Affordable Care Act

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Main Category: Medicare / Medicaid / SCHIP
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Article Date: 29 Jun 2012 – 12:00 PDT

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Over 5,254,000 seniors and people with disabilities have saved $3.7 billion on prescription drugs since the enactment of the Affordable Care Act. In the first five months of 2012, 745,000 people with Medicare saved $453.3 million on prescription drugs in “donut hole” coverage gap for an estimated $651 in savings, according to date released from The Centers for Medicare Medicaid Services (CMS).

The Affordable Care Act has had a valuable impact strengthening Medicare and allowing seniors to take better care of their health. The law has brought about important benefits, such as free annual check ups and free preventive services, such as screenings for chronic diseases.

Most Medicare health care plans that cover prescription drugs (Part D) have a coverage gap that is called a “donut hole”. This means that when a person spends a certain amount of money for drugs covered in the plan, they then need to pay all drug costs with their own money until they have reached a yearly limit.

People in the “donut hole” receive a 7 percent discount on all generic brands. Once they reach their yearly limit, the coverage gap ends and their Medicare plan pays for their covered drugs again.

Once people reach the coverage gap in their Part D coverage, they will automatically get a 50 percent discount on covered brand name drugs and a 14 percent discount on generic drugs. The percentage of discounts will continue to increase until 2020 when the coverage gap is closed.

“Thanks to the health care law, millions of people with Medicare have been paying less for prescription drugs,” said Marilyn Tavenner, CMS Acting Administrator. “The law is helping people with Medicare lower their medical costs, and giving them more resources to stay healthy. By 2020, the donut hole will be fully closed thanks to the Affordable Care Act.”

After people with Medicare hit the Medicare Part D prescription drug coverage gap or “donut hole”, the savings are automatically applied to their prescribed drugs.

In 2010, people with Medicare received a one-time $250 rebate when they hit the donut hole. These people started to receive the 50 percent discount on covered brand name prescribed drugs in the donut hole since 2011.

This year, there has been a 14 percent coverage increase for generic drugs in the coverage gap. The coverage gap will no longer exist in 2020; but until then, Medicare will increase its coverage for generic and brand name drugs each year.


President Barack Obama signing the Patient Protection and Affordable Care Act at the White House, March 2010

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What Is The Affordable Care Act? What Is Obamacare?

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Main Category: Health Insurance / Medical Insurance
Also Included In: Medicare / Medicaid / SCHIP;  Public Health
Article Date: 29 Jun 2012 – 18:00 PDT

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The Affordable Care Act, also known as the Patient Protection and Affordable Care Act (PPACA), and informally as Obamacare, was signed into law by President Barack Obama on 23rd March, 2010. The aim of the Act is a health care law aimed at improving the health care system of the United States by widening health coverage to more Americans, as well as protecting existing health insurance policy holders.

According to the Obama Administration, those who already have health insurance will benefit from the legislation in various ways. For example, insurance companies will not be able to cancel coverage if people get sick, out-of-pocket costs will be covered for proven preventive and screening services, such as mammograms (breast screening) and colonoscopies. The aim is to diagnose potentially chronic and serious diseases earlier on, when treatments are most effective.

People with jobs but no health insurance, as well as those as those with pre-existing conditions, such as asthma or cancer should find it easier to have reliable health care coverage as a result of the 2010 legislation. According to the US government, in 2014 more Americans will have access to health care coverage.

The Affordable Care Act aims to help small businesses get health insurance for their workers. According to the US government, the Act should “help increase the number of primary care physicians, nurses, physician assistants and other health care professionals.”

Below are some highlighted details on the Affordable Care Act:

  • Young adults can remain on their parents’ health plans until they are 26 years old. This will also include young adults who don’t live with their parents, are out of school, are not financially dependent on their parents, and are married (however, spouses and offspring will not be covered).

    Even if the young adult has gone off a parent-owned plan, they will be able to enroll again.

    Parents whose plans were already in place before March 23rd, 2010, can enter their young adult children into their plans if those are not eligible for their own employer-sponsored plan.

    Group plans which started before the Affordable Care Act was signed into law do not have to offer health coverage to young adults who qualify for other group coverage.

