Behavioral Therapy for Obesity.

The Centers for Medicare and Medicaid Services (CMS) has determined that intensive behavioral therapy for obesity is reasonable and necessary for the prevention or early detection of illness or disability.

Intensive behavioral therapy for obesity consists of the following:

1. Screening for obesity in adults.*
2. Dietary (nutritional) assessment.
3. Intensive behavioral counseling and therapy to promote sustained weight loss through high intensity interventions on diet and exercise.

Benefits include:

• One face-to-face visit every week for the first month.
• One face-to-face visit every other week for months 2-6.
• One face-to-face visit every month for months 7-12, if the beneficiary meets the weight loss requirement of at least 3kg over the course of the first 6 months.

* Defined as a body mass index (BMI) of 30 kg/m² or more (weight in kilograms divided by the square of height in meters).

Medicare Benefits.com: Still No Relief in Sight for Long-Term Needs

Medicare Benefits.com: Still No Relief in Sight for Long-Term Needs

Still No Relief in Sight for Long-Term Needs

By GARDINER HARRIS and ROBERT PEAR

WASHINGTON — The law that many Americans had hoped would transform the nation’s dysfunctional system of long-term care for the swelling ranks of people with disabilities and dementia quietly died this month, a victim of its own weaknesses, a toxic political environment and President Obama’s re-election campaign focus on jobs.

Its demise came as an intense disappointment to people like Alison Briolat, a chemist for a pharmaceutical company, whose family is staggering under the burdens of caring for her bedridden parents.

“Everybody at work is very glib about how they’ll never be a burden to their children and how I’m such a saint,” she said. “But unless you have millions sitting in the bank, there’s no other way.”

Unlike the rich, who can afford to pay for services themselves, or the poor, who get help through Medicaid, the federal and state program for low-income people, many members of the middle class have to look after disabled relatives themselves, or pay someone to do it. Polls show that many people believe that Medicare, the federal health program for those 65 and older, pays for such care. Actually, Medicare stops paying nursing home bills after 100 days.

More than 10 million people in the United States already have long-term care needs, and two-thirds of the costs are paid for by government programs, mostly Medicaid. Studies estimate that unpaid family members deliver an even larger share of the care, and the cost of nursing home care averages $72,000 a year.

Ms. Briolat’s parents live in a downstairs bedroom in her home in Lebanon, Ohio. Her father’s decline began eight years ago when he broke his ankle, an injury that failed to heal even after four operations. His foot became infected and was amputated. He went into a nursing home.

Ms. Briolat’s mother, burdened by her husband’s growing needs, soon went into decline as well. By then, five months of nursing home care had already cost the family $60,000. Ms. Briolat moved them both into her home. She pays a home health aide while she and her husband work.

The Community Living Assistance Services and Support program, or the Class Act, was intended to provide a benefit that averaged at least $50 a day, or $18,000 a year. If such a law had been on the books in time for her parents, it would have paid for most of their care.

“We wouldn’t have had to sell their house in Michigan at a fire sale price,” she said.

But the Class Act’s ambitions were undercut by an impractical structure that doomed it from the start, experts and government actuaries say. Its failure harks back to an attempt by President Ronald Reagan and a Democratic Congress to protect the elderly from catastrophic medical expenses and provide a modest prescription drug benefit and somewhat improved nursing home care.

That law, the Medicare Catastrophic Coverage Act of 1988, was repealed within months of enactment after a furious response by elderly voters angry that they had to pay for the benefits themselves through a tax mostly paid by the wealthy. In a famous scene, Representative Dan Rostenkowski, an Illinois Democrat who was chairman of the powerful House Ways and Means Committee, was booed and chased down a Chicago street by a group of elderly people, one of whom draped herself over the hood of his car.

The repeal legislation created a commission to examine the issue of long-term care, but it ended the appetite of many in Congress to resolve the issue. The Clinton health plan made another attempt at improving long-term care, but the bill failed. And now the demise of the Class Act is repeating history.

Senator Edward M. Kennedy made passing the Class Act one of his last priorities, and his advocacy was an important reason that the program, despite its flaws, was included in the overhaul of the health law in 2010. But the Class Act was unusually sparse in its details — accounting for just 20 of the bill’s 900 pages. Senator Judd Gregg, Republican of New Hampshire, succeeded in adding an amendment requiring the administration to certify that the program would be self-sustaining for 75 years before enacting it. The administration concluded that it could not make that certification, killing the program.

Less than 3 percent of Americans now buy private long-term care insurance. The government’s version of long-term care insurance shared a basic flaw with commercial options: It was voluntary, with benefits to be paid entirely by premiums.

The Class Act allowed anyone — even those with serious health problems — to sign up. Policy holders had to pay premiums for only five years and could then get benefits for life. The poor could pay just $5 a month. Both promises all but guaranteed that the program would have needed big government subsidies to avoid going broke, experts said. Internal documents from the Department of Health and Human Services show that officials had doubts about the viability of the Class program before it was signed into law by President Obama. Richard S. Foster, the chief actuary at the federal Centers for Medicare and Medicaid Services, wrote in July 2009 that “36 years of actuarial experience lead me to believe that this program would collapse in short order and require significant federal subsidies to continue.”

The Obama administration continued to insist that the proposed long-term care program would be solvent over 75 years. But even some prominent Democrats disagreed. As the Senate considered the health bill in December 2009, 11 Democrats, including the chairmen of the Finance and Budget Committees, supported efforts by Senator John Thune, Republican of South Dakota, to eliminate the long-term care insurance program.

Senator Charles E. Grassley, Republican of Iowa, said recently, “Everyone involved in the debate knew the proposal was impossible to deliver, and many of us said so.”

If the program had restricted enrollment to the healthy, limited payouts to five years and eliminated subsidies for the poor, it might have worked, said Joshua M. Wiener, a fellow at RTI International, a nonprofit research group. But advocates for the disabled were among the program’s biggest backers, and opposed the restrictions.

The program’s chief actuary, Robert Yee, said that limiting initial enrollment to workers at large companies or excluding benefits for 15 years also might have worked. But such fixes would have required new legislation, and the Obama administration concluded that such a bill had no chance of passing the present Congress, with Republicans, who control the House and can frustrate legislative efforts in the Senate, pushing for outright repeal of the entire health care law.

