All posts by Jason White

Investigating the Medicare missteps


The most fragile members of the medical community are finding themselves on the outside of the healthcare loop, lacking doctors, coverage and treatment. 

At the heart of the issue: the nation’s struggling Medicare system and late reimbursements that don’t cover the treatment. The failing system is pushing doctors away from the Medicare community – leaving seniors with few options. It’s become a critical issue in the River Region.

Alabama ranks among the top 8 states in the nation with the highest percentage of seniors enrolled in Medicare. That’s nearly one million people who
depend on Medicare coverage to survive. What’s keeping seniors healthy is a cancer to healthcare providers, jeopardizing their practices.

“It goes without question,” explained Dr. Greg Jones, “the government has certainly decreased reimbursements to the point you frequently lose money when you see Medicare patients.

Jones is an OBGYN with Montgomery Women’s Health Associates and describes late Medicare reimbursements as the rule, not the exception. In many cases four to five months in the rear, and less than 25 percent of what he would be paid for the same service from a private insurance carrier.

“It is complicated,” Jones admitted. “There’s a great deal of financial juggling to operating this way.  At the end of the day, it’s a business. There’s no grace given to it being a doctor’s office. The power company has to be paid, overhead has to be paid.”

Many offices have been forced to hire additional workers to focus solely on the massive paperwork that would guarantee a Medicare reimbursement, despite
not knowing what the final repayment will be. Often, the time, effort, and lost wages pulls doctors away from the Medicare community or forces them to turn away the sickest seniors who desperately need a doctor.

“It really pushes doctors to screen their patients and only take the healthy folks with minor medical problems,” Jones explained.

Medicare is aware of the chronic issues and is proposing sweeping changes to give doctors more options, shifting the reimbursement schedule to a quality-based outcome model.

“Here’s the scenario,” Jones said. “If the person has complications or issues, I’m not going to pay you. Therefore, you could argue that I am rewarding you for “good” outcome, when in fact you are not going paid for bad outcomes.”

Danne Howard with the Alabama Hospital Association has been at the forefront in the fight for proper Medicare reimbursements at the federal level for decades. She describes the proposals as a risk – and an opportunity – for the medical profession. 

Due to the Area Wage Index, Alabama hospitals are reimbursed less than any other state in the country for providing the same services. Insult to injury for local doctors, and a detractor for recruiting new physicians. In fact, Medicare reimbursement, coupled with the state’s underfunded Medicaid system, is putting the hospitals at risk.

“Many of them have already started putting things in place in order to not have to make that tough decision: laying off people, freezing people’s salaries,” Howard said. “It’s a very tough balance for those people whose hearts are in the right place to do the right thing.”

Hospitals bill Medicare differently for reimbursements than doctor’s offices. In fact, this is the driving force for doctors to leave their private practice
to work as a salaried employee of a hospital.

“As much as half of the physicians in the state are now employed by hospitals now, and they can’t keep up with the regulations,” Howard said.

Jones is surviving in a private practice by seeing more patients with private insurance to fill the Medicare void. He’s also spending two hours at home each
night coding and filing for Medicare reimbursements – with no plans to stop serving this community, as of now.

“Here in the office we take care of our patients, and we have always been confident that if we give patients high-quality care and take care of them,
they will take care of us,” Jones said.

In the River Region, we’ve counted less than 40 specialists serving the Medicare population in cardiology, rheumatology and urology combined. 

If you would like to learn more about the proposed reimbursement changes, watch this short video:

Copyright 2016 WSFA 12 News. All rights reserved.

We need to polish the Medicare jewel instead of chipping away at it


Health Minister Sussan Ley said she wanted to lift the Medicare rebate freeze but was prevented from doing so.

Health Minister Sussan Ley said she wanted to lift the Medicare rebate freeze but was prevented from doing so. Photo: Andrew Meares

We can expect dramatic overstatements to escalate in number and intensity as we get closer to polling day. Bill Shorten got off to an early start in this festival of hyperbole when he declared the July 2 vote to be a referendum on the future of Medicare.

The universal health care system is the jewel in Australia’s policy crown, built on the principle that access to treatment should not be contingent on wealth or location. It distinguishes us favourably from the countries we most often measure ourselves against, the United States and Britain, where being both poor and sick is a far more desperate prospect than in Australia (though that combination is plenty bad enough here too, even with the protection of Medicare).

