Medicare Advantage on the Rise

Medicare Advantage on the Rise

Continued growth, strong performance and new guidelines are good news for plans and their members

Already the choice of more than one-third of the 59 million people with Medicare, the Medicare Advantage (MA) program is growing and changing in ways that will help even more seniors maintain good health and independence as they age.

Strength in Numbers

The number of eligible seniors opting for MA plans over fee-for-service Medicare has grown year after year — and shows no signs of slowing down. Medicare managed care plans now provide coverage to more than 21 million people with another 2 million expected to join in 2019. If that happens, MA plan members will represent 39 percent of the total Medicare population.

Among the largest MA plans in California, SCAN has witnessed this trend first-hand, increasing market share and experiencing significant growth in Los Angeles, Orange and Sonoma counties during the 2018 annual enrollment period.

Bigger and Better, Too

MA plans improve the health of seniors in ways that other coverage options haven’t, and this is fueling increased enrollment. With a focus on preventive services, care coordination, access and continuous improvement, MA plans continue to outperform fee-for-service Medicare in key quality measures. A recent study by Avalere Health shows Medicare Advantage beneficiaries had 23 percent fewer inpatient room visits and better health outcomes overall than individuals enrolled in FFS Medicare at similar costs to regular Medicare. People with chronic conditions, such as diabetes, in particular benefit from the extra benefits and programs available through Medicare managed care, experiencing better health outcomes and fewer complications, including serious complications, from their conditions.

Findings like these are important for several reasons. For one, they confirm that what providers of MA plans like SCAN and others like us are doing is making a meaningful difference in the lives of members, particularly those who need help the most. They also underscore plan’s commitment to providing high quality benefits and services that meet members’ individual needs related to health and independence.

Knowing that MA plan members have better experiences can also be useful to our broker partners, because when you present an MA plan to your clients, you can be confident you are offering them coverage they can rely on for high-quality care, improved access and better health. When it comes to MA, quality begets even greater quality. Since Medicare pays a bonus to plans demonstrating the highest quality, well-performing plans can reinvest these bonuses, continuously improving benefits, access and quality of care for the member.

SCAN’s 4.5 star rating for 2018 from the Centers for Medicare & Medicaid Services is not only a reflection of our efforts to improve quality and services, but an investment that pays off in a meaningful way for us, our provider partners, and our members.

New Laws, New Opportunities

A’s success in providing high-quality, value-driven and cost-effective care has not been lost on lawmakers. At the federal level, MA plans have earned bipartisan support, with more than 360 members of Congress pledging to preserve the program. They showed their support in an even more tangible way earlier this year with legislation that will make it possible for plans to further improve services and health outcomes: Special Needs Plans, which until now were temporary demonstration projects, can now be offered by MA plans on a permanent basis. This change will allow more of the nation’s frailest seniors to benefit from programs that help them age successfully at home for as long as possible.

Health plans that already offer SNPs can begin to think in the long term, while other plans that were put off by the uncertainty of past SNP rules will likely begin exploring these options. The result: More seniors with chronic illnesses and other special needs will have access to programs and services
designed to support them.

The definition of “primarily health related” supplemental benefits has been expanded to allow MA plans to offer food, counseling and other nonmedical services as long as they can help prevent, cure or reduce illness or injury. TeleHealth made headlines when the Bipartisan Budget Act was signed into law in February. The legislation allows MA plans to include delivery of telehealth services in a plan’s basic benefits. This can enable a member to access mental health services from the privacy of their own home, or provide a convenient way to ensure post-hospitalization follow-up care is received.

While plans in the past have been required to offer the same benefits to all their enrollees, new regulations also allow MA plans to tailor benefits to groups within their membership with specific health conditions. For example, a plan could offer all members diagnosed with diabetes additional coverage for podiatry services, offering another way to better tailor plan coverage to member need. Many MA plans have likely incorporated the new benefit flexibility into 2019 plan bids for approval by Medicare.

While 2019 benefits have not been released as of press time, I’m confident that many in our industry are thinking of new and creative ways to provide the most value for members under the new guidelines.

