Medicare

By RICARDO ALONSO-ZALDIVAR  Nov. 12, 2021

WASHINGTON (AP) — Medicare’s “Part B” outpatient premium will jump by $21.60 a month in 2022, one of the largest increases ever. Officials said Friday a new Alzheimer’s drug is responsible for about half of that.

The increase guarantees that health care will gobble up a big chunk of the recently announced Social Security cost-of-living allowance, a boost that had worked out to $92 a month for the average retired worker, intended to help cover rising prices for gas and food that are pinching seniors.

Medicare officials told reporters that about half the increase is due to contingency planning if the program ultimately has to cover Aduhelm, the new $56,000-a-year medication for Alzheimer’s disease from pharmaceutical company Biogen. The medication would add to the cost of outpatient coverage because it’s administered intravenously in a doctor’s office and paid for under Part B.

The issue is turning into a case study of how one pricey medication for a condition afflicting millions of people can swing the needle on government spending and impact household budgets. People who don’t have Alzheimer’s would not be shielded from the cost of Aduhelm, since it’s big enough to affect their premiums.

The new Part B premium will be $170.10 a month for 2022, officials said. The jump of $21.60 is the biggest increase ever in dollar terms, although not percentage-wise. As recently as August, the Medicare Trustees’ report had projected a smaller increase of $10 from the current $148.50.

“The increase in the Part B premium for 2022 is continued evidence that rising drug costs threaten the affordability and sustainability of the Medicare program,” said Medicare chief Chiquita Brooks-LaSure in a statement. Officials said the other half of the premium increase is due to the natural growth of the program and adjustments made by Congress last year as the coronavirus pandemic hit.

The late Friday afternoon announcement – in a time slot government agencies use to drop bad news – comes as Congress is considering Democratic legislation backed by President Joe Biden that would restrain what Medicare pays for drugs. However, under the latest compromise, Medicare would not be able to negotiate prices for newly launched drugs. The news on Medicare premiums could reopen that debate internally among Democrats.

“Today’s announcement … confirms the need for Congress to finally give Medicare the ability to negotiate lower prescription drug costs,” Rep. Frank Pallone, D-N.J., said in a statement. “We simply cannot wait any longer to provide real relief to seniors.” Pallone has been a proponent of the original House version of the legislation, which took a tougher approach toward the pharmaceutical industry.

Alzheimer’s is a progressive neurological disease with no known cure, affecting about 6 million Americans, the vast majority old enough to qualify for Medicare.

Aduhelm is the first Alzheimer’s medication in nearly 20 years. It doesn’t cure the life-sapping condition, but the Food and Drug Administration determined that its ability to reduce clumps of plaque in the brain is likely to slow dementia. However, many experts say that benefit has not been clearly demonstrated.

Medicare has begun a formal assessment to determine whether it should cover the drug, and a final decision isn’t likely until at least the spring. For now, Medicare is deciding on a case-by-case basis whether to pay for Aduhelm.

Cost traditionally does not enter into Medicare’s coverage determinations. But in this case there is also plenty of debate about the effectiveness of Aduhelm. Last November, an FDA advisory panel voted nearly unanimously against recommending its approval, citing flaws in company studies. Several members of the panel resigned after the FDA approved the drug anyway over their objections.

A nonprofit think tank focused on drug pricing pegged Adulhelm’s actual value at between $3,000 and $8,400 per year – not $56,000 – based on its unproven benefits.

But Biogen has defended its pricing, saying it looked carefully at costs of advanced medications to treat cancer and other conditions. The company also says it expects a gradual uptake of the Alzheimer’s drug, and not a “hockey-stick” scenario in which costs take off. Nonetheless Medicare officials told reporters they have to plan for contingencies.

Two House committees are investigating the development of Aduhelm, including contacts between company executives and FDA regulators.

Medicare covers more than 60 million people, including those 65 and older, as well as people who are disabled or have serious kidney disease. Program spending is approaching $1 trillion a year.

By Carmen Heredia Rodriguez, Kaiser Health News

JUNE 9, 2020

Pneumonia. Heart problems. High cholesterol. Betsy Carrier, 71, and her husband, Don Resnikoff, 79, relied on their primary care doctor in Montgomery County, Maryland, for help managing their ailments. But after seven years, the couple was surprised when the doctor informed them she was opting out of Medicare, the couple’s insurer. “It’s a serious loss,” Resnikoff said of their doctor.