Precisely because it is so precious, Medicare is vulnerable to scare campaigns. Seeming to threaten its future is politically dangerous, as it should be. So Labor says the Coalition’s plan to scrap the bulk-billing incentive for pathology services is a major threat. Likewise Mr Shorten thinks outsourcing Medicare’s payment systems to potentially cheaper, more efficient and more technologically adept private providers is such a threat to the system’s integrity that he made the probably useless promise to legislate to keep it in public hands forever.

Mr Shorten has also announced that if elected, Labor would undo the GP rebate freeze which the Coalition extended to 2020 in the last budget. At a cost of $2.4 billion to the forward estimates, it’s Labor’s biggest promise so far and further indication of Mr Shorten’s determination to focus the fight on health and education where Labor is traditionally strong. The Coalition quickly revealed its vulnerability. First there was Treasurer Scott Morrison’s muddle-headed attempt to mollify doctors by saying company tax cuts would compensate them for continuation of the rebate freeze. Then Minister for Health Sussan Ley made the baffling claim that she wanted to unfreeze rebates but “finance and Treasury aren’t allowing me to do it just yet”. This left the impression that the health minister lacks influence on health policy in cabinet.

Restoring indexation so that Medicare schedule fees can again rise with the cost of inflation, instead of being stuck at 2013 levels until 2020, puts Labor on side with the Royal Australian College of General Practitioners and the Australian Medical Association. The doctors say the freeze is “co-payment by stealth” because it will force them to charge patients up to $20 more a visit to cover their rising costs. They say the number of practices willing to bulk-bill will diminish. Yet since the freeze came in bulk-billing rates have grown to their highest level ever at 84 per cent. The Coalition insists the freeze only costs GPs 60 cents a consultation.

The Coalition under Tony Abbott proposed a $7 co-payment for GP, pathology and imaging services, a 10-minute minimum for standard GP consultations and a $5 reduction in the Medicare rebate for standard GP consultations, but such reforms were abandoned in the face of fierce resistance. No government, though, can hide from the escalating price of health care. Life-changing new technologies, the boom in chronic diseases and the ageing of the population add up to unsustainable cost pressures.

Health care in Australia is already edging dangerously towards a two-tier system. The Coalition’s policies to date, favouring user pays and the private sector in healthcare, would exacerbate existing inequalities. Though scare campaigns have so far overstated the threat, we should beware of introducing more “price signals” that detract from equity.

Both parties need to tell voters how they are going to put a brake on costs without further compromising equity and universality. The Herald favours tougher means testing of the private health insurance rebate which would reduce subsidies to the people who least need them. Outsourcing and updating the Medicare payments system is not objectionable if appropriate safeguards are met.

We need greater focus on evidence-based prevention and incentives for successful early interventions. We need more initiatives like the Health Care Homes pilot for co-ordinated health care packages to help keep people with chronic illnesses well at home. We need less along the lines of giving private health fund members priority access to certain GP clinics. Chipping away at the the universality of Medicare will exacerbate, not solve, the policy challenges we confront.

Taking a look at Medicare and insurance

Betty Berry

Q: I recently applied for my Medicare benefits and soon after received a form to complete asking for information about employer’s health plans that I might be entitled to. Why would Medicare need such information?

A: Medicare needs to know about other health care coverage to establish your benefits file and to determine whether or not Medicare will be your primary coverage.

Usually when a person becomes eligible for Medicare, Medicare serves as the primary health care payer. However, some people are entitled to other health care insurance which pre-empts Medicare as the primary health care provider shifting Medicare’s role to that of secondary payer.

The questionnaire you received asks if you have health care coverage under an employer’s health plan either through your or your spouse’s current employment. This initial enrollment questionnaire provides information for the establishment of your Medicare benefit file. Medicare needs to determine if they will be the primary or secondary payer for your health care costs. Without this information Medicare would not be able to pay your claims in a timely manner and you could be billed by your providers for services rendered.

If your or your spouse’s employer coverage is through an HMO you must also provide this information to that HMO. They will then coordinate payments between Medicare and the employer plan.

If you are 65 years old or older and continue to work or you are 65 or older and have a spouse, of any age, who works Federal law protects you from discrimination in employer health care coverage. An employer of 20 or more employees who offers health care benefits must offer you and your spouse the same health care benefits under the same conditions as those offered to other employees.

You have the choice of accepting or rejecting the plan offered by your or your spouse’s employer. If you accept the plan it will be your primary health care coverage as long as you or your spouse continue that employment. Medicare, if you decide to enroll, would then become your secondary insurance and could assist with payment of Medicare covered services that are not covered under the employer plan.