A Strong Choice for Seniors

These “new developments” align with SCAN’s history as a social HMO and our decades of experience caring for the frailest seniors. As a long-time advocate for changes that would allow greater flexibility in meeting seniors’ individual needs, we are excited to be looking at ways to once again provide benefits that can more directly help each member age safely in the setting of their choice.

When evaluating which MA plan is right for each client, think about both the nature of the benefits and the stability of the plan. While it’s exciting to offer “more” and “different” benefits, it’s also imperative that the plan will be there for the long-term. Make sure the plan under consideration is adding benefits and services at prices that are sustainable year over year. While more customized coverage options will only add to MA’s appeal, plan members— your clients—depend on stability of cost and coverage.

The plan should work as hard to retain existing clients as it does to gain new ones. The bottom line is this: 2018 has been a good year for seniors! The many benefits that already come with membership in a Medicare Advantage plan will inevitably get even better.

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website


The New Medicare and You

The New Medicare and You



“It ain’t your father’s or grandfather’s Medicare.” After 48 years Medicare is changing its health care focus from treatment of acute diseases to caring for Medicare beneficiaries with chronic diseases. Why?Simple! Eighty-six percent of the nation’s $2.7 trillion annual health care expenditures are for people with chronic and mental health conditions. About 65 percent of Medicare beneficiaries have two or more chronic diseases, and 43 percent have three or more. Reducing chronic expenses is the fastest way to bring the exploding Medicare costs under control.


Chronic diseases are often caused by unhealthy behaviors that increase the risk of disease—poor nutrition, inadequate physical activity, overuse of alcohol or smoking. Social, emotional, environmental and genetic factors also play a role. As people age, they are more likely to develop one or more chronic disease.

How ill is America’s health? The picture isn’t pretty:
• During 2011–2014, more than one-third of adults (36 percent), were obese.
• 36.5 million adults in the United States (15.1 percent) said they currently smoked cigarettes in 2015.
Cigarette smoking accounts for more than 480,000 deaths each year.
• 90 percent of Americans aged two years or older consume too much sodium, which can increase their risk of high blood pressure. Of course, obesity, smoking-related disease and high blood pressure are key chronic diseases. Chronic diseases are painful diseases; example quotes of chronic patients taken from an online site:
• “Sitting down in the shower to shave because it’s easier on my joints. I sometimes forget that many
people stand to shave.”
• “I have a habit of collecting my hospital bracelets after I get out of the hospital as it reminds me that I won yet another battle. It seems odd, but for some reason, I hold onto the bracelet feeling empowered that I walked away from what tried to defeat me again.”


You better get to know how to present C-SNP plans as ‘chronic’ is the new buzzword with Medicare. The Center for Medicare and Medicaid Services (CMS) has opened the door for health plans to add Value-Based Insurance Design (VBID) benefits such as air conditioners for asthma patients, home health benefits, healthy groceries, home-delivered meals and installing safety items like grab bars.

As an example of a health plan’s preparation for the expansion of VBID, Humana recently purchased Kindred Healthcare. Kindred Healthcare owns an array of businesses including home health, hospice, long term care hospitals and inpatient rehabilitation facilities. Humana has a significant business administering Medicare health benefits for the elderly, and the Kindred deal helps Humana form closer ties with a provider of home care and related services predominantly used by the elderly.

Starting in 2019, health plans in California and other targeted states can expand their benefits to include more Medicare beneficiaries with chronic conditions than previously identified by CMS, such as diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and combinations of these categories. The new chronic list will include beneficiaries with lower back pain, chronic kidney disease, obesity/pre-diabetes, asthma, and tobacco use. Beginning in 2018, CMS also allowed benefits for enrollees with dementia and rheumatoid arthritis. Medicare Advantage plans can cover adult day care services, and in-home help with activities such as dressing, bathing and managing medications. Seema Verma, the administrator CMS, told insurance company executives at a recent conference that “CMS hopes its new ‘reinterpretation’ of the Medicare Advantage program benefits rules will help unleash private-sector innovation and creativity.”

CMS further states, “Plans adding benefits based on the supplemental benefits interpretation must make sure the benefits are ‘primarily health related,’ and not primarily for a patient’s comfort. The services covered must be recommended by a physician or other licensed medical professional as part of a care plan.