Patients can lose doctors for a variety of reasons, including a physician’s retirement or when either patient or doctor moves away. But economic forces are also at play. Many primary care doctors have long argued that Medicare, the federal health insurance program for seniors and people with disabilities, doesn’t reimburse them adequately and requires too much paperwork to get paid.

These frustrations have prompted some physicians to experiment with converting their practices to more lucrative payment models, such as concierge medicine, in which patients pay a fee upfront to retain the doctor. Patients who cannot afford that arrangement may have to search for a new physician. The exact number of physicians with concierge practices is unknown, health care experts said. One physician consulting company, Concierge Choice Physicians, estimates that roughly 10,000 doctors practice some form of membership medicine, although it may not strictly apply to Medicare patients.

Shawn Martin, senior vice president of the American Academy of Family Physicians, estimated that fewer than 3% of their 134,000 members use this model but the number is slowly growing. The move to concierge medicine may be more prevalent in wealthier areas.

Travis Singleton, executive vice president for the medical staffing company Merritt Hawkins, said doctors switching to other payment systems or those charging Medicare patients a higher price for care are likely “in more affluent, well-to-do areas where, frankly, they can get fees.”

It is far easier for physicians than hospitals to opt out of taking Medicare patients. Most hospitals have to accept them since they rely on Medicare payments to fund inpatient stays, doctor training and other functions.

The majority of physicians do still accept Medicare, and most people insured by the federal program for seniors and people with disabilities have no problem finding another healthcare provider. But that transition can be tough, particularly for older adults with multiple medical conditions.

A study of at least 2,200 older adults published in 2016 found that nearly 4 in 10 were taking at least five medications at the same time. Fifteen percent of them were at risk of drug-to-drug interaction. Primary care providers mitigate this risk by coordinating among doctors on behalf of the patient, said Dr. Kellie Flood, a geriatrician at the University of Alabama-Birmingham. “You really need the primary care physicians to serve as the quarterback of the health care team,” said Flood. “If that’s suddenly lost, there’s really not a written document that can sum all that up and just be sent” to the new doctor.

Finding a physician who accepts Medicare depends partly on workforce demographics. From 2010 to 2017, doctors providing primary care services to Medicare beneficiaries increased by 13%, according to the Medicare Payment Advisory Commission (MedPAC), a nonpartisan group that advises Congress. However, the swell of seniors who qualify for Medicare has outpaced the number of doctors available to treat them. Every day, an estimated 10,000 Americans turn 65 and become eligible for the government program, the Census Bureau reported. The impact: In 2010, MedPAC reported, there were 3.8 primary care doctors for every 1,000 Medicare enrollees. In 2017, it was 3.5.

Authors of a MedPAC report out last June suggested that the number of available primary care providers could be an overestimate. Their calculation assumed all internal medicine doctors provided these services when, in reality, many specialize in certain medical conditions, or accept only a limited number of Medicare patients into their practices.

But MedPAC concluded seniors are not at a disadvantage finding a doctor. “We found that beneficiaries have access to clinician services that is largely comparable with (or in some cases better) access than for privately insured individuals, although a small number of beneficiaries report problems finding a new primary care doctor,” the MedPAC researchers wrote.

The coronavirus outbreak has complicated the ability for many Americans to access care, regardless of their insurer. However, many older patients now have an opportunity to connect with their doctors virtually after the Centers for Medicare & Medicaid Services (CMS) broadened access to telemedicine services under Medicare.

Experts said the long-term effects of the virus on doctors and Medicare remain unknown. But Martin said the shortage of cash that many doctors are experiencing because of the coronavirus epidemic has revealed the shortcomings of how primary care doctors are paid. “The COVID crisis really brought to life the challenges of fee for service,” said Martin.

Despite these challenges, the number of doctors choosing to opt out of Medicare has been on the decline, according to data from CMS. Singleton, of Merritt Hawkins, said concern about doctors leaving the Medicare system is part of larger workforce issues. Those include the need to recruit more medical students to concentrate on primary care.

One estimate predicts the nation will face a shortage of 23,600 primary care physicians by 2025. The majority of residents in internal medicine ― those who care for adults — are choosing a subspecialty such as cardiac care or gastroenterology, MedPAC reported.

In 2017, MedPAC reported, the median compensation for all doctors was $300,000 a year. Among primary care doctors, it was $242,000. Creative business models can make up that difference. Under the concierge model, the doctor charges patients an annual fee — akin to a gym membership ― to access their practice. The provider still bills the insurer ― including Medicare — for all patient care.

