Tag Archives: Kaiser Medicare News

Study: Medicare Beneficiaries May Face ‘Treatment Gap’ For Painkiller Abuse, Misuse

When most people think of the victims of the nation’s opioid abuse epidemic, they seldom picture members of the Medicare set.

But a research letter published Wednesday in JAMA Psychiatry found Medicare beneficiaries had the highest and most rapidly growing rate of “opioid use disorder.” Six of every 1,000 recipients struggle with the condition, compared with one out of every 1,000 patients covered through commercial insurance plans.

The letter also concluded that Medicare beneficiaries may face a treatment gap. In 2013, doctors prescribed a high number of opioid prescription painkillers for this population — which put patients at risk for addiction — but far fewer prescriptions for buprenorphine-naloxone, the only effective drug therapy for opioid use disorder covered by Medicare Part D.

“The take home message is we have very effective treatments,” said Anna Lembke, one of the research letter’s authors and assistant professor at the Stanford University School of Medicine. “But they’re not widely accessible.”

Researchers analyzed 2013 Medicare Part D claims to count the number of prescriptions for Schedule II opioids and buprenorphine-naloxone. The latter drug curbs addiction by partially stimulating the same brain receptors as a stronger opioid, but with a lower risk of overdose.

The data showed the number of doctors who prescribed buprenorphine-naloxone equaled less than 2 percent of the 381,575 prescribers responsible for 56,516,854 Schedule II opioid claims. For instance, the researchers found that for every 40 family physicians prescribing pain killers, only one family physician prescribed the addiction management drug.

The letter also found states in the northeast, including Maine, Massachusetts and Vermont, had the highest ratio of buprenorphine-naloxone claims in the country, more than 300 times the national average.

In the last decade, the incidence of opioid addiction in the United States has reached crisis levels. According to the latest data from the Centers for Disease Control and Prevention, more than 19,000 Americans died from prescription opioid overdoses in 2014.

More than 300,000 Medicare recipients battle with opioid use disorder, according to the study. Among beneficiaries, hospitalizations due to complications caused by opioid abuse or misuse increased 10 percent every year from 1993 to 2012.

Lembke said part of the reason doctors do not prescribe more addiction management medications is because they view the problem as one of medicine’s lost causes.

“Doctors feel helpless and hopeless when it comes to addiction,” she said. “They feel that nothing can be done for them.”

And Medicare patients face additional obstacles when it comes to addiction treatment. First, Part D, Medicare’s prescription drug program, only covers buprenorphine-naloxone. Other effective treatments such as methodone are not covered, posing a barrier to access, said Lembke.

Buprenorphine-naloxone also usually requires prior authorization before a patient can receive the treatment. In addition, in order to prescribe it, physicians must take an 8-hour class, apply for a waiver and receive a special Drug Enforcement Administration number in addition to his or her regular DEA registration number. It becomes a hassle many medical professionals do not feel is worth the time, said Dr. Jonathan Chen, co-author of the study and instructor at Stanford.

“Why is it hard to [prescribe buprenorphine-naxolone], yet so easy for me to hand out things that get people dependent in the first place?” he said.

A different JAMA study found only 2 percent of doctors nationwide had obtained the authorization needed to prescribe the medication in 2014. And over half of the nation’s counties did not have a health provider with the ability to prescribe the medication.

But the letter’s authors note that physicians who prescribe opioid painkillers have in place a relationship with their patients that makes them well-positioned — with some additional training — to take steps to intervene when opioids are being misused.

“The bottom line is it’s a heck of a lot more work to get patients off of opioids than to get them on opioids,” said Lembke.