The president’s advisers decided that another fight over the health reform law would be a politically damaging distraction for his re-election prospects and ill timed, given the need to enact the broader health care law, itself under serious legal challenge

Advocates for the Class Act say they have not given up hope for the program. Connie Garner, who helped devise the long-term care program as an aide to Mr. Kennedy, declared: “We don’t see this program as dead. We will not let it die. “

The program’s end is a blow to middle-class hopes, though its modest benefit would have covered only about a quarter of nursing home care.

“This was designed to serve as a bridge between the affluent who can care for their own and the poor who get Medicaid,” said Diane Rowland, executive vice president of the Kaiser Family Foundation, a nonprofit group.

Raymond Eriksen of New Providence, N.J., thought he was safe. He moved his in-laws into an assisted living facility because both were suffering memory problems. Fortunately, both had private long-term care insurance that, along with the proceeds from the sale of their house, pays for their care. Then Mr. Eriksen’s wife, Linda, began to decline and was given a diagnosis of early-stage Alzheimer’s.

He kept her at home until August, when caring for her became so overwhelming that he moved her into the same facility with her parents. Although long-term care insurance was offered by his employer, Mr. Eriksen had not purchased it “because we had three kids we had to put through college.” Mr. Eriksen was an electrician for a major oil company but retired four years ago because of an injury.

“So we put it off until it was too late,” he said.

He is now paying $7,000 per month for his wife’s care, a bill that is likely to rise as her faculties decline. Mr. Eriksen, 61, said that he is unlikely to have any money left by the time he needs care himself.

“I was middle class, but I’ll be impoverished eventually,” he said.

How Medicare Fails the Elderly

By JANE GROSS

Jane Gross is a former New York Times reporter and the author of “A Bittersweet Season: Caring for Our Aging Parents — and Ourselves.”

HERE is the dirty little secret of health care in America for the elderly, the one group we all assume has universal coverage thanks to the 1965 Medicare law: what Medicare paid for then is no longer what recipients need or want today.

No one then envisioned the stunning advances in medicine that now keep people alive into advanced old age, often with unintended and unwelcome consequences. Indeed, scientific reports have showed the dangers, not merely the pointlessness and expense, of much of the care Medicare is providing.

Of course, some may actually want everything medical science has to offer. But overwhelmingly, I’ve concluded in a decade of studying America’s elderly, it is fee-for-service doctors and Big Pharma who stand to gain the most, and adult children, with too much emotion and too little information, driving those decisions.

In the last year alone, and this list is far from complete, here is what researchers have found both useless and harmful, according to leading medical journals:

• Feeding tubes, which can cause infections, nausea and vomiting, rarely prolong life. People with dementia often react with agitation, including pulling out the tubes, and then are either sedated or restrained.

• Abdominal and gall bladder surgery and joint replacements, for those who rank poorly on a scale that measures frailty, lead to complications, repeat hospital stays and placement in nursing homes.

• Tight glycemic control for Type 2 diabetes, present in 1 of 4 people over 65, often requires 8 to 10 years before it helps prevent blindness, kidney disease or amputations. Without enough time to reap the benefits, the elderly endure needless dietary limits and needle sticks.

Yet Medicare, which pays for all of the above, does not, except in rare instances, pay for long-term care in a supervised, safe place for frail or demented old people, or for home aides to help with shopping, transportation, bathing and using the toilet.

Nationwide, the median annual cost of a nursing home in 2010 was $75,000; room and board in an assisted living facility, with no additional help, was $37,500; and the most basic category of home health aide, who can perform no medical tasks, like the dispensing of medication, was $19 an hour. These expenses are left to the elderly (and their adult children) to pay for out of pocket until their pockets are all but empty.

Then they are eligible for Medicaid, the state-run safety net for the poor. While Medicare, a federal program, is financed by payroll taxes, and thus is an “earned” benefit, Medicaid is “charity,” in the minds of the formerly middle class who worked their whole lives and never imagined themselves destitute.

In the case of my mother, who died at 88 in 2003, room and board in various assisted living communities, at $2,000 to $3,500 a month for seven years, was not paid for by Medicare. Yet neurosurgery, which I later learned was not expected to be effective in her case, was fully reimbursed, along with two weeks of in-patient care. Her stay of two years at a nursing home, at $14,000 a month (yes, $14,000) was also not paid for by Medicare. Nor were the additional home health aides she needed because of staffing issues. Or the electric wheelchair after strokes had paralyzed all but the finger that operated the joy stick. Or the gizmo with voice commands so she could tell the staff what she needed after her speech was gone.

She paid for the room. My brother and I paid for the private aides and bought her the chair and the “talking board.” What would her life have been like without the skilled care she required and the ability to get around her floor and communicate her needs? I shudder to think. But none of this was Medicare’s responsibility.

Yet Medicare would pay for “heroic” care for a woman who was dying of old age, not a disease that could be treated: Diagnostic tests. All manner of surgery. Expensive medications. Trips to the emergency room or the hospital — had she not refused all of them, in the last year of her life. So, in less than a decade, by my low-ball estimate, my mother spent $500,000 of her own money and uncalculated sums from her two children before winding up what she considered, with shame, “a welfare queen.”

A recent state-by-state study of long-term care, the first of its kind, by a consortium of researchers, has found that this kind of essential help costs anywhere from 166 percent to 393 percent of the average annual income of America’s elderly.

BY now, you may be wondering if your parents have a half million dollars for old age. Or if you or your children do. You may be counting on quick and easy deaths. Shoot me, so many people say. Alas, 70 percent of the elderly will need extended care before they die. Denial is powerful but doesn’t pay the bills.

This mismatch between what is covered and what is actually useful is the central flaw in Medicare today, a shock to families who have no clue, until they’re smack in the middle of it, about how this system works.

This mismatch tortures our elderly, drains the Medicare trust fund and leaves adult children with depleted retirement reserves. Yet in all the debate about the national debt, medical inflation and the need to pare Medicare costs by such means as raising the eligibility age, why is nobody, outside the insular community of long-term care providers, even mentioning the difference between acute and chronic care and how each is paid for (or not)?

Why is nobody enraged that our taxes are paying for hip replacements, for example, for people with advanced Alzheimer’s disease, who are incapable of physical therapy? Why is nobody saying out loud, like it or not, that one of our great challenges is figuring out what to do about our elderly people, our fastest growing-population cohort, which will grow exponentially when 76 million baby boomers join the ranks?