The new benefits must not include items or services used to induce enrollment. “The primary contributor to the shift in focus to chronic diseases is Congress passing “The Chronic Care Act of 2018,” February 9, 2018, which opened the doors to the inevitable expansion of C-SNP or “Look-Alike” C-SNP Medicare Advantage Plans that provide VBID benefits. Two of the main sections of the bill that impacts health plans and the brokers that sell them are:

1. Allows MA plans to offer an expanded set of supplemental benefits to the chronically ill enrollee. Enables MA plans to experiment with different types of benefit packages to meet the needs of chronically
ill beneficiaries.
2. Permanently authorizes three types of SNPs: D-SNP (dual eligibles), C-SNP (those with severe disabling chronic conditions), and I-SNP (those in institutions). C-SNPs must meet additional care management requirements starting in 2020. By 2022, and every five years after that, the Health and Human Services (HHS) Secretary must update the list of chronic conditions eligible for participation. The list must include HIV/AIDS, end-stage renal disease and chronic/disabling mental illness.


The Centers for Disease Control and Prevention (CDC) established a comprehensive chronic disease program.The four major components are:

1. Implemented systems that track chronic diseases and their risk factors.
2. Promotes health and support healthy behaviors across the nation, in states and communities, and in settings such as schools, child care programs, work sites and businesses.
3. Developed programs and policies that allow doctors to diagnose chronic diseases earlier and manage them better.
4. Established community programs linked to clinical services to help patients prevent and manage their chronic diseases, with guidance from their doctor. The State of California Chronic Programs,, includes services for health self-management, fall prevention and physical activity, and caregiver and memory programs. The VBID benefits cannot cure chronic diseases but can aid in reducing the hospitalizations due to chronic illnesses. CDC recommends six healthy aging suggestions (as seen by the graph on this page).


The New Medicare and You has a chronic condition focus. You can count on the majority of your Medicare
clients having one or more chronic diseases and they would probably like to to hear about the VBID benefits
of a C-SNP or an MA plan with VBID benefits. Already, there are MA and C-SNP health plans with added benefits, such as:

• Health Coach
• Care Management
• Acupuncture
• Telehealth
• Chiropractic
• OTC Supplies
• International
• Lower Cost Travel Tiered Copays
• Gym Membership
• Transportation
• Quit Smoking Programs
• Nutritional Programs

The emphasis on chronic and CSNP plans also creates a yearlong enrollment opportunity for brokers. Eligible Medicare beneficiaries can enroll anytime during the year into a C-SNP plan with their PCP’s confirmation of their chronic illness. ‘Lockin’–where you can only enroll new to Medicare beneficiaries – is becoming antiquated given C-SNPs. With the new OEP now January 1 to March 31 and AEP October 15 to December 7 and C-SNP’s and New-to-Medicare, enrollments are now a full-time enrollment opportunity. Oh, not forgetting D-SNPs for Dual Eligibles and I-SNPs for Institutional members, brokers have unlimited enrollment opportunities.


The ‘New Medicare and You’ is BetaBenefits’ title for our Medicare educational classes in which we discuss Medicare’s milestones (see chart) and the benefits each milestone provides Medicare beneficiaries. With CMS’ emphasis on chronic diseases and VBID benefits, shouldn’t you rethink how you present Medicare to your clients?

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

Medicare Fraud – Learn How to Help your Clients Protect Themselves

Medicare Fraud – Learn How to Help your Clients Protect Themselves

Medicare fraud costs an estimated $60 to $90 billion a year. Losing billions of dollars to fraud is a waste of taxpayer money, and fundamentally increases the cost of healthcare for everyone. It can also jeopardize beneficiaries’ personal and medical identity, and their ability to access entitled benefits and services. Knowing about fraud is key to protecting yourself and your loved ones.

Types of Medicare Fraud

Medicare fraud comes in all shapes and sizes reflecting Medicare’s huge and complex program with its Parts A, B, C and D (for readers who don’t sell Medicare yet: Part A is hospital insurance, Part B is outpatient medical insurance, Part C is Medicare Advantage plans and Part D is prescription drug

This is a lot of information, so let’s get started….