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

Categories: Aging, Medicare, Public Health, Syndicate

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How Medicare Advantage Plans Factor Into Aetna-Humana Proposed Mega-Merger

Medicare Plans May Be More Competitive Than The DOJ Thinks—Here’s Why It Matters

The Department of Justice is widely expected to be nearing a decision on Aetna’s $34 billion deal with Humana and Anthem’s $54 billion agreement to buy Cigna, one year after the mega-health insurance mergers were announced. For months, analysts thought the Anthem-Cigna deal was the more challenged of the two when it comes to regulatory approval, because of the potential impact their combination would have on competition in the commercial large-employer market. Now, investors are increasingly concerned regulators could block Aetna and Humana’s merger because of the potential dominance the combined company would have in the market for private Medicare health plans known as Medicare Advantage. (Coombs, 7/17)

CMS Says It Will Release Hospital Star Ratings ‘Shortly’

Kaiser Health News:
Medicare Prepares To Go Forward With New Hospital Quality Ratings

Despite objections from Congress and the hospital industry, the Obama administration said it will soon publish star ratings summing up the quality of 3,662 hospitals. Nearly half will be rated as average, and hospitals that serve the poor will not score as well overall as will other hospitals, according to government figures released Thursday. The government says the ratings, which will award between one and five stars to each hospital, will be more useful to consumers than its current mishmash of more than 100 individual metrics, many of which deal with technical matters. The hospital industry, however, fears the ratings will be misleading and oversimplify the many types of care at the institutions. (Rau, 7/22)

Medicare Prepares To Go Forward With New Hospital Quality Ratings

Despite objections from Congress and the hospital industry, the Obama administration said it will soon publish star ratings summing up the quality of 3,662 hospitals. Nearly half will be rated as average, and hospitals that serve the poor will not score as well overall as will other hospitals, according to government figures released Thursday.

The government says the ratings, which will award between one and five stars to each hospital, will be more useful to consumers than its current mishmash of more than 100 individual metrics, many of which deal with technical matters. The hospital industry, however, fears the ratings will be misleading and oversimplify the many types of care at the institutions.

The Centers for Medicare Medicaid Services said it would release the ratings “shortly.” In a preemptive effort to rebut criticisms, it noted its analysis showed “hospitals of all types are capable of performing well on star ratings and also have opportunities for improvement.”

The stars are based on 64 individual measures of hospitals that are already public on the government’s Hospital Compare website. Those include mortality rates, the number of readmissions, patient opinions, infection rates and frequency of medical scans like MRIs.

Medicare said that based on its current data, 102 hospitals would receive the best rating of five stars, 934 would get four stars, 1,770 would receive three stars, 723 would be awarded two-stars and 133 would get the lowest rating of one star. Another 937 hospitals would not be rated because the government did not have enough data to properly evaluate them.

“The star ratings provide people a broader picture,” Medicare officials said in a statement. “CMS used a similar approach to simplify complex quality information on other healthcare quality reporting websites, such as Nursing Home Compare, Home Health Compare, Dialysis Facility Compare and Medicare Plan Finder.”

The ratings factor in the mix of patients at a hospital, so those with a high proportion of sicker patients are not supposed to rate lower than those that handle more run-of-the-mill cases. The analysis showed hospitals of different sizes also did about the same, and critical access hospitals — small, mostly rural facilities — performed slightly better overall.

Medicare did not consider the relative wealth of patients. Its analysis showed hospitals serving large swaths of low-income people tended to receive lower star ratings. An analysis by Kaiser Health News of the hospitals that CMS rates shows 22 percent of safety-net hospitals were rated above average — four or five stars — compared with 30 percent of hospitals overall. Twenty-nine percent of safety-net hospitals were rated as below average, with just one or two stars, while 22 percent of other hospitals received those lower ratings.

Teaching hospitals also received lower scores on average. A third were rated with only one or two stars, while only a fifth of other hospitals received fewer than three stars, according to the KHN analysis. The teaching hospitals include large academic medical centers that often top the lists of best hospitals put together by groups like Healthgrades and U.S. News World Report.

Dr. Janis Orlowski, an executive at the Association of American Medical Colleges, said the fact that so many prestigious hospitals fare poorly in the star ratings is a signal that Medicare’s methods are flawed.