  • Employers with fewer than 25 workers may receive help in funding the cost of providing health insurance. Some small businesses are taking advantage of new tax credits which makes the purchasing of health insurance for employees more affordable. Small businesses are eligible if they provide health care for their employees, have no more than 25 full-time workers, and pay an average yearly salary of less than $50,000. Starting in 2014, the tax credit will be 50% for small businesses and 35% for non-profit ones.
  • Kids with pre-existing conditions may not be denied health coverage by insurance companies. This applies to people up to the age of 19 years and includes any pre-existing health problem, disease or disability that developed before their parents applied for health coverage.

    In 2014 this will apply to anybody, regardless of age.

    Premiums will not be allowed to be raised for babies or children because of a pre-existing condition or disability.

  • Adults who have been denied coverage because of an existing precondition and have been uninsured for 6+ months may now get insurance. PCIP (Pre-Existing Condition Insurance Plan) is aimed at adults who could not get coverage because of a pre-existing condition, such as diabetes or cancer. In 2014, access will be available to them.
  • Individuals in the “doughnut hole” now receive a 50% discount on brand named prescription medications and a 7% discount on generic ones. Those enrolled in the Medicare Part D program often fell into a “coverage gap”, commonly referred to as a doughnut hole. As soon as their plan had spent a pre-determined amount of money, further expenses had to be paid for fully out-of-pocket. The new legislation aims to gradually eliminate this problem, so that it no longer exists by the end of this decade.
  • Medicare patients are now eligible for mammograms, colonoscopies, and some other preventive services
  • All new health policies must offer screening and preventive services free of charge (mammograms, colonoscopies, etc.)
  • The following benefits will soon come:

  • Health insurance policies will be available for all people with pre-existing conditions (companies will not be allowed to refuse them). As from January, 2014, refusing coverage because of a pre-existing condition or disability will not be possible. Companies will not be allowed to raise premiums for those reasons either.

    What is a pre-existing condition? This is a health problem, disability or disease that started before the individual applied for health coverage.

    As from January 2014, health insurance companies will not be able to raise premiums because of an individual’s gender or health status – this applies to individual and small group markets (small businesses that buy health insurance for their employees).

  • Essential health benefits and coverage will be guaranteed for almost all Americans. As from January, 2014, policies will be required to offer a set of basic benefits which will be available on state-based marketplaces (exchanges). All exchanges will list the health plans on offer, so that people can make comparisons and shop around for the best plans. By 2014, all Medicaid state plans must offer at least:

    – Chronic disease management (such as asthma or diabetes)
    – Emergency room visits
    – Hospitalizations
    – Laboratory services
    – Maternity and newborn care
    – Mental health
    – Prescriptions
    – Preventive care

  • The majority of Americans who do not already have health insurance or health coverage will have to make sure they do in 2014. Financial assistance will be available for those who cannot afford it. Individuals who decide not to be covered will have to pay a fee – many call this a form of taxation (in fact, in a Supreme Court ruling yesterday, they allowed the introduction of the word “tax” when referring to this part of the Act). Individuals who pay over 8% of their monthly income to buy health insurance will be exempt.
  • Dollar limits on the amount of care people are entitled to with insurance companies will eventually be done away with
  • Exchanges will be created in 2014, state-based marketplaces where Americans without insurance will be able to buy health insurance. The aim is to increase competition between insurers in a state and allow people to compare and shop around for health plans that suit their circumstances and pockets.
  • A larger percentage of American citizens will have access to Medicaid health coverage

Affordable Care Act – What do people think?

Polls vary significantly on what the majority of Americans think – but the trend seems to be that slightly more do not support the law overall, while certain elements within it are very popular. While Republicans and Independents are mainly against the law, the majority of Democrats are in favor.

Many commentators have noticed that although most people are against the new law overall, they are mainly in favor when asked about specific provisions within it.

A Reuters-Ipsos poll carried out on 24th June 2012 showed that:

  • 56% of the US adult population were generally against the law. 44% supported it
  • 75% of Democrats, 14% of Republicans and 27% of Independents support the law overall
  • 82% of Americans agreed that insurance companies should not be allowed to deny coverage for those with pre-existing conditions
  • 61% agreed that young adults should be allowed to remain on the parents’ insurance plans up to 26 years of age
  • 72% agreed that companies with over 50 employees should provide their employees with health insurance
  • 61% were against forcing everyone to have health insurance. This part of the law was favored by 41% of Democrats, 27% of Independents, and 19% of Republicans.
  • There was overall support for the creation of insurance pools so that small companies and uninsured people may have access to insurance exchanges, as well as financial help for families which cannot currently afford health insurance

Is US Healthcare spending good value for money?