Overview on various types of fraud

Medicare fraud most commonly occurs in:
(1) Billing for institutional facilities such as nursing homes, residential facilities, hospitals, home health and hospice.
(2) Billing for physician visits and services not rendered or not medically necessary.
(3) Billing for durable medical equipment such as wheelchairs, body jackets, incontinence supplies or diabetic supplies without a doctor’s prescription.
(4) Improper marketing of health insurance plans through phone calls, door-to-door sales and misleading flyers.

Provider Fraud

(1) Providers can commit fraud if they submit bills for services not provided, or unnecessary services.

(2) They can also commit fraud if they upcode a service. This is when a provider charges Medicare for a more expensive service than was provided. For example, a provider may bill for surgery, when only a bandage was placed over a cut.

(3) Unbundling services can also be fraud. This occurs when a provider submits separate bills for lab services that combine three or four tests, which are intended to be billed as one service.

Billing for non-covered services as covered services is also fraud. This occurs when a provider bills a service such as routine toenail clipping (non-covered service) as foot surgery (covered service).

Suppliers and Recruiters Fraud

Suppliers can commit fraud if they:
Bill for different equipment than what the beneficiary received, bill for home medical equipment after it is returned or solicit, offer or receive a bribe or kickback.

Recruiters may stop Medicare beneficiaries on the street or make an at-home visit, offering money and promotional gifts as incentives to take “free” medical exams, after which they give the beneficiary medical
equipment they do not need.

Insurance Broker Fraud

Insurance brokers can commit fraud if they bribe, mislead, or coerce a beneficiary to enroll into or switch plans just to make a commission even though the plan may not be the best choice. Or if they enroll a beneficiary into an MA plan without the beneficiary’s consent or make unsolicited phone calls, emails or home visits.

Pharmacists Fraud

Pharmacists can commit fraud if they dispense expired drugs or short the beneficiary on the number of pills in the prescription they deliver.

Beneficiary Fraud

A beneficiary can commit fraud if they provide their Medicare number in exchange for money or a free gift. In some cases, beneficiaries may unknowingly commit fraud in this way. One of the best ways for your Medicare clients to detect fraud is to examine both their Medicare Summary Notice (MSN) they receive from Medicare after their claims are paid, and the Explanation of Benefits (EOB) they receive from their Part C and D plans. (Clients can access their Medicare account at

These are some helpful questions to ask when clients review their MSN and EOB:

(1) Did they receive all the services/prescriptions listed?
(2) Were they billed for something they didn’t get? Or billed for the same thing twice?
(3) Did the doctor order the services?
(4) Do the prescriptions listed match their prescriptions?
(5) Are the dates of the services/prescriptions correct?

If after answering these questions, your clients suspect fraud, they can call our California Senior Medicare Patrol (SMP) at 1-855-613-7080.

Common Recent Scams

The most common fraud schemes our California SMP currently sees are hospice fraud, new Medicare card scams and “free” back brace scams. Medicare’s hospice benefit provides palliative care for people who are terminally ill and have 6 months or less to live. Yet scammers are signing up healthy people for this benefit while offering them “free housekeeping services covered by Medicare,” or “free milk for an entire year covered by Medicare!” They get beneficiaries’ Medicare numbers in exchange for the “free” benefit and sign them up.

In addition, some beneficiaries residing in low-income housing units are offered assistance with cooking and cleaning while unknowingly being placed in home health or on hospice. Help keep a look out and spread the word on these schemes to stop this fraud.

Beneficiaries should have received their new Medicare cards by now in California. If they haven’t, though, it is coming soon in the mail. Of course, there is no charge for the new card, so remind clients not to be tricked into sending money to scammers. Postcards, TV commercials, ads offering a “free” Medicare-approved back brace in exchange for your Medicare number.

Medicare only covers braces and other durable medical equipment (DME) that are medically necessary with a doctor’s prescription. Scammers, however, hope people don’t know that. They just want beneficiaries’ Medicare numbers to bill Medicare for equipment they never deliver, or to bill Medicare for much more expensive equipment. If clients think they need a back or knee brace, they should call their doctors first.