If you decide to reject the employer’s plan then Medicare will be your primary plan.

It is very important that you let your health care providers know what plan is providing your primary coverage. If it is an employer’s plan providers of care will need the name and address of the employer’s plan and policy number. Providers should be instructed to bill that plan first for any services received.

As soon as you are no longer covered by an employer’s plan it is very important that you enroll in Medicare Part B (Medical Coverage), if you have not previously done so. You should also notify the insurance carrier or HMO responsible for your Medicare claims that you are no longer covered by an employer’s plan and that Medicare will now be the primary payer. Make sure they know the effective date of this change.

Last, but not least, inform your health care providers of your change in primary coverage so they can direct their claims to the proper insurer for payment.

Q: In a past column you wrote about the OSHER Lifelong Learning Institute academic semester courses. I am looking for single lectures. Does Osher offer such individual lectures?

A: During semester break OLLI will be offering several single session lectures. These lectures will start on June 1 and will be offered at Ventura Adult and Continuing Education, Channel Islands satellite campus in Thousand Oaks and an expanded site at CSU Channel Islands main campus.

Fourteen different courses are being offered and they will cover a variety of topics. For those interested in history there will be Ivor Davis’ “Eyewitness to History; From the Beatles to Bobby Kennedy.” If interested in science there will be Fan’s “The Science of Acupuncture” and if culture is your interest there will be Garlington’s “Gandhi: A Life.”

Enrollment is currently in progress and can be completed by calling 437-2748.


June 1: 1 p.m. — Presentation — at Thousand Oaks Council on Aging Meeting — at 2100 E. Thousand Oaks Boulevard in the Board Room — “Why Volunteer? — In Their Own Words” — Barbara Minkoff Senior of the Year 2015 will talk about volunteering and introduce the 2016 Senior of the Year nominees.

June 2: 5:30 p.m. — Senior of the Year Award Dinner — at Goebel Adult Community Center — enjoy a fantastic evening with dinner, entertainment and door prizes. Tickets are $6 at the Goebel front desk.

June 5: Senior Concerns-Ladin Subaru 23rd Annual Love Run — half-marathon, 10K, 5K and 1-mile run/walk 3011 — at Townsgate Road in Westlake Village. For more information and registration call 497-0189.

June 6: Economic Check-Up appointments from 9 a.m. to 2:30 p.m. at Simi Valley Senior Center, 3900 Avenida Simi in Simi Valley. For more information or to make an appointment call 583-6363.

Betty Berry is a senior advocate for Senior Concerns. The advocates are located at the Goebel Adult Community Center, 1385 E. Janss Road, Thousand Oaks. Call 495-6250 or email (please include your telephone number.) You are invited to submit questions on senior issues.

Betty Berry Archive

Din Erupts Over Obama’s Proposed Medicare Payment Plan

The Associated Press:
Elderly Book End-Of-Life Talks Once Labeled ‘Death Panels’

The doctor got right down to business after Herbert Diamond bounded in. A single green form before her, she had some questions for the agile 88-year-old: about comas and ventilators, about feeding tubes and CPR, about intense and irreversible suffering. “You want treatments as long as you are going to have good quality of life?” Dr. Manisha Parulekar asked. The retired accountant nodded. “And at that point,” she continued, “you would like to focus more on comfort, right?” There was no hesitation before his soft-spoken reply: “Right.” Scenes like this have been spreading across the U.S. in the months since Medicare started paying for conversations on end-of-life planning. Seven years after that very idea spurred fears of “death panels,” supporters hope lingering doubts will fade. (5/22)

Viewpoints: Zika Readiness Falls Short; A Lack Of Obamacare Enthusiasm?

The Charlotte Observer:
An Insurer’s Obamacare Grade: Passing, But Barely

Last month in this space, we suggested that Obamacare is working, at least with regards to its goals of slowing health care costs and bringing insurance coverage to millions more Americans. Our readers, however, were quick to point out that insurance providers are not nearly as enthusiastic. That’s true. One of the nation’s larger insurers, UnitedHealth, announced last month that it would pull out of several Obamacare markets, including North Carolina. Another N.C. provider, Blue Cross Blue Shield, might stop selling ACA policies in 2017, CEO Brad Wilson said in February. (5/22)

Doctors’ House Calls Saving Money For Medicare

Looking for ways to save money and improve care, Medicare officials are returning to an old-fashioned idea: house calls.