“These are hospitals that everyone in the know tries to get into, so we need to be careful about the consequences, that this star rating can be misleading,” Orlowski said. “Putting the information out at this time is not in the patient’s interest.”

The American Hospital Association also expressed continued concerns.

The government originally planned to release the star ratings in April but postponed it after a majority of members of Congress echoed the industry’s concerns. Debra Ness, the president of the National Partnership for Women Families, a nonprofit in Washington, urged Medicare to post the ratings before the end of the month.

“We believe great thought and care went into development of the Hospital Star Ratings Program,” she wrote on the group’s website.  “If needed, the program can be adjusted over time. But now is the time to move forward and give consumers a tool that will allow them to assess which hospitals do the best job of providing the care they need.”

Categories: Cost and Quality, Health Industry, Medicare, Syndicate

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Push To Lift Medicare Ban On Obesity Drugs Grabs Attention At Republican Convention

At The Republican Convention, Drug Maker Lobbies For More Coverage Of Obesity Drugs

The main hall at the Republican National Convention has been ringing all week with talk about terrorism, immigration, and national security. But in a side venue on Wednesday, a small crowd gathered to talk about a more intimate topic: Obesity. Pharma giant Novo Nordisk co-sponsored the “Rethink Obesity” panel here, and plans to co-host a similar event during the Democratic convention next week in Philadelphia. The goal: To push lawmakers to enact a bill, pending in Congress, that would lift a longstanding ban on Medicare paying for obesity medication. (Keshavan, 7/21)

Research Roundup: International Travel Risks; Telehealth; Freestanding ERs; Methadone Use

Morbidity and Mortality Weekly (CDC):
Trends In Methadone Distribution For Pain Treatment, Methadone Diversion, And Overdose Deaths — United States, 2002–2014

Use of the prescription opioid methadone for treatment of pain, rather than for treatment of opioid use disorder, has been identified as an important contributor to the rise in opioid-related overdose deaths. In recent years, a number of actions to reduce the use of methadone for pain treatment have been taken. … During 2002–2006, the national distribution rate of methadone increased, on average, 25.1% per year, methadone-involved drug overdose deaths increased 22.1% per year, and methadone diversion increased 24.3% per year. After 2006, methadone distribution declined 3.2% per year, and methadone-involved overdose deaths declined 6.5% per year. Rates of methadone diversion continued to increase during 2006–2009, but substantially more slowly, and then declined an average of 12.8% per year beginning in 2010. (Jones et al., 7/8)

Medicare Proposes Changes In Pain Questions, Cuts In Payments To Hospitals’ Off-Site Facilities

The changes are part of the proposed hospital payment rule, which was released Wednesday. Also in Medicare news, a House committee is calling for funding for a consumer assistance program that a Senate committee rejected, Sen. Chuck Grassley, R-Iowa, questions plans for possible changes in cancer drug payments and some Medigap rates are rising in Michigan.

Modern Healthcare:
CMS Angers Hospitals With Plans For Site-Neutral Rates In Outpatient Payment Rule

The CMS has responded to calls to eliminate patient satisfaction on pain management from Medicare’s value-based purchasing program. The agency angered hospitals, however, with plans to stop paying their off-campus facilities the same as hospital-based outpatient departments. Both policies are included in the proposed rule for the 2017 Hospital Outpatient Prospective Payment System issued Wednesday.
(Dickson, 7/6)

Winston-Salem (N.C.) Journal:
Proposal Saves Medicare Counseling Program

Federal funding for free local counseling on annual Medicare options may be preserved for fiscal 2016-17 after all. The U.S. House Appropriations Committee’s draft bill for education, health and human services and labor, released Wednesday, includes $52 million for the State Health Insurance Information Plan — the same amount in the current federal budget. The $52 million was stripped in June from the budgets of the same three agencies by the U.S. Senate Appropriations Committee in a 29-1 vote. (Craver, 7/7)