Open Enrollment Fraud Tips for Clients

In addition to all the scams we’ve covered thus far, more scams come during Medicare’s annual open enrollment (October 15 through December 7). This is the time beneficiaries can enroll into or change their Medicare Advantage and/or Part D plan, or return to Original Medicare. As MA and Part D plan coverage can change annually, it’s important for beneficiaries to review the changes in their coverage for the coming year. Navigating this information can be confusing and hence makes open enrollment a ripe time for scams.

Below are a few tips for clients to protect themselves from fraud during this time.

(1) Beware fake Medicare sales representatives: Make sure clients understand not to believe a salesperson who claims to be a Medicare representative. Of course, Medicare does not send “representatives” to solicit anyone’s business. Federal regulations prohibit unsolicited telephone calls, door-to-door visits, emails and other forms of sales without permission. Make sure clients understand that if they have not requested that someone contact them, it may be a scam.

(2) Guard personal info: Tell clients to never give out personal information such as a Social Security number, bank account numbers, or credit card information over the telephone.
(3) Keep good records: Advise clients to keep records of who they speak with – even you! — and the information that they provide.
(4) Take their time: Clients shouldn’t feel pressured to make a quick decision. Tell clients to be sure that they understand the details of a plan before they enroll. They should verify copayment amounts and whether their medical providers participate in the plan that they are considering.
(5) Change isn’t mandatory: If clients are satisfied that their current plans will meet their needs for the coming year, they don’t need to change plans. They should confirm the details of their current plan before making a switch.

Thanks to all of you for being the “eyes and ears” of Medicare and watching out for scams. Please share this information and report any suspected fraud to our California Senior Medicare Patrol at 1-855-613-7080.

More information on Medicare fraud, resources for education and outreach are in the fraud and abuse section of our website at

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

New Medicare Law to Notify Patients of Loophole in Nursing Home Coverage

New Medicare Law to Notify Patients of Loophole in Nursing Home Coverage

In November, after a bad fall, 85-year-old Elizabeth Cannon was taken to a hospital outside Philadelphia for six and a half days of “observation,” followed by nearly five months at a nearby nursing home for rehabilitation and skilled nursing care. The cost: more than $40,000.

The hospital insisted that Ms. Cannon had never been formally admitted there as an inpatient, so under federal rules, Medicare would not pay for her nursing home stay. The money would have to come from her pocket.

The experience of Ms. Cannon and thousands like her inspired a new Medicare law — in force as of Saturday — that requires hospitals to notify patients that they may incur huge out-of-pocket costs if they stay more than 24 hours without being formally admitted. Because of the Notice Act, passed by Congress last year with broad bipartisan support, patients can expect to start receiving the warnings in January.

“It was extremely distressful to my mother, who was frugal her whole life,” said Cynthia Morgan of Chadds Ford, Pa., Ms. Cannon’s daughter. “She asked, ‘How can I pay into Medicare for so many years, and now Medicare won’t help pay for my care?”’ Ms. Cannon died in April.

Hospitals have been keeping patients like Ms. Cannon in limbo — in “observation status” — for fear of being penalized by Medicare for inappropriate admissions. While under observation, patients can be liable for substantial hospital bills, and Medicare will not pay for subsequent nursing home care unless a person has spent three consecutive days in the hospital as an inpatient.

Time spent under observation does not count toward the three days, even though the patient may spend five or six nights in a hospital bed and receive extensive hospital services, including tests, treatment and medications ordered by a doctor.

Under the new law, the notice must be provided to “each individual who receives observation services as an outpatient” at a hospital for more than 24 hours. Medicare officials estimate that hospitals will have to issue 1.4 million notices a year.

“The financial consequences of observation stays can be devastating for seniors,” said Senator Susan Collins, Republican of Maine and the chairwoman of the Senate Special Committee on Aging.

Senator Benjamin L. Cardin, Democrat of Maryland, the chief sponsor of the Senate version of the legislation, said it would “save seniors from the sticker shock that comes after they are discharged from the hospital and realize that Medicare will not cover the cost of care in a skilled nursing facility.”

The median cost for a private room in a nursing home is roughly $92,000 a year, according to a survey by Genworth Financial, an insurance company. Medicare covers up to 100 days of skilled nursing home care at a time.