The current system is unsustainable, but the alternative is the third rail of health care policy. President Obama’s original legislation included Medicare reimbursement to doctors for discussion of end-of-life issues. These are what Sarah Palin called “death panels”; days later, they were cut from the legislation. An Independent Payment Advisory Board will make recommendations to Medicare about what works and what doesn’t, beginning in 2015, but its proposals are not binding, as intended. A long-term-care insurance provision — with an average daily benefit of a mere $50 — is under siege.

Reading the history of the Medicare law, which was not intended for long-term care because today’s technology and demographics were unimaginable then, one is struck by the battles and ultimate compromises between President Lyndon B. Johnson and Wilbur Mills, the head of the House Ways and Means Committee, who originally opposed Medicare.

That the crafting of that legislation was so difficult leaves one despairing that this pillar of the Great Society could now be rewritten, given our partisan incivility. But right now, according to the health economist Marilyn Moon, there are 47 million Medicare beneficiaries, costing a half trillion dollars a year, or one-fifth of the nation’s health spending. In 2050, the population on Medicare will number 89 million. How scary is that?

Eye Treatment Medications

By ANDREW POLLACK

Dr. Robert Feig, a retina specialist in Brooklyn and the Bronx, says he wants to save patients and Medicare money by treating eye diseases with a drug that costs $50 a dose, rather than one that costs $2,000 a dose.

But three recent incidents around the country in which a total of 21 patients lost some or all vision in the affected eye after injections of the less expensive drug have made him fearful of a malpractice lawsuit, should something similar happen at his practice.

“Why would I want to risk my family to save America $1,950 a dose?” asked Dr. Feig. So even though he laments it, he is starting to use more of the expensive product, Lucentis, instead of the cheaper one, Avastin.

Similar trade-offs of cost versus perceived risk are being weighed across the country.

The Department of Veterans Affairs has temporarily halted use of Avastin for eye conditions while it reviews the situation. In Los Angeles, the pharmacy company that was supplying Avastin to Harbor-U.C.L.A. Medical Center decided to get out of that business, leaving the hospital without supplies and forcing it to cancel patient appointments.

But many eye doctors say the problems occur in fewer than one in 1,000 injections. The recent incidents, they say, were isolated and apparently stemmed from easily correctable sloppy procedures at pharmacies, not from anything wrong with Avastin itself.

“Are you going to stop eating hamburgers because there was some tainted meat in Texas?” said Dr. Randy Dhaliwal, a retina specialist in August, Ga. “I’m not aware of anyone previously using Avastin in private practice making a switch because of this.”

Moreover, such problems can occur with Lucentis as well, and some studies suggest the rate of such problems for the two drugs is similar.

If all doctors switched to Lucentis, “You are going to tremendously jack up the cost to the country and achieve absolutely nothing,” said Dr. Jon Adleberg, a retina specialist in Chesapeake, Va.

Avastin and Lucentis work in similar ways and both are made by Genentech. Lucentis has regulatory approval as a treatment for the wet form of age-related macular degeneration, the leading cause of severe vision loss in the elderly, and for another eye condition.

Avastin, by contrast, is a cancer drug. But many eye doctors say Avastin, used off-label, works roughly as well while costing one-fortieth as much.

A report last month from the inspector general of the Department of Health and Human Services estimated that in 2008 and 2009, Medicare paid $1.1 billion for 696,927 Lucentis injections but only $40 million for a greater number — 936,382 — of injections of Avastin. Patients get an injection as often as once a month.

If Lucentis had been used for all the injections, Medicare would have paid an extra $1.5 billion over those two years, the report said. And patients would have had to pay an extra $370 million because the co-payment for Lucentis was $406, compared to only $11 for Avastin.

However, dividing a vial of Avastin meant for a single cancer patient into many tiny doses for the eye introduces the risk of microbial contamination. That job is usually done under sterile conditions by compounding pharmacies.

A clue to how much the recent incidents are changing practice might come when Roche, Genentech’s parent company, reports third-quarter sales on Oct. 13. Despite being undercut by its own drug, Genentech sold about $1.5 billion worth of Lucentis in the United States last year.

The incidents could also help Regeneron Pharmaceuticals, which hopes to win approval in November of a new drug for macular degeneration that is expected to cost at least as much as Lucentis.

One of the three incidents occurred in Miami, where 12 patients suffered eye infections from Streptococcus bacteria in July after receiving Avastin injections that came from the same compounding pharmacy.

Four patients got Streptococcus infections at the Veterans Affairs hospital in Nashville earlier this year, the hospital has acknowledged.

And five patients treated in August at a V.A. hospital in Los Angeles lost all or most vision in the injected eye. No infectious agent has been identified, prompting speculation that the patients were injected with some drug other than Avastin.

Yet there is also a risk of infection from Lucentis. That drug comes in a vial meant for a single patient. But a doctor or a nurse still must put a syringe into the vial and draw out the medicine. And this is usually done in the doctor’s office, not under the sterile conditions of a compounding pharmacy.

Dr. Colin A. McCannel, an expert at the University of California, Los Angeles, said a source of infection appeared to be droplets from the mouths of doctors who talk while handling the syringe.

Biren Amin, an analyst at Jefferies & Company, tallied the data from clinical trials involving 140,000 injections of either Avastin or Lucentis. The rate of endophthalmitis, an inflammation of the eye presumably caused by infection, was identical for the two drugs — about one in 2,000 injections.

Another study, published this month in the journal Ophthalmology, followed 27,736 consecutive injections over 17 months at a 16-physician retinal practice in Philadelphia. Endophthalmitis occurred in about 1.1 of every 1,000 Avastin injections compared to 0.66 of every 1,000 Lucentis injections, a difference that is not statistically significant.

The incidents have focused attention on compounding pharmacies, whose standards vary from state to state. Both the American Society of Retina Specialists and the International Academy of Compounding Pharmacists are surveying members and trying to compile recommended best practices for the pharmacies.

Dr. Yu-Guang He of the University of Texas Southwestern Medical Center in Dallas visited the compounding pharmacy that supplies his Avastin. He said he was reassured that the pharmacy was testing Avastin syringes for bacterial contamination.

“Right now, everyone is scared,” said Dr. He, who has slightly increased his use of Lucentis. “But over time people will gradually come back, because the price differential is so great.”

Surgery Rate Late in Life Surprises Researchers

By GINA KOLATA

Surgery is surprisingly common in older people during the last year, month and even week of life, researchers reported Wednesday, a finding that is likely to stoke, but not resolve, the debate over whether medical care is overused and needlessly driving up medical costs.

