries have not realized what Medicare laws have been passed nor do they know how this may bring about changes in the coverage they now have.  Rest assured a sleepy giant may awake once the changes do come about and answers from their Senators and Representatives will be needed.

Home Health Care is vital to any area.  In the Grand Junction, CO area there are online comparisons available for facility performance in terms of:

• Percentage of patients who get better under the care
• Percentage of people who needed additional, unplanned care
• Percentage of people who get better at taking their meds correctly
• Percentage of people who stay at home after an episode of home health care ends.

Medicare.gov or HHS.gov are excellent websites for those who want to go online and see the comparisons themselves, but for our purposes for western Colorado residents we looked at the following facilities based on region:

Alpine Home Health Care in Clifton, CO –

• Scored typically lower than the state and national averages for patients who get better under care
• Scored typically lower than the state and national averages for patients who needed additional, unplanned care
• Scored a bit lower than the state average and 10% lower than national average for patients who get better at taking their meds
• Scored the same as the state average and higher than the national average for patients who stay at home after an episode of home health care ends

Community Hospital Home Health Services in Grand Junction, CO -

• Scored typically higher than the state and national averages for patients who get better under care
• Scored typically much higher than the state and the same as the national averages for patients who needed additional, unplanned care
• Scored higher than the state and national averages for patients who get better at taking their meds
• Scored much higher than the state and national averages for patients who stay at home after an episode of home health care ends

Hilltop Community Resources in Grand Junction, CO -

• Scored typically lower than the state and national averages for patients who get better under care.
• Scored a little higher than the state and national averages for patients who needed additional, unplanned care
• Scored considerably lower than the state and national averages for patients who get better at taking their meds
• Scored higher than the state and national averages for patients who stay at home after an episode of home health care ends

Homecare of the Grand Valley in Grand Junction, CO –

• Scored typically higher than the state and national averages for patients who get better under care
• Scored typically lower than the state and national averages for patients who needed additional, unplanned care
• Scored higher than the state and national averages for patients who get better at taking their meds
• Scored higher than the state and national averages for patients who stay at home after an episode of home health care ends

See :  about-the-nursing-home.doc for comparisons on long-term assisted living homes in Mesa County area.  You can view inspection information, quality, staffing and more at this link Nursing Homes.

Prescription Tidbits – for the insured

If you have prescription coverage in your health plan, you’ve probably noticed the difference between Brand Name coverage and Generics – especially in out-of-pocket costs.  But, did you know why that is?  Most drug companies are allowed to carry patents on their new drug releases for 17 years.  They must wait for the patents to run out before the drug can go out to market in a generic form.  Typically the savings discount for generic drugs compared to their Brand Name counterparts is about 65-70%.  According to the Congressional Budget Office, generic drugs save consumers an estimated $8-10 Billion a year at retail pharmacies.  Even more Billions are saved when hospitals use generics. 

 Worried about the differences in effectiveness between taking a Brand Name drug and a generic drug?  Prescription drugs are regulated by the FDA.  They require that all generic drugs have the same high quality, strength, purity and stability as brand-name drugs.  Although, it is believed that current regulations permit a variation of approximately 20% either way in the bioavailability of the active ingredient in generic drugs.  Bioavailability is used to describe the fraction of an administered dose of unchanged drug that reaches the systemic circulation (oxygenated blood flow from the heart to the body) – or, in other words, absorption into the bloodstream.  However, the general consensus is still that if there is a viable generic alternative to the Brand Name then that is the way to go. A little history on how and why Brand Name drugs “go generic.”  Drug Patents are protected for 17 years in order to protect the original developer.  Creating drugs costs a lot of money.  So, drug companies have exclusivity in a way to sell the drug at the price they want to.  When the patent expires and the FDA approves the generic version any other drug companies can start selling the generic version.   

August 6, 2008

UNINSURED vs. UNDERINSURED

Colorado Public Radio host Ryan Warner held an interview with Dr. Kent Voorhees, Vice President of Education of Family Medicine for the University of Colorado’s School of Medicine, on a Focus Group study he did on the underinsured (for healthcare) in Colorado.  For the purposes of the study he defines “underinsured” as those who spend 10% or more of their income on healthcare OR those who are at 250% of the poverty line and spend 20% or more of their income on healthcare.