Iowa Public Radio:
Grassley Implores Federal Government To Not Change Medicare Policy

Sen. Chuck Grassley has sent a letter to the Centers for Medicare and Medicaid Services, urging the agency to keep a policy in place that requires private Medicare insurers to cover all antidepressant medications and all immuno-suppressant drugs used for transplant patients. CMS is considering changing this rule. In a report last month, the agency reasons that medications in these categories include a number of generic options. (Boden, 7/5)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Advance Planning For Your End-Of-Life Care

Millions of Californians are newly eligible for a health care benefit that could determine the treatment they receive in their final days — and most don’t know it.

Medi-Cal, which covers more than 13 million Californians, and Medicare, with more than 5 million California enrollees, now pay for “advance care planning” discussions with doctors.

Advance care planning isn’t about long-term care options, such as nursing homes or assisted living.

It’s about “your wishes for your care if you are not able to speak for yourself,” said Helen McNeal, executive director of the California State University Institute for Palliative Care.

“If you’re incapacitated, if you need someone to speak for you, who do you want to speak for you? And what would be your medical wishes?” she said.

If, for instance, you have a stroke that leaves you unconscious and unable to communicate, with little hope for improvement, would you want to be kept alive with a feeding tube and or ventilator?

“These decisions may have consequences for the quality of life you have for the rest of your life. They may also have consequences for whether you live or die,” McNeal said.

In other words, they’re important. But many doctors and patients don’t yet realize that talking about these decisions — and possibly putting them into writing — is a covered benefit.

Starting in October, Medi-Cal — the state’s version of the federal Medicaid program for low-income residents — began covering advance care planning discussions between doctors (or other qualified providers) and patients (or a family member), said Tony Cava, spokesman for the state Department of Health Care Services, which administers Medi-Cal.

Any Medi-Cal recipient can use the coverage regardless of age, he said. Doctors can bill for the conversation twice a year per patient — plus an additional 30 minutes for one of the conversations — before they have to seek authorization for more coverage.

Medicare, the federal health insurance program for people 65 and older, and for people younger than 65 who have certain disabilities, started covering the discussions on Jan. 1. Medicare does not limit the number of discussions per patient each year.

Some private insurance plans cover these discussions and some don’t, McNeal said. Check with your plan.

Both Medicare and Medi-Cal will cover the conversations even if patients don’t end up completing an “advance care directive” as a result. That’s a document that formalizes your wishes, which should be shared with your family and doctor.

McNeal believes that anyone over 18 should have this discussion and complete an advance directive.

But don’t expect your doctor to initiate the conversation.

“Many physicians may not be very comfortable having this conversation,” said Dr. Richard Thorp, president of the Paradise Medical Group near Chico, and past president of the California Medical Association, which represents the state’s doctors.

A poll of more than 700 doctors, released in April, found that nearly half of them feel unsure some or much of the time about what to say when discussing end-of-life care with patients. (The poll was commissioned in part by the California Health Care Foundation. California Healthline is an editorially independent publication of the California Health Care Foundation.)

Thorp’s patients are mostly older, so he incorporates advance care planning into their annual Medicare Wellness exams. Medicare reimburses him about $86 for the initial 30-minute discussion, and about $75 for each additional 30 minutes, he said.

“There’s an art to having the discussion,” he said. “There’s an art to recognizing when people are uncomfortable.”

McNeal’s institute, in partnership with the Coalition for Compassionate Care of California, offers online training for doctors about advance care planning. One course specifically focuses on how to have an effective conversation with patients.

Because many doctors don’t know about this benefit — or may feel uncomfortable broaching the topic — most people should start by having a conversation with family and loved ones, suggested Mark Beach, an AARP spokesman based in Sacramento.

After your discussion, write down your wishes, he said.

“It’s difficult to discuss, but when you’ve done it, it’s a comfort,” Beach said. “Not only will your wishes be followed, but your loved ones will know what to do.”