Source: The Economist

From 1960 to 2009, US Healthcare spending rose from 5.1% of GDP (Gross Domestic Product) to 17.4%. The figure today is estimated to be even higher. Today, even though the country uses up a significantly higher percentage of its economy on healthcare, the USA has over 50 million people with no health coverage at all, and tens of millions of others with “inadequate coverage” – a situation exclusive to America when compared to other rich nations.

In the United Kingdom, for example, only 8% of GDP is spent on healthcare, and health coverage is offered to all its citizens – the UK has a universal coverage healthcare system. In Japan people live nearly ten years longer, on average, than Americans do, and spend considerably less on healthcare.

The USA has fallen behind other rich nations in life expectancy, infant mortality, teenage pregnancies, and a series of other healthcare statistics.

In 2011 the USA ranked 50th in global life expectancy. Although the country’s people are living longer than before, the increase in lifespan in other countries has improved at a much faster rate. (Link to article)

Whatever arguments people of different affiliations use in America regarding its healthcare system, most have to agree that it has become extremely expensive and provides very poor value for money, compared to what other rich nations have managed to achieve.

Written by Christian Nordqvist

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Rheumatoid Arthritis Biomarker Test Shows Promise

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Main Category: Arthritis / Rheumatology
Article Date: 29 Jun 2012 – 9:00 PDT

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A new study led by researchers at the University of Alabama, reveals that a multi-biomarker blood test for rheumatoid arthritis (RA) may help physicians track the progression of RA disease activity. The study is published online in Arthritis Care and Research.

Jeffrey Curtis, M.D., associate professor in the division of clinical immunology and rheumatology and lead author of the study explained:

“Previously, the disease activity of RA was assessed through clinical observation by a physician, noting the number of tender and swollen joints and assessing pain and functional abilities.

This blood test measures the underlying amount of RA activity within the joints using sophisticated biochemical means intended to reflect the underlying pathophysiology of the disease. A highly reproducible, easily standardized blood test that measures multiple biologic pathways to augment a physician’s and patient’s clinical assessment has not been previously available to physicians.”

The researchers highlight that the test, called Vectra DA, should provide different, but complementary, information from clinical assessment as it emphasizes the activity of underlying biological pathways instead of external signs and symptoms. In addition, the test may help evaluate how well patients respond to treatments. Currently it takes around three to four months in order to determine whether a particular treatment is effective, but the blood test could show therapy effectiveness in just a few weeks.

Vectra DA, developed by Crescendo Bioscience® of South San Francisco, is a measure of inflammation. The test looks for the presence of 12 cytokines (biomarkers) that can indicate the presence of disease.

The 12 biomarkers used in the multi-biomarker disease activity (MBDA) test were selected in previous studies from 396 candidates. In these studies the researchers determined an algorithm that weighted the significance of each biomarker and produced a composite score.

According to Curtis: “The MBDA score is a complementary tool that could provide physicians with an objective consistent and biologically rich measure of RA disease activity.”

Furthermore, Vectra DA could help predict potential disease flare-ups as well as subsequent joint damage, say the researchers, but those potential applications have not been shown yet.

The study, which involved 512 patients with RA, was funded by the National Institutes of Health, the Agency for Healthcare Research and Quality and various pharmaceutical companies.

Written by Grace Rattue

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Validation of a novel multi-biomarker test to assess rheumatoid arthritis disease activity
Jeffrey R. Curtis, Annette H. van der Helm-van Mil, Rachel Kneve, Tom W. Huizinga, Douglas J. Haney, Yijing Shen, Saroja Ramanujan, Guy Cavet, Michael Centola, Lyndal K. Hesterberg, David Chernoff, Kerri Ford, Nancy A. Shadick, Max Hamburger Roy Fleischmann Edward Keystone Michael E. Weinblatt
Arthritis Care and Research, June 2012, doi: 10.1002/acr.21767

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Study Of Heart Disease In Rheumatoid Arthritis Patients Aided By New Animal Model

Main Category: Arthritis / Rheumatology
Also Included In: Heart Disease;  Cardiovascular / Cardiology
Article Date: 29 Jun 2012 – 1:00 PDT

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Researchers at Northwestern University Feinberg School of Medicine have created the first animal model that spontaneously develops rheumatoid arthritis (RA) and is predisposed towards atherosclerosis, or hardening of the arteries.