 Dr. Voorhees stated that they went to 37 different doctors offices to get their statistics and the patients they used included a combination of people who are uninsured, have health insurance, have Medicare and/or have Medicaid.  Approximately 36% of the group were underinsured - they have health insurance, but often skip treatments, recommended care and prescriptions because they cannot afford to pay for them due to high deductibles, copays, etc.  50% of these underinsured feel that their health suffers because of this.   Of the Uninsured who skip treatments and prescriptions, 48% felt their health suffers. 

Another point brought up by the underinsured is that there are often exclusions or limitations in their health coverage that prevent them from getting covered for certain treatments that ARE AVAILABLE TO THE UNINSURED.

 This study did not even include people who never go to the doctor at all for treatments.

1/3 of the total group said they often skip recommended treatments and prescriptions due to cost.

In response to emails Insurance Advisors Agency, Inc. sent Congressman Ken Salazar, he had this to say:

“Thank you for contacting me regarding H.R. 6331, the Medicare Improvements for Patients and Providers Act of 2008. I appreciate your comments on this important issue.

On July 15th, the Senate and the House of Representatives both voted to override the President’s veto of H.R. 6331. The Senate voted 70-26 in favor of overriding the veto, and I am very pleased that my colleagues and I came together in a bipartisan fashion to ensure that H.R. 6331 would become law.

As you know, due to an outdated Medicare formula that must be permanently corrected, Medicare reimbursement rates for doctors were scheduled to drop over ten percent on July 1st. As a result, over half a million Colorado seniors on Medicare were at risk of finding that their doctors could no longer afford to treat them. The cut would also affect tens of thousands of the service members and their families stationed in Colorado at places like Fort Carson and Buckley Air Force Base who are serving our country and rely on Tricare for their health needs.

To the relief of Medicare and Tricare patients and providers across our state and country, H.R. 6331 replaced the drastic 10.6 percent Medicare reimbursement rate cut for physicians with a modest increase. In addition to this reimbursement rate fix, H.R. 6331 also included important Medicare improvements, such as an extension of the therapy cap exception, a plan to reduce mental health co-payments from 50 percent to 20 percent, and coverage of both cardiac and pulmonary rehabilitation and more preventative care.

H.R. 6331 also included a number of measures that will help health care providers across our state, including rural hospitals, independent pharmacies, community health centers, and others. Many constituents shared with me how important these measures are to their lives, and I am proud that my colleagues on the Senate Finance Committee and I were able to successfully work towards the passage of this bipartisan bill.

I supported the need to enact changes early on and you can be assured that I will continue to work to strengthen the Medicare program, and address the broader reforms to our health care system that are so desperately needed.

For more information about my priorities as a U.S. Senator and about issues of importance to Colorado and our nation, I invite you to visit my website at http://salazar.senate.gov/.”

In response to emails that Insurance Advisors Agency, Inc. sent our Colorado congressmen, Wayne Allard had this to say:

“Thank you for contacting me about Medicare. I appreciate your taking the time to write about this issue. Medicare for seniors is an important issue to me and I have worked diligently to maintain quality Medicare coverage. During my tenure in the Senate I sponsored a number of pieces of legislation that aim to ensure the continued stability of the Medicare program. Unfortunately, many of my colleagues in the Senate are more interested in temporary, minor fixes to our current Medicare system, even if it is to the detriment of millions of seniors who take part in the Medicare Advantage program. I believe it is wrong to take options away from seniors and place greater control of their health into the hands of bureaucrats. Choice and competition are necessary to fit the needs and desires of beneficiaries and ensure long term solvency of the program. The funding cuts to the Medicare Advantage Program in House Resolution 6331, the “Medicare Improvements for Patients and Providers Act of 2008″, will put many Colorado seniors at a disadvantage. That is why I supported different bi-partisan legislation which contained identical physician reimbursement language to HR 6331. I had hoped a bi-partisan solution to this issue could be reached. I am hopeful that in the future Congress will work to pass legislation that enacts long- term reform and fixes the physician reimbursement formula for longer than a few months. I am very appreciative of your comments. We share a common goal: access to quality Medicare benefits for seniors. I will continue to work towards that goal on the behalf of all Coloradans and seniors. For more information regarding this and other important issues, please feel free to visit my website at http://allard.senate.gov . I look forward to hearing from you in the future.