Another model ― called direct primary care — charges the patient an annual fee for access and care; doctors do not bill health insurance plans. Proponents say that the model enables them to take more time with their patients without dealing with the bureaucracy of getting paid by health insurers. “I think what is most attractive to direct primary care is that they just practice medicine,” Martin said.

The size of a physician practice can also determine whether it accepts Medicare. Large practices can better offset the lower Medicare payment rates by leveraging their influence with private insurers to raise those reimbursements, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy. But small, independent clinics may not have the same clout.

“If you’re a large primary care practice, private insurers are really going to want to have you in their network,” he said. “And they’re willing to pay more than they might pay an individual solo practitioner who they’re not as concerned with because it’s only one physician.”

Luckily, after more than a dozen calls to physicians, Carrier and Resnikoff said they found another primary care doctor. They said she accepts Medicare and impressed them during their meet-and-greet with her knowledge of their medical history. She also met their criteria for age and expertise. “At this point in our lives, I’d be eager to find somebody who’s young enough that they might be in practice for the next 10 years,” Carrier said.

The coronavirus legislation signed by President Donald Trump would let Medicare expand the use of telemedicine in outbreak areas, potentially reducing infection risks for vulnerable seniors.

By Associated Press, Wire Service Content March 6, 2020

BY RICARDO ALONSO-ZALDIVAR, Associated Press

WASHINGTON (AP) — The coronavirus legislation signed by President Donald Trump on Friday, March 6, 2020 lets Medicare expand the use of telemedicine in outbreak areas, potentially reducing infection risks for vulnerable seniors.

Coverage of telemedicine is now limited primarily to residents of rural areas facing long road trips for treatment from specialists. The law allows the government to waive those restrictions to help deal with the public health emergency created by the coronavirus outbreak.

It also could open the way for more lasting changes in Medicare’s coverage of virtual health care, including Skyping with the doctor or using devices that beam over measurements such as heart rate.

“Telehealth is really instrumental in containing and treating disease, particularly in a public health emergency,” said Megan O’Reilly, a lobbyist with AARP, the advocacy group for older people, which pushed for the telemedicine provisions. “For older Americans, this can help keep them safe.”

Scientists tracking the global respiratory disease outbreak have documented that coronavirus takes a higher toll on older people, on patients with multiple chronic conditions, and on those with compromised immune systems. Death rates are higher among older patients, while younger people are more likely to get a milder form of the illness.

To be clear, seniors who suspect they may have COVID-19 — the illness caused by the coronavirus — will still have to get tested physically, whether at a clinic or their doctor’s office.

Telemedicine cannot take the place of a swab of the throat to collect a sample for scientific testing. But it can help doctors make special arrangements to safely receive a patient who is sick and suspects the virus may be involved.

Perhaps even more important, telemedicine would offer a way for Medicare recipients in outbreak areas to take care of ongoing medical issues without having to go to the doctor’s office and risk coming into contact with someone who is sick. Many seniors have several doctors’ appointments every month.

Like the rest of the $8.3 billion coronavirus response bill, the telemedicine provisions were the result of a bipartisan effort by Democratic and Republican lawmakers in both chambers of Congress. “This will give seniors greater access to their health care providers without leaving home,” said Sen. Ron Wyden, D-Ore., a longtime telemedicine advocate who helped shoehorn the provisions into the coronavirus bill.

Seema Verma, head of the Centers for Medicare and Medicaid Services, has said she wants to find ways to focus government assistance on the people deemed most vulnerable. But her agency has not yet said how it would use its newly granted waiver authority.

To protect seniors from scams, the legislation requires that the doctor’s office billing for a telehealth visit have an established, ongoing relationship with the patient. And communication must take place through a two-way interactive video and voice link.

If telemedicine shows its worth in the coronavirus outbreak, that could lead to permanent changes making it more widely available to seniors. “While this law applies to the current public health emergency, we’ll continue to work on expanding the use of telehealth so that every American has access,” said Sen. Brian Schatz, D-Hawaii, who also worked on the provision.

Medicare is the government’s flagship health insurance program, covering about 60 million people age 65 and over, as well as younger people who qualify because of a disability. Medicare Advantage plans offered by private insurers have been allowed to offer telemedicine as a supplemental benefit like dental coverage or a gym membership for several years now, said Gretchen Jacobson, vice president for Medicare at the Commonwealth Fund think tank.