The most comprehensive examination of operations performed on Medicare recipients in the final year of life found that nationally in 2008, nearly one recipient in three had surgery in the last year of life. Nearly one in five had surgery in the last month of life. Nearly one in 10 had surgery in the last week of life.

The very oldest patients were less likely to have surgery. Those who were 65 had a 38.4 percent chance of having surgery in the last year of life. For 80-year-olds, the chance was 35.3 percent, but the rates fell off more sharply from there, declining by a third by age 90.

But such analyses are controversial. By looking only at people who died, researchers can get a skewed picture of what is taking place, critics say.

“Because the patient died, you can’t assume that the treatment and therapies were not of value,” said Dr. Peter B. Bach of Memorial Sloan-Kettering Cancer Center. “Although in that individual, things may not have worked out, you have no insight into whether the decision to operate was appropriate.” Nor is it known how many similar patients who had that same surgery did not die.

But the sheer number of operations at the end of life was unexpected, said the researchers, at Harvard School of Public Health. They added that they did not know why the operations had been done. Some undoubtedly were necessary to relieve pain and suffering or to prolong life. But, they said, they know from experience that doctors often operate to repair something that can be fixed but that will not save a dying patient, avoiding the difficult discussions with patients about their prognosis and whether the surgery will improve or compromise their quality of life.

In their study, published Wednesday in The Lancet, the investigators analyzed data for all the 1,802,029 Medicare recipients 65 and older who died in 2008. In addition to the number of operations nationally, they reported marked regional variations in the use of surgery at the end of life. For example, the rate of surgery in Honolulu was a third of that in Gary, Ind.

“Honolulu and Gary, Ind., can’t both be doing it right,” said Dr. Ashish Jha, an associate professor of health policy at Harvard and the lead author of the study.

But regional variations in health care have been controversial because it is not clear whether they reflect true differences in patient needs or in health care practices or regional differences in health care payment rules, Dr. Bach said.

Dr. Scott Ramsey, an economist and a physician who is director of cancer outcomes research at the Fred Hutchinson Cancer Research Center in Seattle, faulted the researchers for citing regional differences but then suggesting a long list of factors that might be causing them, including the health of the population, the patterns of medical practice, and the availability of hospice care and other end-of-life services.

Their list of potential explanations “covers about everything and says absolutely nothing,” Dr. Ramsey said.

But the researchers said their study — done from public records and with no financing — probably pointed to a real problem in American medicine: surgery, which can be painful, expensive and debilitating, is tempting for doctors and patients alike.

“I will admit to being guilty of this,” Dr. Jha said. “Often we say, ‘If you have this intervention, we will be able to fix that problem. You have an intestinal blockage. Surgery will fix it.’ But will it let you walk out of the hospital alive? Will it let you return to your old life?”

Dr. Mark McClellan, a former commissioner of the Centers for Medicare and Medicaid Services, who directs the Engelberg Center for Health Care Reform at the Brookings Institution, said, “Evidence like this — and a lot of previous evidence, directly from patients and their families — shows that we need much better support for patients and their families when they have serious illnesses and may need intensive treatments.”

Dr. Jha said he and his colleagues were continuing to study the causes and consequences of surgery at the end of life, adding, “It is hard to take these data and make clear policy recommendations about what is appropriate and what is not.”

But he said he had no doubt that the difficult conversations that should precede a decision to operate all too often never occurred.

“As clinicians, we often end up focusing on something narrow and small that we think we can fix,” Dr. Jha said. “That leads us down the path of surgical intervention. But what the patient cares about is not going to get fixed.”

Dr. Jha provided a recent example from his hospital. A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine.

“No one had talked to him about how close he was to death,” Dr. Jha said. “It’s the worst kind of conversation to have.”

Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Dr. Jha said.

The man died of a complication from the surgery.

“The tragedy is what we should have done for him but didn’t,” Dr. Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can’t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea.”

Instead, Dr. Jha said, “we sent him to the O.R.”

What Boomers Need to Know About Medicare Open Enrollment Season

September 29, 2011
FOXBusiness

The Medicare open enrollment period is upon us once again, and now is the time for Medicare recipients to review their options and make unrestricted changes to their coverage options. The period, which runs from Oct. 15 to Dec. 7, is a good time to assess current coverage and shop around for other plans that might better meet your needs and financial situation.

In order to make the most-informed decision, Medicare consumers need to be aware of the changes coming to the system.

Joe Baker, president of the Medicare Rights Center, a non-for-profit counseling organization in New York, discussed the following changes and updates for 2012 that boomers need to know:

Boomer: What changes and updates have been made to Medicare for 2012?

Baker: The first change is when you can make a change to your current plan. It now starts earlier, on Oct. 15th and it ends earlier on Dec. 7. In the past the enrollment period started in November and extend through the holidays and the end of the year. Folks in Medicare Advantage plans will be getting an annual notice of change about what might be changing in their plan, Part D plan or prescription drug coverage, by the end of this month.

When it comes to benefits and other costs, there’s some good news this year. If you are in a Medicare Advantage plan and have Part D as a separate prescription drug plan, or part of Medicare Advantage, premiums are not going up this year. The federal government announced that on average, Medicare Advantage premiums would probably decrease by 4%, and Part D prescription drug premiums would stay about the same.

This is good news if you are not looking to change plans, prices and benefits are remaining stable despite the volatility in the marketplace. With that said, you should still research your own individual plan, any notices that detail plan changes will be more general and won't be individualized for you. If you are taking a particular drug, or getting a specific type of treatment, be sure to check there are no changes that might impact them.

Boomer: What impact has health-care reform had on Medicare if any?

Baker: The Affordable Care Act had a lot less of a negative impact than what was predicted, along with some expected good changes.

Negative first: Part of the reform significantly scaled back (starting this year) the level of subsidies or payments that Medicare Advantage plans received from the federal government. Many of the reform’s critics expected to see big premium increases, plans leaving the market and reduced benefits—all of which would be bad for consumers. The good news: those disaster scenarios did not occur. Some of the additional benefits the law enacted to Medicare will further enhanced this year. For example, in the coverage gap (also known as the doughnut hole), you are still going to have a 50% discount for brand name drugs and the discount on generic drugs will increase to 14% from 7%, giving a little more relief on out-of-pocket costs.

In the government program, preventative care is going to be free of charge along with your annual wellness visit, mammograms and colonoscopies. That is also going to be in place for Medicare Advantage plans.