The text of the standard “Medicare outpatient observation notice” is subject to approval by the White House Office of Management and Budget. In its current form, the notice to beneficiaries says: “You’re a hospital outpatient receiving observation services. You are not an inpatient.” And it explains that Medicare will cover care in a skilled nursing home only if the beneficiary has had an inpatient hospital stay of at least three days.

Patients can then consult their doctors and may ask to be reclassified as inpatients.

Hospitals have found themselves in a squeeze. They increased their use of “observation status” in response to close scrutiny of their billing practices by Medicare auditors — private companies hired by the government to review claims. In many cases, these companies challenged decisions by doctors to admit patients to a hospital, saying the services should have been provided on an outpatient basis. The auditors then tried to recover what they described as improper payments.

Doctors and hospitals said the auditors were like bounty hunters because they were allowed to keep a percentage of the funds they recovered.

But patients now will at least be better informed. The Senate Finance Committee explained the reason for the law this way:

“The number of Medicare beneficiaries receiving outpatient observation care over the last several years has been steadily increasing. Some beneficiaries are surprised to learn that although having received treatment overnight in a hospital bed, the beneficiary was never formally admitted as an inpatient but was instead a hospital outpatient.”

Federal officials acknowledged that Medicare beneficiaries sometimes had to pay more as outpatients under observation than they would have paid if they had been formally admitted to the hospital and received the same services as inpatients.

The administration issued rules last week to carry out the new law. The purpose, it said, is “to inform beneficiaries of costs they might not otherwise be aware of.”

“Even if you stay in a hospital overnight, you might still be considered an outpatient,” the administration said in a publication for beneficiaries.

Consumer advocates and nursing homes support the new requirement.

“Medicare beneficiaries are spending more and more time in the hospital without being formally admitted,” said Joyce A. Rogers, a senior vice president of AARP, the lobby for older Americans, adding that this “can expose beneficiaries to unexpectedly high out-of-pocket costs amounting to thousands of dollars.”

Mark Parkinson, the president and chief executive of the American Health Care Association, a trade group for nursing homes, said, “Patients often have no idea what their status is in a hospital.” Observation stays impose a “financial burden on seniors,” he said, and increase the likelihood that they will have to turn to programs like Medicaid, the federal-state program for low-income people.

“The new law is an important first step, but Congress and the administration need to do more to protect beneficiaries,” said Judith A. Stein, the executive director of the nonprofit Center for Medicare Advocacy.

Under the law, hospitals can still keep Medicare patients in observation status, and some of the patients will be responsible for nursing home costs. Twenty-four senators and more than 120 House members are supporting bipartisan legislation to address that concern. Under that bill, time in a hospital under observation would count toward the three-day inpatient stay required for Medicare coverage of nursing home care.

Source: The New York Times

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

“As your Medicare agent you become my TOP priority”
“The Medicare Answer Guy’s Mission is to help you with your Medicare planning all year long”
“The Medicare Answer Guy will help you with the A,B,C’s of Medicare”
“The Medicare Answer Guy will make Medicare Easy”

The Medicare Answer Guy © 2016 - Website Design by Mike Stahl Web Design

Syncing Up Drug Refills: A Way To Get Patients To Take Their Medicine

Syncing Up Drug Refills: A Way To Get Patients To Take Their Medicine

You have your red pill and your green pill. There’s the one you take at breakfast, the one you take before bed and the one you have to take six hours after eating. All told, it is a lot to keep track of. And remembering the refills, all of which often happen at different times of the month, gets so complicated that sometimes you forget — and simply go without.

For the quarter of Americans with multiple ailments, this scenario is very familiar. It is also part of the reason, experts suggest, close to half of people with chronic conditions don’t take their medications as directed by their doctors. This noncompliance costs the health care system hundreds of billions of dollars.

But a study published Monday in Health Affairs suggests a possible fix: syncing up prescription refill timelines for patients who take multiple medications.

“We have so many things going on and so many complexities in our daily lives that reducing one level of complexity, and getting rid of issues related to forgetfulness — that’s a huge service,” said Jalpa Doshi, an associate professor at the University of Pennsylvania’s medical school, and the study’s lead author.