The new telemedicine waivers would most benefit the roughly two-thirds of Medicare recipients in the traditional program. Overall, telemedicine has grown steadily in recent years. Most mid-size or large employers now offer some way to connect patients and health care providers virtually. But researchers say patients have been relatively slow to try telemedicine, especially if they are used to in-person visits.

By Michelle Andrews – The New York Times – July 18, 2019

San Miguel de Allende. Mexico is home to the third-largest number of expatriate American retired workers, with 30,000.  CreditAlfredo Estrella/Agence France-Presse — Getty Images

When Karen Schirack, 67, slipped on her way into her house in January and broke her left femur in multiple places, she had a decision to make. Should she get surgery to repair the fractured thigh bone and replace her hip near Ajijic, Mexico, where she has lived for 20 years, or be airlifted back to her home state, Ohio, for surgery and rehabilitation?

As the number of American retirees living overseas grows, more of them are confronting choices like Ms. Schirack’s about medical care. If they were living in the United States, Medicare would generally be their coverage option. But Medicare doesn’t pay for care outside the country, except in limited circumstances.

Expatriate retirees might find private insurance policies and national health plans in other countries. But these may not provide the high-quality, comprehensive care at an affordable price that retirees expect through Medicare. Faced with imperfect choices, some retirees cobble together different types of insurance, a mix that includes Medicare.

That’s what Ms. Schirack has done. She pays about $3,700 annually for an insurance policy through Allianz that covered her surgery at a private hospital in Guadalajara, about an hour from Ajijic. She also has a medical evacuation policy that would have paid for her flight to the States, if she had opted for that. That policy costs roughly $3,000 for five years. And she pays for Medicare Part B, which she can use for care when she visits family in the United States. (The standard Part B premium is $135.50 monthly.)

Ms. Schirack has a scar running from her waist to the middle of her thigh, but she no longer needs home nursing care and wrapped up months of physical therapy in June. After five more months of healing, she hopes to be back to normal.  Her private plan paid the equivalent of about $20,000 for her surgery. Before she left the hospital, Ms. Schirack had to cover her portion of the total, about $2,400, and bills for other expenses, including blood transfusions.

After leaving the hospital, she was responsible for paying for other services — home nurses, physical therapy, medications — and submitting receipts to the insurer for reimbursement. She estimates she has spent $10,000 and has been reimbursed for about two-thirds of that so far.  If she had had surgery in the United States, she might have faced fewer paperwork hassles, Ms. Schirack said, “but all in all, I’m not going to complain.”

The quality of health care varies widely by country, as do the services available to foreign residents. And there are quite a few of these transplanted Americans.  Between 2012 and 2017, the number of retired workers living in foreign countries who were receiving Social Security benefits grew nearly 15 percent, to more than 413,000, according to the Social Security Administration. The largest numbers of expatriates were in Canada (nearly 70,000) and Japan (more than 45,000). Mexico was third, home to nearly 30,000 retired American workers.

Commercial health care policies for them may provide decent coverage, but people can generally be denied a policy or charged higher rates for medical reasons. The plans may refuse to cover some pre-existing conditions. Ms. Schirack’s policy, for example, doesn’t cover any services related to her allergies.  Private policies can be problematic for another reason: They may have age limits. The GeoBlue Xplorer Essential plan, for example, enrolls only people who are 74 or younger, and coverage expires when people turn 84. In contrast, Medicare eligibility generally begins at 65 and continues until a beneficiary dies.

And the policies aren’t cheap. A 70-year-old might pay $1,900 a month for an Xplorer Essential plan with a $1,000 deductible, said Todd Taylor, a sales director for GeoBlue. A plan with a $5,000 deductible might run $1,400 monthly. That doesn’t include coverage for services in the United States.  Rates may also vary by country. A 67-year-old American living in Costa Rica who buys a midlevel Cigna plan with a deductible of $750 for hospital care and $150 for outpatient care might pay $1,164 a month, said David Tompkins, president of TFG Global Insurance Solutions. The same policy might cost $913 in France. If the person wanted to add coverage for treatment in the United States, the monthly premium would increase to $1,440 in Costa Rica and $1,138 in France, Tompkins said.

Since medical care is sometimes much less expensive overseas, some retirees opt to pay out of pocket for minor or routine services.

Claudia Peresman, who will turn 63 on Sunday, moved from Stonington, Conn., to San Miguel de Allende in central Mexico in November. On her first night there, she tripped in the bathroom, hit her face on a wall and split her lip. Her neighbors helped her get a cab to a 24-hour emergency room at a hospital about five minutes away, where staff cleaned up the cut and sent her home. She paid the roughly $25 fee in cash.