This model is considered of critical importance because patients with RA are at increased risk for heart attack and other premature cardiovascular events, but scientists don’t know why.

“Generally, people with RA die because of cardiovascular disease,” said Harris Perlman, associate professor of rheumatology at Feinberg, who is corresponding author on the paper. “This new model will allow us to examine the systemic influence of inflammatory arthritis on the development of heart disease.”

RA is a chronic, inflammatory disease that causes pain, swelling, stiffness and loss of function in joints. The disease can affect any joint but is common in the wrist and fingers. Approximately 1.3 million people live with RA, and more women than men have the disease, which often starts between ages 25 and 55.

Perlman’s team developed a specialized mouse model with RA, then fed the animals a “high-fat, Western-type” diet. “As we see in patient populations, the RA-affected mice spontaneously developed atherosclerosis,” he said. Mice without RA who were fed the same diet did not develop atherosclerosis.

Next, Harris’ team treated the affected animals with Enbrel®, a common first-line therapeutic for joint inflammation in humans. Following an eight-week course of treatment, the occurrence of atherosclerosis decreased by 50 percent in the animal model.

The findings are published online in Annals of the Rheumatic Diseases.

“This unique animal model will allow us to address a number of important questions regarding the connections between RA and cardiovascular disease,” said Perlman. “The most pressing question will be to explore how drugs that treat RA inhibit cardiovascular disease. What’s the mechanism at work? We also want to understand how cardiovascular disease and RA work together in the body.”

Perlman says the findings were made possible by a series of collaborations at Northwestern University involving the divisions of rheumatology and cardiology at Feinberg, as well as the Center for Advanced Molecular Imaging (CAMI) on the Evanston campus.

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This work was supported by grants Driskill Fellow Scholarship award, NIH grant (AR07611) and NIH LRP to Shawn Rose, HHMI (57006753) to C. Shad Thaxton, NIH grants (HL051387 and HL108795) to Douglas Vaughan, NIH grants (EB005866 and CA151880) to Thomas Meade, and NIH grants (AR050250, AR054796,AI092490, and HL108795) and Funds provided by Northwestern University Feinberg School of Medicine to Harris Perlman.

Northwestern University investigators Shawn Rose, Mesut Eren, Sheila Murphy, Heng Zhang, C. Shad Thaxton, Jamie Chowaniec, Emily A. Waters, Thomas Meade, and Douglas Vaughan were co-authors on the study.
Northwestern University

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Obamacare Upheld By Supreme Court Ruling

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Article Date: 28 Jun 2012 – 13:00 PDT

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President Barack Obama’s healthcare law has been upheld by the US Supreme Court today in a 5-4 ruling. Commentators and media experts around the world say this is a triumph in an election year for the Democrats and a serious setback for the Republicans. Obama’s healthcare law has been described as the most sweeping change in America’s healthcare system in over fifty years.

This means that Congress is authorized to impose taxes, and the Federal Government can insist that the majority of Americans must make sure they have health insurance coverage by 2014 – if they don’t, they will have to pay a levy (tax).

Republicans believe the mandate is an example of ‘nanny-state government’, where the state moves into the private lives of individual citizens and takes away their right to choose.

A Supreme Court Majority, albeit a thin one (5-4), ruled that Congress’ power to tax people takes priority over individual choices in this case. The issue has divided the country, and so it seems, the Supreme Court.

Chief Justice, John Roberts wrote on behalf of the court’s majority:

“Requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax. Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.”

The other four justices who voted in favor, along with Roberts, were Sonia Sotomayor, Elena Kagan, Stephen Breyer, and Ruth Bader Ginsburg.. Those voting against were Justices Samuel Alito, Clarence Thomas, Anthony Kennedy, and Antonin Scalia.

Nancy-Ann DeParle, Assistant to the President and White House Deputy Chief of Staff, wrote in a communiqué today:

“Today, the Supreme Court’s decision to uphold the Affordable Care Act ensures hard-working, middle class families will get the security they deserve and protects every American from the worst insurance company abuses. The Court has issued a clear and final ruling on this law.”