President Bush vetoed this bill and sent it back to Congress who in turn quickly overrode it.  Bush said he supports the objectives of the bill (one of which is to avoid the rate cuts to doctors), but the funds shouldn’t have to come out of the private health plans available for Medicare Beneficiaries.  In effect, the bill will deter Medicare Beneficiaries from being able to find a private plan to “supplement” or replace their Medicare Benefits.  FEWER CHOICES FOR SENIORS.  Be sure you know the facts of this bill. 

YES, It will eliminate the Medicare cuts to doctors — AT THE EXPENSE of seniors’ choices.  Fewer choices in insurance add up to more out-of-pocket costs.  This bill may effectively eliminate choices - especially in the arena of Private-Fee-For-Service plans that so many people in rural areas - non-Metropolitan - rely on for comprehensive health coverage.  We do not support reducing reimbursement for Medicare services to doctors, but we do want to see choice and competition remain in place for seniors who need or want extra supplemental or other insurance coverage in conjunction with their basic Medicare.  If not, we estimate that more and more out-of-pocket costs will become the norm.  When Medicare beneficiaries struggle with these additional costs and possibly are unable to pay their medical bills, healthcare rates rise to make up for it. 

Colorado lawmakers passed about 50 bills dealing with healthcare this year.  We have posted some information on a couple of them (see below).  Some of the bills add additional regulations for insurance companies in Colorado which could cause additional administrative costs for the providers and the insurers.  These bills are intended to make health care more readily available to people and promote consumer protection in the insurance industry.  Democrats & Republicans are at odds as to whether or not these bills will actually improve coverage options and healthcare for the average consumer. 

… if the Colorado House Democrats have anything to say about it.  In May of 2008 House Bill 1407, the Insurance Accountability Act of 2008, was passed.  The Bill is aimed at strengthening penalties for the unreasonable conduct of an insurance carrier, and making appropriation in connection with that. 

Consumers can expect this bill to give Colorado’s Commissioner’s office increased ability to deter unreasonable conduct by a Colorado insurer, help consumers recover their damages, and clarifies the definition of resitution.  The Commissioner’s office can charge an insurance company a $3,000 minimum fine for any violation of any law, rule, or prior lawful order regarding these issues - and up to $30,000 maximum fine.

Providing Coloradans with fair and accessible insurance coverage is the goal of this FAIR Act (Fair Accountable Insurance Rates) presented by the Colorado Democratic House of Representatives.  The Bill passed into Act in early June 2008 and will become effective on January 1, 2009.  The Act is designed to make insurance carriers and companies accountable for rate changes - the most significant piece of this is that ALL insurance companies must submit any rate increases to the Colorado Commissioner 60 days prior to the rate change effective date.  Any insurance company doing business in CO must fulfill the Commissioner’s requirements for a proposed rate increase:

• benefits provided must be reasonable in relation to the premiums charged;
• the rate increase must not be unjust, unfair, inequitable, discriminatory, excessive, or inadequate;
• claims experience and data must justify the increase; OR
• filing must be complete.

Also included are reports to the Commissioner regarding certain cost changes (since previous rate filings) due to catastrophic loss, medical costs and commissions.  The insurance company providing coverage in CO must explain all of these issues to the Commissioner who makes the information public by posting it on their website. 

WHAT does this mean to you, the consumer?  Insurance companies will be deterred from “knee-jerk” reactions based on losses & profitability, consumer’s can simply go to http://www.dora.state.co.us/Insurance/ to view any proposed rate increases for their type of plan/policy and insurance company.