A variety of forms and templates are available to consumers. Thorp sometimes uses what’s called a “POLST” form, which is a medical order that must be completed and signed by a health care professional.

It is typically for seriously ill or frail patients, McNeal said, whereas an advance care directive is a legal document for people of any age or condition.

McNeal recommends the “Five Wishes” form, which can be personalized and is available online for $5 at www.AgingWithDignity.org. Other options for advance directives can be found at www.CaringInfo.org or through AARP. (A lawyer can help you prepare an advance directive, but you usually don’t need an attorney to get it done.)

After you have filled out your advance care directive, take it to your doctor and tell her you want to talk with her about it, McNeal said. Don’t forget to give your doctor a copy.

“The role of the physician is really to provide information, not to persuade one way or the other,” Beach said.

Thorp explains to his patients what it means to be intubated, fed artificially and kept on life-support.

Most are open to the discussion, he said, and their responses are mixed. Some older or sicker patients tell him they don’t want any extraordinary measures if they’re incapacitated. Others, who are younger and healthier, say they would probably want medical intervention if they might have a chance to thrive afterward.

“Most people don’t want to be kept on life-support indefinitely. They really don’t want that,” Thorp said. “They want to live a productive life.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Categories: Aging, Ask Emily, Medicare, Public Health, Syndicate


Perspectives On Drug Costs: It’s A Drugmaker’s World And We’re All Just Living In It

Pfizer Wins Big In Opioid Deal With Chicago. But What Does The City Get?

In an unusual development, Pfizer signed a pact with the city of Chicago and agreed not to engage in the sort of marketing that helped fuel the epidemic in the first place. Chicago Mayor Rahm Emanuel boasted of a “landmark agreement” and a “big step” toward blunting the risks of these prescription painkillers, which were blamed for more than 14,000 deaths two years ago, according to federal health officials. To be sure, any time a drug maker agrees to restrict or enhance its marketing in ways that benefit public safety is noteworthy, especially given the eye-popping fines that so many of these companies have paid over the past decade to settle charges of illegal marketing. But this particular deal is unlikely to make much, if any, difference. In fact, for the moment, the only certain winner in this arrangement is Pfizer. And it’s a big win. (Ed Silverman, 7/12)

Democrats Unite, But What Happened To ‘Medicare For All’?

After a raucous debate lasting nearly a year, the Democrats are united on health care. But that unity does not include a call for a single-payer “Medicare for all” health system.

“This campaign is about moving the United States toward universal health care and reducing the number of people who are uninsured or under-insured,” Sen. Bernie Sanders (I-Vt.) said Tuesday in endorsing his rival Hillary Clinton, the presumptive Democratic presidential nominee.

Sanders did win a few health care concessions in the negotiations leading to the endorsement. Clinton vowed to support more funding for community health centers and access to a “public option” government insurance plan, which she has supported in the past.

But on Sanders’ top health priority — his “Medicare for All” plan — there was not a word. At the Democratic Platform Committee meeting over the weekend, an amendment to add a single-payer plan to the document was defeated.

It wasn’t much of a surprise.

Most health policy analysts — including those who are sympathetic to the idea — say moving from the current U.S. public-private hybrid health system to one fully funded by the government in one step is basically impossible. And that’s making a huge assumption that it could get through Congress.

“To try to do it in one fell swoop would be massively disruptive,” said Paul Starr, a professor at Princeton who was a health policy adviser to President Bill Clinton.

The U.S. health care system, said Jeff Goldsmith, a health care consultant and health futurist, is “the size of a country — it’s bigger than France — and it employs 16 million people.”

In moving to a single-payer system, he said, “you’re talking about reallocating $3 trillion, reducing people’s incomes and creating” in effect a single entity that would set prices for all medical services. Single-payer supporters dispute the idea that getting from here to there could not be done.