President Obama said today at the White House:

“The highest court in the land has now spoken. We will continue to implement this law and we’ll work together to improve on it where we can.

What we won’t do – what the country can’t afford to do – is re-fight the political battles of two years ago or go back to the way things were. With today’s announcement, it’s time for us to move forward.”

Individual States Will Not Be Penalized if they do not comply with the expansion

The Supreme Court also said that Congress exceeded its authority in part of the new legislation that forces states to expand Medicaid health insurance programs for the poor so that currently uninsured people obtain coverage. It said that the federal government will not be able to withdraw existing Medicaid funds from states that do not adhere. The Court added that in order to do this, it was not necessary to bring down other parts of the law.

Patient Protection and Affordable Care Act

The Patient Protection and Affordable Act was signed in by President Obama in 2010. The new legislation found itself challenged in the courts of the country’s 50 states.

According to The Whitehouse today, the new ruling by the Supreme Court means that for America’s middle class:

  • Health insurance companies can no longer cancel people’s policies like they used to, or deny coverage
  • Health insurance companies will not be able to charge females more than males
  • Insurance companies will soon not be able to deny care or charge more for people with pre-existing conditions
  • Insurance companies will continue to provide preventive care services free of charge, such as wellness visits for the elderly and breast screening for women
  • Millions of Americans will receive a rebate by August 2012 because their insurance company overspent on directors’ bonuses or administrative costs
  • Prescription drugs savings amounting to $600 per senior for prescriptions will continue – 5.3 million seniors are benefiting from this
  • 6.6 million people aged between 18 and 26 will be able to stay on their family’s plan

18% of economy spent on healthcare, while 16% have no coverage

The USA spends 18% of its economy on healthcare, much more than any other developed nation – and 16% of its people have no insurance coverage. A large percentage of Americans have “inadequate cover”. In the United Kingdom, for example, about 9.5% of the economy is spend on healthcare, but everyone is covered.

Unlike other rich nations, the American system is a patchwork of restrictive government programs and private insurance.

Congressman Michael C. Burgess, M.D. (TX-26), Vice Chair of the House Energy and Commerce Committee’s Subcommittee on Health and Chairman of the Congressional Health Care Caucus, commented on today’s ruling:

“The Patient Protection and Affordable Care Act is detrimental to our society, our economy, and to the future of health care in America. Since its inception we have seen the strain it has placed on our economy through its ever increasing price tag, provisions which discourage small businesses to hire, and higher costs, and excessive government regulations.

President Obama stated multiple times that the penalty associated with the individual mandate was not a tax; however, the Supreme Court today affirmed that indeed it was a tax. In fact, it is a tax increase and a very large tax on middle-class America. When millions are unemployed the last thing America needs is another tax.

This decision by the Supreme Court is paramount and signals to the House of Representatives that it is our responsibility to repeal this over burdensome law which increases taxes on middle class families, and replace it with common-sense policies that encourage economic growth and protect American’s access to care. The House has voted to repeal the legislation and will do so again next month.”

Texas Attorney General, Greg Abbott, said:

“This is an historic victory for individual liberty, states’ rights, and limited government. Today the Supreme Court made crystal clear that the federal government is more restrained than yesterday and yet, through a novel application of the facts, the Court did what Congress was afraid to do–called ObamaCare a tax on all Americans. This is particularly ironic since President Obama, himself, insisted this was not a tax.

The decision marks a turning point in constitutional history. The Supreme Court rebuked a runaway federal government that tried to hijack the Constitution by imposing an unprecedented requirement forcing Americans to buy a product against their will. In doing so, the Court dismantled the centerpiece of Obamacare – the federal government’s authority to compel Americans to purchase a product.

The Court also agreed that States are individual sovereigns that cannot be commandeered by the federal government. In this instance, by forcing States to expand Medicaid, the federal government tried to hold States hostage.

Our challenge to Obamacare was never about healthcare or insurance – it was about the rule of law and a fight against a federal government that continues to expand. In this respect, today’s decision was a total victory. As the federal government seeks to impose the remainder of ObamaCare, it must do so within the limits prescribed by the Constitution.

Although the individual mandate was ruled unconstitutional, the remainder of ObamaCare may be on life support – and we will continue our work to pull the plug on this unworkable and unpopular law. It is time for Congress to step in and end the Obamacare nightmare by repealing an unprecedented tax on all Americans.”