It is going to be a fairly stable year for folks in both the original Medicare and Medicare Advantage plans. Some of the improvements include in the health-care law will continue to be rolled out and enhanced over the year as well.

Boomer: What basic coverage is offered with Medicare?

Baker: Usually if you are in original Medicare you need supplemental coverage to pay coinsurance and deductible amounts. If you go to the doctor on original Medicare you pay 20% of the doctor’s approved fee, and most people get what is called Medi gap or supplemental coverage to pay that 20% coinsurance or they have retiree insurance from their former employer that might cover those costs.

Most people also purchase prescription drug coverage under Part D. About 70 to 75% of people have the original Medicare, retiree insurance or Medi gap insurance. The other 25% of people are in the Medicare Advantage, which includes a variety of plans. Most people are in what we call HMOs or Medicare health maintenance organizations that are run by private companies like UnitedHealthcare or Humana. When you sign up with a Medicare Advantage plan, you normally don't need supplemental coverage because the plan usually combines with extra benefits to cover some of what Medi gap would and your Part D coverage.

It’s important to know that under a Medicare HMO, you can only use the doctors and hospitals that are in that plan’s network. With original Medicare you can go to any doctor and you may have out-of-pocket costs like deductibles and co-insurance and that can add up if you are sick. Be careful when choosing a Medicare Advantage plan: If you travel a lot or like the freedom of your doctor want, original Medicare may be the better option. If you don't mind having a more limited network of doctors you could save some money with a Medicare Advantage plan.

Boomer: What questions should consumers ask before enrolling in a supplemental Medicare health plan?

Baker: Medicare supplements are Medi gap policies and you want to make sure you are dealing with a reputable company. These supplements are standard plans that are offered across the country and are highly regulated usually work well with Medicare. When choosing the right plan, make sure to consider price and services offered.

With a Medicare Advantage plan you have a much more complicated decision-making process. You want to make sure your doctor and hospitals are in the network. It’s a good idea to get your doctor’s opinions on the different offerings to see if they are a good fit, particularly if you have an ongoing medical condition. A lot of people just look at the price and that is not always a good idea, especially for those in need of medical care or currently in treatment. A cheaper premium may be attractive, but you may have higher costs of copayments, deductibles and co- insurance or less coverage, and those costs could be enormous.

You can call your state’s Department of Insurance and request a list of the Medi gap insurers in your state as well as consumer satisfaction information.

Boomer: For people turning 65 next year, what steps should they take to get my Medicare?

Baker: Three months before your 65th birthday, either check out the medicare.gov website, visit your local Social Security office or can call 1-800 Medicare and enroll in Medicare. If you are still working or your spouse is still working and you have insurance through that spouse, you may be able to put off your enrollment, but you need to know the rules. It’s always a good idea to know the system early. If you are of age and not working, you will want to enroll in Medicare because it is the only show in town for you. Your coverage starts on the first of the month on your 65th birthday.

Boomer: Are there any programs available to help pay Medicare costs?

Baker: The Medicaid program helps people with very low income cover health-care costs, and consumers can find information about this program from their state’s Department of Health or the Medicare agency in their state.

Medicare savings programs also help people with higher levels of income cover their costs. These programs pay for your Medicare Part B premiums. The Part B premium is deducted from your Social Security check--and we still don’t know what the premium will be in 2012, but it will be higher than the current $115.

There is another program called Low-Income Subsidy for Part D that will cover most of that premium if you fall under a certain income level (usually between $12,000 and $20,000). The plan also has a lower cost sharing or copay when you go to pick up your medication at the pharmacy.

Read more: http://www.foxbusiness.com/personal-finance/2011/09/29/what-boomers-need-to-know-about-medicare-open-enrollment-season/print#ixzz1ZYO7ByWE

Bariatric Surgery

Medicare has issued a new list of approved centers for bariatric surgery. See this link for complete list. https://www.cms.gov/MedicareApprovedFacilitie/BSF/list.asp#TopOfPage

76 Cents Worth of Good News

By PAULA SPAN

In a slightly desperate hunt for good economic news, I’ve come up with this small consolation: Average premiums for Medicare Part D, the prescription drug benefit, will not rise in 2012. In fact, they will fall slightly.

The last time this happened was in 2007, the year after Part D took effect. Insurers weren’t certain how to price the new benefit, so they had set the price high to protect their profit margins. They guessed wrong — the drug benefit continues to cost less than originally estimated, according to the federal Centers for Medicare and Medicaid Services — so premiums dropped sharply the following year. But each year since, they’ve crept up, by a buck here and three bucks there — until now, when the national average will drop to $30 from $30.76 a month next year. (Hey, I said it was small consolation.)

Even the comparatively small number of Medicare recipients with incomes of over $85,000 for an individual or $170,000 for a couple — at which point something called an income-related monthly adjustment amount kicks in — will see a little dip, to $11.60 a month from this year’s $12 a month, charged in addition to the monthly premium.

The main cost-control factor is Medicare’s heavy use of generic drugs, the agency says, along with competition, as insurers bid against one another to attract customers, plus the inflation-busting effects of lingering recession.

The other good Part D news is how many people in the infamous “doughnut hole” are getting some relief from the 50 percent discounts on covered name-brand drugs (and 7 percent on generics) that took effect this year. Through June, nearly 900,000 people had used the discounts, a number that will increase as the months pass, and each had saved $517 on average.

Of course, one might argue that small consolations are outweighed by the misery of falling into the doughnut hole, which won’t close completely until 2020, in the first place. Or outweighed by the fact that this is an average of many plans in many regions, so some people may actually find their 2012 Part D premiums rising slightly.

So it makes sense, as Medicare officials always caution, to evaluate those plans carefully before making a choice. The Part D enrollment period comes earlier than usual, too. It starts on Oct. 15 and ends Dec. 7.

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”http://newoldage.blogs.nytimes.com/2011/08/18/76-cents-worth-of-good-news/?pagemode=print

Medicare Extends Experiment in Paying Doctors

After five years of testing the idea, Medicare officials said Monday that they believe that doctors who coordinate care and keep their patients out of the hospital can help reduce the nation’s health care costs.

Under an experiment begun in April 2005, 10 physician groups were able to improve the quality of care significantly in conditions like heart failure and diabetes while reducing costs by $134 million. The doctor groups, depending on how they fared on various quality measures, were able to share in the bulk of those savings.

In making the announcement, Medicare said it would extend the program, called the Physician Group Practice Demonstration, by another two years from January 2011.