Researchers began with a group of patients who were Medicare Advantage plan members, were taking medications for diabetes, hypertension or cardiac disease, and who participated in Humana’s pharmacy mail-order service. They then randomly assigned 2,500 of them to an “intervention invitation group.” Of those, 691 were reachable and agreed to enroll in this “pilot prescription synchronization program.” A separate 695 were not contacted and made up a control group that continued to receive prescriptions as usual.

Patients whose prescription refills were aligned were more likely to follow their medication regimens, with overall rates of adherence increasing by 3 to 10 percentage points between September 2013 and December 2014. For those in the control group, adherence increased by only 1 to 5 percentage points. Improvement was greater for people who, at the start of the study, were already less likely to take medications correctly. For this group, syncing prescriptions boosted adherence by between 23 and 26 percentage points, as opposed to between 13 and 15 in the control group.

These findings come as more states pass laws that support the concept by requiring health insurance plans to cover partial refills of medication, and to charge pro-rated copays when they do so. Such measures make it possible for consumers and physicians to work together to make sure that prescription refill cycles match up.

That policy change can make a huge difference for people on multiple chronic prescriptions, Doshi said — a circumstance particularly common among elderly patients.

“If I’m an elderly person who needs care and support, I need someone to go to the pharmacy, or drive me. That in itself is a huge issue,” she said. Even with mail-order prescriptions, remembering when individual ones end and making sure to keep them on schedule is a huge challenge. And if patients aren’t getting their medications on the correct schedule, they can hardly take them as directed, she said.

Some independent researchers, however, were quick to point out that these findings are only a first step and that additional research is necessary. But if these results hold, the approach could help make a dent in unnecessary health expenses and keep chronically ill patients healthier.

They also cautioned against placing too much weight upon these findings. For instance, there’s the self-selecting nature of people who had their prescriptions synced. Because they opted into the program, they may have been people already looking for ways to improve their medication habits, said Walid Gellad, co-director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. That could have inflated the improvement researchers found.

He added, though, that the practice seems promising.

“Intuitively, it would be great if you could get all the medications at the same time, rather than having to figure out when each one was due” for a refill, said Gellad, who wasn’t involved with the study. “It’s really patient-centered, and a good way to simplify things.”

The study also doesn’t link greater medication adherence to patients getting or staying healthier. That makes it hard to measure how much syncing prescriptions would really help consumers, noted Hayden Bosworth, a professor of medicine at Duke University.

But, that said, “with these particularly effective drugs — there’s no question that if you take them, you’re going to have benefits,” he added. Bosworth also was not involved with the study.

Other research has strongly associated better adherence with improved patient health, said Niteesh Choudhry, a professor of medicine at Harvard Medical School, who was also not involved.

Meanwhile, it’s still unclear how many patients actually want the service. In the study, only about 28 percent of customers opted to have their medications aligned. That could undermine the practice’s potential.

The study’s authors attributed that reluctance to what they call “status quo bias” — the idea that people are generally reluctant to deviate from a system they have in place.

Plus, the study only looked at Medicare Advantage patients who got mail-order prescriptions. That’s a very specific group, said Choudhry. It’s possible that when you extend out, the potential to benefit from prescription syncing changes.

And it’s unclear who is most likely to benefit. This study looked at older patients, who are already more likely to adhere to their medications. More research should examine whether younger people — who are worse about taking their pills — could stand to gain from prescription syncing, Choudhry said.

No matter what, Bosworth said, the practice must be part of a larger strategy. Given how many people don’t take their medications properly, there’s no single silver bullet.

“Medication adherence is one of the largest public health problems we have,” he said. “I don’t think this is going to get us there, but it is part of the puzzle.”

Source: Kaiser Health News

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website

“As your Medicare agent you become my TOP priority”
“The Medicare Answer Guy’s Mission is to help you with your Medicare planning all year long”
“The Medicare Answer Guy will help you with the A,B,C’s of Medicare”
“The Medicare Answer Guy will make Medicare Easy”

The Medicare Answer Guy © 2016 - Website Design by Mike Stahl Web Design

How Common Procedures Became 20 Percent Cheaper for Many Californians

How Common Procedures Became 20 Percent Cheaper for Many Californians

At a time when health care spending seems only to go up, an initiative in California has slashed the prices of many common procedures.