Written by Christian Nordqvist

Copyright: Medical News Today

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Medicare Changes: What You Need To Know Now

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Health Insurance / Medical Insurance
Article Date: 28 Jun 2012 – 1:00 PDT

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Today, many hospitals are filled to capacity, and as a consequence, physicians are continually pressured to discharge their patients as quickly as possible. Because of inefficiencies in how they communicate with case managers, nurses, and patients, patients are frequently discharged with many loose ends.

Recognizing these realities, the new Medicare reimbursement rules will force hospitals and doctors to give a 30-day guarantee for any hospital treatment. If the patient is readmitted within 30 days for the same ailment, Medicare won’t pay the hospital. Here are a few things you, the patient, need to know now about these changes:

Why the change?

Because of the ineffective discharge processes described above, many patients may not understand how to take their medications; they may not have the follow-up appointments they need, or their primary care physician may not have been contacted about their hospitalization. All too frequently, the primary care physician does not receive a discharge summary in a timely fashion.

Because of these loose ends, patients too often do not receive the care at home they need, and their illness worsens. With no one to turn to, these patients all too frequently end up in the emergency room, where they are readmitted to the hospital. In the past, hospitals made more money because they were able to bill for these repeat hospitalizations, despite the fact that the readmission represented a failure in the discharge planning.


What’s the change?

Beginning in October 2012, Medicare will no longer reward caregivers and hospitals for poor planning.
If a patient is readmitted within 30 days with the same diagnosis, Medicare will no longer pay for the care. Medicare is now expecting health delivery systems to guarantee their care for a minimum of 30 days. This is a far cry from automobile repairs, which are often guaranteed for years, or even for the lifetime of the car.

Why do patients have such low expectations for healthcare? Through this change in policy, Medicare will be creating a major driver for improving discharge planning and hand-offs to those responsible for the long-term care of patients. Fumbles by the acute caregivers will no longer be rewarded. Other insurance companies are likely to follow Medicare’s lead.


How can patients who utilize Medicare to take advantage of these changes?

As a consequence of this new rule, caregivers and patients will need to be on the same team. Physicians and hospitals will be penalized if you do not understand how to take your medications and if you do not understand and follow the plans for follow-up care. If you do not understand what to do when you are discharged, it is important that you speak up and ask questions.

Also, you should insist that your care team provide you with contact information that will allow you to get all your questions answered when you return home. Experience has shown that many patients think they understand their treatment plans, but upon reaching home, they realize they did not fully understand the instructions for taking their medications or what appointments they were supposed to arrange. Many hospitals will be providing a care coordinator to assure that everything goes smoothly after your discharge. This is an ideal solution and will provide you with a go-to person who can help you when the unexpected occurs.


Do these new rules apply to readmissions related to a byproduct or side effect of a treatment?

If the side effect should have been anticipated or could have been prevented, the answer is yes. Too often, patients are discharged on too high a dose of a drug or, alternatively, are prescribed two medicines that interfere with each other. I am unclear what position Medicare will take when there is an unexpected side effect that could not have been predicted or prevented.

Healthcare is undergoing a major and necessary transformation. And we all should be prepared for more change. Keep a close eye on news reports and articles like this one to stay up-to-date and knowledgeable about your health care. These changes represent a move in the right direction, and hopefully, our health system will continue to move forward. Changes like the 30-day readmission rule promise to benefit every patient. By focusing on what is best for patients, Medicare promises to continue to motivate all caregivers and hospitals to improve the quality of their care.

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Duplicate Heath Coverage Costs U.S Government A Fortune

Editor’s Choice
Main Category: Medicare / Medicaid / SCHIP
Also Included In: Veterans / Ex-Servicemen;  Public Health
Article Date: 27 Jun 2012 – 12:00 PDT

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About 1.2 million veterans are covered under the Veterans Affairs health care system and the Medicare Advantage plan. An analysis, published in the Journal of the American Medical Association (JAMA) has now revealed that because these care programs are managed separately, the federal government spends a substantial and increasing amount of potentially duplicated funds in caring for the same individuals.