The impetus behind the experiment, whose early results we reported on in a 2007 article, was to see if Medicare could fundamentally change the way doctors are paid.

Instead of simply reimbursing doctors more when they conducted more tests or performed more procedures, Medicare tried to reward them for providing a higher quality of care that saved money by keeping people out of the hospital or emergency department when they did not need to be there.

The same thinking influences some of the current interest by federal officials in accountable care organizations.

“As we work to help bring care coordination to a broader set of providers through Accountable Care Organizations, the lessons learned by this demonstration provide great insight into how to use Medicare’s payment systems to improve quality while reducing costs,” said Dr. Donald M. Berwick, who oversees the Medicare program, in a statement. “We have learned to invest in sustained improvement over time, and that short-term comparisons between start-up costs and measureable results may fail to realize the long-term value of these efforts.”

Two of the physician groups, Marshfield Clinic in Wisconsin and the University of Michigan Faculty Group Practice, have managed to share in the savings for all five years. For the fifth year, four groups received $29 million out of the $36 million they saved Medicare.

Those four also include St. John’s Health System, in Springfield, Mo., and Park Nicollet Health Services, in St. Louis Park, Minn. For Park Nicollet, the nearly $6 million payout will represent the first time that the doctors there will be paid for their efforts, despite having hit all the quality targets for the previous three years.

“Our results provide compelling evidence that paying for outcomes, rather than volume, helps our patients, helps make health care more affordable and saves money for taxpayers,” said Dr. David Abelson, Park Nicollet’s chief executive, in a statement.

Medicare Drug Costs Unlikely to Rise

The average monthly premium for Medicare’s prescription program is not expected to go up next year, the administration said Thursday. The Health and Human Services Department projects the average premium for 2012 will be about $30 a month, hardly changed from $30.76 this year. Officials credited growing use of generics and competition within the program, which is delivered through private insurance companies. Medicare also expects to see costs drop as a number of top-selling brand name drugs get generic competition.

Free Preventive Services

Medicare offers the following preventive services free of charge (no co-pay and no-deductible).

Abdominal Aortic Aneurysm Screenings
A one-time screening ultrasound for people at risk.

Bone Mass Measurements
Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria.

Cardiovascular Screenings
Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels.

Colon Cancer Screenings (Colorectal)
Medicare covers colorectal screening tests to help find pre-cancerous polyps (growths in the colon) so they can be removed before they turn into cancer.

Diabetes Screenings
Diabetes screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Based on the results of these tests, you may be eligible for up to two diabetes screenings every year.

Diabetes Self-Management Training
Your doctor or other health care provider must provide a written order.

EKG Screenings
Medicare covers a one-time screening EKG if you get a referral for it as a result of your one-time
"Welcome to Medicare" Preventive Visit.

Flu Shots
Covered once a flu season in the fall or winter.

Glaucoma Tests
Covered once every 12 months for people at high risk for glaucoma.

Hepatitis B Shots
This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia,End-Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

HIV Screenings
Medicare covers HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test.

Mammograms
Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35–39.

Medical Nutrition Therapy Services
Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service.

Pap Tests and Pelvic Exams
Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years.

Preventive Visits
Medicare will cover two types of preventive visits—one when you’re new to Medicare and one each year after that.

Pneumococcal Shots
Most people only need this preventive shot once in their lifetime.

Prostate Cancer Screenings
Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50.

Smoking Cessation (counseling to stop smoking)
Medicare covers smoking cessation counseling as a preventive service and you'll pay nothing for the counseling sessions.

MRI and Pacemakers

MEDICARE EXPANDS COVERAGE FOR PATIENTS WITH PACEMAKERS THAT ARE FDA-APPROVED FOR USE WITH MRI EXAMS

The Centers for Medicare & Medicaid Services (CMS) today expanded Medicare coverage of Magnetic Resonance Imaging (MRI) for beneficiaries with implanted pacemakers when used according to FDA-approved labeling in an MRI environment. A final National Coverage Determination (NCD) posted today provides access to the MRI environment for patients with FDA-approved pacemakers.

On February 8, the Food and Drug Administration (FDA) approved the RevoMRI SureScan Pacing System, which is designed for use in the MRI environment for certain MRI exams. Currently, there are no other pacemakers or implantable cardioverter defibrillators that are FDA-approved for use in the MRI environment.

“This swift action by CMS provides patients who need a pacemaker with greater access to MRI exams,” said Donald M. Berwick, M.D., CMS administrator. “The expedited review of this decision demonstrates our commitment and support of new technology that will help improve the health of our beneficiaries.”

MRI is a noninvasive method of imaging that has the capability of demonstrating a wide variety of soft-tissue lesions in various parts of the body. It is used to diagnose many medical conditions, such as cancer, and is used to look at various parts of the body, including the head, central nervous system, and the spine. MRI also has advantages over other imaging techniques such as computed tomography (CT) and conventional radiographs, including no radiation exposure and easier visibility of soft tissue.

However, MRI exposes the patient to high magnetic and radio-frequency fields that may cause the movement or heating of implanted medical devices that are ferromagnetic (e.g. surgical clips) or that have ferromagnetic components (e.g. pacemakers, prostheses). The American College of Radiology’s (ACR) guidance document on safe MRI Practices (Kanal, 2007) explicitly discusses the need to address potential risks of exposure for patients that may have ferromagnetic foreign bodies or implants.

The final coverage policy issued today follows a proposed decision issued in April 2011. The final decision memorandum is available on the CMS website at https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Magnetic%20Resonance%20Imaging%20(MRI)%20(3rd%20Recon)&bc=ACAAAAAAIAAA&NCAId=252&.

Private Non-Profit Health Plans

NEW PRIVATE NONPROFIT HEALTH PLANS

Today (July 18, 2011), the Centers for Medicare & Medicare Services (CMS) took steps to encourage the creation of Consumer Operated and Oriented Plans (CO-OPs), new private non-profit, consumer-governed health insurance plans that will help increase competition and give consumers and small businesses additional affordable health insurance choices. CMS is proposing standards for CO-OPs, and for qualifying for $3.8 billion in repayable loans to help start-up and capitalize these new health plans. All CO-OP loans must be repaid with interest and loans will only be made to private, nonprofit entities that demonstrate a high probability of becoming financially viable.

CO-OPs are designed to give consumers and small businesses control over their own health insurance. CO-OPs are private, non-profit insurers governed by their members and offering affordable, consumer-friendly health insurance options. CO-OPs will use any profits to benefit its members, including actions to lower premiums, improve health benefits, improve the quality of members’ health care, expand enrollment, or otherwise contribute to the stability of coverage for members.