But the experiment, called Independence at Home, is more than a nostalgic throwback to the way medicine was practiced decades ago when the doctor arrived at the patient’s door carrying a big black bag. Done right and paid right, house calls could prove to be a better way of treating very sick, elderly patients while they can still live at home.

“House calls go back to the origins of medicine, but in many ways I think this is the next generation,” said Dr. Patrick Conway, who heads the Center for Medicare and Medicaid Innovation, which oversees Independence at Home.    

In the first year of the experiment, Housecall Providers of Portland, Oregon, which had been operating at a loss, saved Medicare an average of almost $13,600 for each patient in the pilot project. Its share of the savings was $1.2 million. The house calls practice at MedStar Washington Hospital in Washington, D.C., cut the cost of care an average of $12,000 per patient.

Medicare reported overall savings of $25 million in the pilot’s first year, officials reported last June. From that money, nine practices earned bonuses totaling nearly $12 million, including a $2.9 million payment to a practice in Flint, Michigan.

After three practices dropped out, there are now 14 around the country participating in the project — including five sites run by the Visiting Physicians Association.

Medicare officials are expected to announce the second round of payments next month.

(Story continues below)

By all accounts, saving any money on these patients is a surprise. Independence at Home targets patients with complicated chronic health problems and disabilities who are among the most expensive Medicare beneficiaries. But a key study, published in 2014 in the Journal of the American Geriatrics Society, found that primary care delivered at home to Medicare patients saved 17 percent in health spending by reducing their need to go to the hospital or nursing home.

In addition to Medicare’s usual house calls payment, doctors in the Independence at Home project get a bonus if patients have at least 5 percent lower total Medicare costs than what is expected for a similar group of beneficiaries. Medicare keeps the first 5 percent of the savings and the house call providers can receive the rest. The doctors must meet at least three of the six performance goals — such as reducing emergency room visits and hospital readmissions, and monitoring patients’ medications for chronic conditions such as diabetes, asthma and high blood pressure.

Under the law creating the program, practices could join only if they make house calls to at least 200 patients with traditional Medicare who have been hospitalized and received rehab or other home health care within the past year. These patients also must have trouble with at least two activities of daily living, such as dressing or eating. The health care providers must be available 24 hours a day, seven days a week. They make visits at least once a month to catch any new problems early, and more often if patients are sick or there’s an emergency.

“You never know what you’re walking into,” said Terri Hobbs, Housecall Providers’ executive director. “This is a very sick group of people, with multiple chronic conditions, taking multiple medications and [they] have a very long problem list.” About half the Portland patients have some degree of dementia.

Yet the Medicare reimbursement for house calls is about the same as an office visit and doesn’t cover travel time or the extra time needed to take care of complex patients. It’s not enough to convince most doctors “to leave the relatively comfortable controlled environment of an office or hospital to do this sort of work,” said Dr. William Zafirau, medical director for Cleveland Clinic’s house calls program in Ohio, which has 200 patients in the Medicare pilot and plans to add 150 more.

A house calls doctor can see only five to seven patients a day. One reason is that a house call visit can take longer than an office visit, even after taking travel time into account. After Zafirau examines his patients, he also takes a look around the home. He may open their refrigerators to make sure they have enough food or see if medicine bottles are running low. He may arrange home-delivered meals or other social services.

“How people are functioning is often the best indicator of their overall health,” he said.

The care can also extend to other professional services. Portland’s Housecalls Providers hired a nurse and a social worker to serve as an advocate for patients who enter the hospital. When the patient returns home, they visit. “They make sure if patients are supposed to get an antibiotic, a hospital bed or oxygen, that they get them,” said Hobbs.

Hospital admissions dropped so significantly that Hobbs expanded the transition team to serve house calls patients who were not part of the pilot program when they were hospitalized.

A similar team serves MedStar Washington Hospital Center’s house calls patients, said Dr. Eric De Jonge, director of geriatrics at the hospital and president-elect of the American Academy of Home Care Medicine. “When patients go to the hospital, there is very little contact from the primary care doctor with the hospital care,” he said. Independence at Home “is actually pushing back to reverse that trend.”

Ironically, Medicare doesn’t pay for the transition team even though Hobbs said it saves Medicare “a tremendous amount of money.”

KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

Categories: Aging, Medicare, Syndicate


Health Minister says Medicare freeze will be lifted ‘as soon as possible’


Labor’s pounced on Health Minister Sussan Ley’s sympathy for doctors facing difficulties due to the continuation of a freeze in Medicare payment increases announced in the budget. Opposition leader Bill Shorten says it shows Labor’s decision to abolish the freeze is right, but the Prime Minister Malcolm Turnbull says Ms Ley’s comments are ‘common sense.’


ELEANOR HALL: Well staying with Federal politics, the Coalition is assuring voters today that its freeze on increasing Medicare payments to doctors is temporary.

Labor announced last week that if it wins government, it will abolish the freeze to make sure patients don’t have to pay more to see a GP.

Now the Health Minister says she’s committed to doing the same, but will only say she’d do so “as soon as possible”.

Political reporter Tom Iggulden has more from Canberra.

TOM IGGULDEN: The Health Minister Sussan Ley is sounding sympathetic to doctors claims that the freeze on increasing their Medicare payments will cause difficulties.

She spoke on radio national this morning.

SUSSAN LEY: I understand for doctors that the GP freeze has been difficult, and I appreciate theyre working with us. I’ve said to doctors I want that freeze lifted as soon as possible, but I appreciate that finance and treasury aren’t allowing me to do it just yet.

TOM IGGULDEN: Just what is meant by “as soon as possible” is open to interpretation.

Last month’s budget has the freeze continuing for the next four years, but the Prime Minister Malcolm Turnbull is also clouding that as a precise timetable.

MALCOLM TURNBULL: The freeze will end at some point, clearly. The question is it will end when we judge it is affordable within the context of the health budget and that’s all that Sussan is saying. I mean its common sense.

TOM IGGULDEN: The Opposition leader Bill Shorten is claiming the Health Minister’s comments are a victory for Labor.

BILL SHORTEN: No less a person than Mr Turnbull’s own minister for health has today said that she doesn’t support the policies of the government and instead says she’s been rolled by other people in the Government.

When the minister for health in a Liberal government says that their own policies are looking sick and that Labor policies are on the right track, it just shows Australians I think the fundamental choice at this election.

TOM IGGULDEN: The Australian Medical Association’s estimated some doctors could charge as much as $20 per consultation to cover the loss of expected revenue from the freeze.

That’s a figure Labor’s repeated to justify its announcement last week that it’ll immediately abolish the freeze if it wins office in July.

But Mr Turnbull says that $20 is nothing like what doctors would lose from the freeze.

MALCOLM TURNBULL: Mr Shorten’s claim that if the indexation freeze continues, it will result in patients paying $20 more, is plainly false, because if the indication were to be restored from the 1st of July, it would add less than 60 cents per consultation to what a GP receives.

So he knows he’s being misleading.

TOM IGGULDEN: The Government says bulk billing rates, which allow patients to see a doctor with no out-of-pocket payment, have gone up since Labor first temporarily introduced the freeze.

And the Prime Minister adds Mr Shorten hasn’t yet explained how he’d pay for the extra $2.4 billion it would cost to restore the increase in payments to doctors.

MALCOLM TURNBULL: He goes round the country with a list of grievances, he’s the grievance man. He’s got a complaint about everything and the solution is always to spend more money.

TOM IGGULDEN: The Prime Minister was campaigning on the far South Coast of New South Wales in the marginal bellwether seat of Eden Monaro.

Alongside him was popular New South Wales Premier Mike Baird.

REPORTER: Are you standing up with Mike Baird today hoping that some of his popularity rubs off on you?

MALCOLM TURNBULL: We are committed to growing jobs and growth here on the far south coast and Mike Baird and I are on a unity ticket, committed to jobs and growth. In New South Wales and indeed right across Australia.

TOM IGGULDEN: Two recent opinion polls have shown that despite two weeks of campaigning, there’s been little shift in voters intentions at the ballot box on July 2.

The predicted two party preferred vote remains a virtual tie, with Mr Turnbull’s personal satisfaction rating continuing to outrank Mr Shorten, though by a slightly diminished margin.

The Treasurer Scott Morrison, speaking on Sydney Radio 2GB this morning, was asked about the polls by host Ray Hadley.

SCOTT MORRISON: Every vote’s important in an election, everybody gets to have their say and we all respect that, but elections, particularly federal elections, are always very tightly contested and things do get closer as you go into a campaign.

ELEANOR HALL: That’s the Treasurer Scott Morrison ending Tom Iggulden’s report.