Background information in the articles states: “In the United States, some adults may be eligible to enroll simultaneously in 2 federally funded managed care systems: the Medicare Advantage (MA) program administered by the Centers for Medicare Medicaid Services (CMS) and the Veterans Healthcare System (VA) administered by the Veterans Health Administration in the U.S. Department of Veterans Affairs. Dual enrollment in the VA and MA presents a vexing policy problem.

The federal government’s payments to private MA plans assume that these plans are responsible for providing comprehensive care for their enrollees and are solely responsible for paying the costs of Medicare-covered services. If enrollees in MA plans simultaneously receive Medicare-covered services from another federally-funded hospital or other health care facility, and this facility cannot be reimbursed, then the government has made 2 payments for the same service.”

Amal N. Trivedi, M.D., M.P.H., of the Providence VA Medical Center and Brown University, Providence, R.I., and his team investigated incidences of dual enrollment, the use of outpatient and acute inpatient care in both VA and MA, and the costs of Medicare-covered services incurred by the VA to care for MA enrollees in a retrospective analysis of 1,245,657 veterans, who simultaneously enrolled in the VA and an MA plan between 2004-2009.

In comparison with 485,651 dual enrollees in 2004, the team noted an increase to 924,792 in 2009. They also noted that the numbers of dual enrollees who used VA services increased from 316,281 in 2004 to 557,208 in 2009. Furthermore, they discovered that 8.3% of the MA population enrolled in the VA in 2009, with 5% of MA beneficiaries being VA users.

The team discovered that in 2009, the total estimated cost of VA care for MA enrollees was $13.0 billion over 6 years. This is an increase from $1.3 billion to $3.2 billion per year.

The researchers write:

“The largest component of this spending was outpatient care, followed by acute and post-acute inpatient care, then prescription drugs. The annual costs of VA-financed fee-basis care increased by a factor of 5 during the study period (from $52 million in 2004 to $249 million in 2009), and represented approximately 8 percent of VA total spending for this population in 2009.”

The team found that 50% of the dual enrollees used both the VA and MA. In 2009, 419 MA plans participated in Medicare, of which an average of 7% of the plan’s enrollees used VA services. The VA paid for 44% of outpatient visits, 18% of acute medical and surgical hospital days and 15% of acute medical and surgical admissions for those who were dually enrolled.

The researchers write: “In 2009, the VA submitted collection requests to private insurers totaling $52.3 million on behalf of care provided to MA enrollees (amounting to 2 percent of the total cost of care for these enrollees in 2009). Of these requests, the VA collected $9.4 million for care (18 percent of the billed amount; 0.3 percent of the total cost of care).”

In order to decrease duplicate expenditure, the researchers recommend for policymakers to consider two strategies:

“First, the VA could be authorized to collect reimbursements from MA plans for covered services, just as the VA currently collects payments from private health insurers for non-Medicare patients. … A second approach may involve adjusting payments to MA plans on behalf of veterans who receive most or all of their care in the VA.”

They conclude, writing: “In light of the severe financial pressure facing the Medicare program, policymakers should consider measures to identify and eliminate these potentially redundant expenditures.”

Written by Petra Rattue

Copyright: Medical News Today

Not to be reproduced without permission of Medical News Today

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“Duplicate Federal Payments for Dual Enrollees in Medicare Advantage Plans and the Veterans Affairs Health Care System”
Amal N. Trivedi, MD, MPH; Regina C. Grebla, MGA, MPH, PhD; Lan Jiang, MS; Jean Yoon, PhD; Jent Mor, PhD; Kenneth W. Kizer, MD, MPH
JAMA, June 2012, doi: 10.1001/jama.2012.7115

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In Lyme Disease, Inflammatory Bacterial Deposits Remain After Antibiotic Treatment

Main Category: Infectious Diseases / Bacteria / Viruses
Also Included In: Arthritis / Rheumatology
Article Date: 27 Jun 2012 – 0:00 PDT

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Lyme disease is caused by the bacterial spirochete B. burgdorferi, which is transmitted to humans through tick bites.
The disease typically begins with a skin rash and is followed by fever, joint pain, and other flu-like symptoms. If diagnosed early, Lyme disease can be successfully treated with antibiotics; however, up to 25% of patients experience arthritis-like symptoms after treatment. The cause of this condition, termed antibiotic refractory Lyme arthritis, is currently unknown.
In the current issue of the JCI, researchers led by Dr. Linda Bockenstedt at Yale University reported on a fluorescent form of B. burgdorferi spirochetes used to determine what happens to the bacteria during and after antibiotic treatment. Using a special type of microscopy to examine the joints and cartilage in living mice, the researchers found that the number of spirochetes diminished quickly during antibiotic treatment and that live spirochetes were entirely eradicated by the time the treatment was completed. Despite being unable to detect live spirochetes after treatment, the researchers detected a fluorescent signal in the joints of the infected mice, which they attributed to bacterial debris. This debris could not cause an infection, but was still be detected by antibodies and elicited an inflammatory immune response.