Ms. Peresman recently bought a private insurance plan with a $2,500 deductible, for which she pays about $100 a month.  “What I wanted was catastrophic coverage,” she said. “Things are so affordable here that, outside of being admitted to the hospital, I can probably afford it.”

By Sarah O’Brien – PERSONAL FINANCE – July 19, 2019

If you’re among the growing contingent of Americans who plan to continue to work after age 65, be sure to review your Medicare options before you do eventually decide to finally say farewell to your coworkers.  While it’s common for people working past that age to stick with a company-sponsored health plan and delay enrolling in Medicare, impending retirement means you should be planning ahead to avoid a coverage gap or costly missed deadlines.

“It’s important to do everything you need to do before you set your retirement date,” said Elizabeth Gavino, founder of Lewin & Gavino in New York and an independent broker and general agent for Medicare plans. “I’d start planning at least a few months before then to make sure all your ducks are in a row.”

Most people sign up for Medicare when first eligible at age 65 either because they no longer are working or don’t have qualifying coverage through a job. For a small but growing number of older Americans who continue to work past that age, however, having workplace coverage means having options.

Regardless of when you sign up, Medicare Part A (hospital coverage) costs nothing as long as you have at least a 10-year work history. Part B, which covers outpatient care and medical equipment, has a standard monthly premium of $135.50 for 2019. Part D prescription coverage also comes with monthly premiums averaging $32.50. For both Parts B and D premiums, higher-income enrollees will pay more.

For those in the age-65-and-older crowd who work for a large company and get qualifying health-care coverage through their job (the rules are different for small firms), it can sometimes make sense to delay signing up for the Medicare parts that come with a cost.

“They tend to enroll in just Part A because it’s free and then delay Part B and Part D because they’d have to pay premiums,” said Danielle Roberts, co-founder of insurance firm Boomer Benefits in Fort Worth, Texas.

However, be aware that if you also have a health savings account through work, you cannot continue to make contributions once you enroll in Medicare, even if only Part A.

Once you’re planning to retire from your job and will lose workplace coverage, you need to be aware of various Medicare deadlines and rules to avoid shelling out more for premiums than necessary.  As long as your employer-sponsored health care is considered qualifying coverage (called “creditable”), you can avoid paying a penalty for having delayed Part B signup — although you must enroll within eight months of stopping work.

Ideally, however, you should coordinate the end of your work-sponsored coverage with your Medicare effective date so you don’t find yourself without insurance.  If you were to be subject to the late-enrollment penalty for Part B, it would be 10% per year that you should have been signed up but were not. The amount would be life-lasting and tacked on to your premium.

Be aware that when you retire, if for some reason you end up continuing your workplace health plan under COBRA — a law that allows you to continue the coverage for a set time if you pay the full premiums — Medicare does notconsider that coverage creditable. The same goes for insurance through your ex-employer after you retire.

For Part D prescription coverage, the late-enrollment penalty is 1% for every month that you could have been signed up. People with qualifying coverage through an employer plan don’t face that life-lasting penalty as long as they secure coverage within two months of their other plan ending.  However, once you do enroll, you’ll get a form from the insurance company that needs to be filled out and returned to confirm you were permitted to delay enrollment, Roberts said.  “If you miss that letter and fail to send it back, you’ll get charged the penalty,” Roberts said. “We’ve seen where someone misses it because they get so much mail and accidentally throw it out and it can take months to appeal that late penalty,” she said.

Meanwhile, if you want to sign up for a Medicare Advantage Plan, you also get two months from when your workplace coverage ends to do so without having to wait until the fall general enrollment period.  If you go this route, your Parts A and B coverage — and typically Part D — will be delivered through the insurer offering the plan. The cost of an Advantage Plan (on top of your Part B premium) depends on the level of coverage you choose and availability of options in your area.

For some Medicare recipients, however, an Advantage Plan isn’t a good fit. Those folks often pair a so-called Medigap policy with their Parts A, B and D coverage (you cannot have both Medigap and an Advantage Plan). Those policies provide help with things such as deductibles, copays and coinsurance.

If you plan to go this route: Once you sign up for Part B, you have six months to get a Medigap policy without the insurer being allowed to nose through your health history. After that window, you could face that underwriting process and possibly be charged more for coverage or rejected altogether.

At ‘Greg Says’ we’re ready to help those who have delayed their enrollment in Medicare Parts B and D adhere to the rules in order to avoid the penalties and possible coverage gaps.