“CO-OPs will provide consumers more choices, greater plan accountability, and help ensure a more competitive insurance market,” said Steve Larsen, Director of the Center for Consumer Information and Insurance Oversight. “Today’s announcement shows how the Affordable Care Act is bringing new choices and giving consumers a voice in insurance markets throughout the nation.”

Working from the recommendations of the public advisory committee, the rules proposing the framework were developed with significant input from many stakeholders, including testimony at public meetings from consumers, small businesses and health care providers. The proposed rule is only a first step. CMS is taking public comment on the proposal and expects to release a Funding Opportunity Announcement regarding the availability of loans to start up CO-OPs soon.

The CO-OP program provides for loans to private entities with the goal to create a new CO-OP in every State to expand the number of Exchange health plans with a focus on consumer accountability. The CO-OP program contains extensive provisions to protect against fraud, waste, and abuse. Loan recipients are subject to strict monitoring, audits, and reporting requirements for the length of the loan repayment period plus 10 years. Recipients must submit semi-annual program reports and quarterly financial statements. Additionally, CMS will conduct audits, including site visits, as appropriate. CO-OPs must meet a series of milestones as laid out in their loan term agreements before drawing down any money from the program.

CO-OPs will sell coverage through the State’s Affordable Insurance Exchange as well as have the opportunity to sell coverage to small businesses through the State’s Small Business Health Option Programs (SHOP Exchanges).Several successful health insurance cooperatives currently exist around the country, covering nearly 2 million individuals. A number of diverse groups are organizing to take advantage of this new opportunity. In one state, primary care providers are working to create a CO-OP to focus on care for rural areas. In another, a CO-OP steering committee has been formed by interested physicians, technology and business experts, and community groups.

¿Habla usted español?

Es.Medicare.gov speaks your language.

You already know that Medicare.gov has a wealth of current information: everything from basic costs and coverage to details about screening tests and visits to help you stay healthy.

Es.Medicare.gov is one of many ways we’re sharing Medicare information so everyone can better understand their health care options and get the best care. Now, Es.Medicare.gov also includes everything you need to know about preventive benefits, like recommended cancer screenings and discounts on brand-name drugs in the donut hole.

Here’s what you’ll find:

• · Details about exactly what Medicare covers and what you pay, including for preventive tests and screenings
• · Helpful Web sites and phone numbers for people who can answer your questions
• · “Medicare & You” handbook
• · Fact sheets and publications with specific details about the Medicare Program
• · Step-by-step information about how to file an appeal
• · Forms to apply for Medicare , file claims, and more

Visit Es.Medicare.gov, and tell your friends and family. Because when you share the news, you share the health.

Medicare Will Pay for Prostate Cancer Drug

New York Times
June 30, 2011, 6:38 pm

By ANDREW POLLACK

Medicare confirmed on Thursday that it would pay for Provenge, the prostate cancer drug whose $93,000 price had set off debate about the cost of cancer treatments.

The Centers for Medicare & Medicaid Services said in a final decision that the evidence was adequate to conclude that Provenge “improves health outcomes for Medicare beneficiaries’’ and was therefore “reasonable and necessary” for their treatment.

However, reimbursement would be only for men who matched the criteria in the drug’s label, meaning they had few or no symptoms and cancer that had spread beyond the prostate gland and was no longer controlled by hormone therapy.

The final decision follows a yearlong review and confirms a tentative decision announced three months ago. Most men with prostate cancer are covered by Medicare.

Provenge, developed by Dendreon, based in Seattle, is one of a series of new prostate cancer drugs that have been shown to prolong men’s lives and in some cases relieve symptoms, but whose costs are raising questions.

The announcement that Medicare would undertake the a “national coverage determination’’ had drawn an outcry from some men with the disease and investors in Dendreon, who saw it as a warning by Medicare about high prices.

But Medicare officials denied that cost was the issue. One reason for the review, they said, was that it was unclear if Provenge was a drug or a treatment process.

Provenge, which was approved by the Food and Drug Administration in April 2010, is the first cancer treatment that works by training a patient’s own immune system to fight the disease. White blood cells are taken from each man, processed by Dendreon, and then infused back into his body.

In its largest clinical trial, men who received Provenge lived a median of 25.8 months compared with 21.7 months for those who got a placebo.

Medicare Will Continue to Cover 2 Expensive Cancer Drugs

New York Times
June 30, 2011

By ANDREW POLLACK

Medicare confirmed on Thursday that it would continue to pay for two expensive cancer drugs that had been at the center of debate — Avastin from Genentech for breast cancer and Provenge from Dendreon for prostate cancer.

A spokesman for the Centers for Medicare and Medicaid Services said the agency would continue to pay for Avastin for breast cancer, even if the Food and Drug Administration revoked the drug’s approval as a treatment for that disease.

“The label change will not affect our coverage,” the spokesman, Don McLeod, said.

An advisory committee to the F.D.A. voted unanimously Wednesday in favor of rescinding the breast cancer approval, saying the latest evidence suggested the drug was not effective. The final decision will be made by the F.D.A. commissioner, Dr. Margaret A. Hamburg, after a public comment period ends on July 28.

Avastin would retain approval for other cancers so doctors could still use it off label for breast cancer. But some women fear that insurers will no longer pay for the drug, putting the medicine, which costs about $88,000 a year, out of reach for most women.

Mr. McLeod’s statement could allay those concerns, at least for women covered by Medicare. He said that Medicare commonly paid for off-label use of cancer drugs.

Still, Mr. McLeod said that while there were no plans for one right now, he could not totally rule out that Medicare might one day undertake a national coverage determination to decide whether to pay for Avastin. That process would take at least a year and involve public input.

Such a national coverage determination was undertaken for Provenge, which costs $93,000 for a complete course of treatment.

The final decision, issued Thursday, said the evidence was adequate to conclude that Provenge “improves health outcomes for Medicare beneficiaries” and was therefore “reasonable and necessary” for their treatment.

The result confirmed a preliminary decision announced three months ago.

The decision applies to men who meet the criteria in the drug’s label, meaning the cancer has spread beyond the prostate gland, it is no longer controlled by hormone therapy and the men have few or no symptoms.