“We’re so used to such a complicated system in the U.S. that we envisage any change would be incredibly complicated as well,” said Steffie Woolhandler, a physician and one of the founders of the single-payer advocacy organization Physicians for a National Health Program. “But what you’re doing with single-payer is actually simplifying the system.”

For example, said Woolhandler, “the latest data is U.S. hospitals are spending 25 percent of their total budget on billing and administration, and hospitals in single-payer nations like Canada and Scotland are spending 12 percent.”

But while a single-payer system would undoubtedly produce efficiencies, it would also bring huge disruptions. Said Starr, single-payer supporters “haven’t worked through the consequences.”

One of the biggest is exactly how to redistribute literally trillions of dollars. The problem, said Harold Pollack, a professor at the University of Chicago, is that the change will create losers as well as winners.

“Precisely the thing that is a feature for single-payer proponents is a bug for everyone who provides goods and services for the medical economy,” he said, since their profits — and possibly their incomes — could be cut.

And it’s not just the private insurance industry (which would effectively be put out of business) that could feel the impact to the bottom line. Parts of the health care industry that lawmakers want to help, like rural hospitals, could inadvertently get hurt, too. Many rural hospitals get paid so little by Medicare that they only survive on higher private insurance payments. Yet under single-payer, those payments would go away and some could not make it financially. “You would not want to wipe out a third of the hospitals in Minnesota by accident,” Pollack said. “And you could,” if payments to hospitals end up too low.

There are also questions about how feasible it would be to have the federal government run the entire health care system. “It’s hard to be nimble” when a system gets that big, said Ezekiel Emanuel, a former health adviser in the Obama administration now at the University of Pennsylvania. “No organization in the world does anything for 300 million people and does it efficiently.”

To try to do it in one fell swoop would be massively disruptive.

Paul Starr

The politics of Medicare — which serves roughly 50 million Americans — already make some things difficult or impossible, he said, pointing to a current fight in which doctors and patient advocacy groups blasted a proposal to move to a more cost-effective way to pay for cancer drugs. “You already can’t do certain things in Medicare because of the politicization,” he said. ”When you cover the whole country, it would be a lot of gridlock.”

Pollack agreed, and pointed out it’s not just the health care industry that could revolt. When the Affordable Care Act was rolled out in 2013, he said, “the people who couldn’t keep their old plans — a very tiny number as a percent of Americans” were furious. “We saw how difficult that was and how angry the public was when that promise wasn’t kept. Now imagine the major shift we’d have to do to move to a single payer system.”

There’s also the question of whether it’s simply too late to go back to the health care drawing board.

Single-payer supporter Woolhandler insists it is not. “Other nations have gone to single-payer systems,” she said. “It usually can be done in about a year.”

The last industrialized country that did the switch was Taiwan, in the mid-1990s. Taiwan, however, with its 23 million residents, has a population larger than New York and smaller than Texas, and had no existing private health insurance system at the time.

“What I’ve often said is we could have done this in the 1940s when Harry Truman proposed it,” said Starr, who has written at length on the history of American health politics. “Health care at that point was probably about 4 percent of [gross domestic product] and there existed at that time a relatively small private insurance industry.” Today health care spending in the U.S. is approaching 18 percent of the nation’s GDP and the private health insurance industry accounts for half a trillion dollars per year.

Both Starr and Pollack, however, said it would be possible to make a switch, although it would have to be carried out over a very long period of time.

“You could imagine some kind of long transition, where you gradually expanded Medicare,” said Starr, “for example moving it down to age 55” and then in later years continue to lower the age threshold.

But even if the U.S. did manage to execute a single-payer system, said Pollack, it would likely prove problematic, particularly in how it would be financed.

“The major value of a single-payer system would be to help the bottom third of the income distribution, and that means the top 20 percent of the population will have to pay more,” he said. “I’m actually in favor of that, but let’s not kid ourselves. That’s a knife fight that’s going to be had.”

Categories: 2016 Campaign, Cost and Quality, Health Industry, Insurance, Medicare, Public Health, The Health Law