TITLE:
Spirochete antigens persist near cartilage after murine Lyme borreliosis therapy

In a related commentary, Alan Barbour of the University of California Irvine notes the important ramifications of discovering non-viable and non-transmissible bacterial remnants following antibiotic treatment and the implications for antibiotic-refractory Lyme arthritis. Further studies will be required to determine if B. burgdorferi debris can cause arthritis in humans, as mice do not develop chronic Lyme arthritis.

TITLE:
Remains of infection

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The Affordable Care Act Could Have Negative Consequences For Elderly Recipients

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Seniors / Aging;  Public Health
Article Date: 25 Jun 2012 – 1:00 PDT

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Ellen Kurtzman, Assistant Research Professor at GW School of Nursing, co-authors study examining how 3 of the law’s provisions affect vulnerable older adults.

Three provisions of the Affordable Care Act (ACA) intended to enhance care transitions and prevent avoidable outcomes for the Medicare population are found to have inadequately addressed the needs of older, vulnerable recipients of long-term services and supports, according to George Washington University School of Nursing Assistant Research Professor Ellen Kurtzman, MPH, RN, FAAN.

Ms. Kurtzman was one of six authors of the paper examining the consequences of select ACA provisions on this subgroup of frail older adults. In the paper “Unintended Consequences Of Steps To Cut Readmissions And Reform Payment May Threaten Care Of Vulnerable Older Adults” published first online in the medical journal, Health Affairs, three provisions were reviewed: the Hospital Readmissions Reduction Program, the National Pilot Program on Payment Bundling and the Community-Based Care Transitions Program.

The research found that these provisions inadequately address the unique needs of elderly Americans receiving long-term services and supports, and in some instances, produce unintended consequences that contribute to avoidable poor outcomes.

  • Hospital Readmission Reduction Program. This program financially penalizes hospitals with excessive Medicare 30-day rehospitalization rates for three target conditions and should lead to improvements in care that will benefit all inpatients including the subgroup studied. However, in order to reduce frail older adults’ risk of rehospitalization, attention will need to be paid to the alignment and coordination between providers of acute care and long-term services and supports. Furthermore, older adults receiving long-term services and supports are frequently rehospitalized for conditions that are not being targeted by this policy. Therefore, more immediate improvements in care are likely to be realized for this vulnerable population if penalties targeted alternative diagnoses and accounted for coexisting conditions.
  • National Pilot Program on Payment Bundling. Bundled payments – a set dollar amount paid to a hospital system for an episode of care – are designed to motivate providers to deliver care in the lowest-cost setting and to maximize operating margins while avoiding expensive post-acute stays and preventable rehospitalizations. However, under the pilot program, long-term services and support, which are chronic in nature and do not lend themselves to this payment model, are excluded as part of the “bundle.” The authors point out that while the pilot should increase coordination within the bundle, there are no incentives to coordinate care before or beyond the bundle. Additionally, the fixed-fee structure of the payment model creates legitimate concerns about withholding services to realize savings.
  • Community-Based Care Transitions Program. To date, 30 sites have been selected to participate in this program, which links community-based organizations with one or more hospitals with high readmission rates to provide transitional care services. However, the authors point out that under this program, hospitals serve as the “hubs” of care and frail older adults who are not hospitalized or who live outside the geographic regions served by these organizations may have limited access to needed transitional care services.

“While the Affordable Care Act makes significant investments in improving care transitions and reducing fragmentation, there are significant gaps for a vulnerable subgroup of older adults receiving long term services and supports,” said Ms. Kurtzman. “To address potential gaps and emerging risks, we recommend policy makers carefully monitor the law’s implementation, advance payment policies that integrate care more fully and support providers in delivery system changes. Without anticipating unintended consequences and retooling the payment and delivery systems, reform could fall short of its transformative promise.”

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