The national coverage determination drew outcries from some men with prostate cancer, investors in Dendreon and critics of health care reform, who said the government was singling out the drug because of its cost and was on its way to rationing health care. Similar accusations about rationing greeted the F.D.A.’s proposal to remove the breast cancer approval for Avastin.

Both Medicare and the F.D.A. said the costs of the drugs were not a factor in their deliberations.

Private insurance companies must also decide whether to continue paying for Avastin as a breast cancer treatment.

WellPoint said it would review the medical necessity after the F.D.A. makes its final determination.

Cigna and the Health Care Service Corporation, which operates Blue Cross and Blue Shield plans in Illinois, Texas, Oklahoma and New Mexico, both said they would evaluate their coverage positions after the F.D.A. made a final decision.

UnitedHealthcare said its chemotherapy coverage decisions were based on a reference published by the National Comprehensive Cancer Network. That reference lists Avastin as a valid treatment for breast cancer.

Better Odds for Surviving Complex Surgery

June 13, 2011

By RONI CARYN RABIN

The odds that a Medicare patient will die after undergoing one of eight high-risk operations have fallen sharply, an analysis of medical records has found.

Fewer hospitals are performing these procedures, and the hospitals that do them are high-volume facilities that tend to have more experience caring for high-risk patients, the researchers found. But that trend does not fully account for the decline in deaths.

Patients who had surgery to repair abdominal aortic aneurysms experienced the steepest decline in mortality in the analysis. Their death rate fell to 2.8 percent in 2007-8 from 4.4 percent in 1999-2000 — a 36 percent drop, due mostly to new medical technology, the researchers said.

Death rates also fell among patients after operations to treat cancers of the esophagus, pancreas, lung and bladder, and among those who had had coronary artery bypass grafting, aortic valve replacement and carotid endarterectomy, according to the study, published this month in The New England Journal of Medicine.

The declines in mortality translate into about 2,000 fewer deaths each year, said Dr. John D. Birkmeyer, director of the Center for Healthcare Outcomes and Policy at University of Michigan and the paper’s senior author. Much of the improvement stems from a new emphasis on patient safety, Dr. Birkmeyer added.

Get Free Help Finding Insurance

• If you're having trouble finding, keeping or using health insurance, your state has a free Consumer Assistance Program (CAP) that can help.

  Even if you already have insurance, it's not always easy to read the fine print and get the benefits your paid for. Here's what your CAP can do for you:

  • Help you find a health insurance plan or policy
  • File a complaint or appeal
  • Learn about your rights and new industry reforms

  Learn more at www.healthcare.gov.

‘Ask Medicare’ 2.0

What is Ask Medicare?

Ask Medicare is a one-stop source of information and support just for caregivers like you. If you're one of the nearly 66 million Americans caring for an aging, seriously ill, or disabled family member or friend, we're here to help make your life a little easier.
Learn More

April 18, 2011, 11:36 am

By PAULA SPAN

Medicare.gov gets up to 2.8 million visitors a month who use the Web site to do everything from ordering new cards to learning how many problems inspectors found at local nursing homes.

But Ask Medicare, the section devoted to family caregivers, has been drawing far less interest. Though the information it provides is comprehensive and valuable, the section was “hard to navigate and hard to read,” said Brian Smart, account manager for the Centers for Medicare and Medicaid Services.

So Medicare spent months revamping Ask Medicare, and the new and improved version made its debut last week. “My goal was to make it as easy and quick to use as possible,” said Aaron Murphy, who designed the new site. “This is already a stressful process, and people don’t have a lot of time on their hands.”

On the revamped Ask Medicare, you can sign up for an e-mail newsletter that alerts you to changes and new benefits. You can read other caregivers’ stories and share your own.

Basic information on eligibility and coverage, directions on filing claims, updates on common diseases and conditions, links to many other organizations and agencies, downloadable fact sheets and pamphlets — it’s a trove. Take a look.

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

Improving Care for People with Medicare

April 4, 2011 by Centers for Medicare & Medicaid Services

By Don Berwick, M.D., Administrator of the Centers for Medicare & Medicaid Services. Crossposted from HealthCare.gov

If you or a loved one has ever had the unfortunate experience of having a chronic or serious illness, you’ve experienced the frustration of our fragmented health care system. Just when you are feeling your worst, there you are in the doctor’s office or hospital room, repeating the same information time and time again, sitting through the same medical test more than once, and trying to track down lost or unavailable medical charts. These are all aspects of our current health care system we could each do without.

This can be a particular problem for the more than half of Medicare beneficiaries with five or more chronic conditions such as diabetes, arthritis, and kidney disease. These patients often receive care from multiple physicians and in multiple sites. A failure to coordinate care can lead to patients not getting the care they need or receiving duplicative care. This lack of coordination also increases their risk of suffering medical errors, such as receiving prescriptions for medications that ought not to be taken together. It can also cause complications that lead to needless hospital stays. Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days – a readmission many patients could have avoided if their care outside of the hospital had been better coordinated.

Improving coordination and communication among physicians and other providers and suppliers will help improve the care Medicare beneficiaries receive, while also helping lower costs. Numerous studies have shown that better care often costs less, because coordinated care helps to ensure that the patient receives the right care at the right time.

Thanks to the Affordable Care Act, the Department of Health and Human Services (HHS) today released proposed new rules to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs). ACOs are designed to create and support a team of health care providers who treat individual patients by working together across care settings.

Over the last months, CMS has conducted extensive outreach to patient advocates, doctors, nurses, hospitals, health plans, employers, and other interested stakeholders to hear their thinking about the best way to shape this effort. We will continue to seek feedback on the proposed rules released today so that the final rules reflect the broadest consensus on how to improve care for people with Medicare and to provide a model for private payers to draw upon. We look forward to working with patients and care providers to build the most patient friendly and cost-effective health care system achievable

Under the proposal, ACO teams of doctors, hospitals and other health care providers and suppliers working together would coordinate and improve care for patients with Original Medicare. ACOs would have to meet high quality standards in five key areas:

•Patient/Caregiver Experience of Care
•Care Coordination
•Patient Safety
•Preventive Health
•At Risk Population/Frail Elderly Health

An ACO will be rewarded for providing better care and investing in bettering the health and lives of patients. ACOs are not just a new way to pay for care. They are a new model for the organization and delivery of care. Accountable Care Organizations are designed to lift the burden of fragmented and disconnected care from patients, while improving the partnership among patients, doctors, hospitals and other providers of care in making health care decisions.

To read more on this, check out the fact sheet. You can also read my blog at the New England Journal of Medicine.