The California Public Employees’ Retirement System (Calpers) started paying hospitals differently for 450,000 of its members beginning in 2011. It set a maximum contribution it would make toward what a hospital was paid for knee and hip replacement surgery, colonoscopies, cataract removalsurgery and several other elective procedures. Under the new approach, called reference pricing, patients who wished to get a procedure at a higher-priced hospital paid the difference themselves.

For example, in 2011 the Calpers maximum contribution for a knee or hip replacement surgery was set at $30,000. A Calpers patient receiving knee or hip replacement surgery at or below this reference price paid the usual cost-sharing: 20 percent of the cost, up to a maximum of $3,000. But a patient electing to use a hospital that charged, say, $40,000 paid the usual cost-sharing in addition to the $10,000 above the reference price.

As Calpers initiated the new approach, 41 of the several hundred hospitals in California could provide knee and hip replacement procedures at or below $30,000 and with acceptable quality, as measured by things like low readmission rates and high rates of use of guideline infection controls. Some hospitals charged more than $100,000 for the procedures.

The results of knee and hip replacement surgery reference pricing were striking, as were those for cataract removal, arthroscopy and colonoscopy. In a series of studies, James Robinson and Timothy Brown, University of California, Berkeley, health economists, found that under reference pricing, Calpers patients flocked to lower-priced hospitals and outpatient surgical centers. Prices and total spending for the procedures plummeted.

For knee and hip replacements, lower-priced hospitals saw their market share increase by 28 percent. As higher-priced ones lost market share, many chose to reduce their prices. Prices for the procedures fell by an average of more than 20 percent, saving Calpers and its patients $6 million over two years.

Under reference pricing for cataract removal surgery, the average price paid also dropped by nearly 20 percent, saving $1.3 million over two years. For colonoscopies, $7 million was saved — a 28 percent drop. And for knee or shoulder arthroscopy, prices fell by about 17 percent. For these procedures, Calpers reduced patient cost-sharing if they chose a free-standing, outpatient surgical center, as opposed to a much more expensive hospital.

During the period of time Calpers saw 20 percent price declines for reference-priced services, typical health care prices paid by employer-sponsored plans rose by about 5.5 percent.

Despite the success of the effort by Calpers, reference pricing is not a full solution to rampant health care spending growth. Because it relies on encouraging patients to visit lower-priced hospitals and surgical centers, it works only with procedures for which patients can reasonably shop around.

This excludes care over which patients have little control, such as that provided in emergencies or while they are already hospitalized or incapacitated. One study estimated that about 40 percent of health care spending is for services for which patients could shop.

But there is another reason reference pricing is hard to install broadly. It requires patients to have ready access to comprehensible price and quality information. Such transparency is not commonplace. Even when this information is available, consumers with cognitive impairments or who are overwhelmed with illness and other demands would have trouble making the best use of it.

Some consumers might prefer to delegate to insurers the decisions about where to obtain care. In narrow network plans, for instance, insurers select high-quality hospitals and negotiate the best price; patients pay the same amount out of pocket no matter which hospital they visit within the network. Reference pricing shifts some of the burden of figuring out where to obtain care from insurers to consumers. On the other hand, compared with narrow network models, it preserves broader choice for the consumer.

Reference pricing also requires sufficient competition among hospitals. If the number of hospitals is too low, patients will not have a choice about where to receive care, and hospitals will not have an incentive to reduce prices. Assessing the degree of competition, quality and choice for the purposes of establishing and updating reference prices imposes an administrative cost that should be weighed against any savings.

For this reason, some large employers are contracting with regional “centers of excellence,” such as the Cleveland Clinic, to which patients can be referred even if there is limited hospital choice in their hometowns.

Another concern is that reference pricing could encourage lower quality, as health care organizations cut costs to reduce prices. Analysis by Mr. Robinson and colleagues did not find adverse effects of reference pricing, however. “Significant reductions in cost with no change in quality: That’s called improved value,” he said.

Source: The New York Times

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