HCR -- Seven Changes You May Have Missed

By John Ballard

Kaiser Health News summarizes seven meaningful healthcare reforms.
Not glamorous but very much to the point of improving medical care and the role of insurance.

Go to the link for more details, including when these are scheduled to commence.

1. Insurers won't be able to charge co-payments or deductibles for certain preventive services such as breast cancer screenings every one to two years, cholesterol blood tests and some sexually transmitted disease screenings. Insurers will also have to cover recommended immunizations at no cost to patients. Some health care analysts have suggested that premiums may rise as a result of this and other new requirements, but administration officials say any increase in premiums would be miniscule.


2. A nonprofit research institute will examine various medical treatments -- by looking at data and conducting its own studies -- to determine which methods work best. This is often called "comparative effectiveness research."


3. A new program will help employers handle the cost of health care for retirees age 55 and older who are not eligible for Medicare, the federal program for the elderly. The reimbursements will cover 80 percent of medical claims between $15,000 and $90,000 for retirees, their spouses and dependents.


4. Insurers must justify premium increases to the federal government and state insurance commissioners. If premium hikes are deemed to be unreasonable � federal regulators have yet to define what "unreasonable" means � states could exclude insurers from offering their coverage on health insurance exchanges beginning in 2014.


5. In 2014, Medicaid, the state-federal program for the poor, will expand to include everyone who makes less than 133 percent of the poverty line ($14,400 this year for individuals). Currently, most poor people without children aren't covered by the program. But in the meantime, under the law, states can expand their Medicaid programs to cover these people, and get federal aid to do so.


6. Approximately 8.8 million "dual eligibles" -- individuals who qualify for both Medicare and Medicaid, many of whom are poor elderly -- could benefit from a new federal office designed to coordinate their medical care.


7. The health overhaul law gives the Food and Drug Administration the power to approve lower-cost versions of biologic drugs � often called biosimilars or follow-on biologics � after drugmakers have 12 years of market exclusivity. These drugs can be used to treat serious diseases such as cancer and multiple sclerosis.
   
   

I could knock out a thousand word rant about each of these but decided against it. When I reflect on how overdue these changes are I have to take a deep breath and move on to something else.

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As a senior caregiver I regularly see #6. Under the most extreme of conditions Medicare pays up to 100 days of long-term care, and then only under the questionable rubric of "rehabilitation" or "therapy."
After 100 days the patient is reclassified as a resident and relabeled custodial. 
At that point the individual or some other responsible party is charged as a private pay resident. Long term care costs vary but start at about sixty-five thousand dollars per year. Some people have that kind of income but most do not and are will be liquidating a lifetime of assets until they become officially destitute. Then and only then will they become eligible for Medicaid.
It's called "spending down." 

The dimensions of how these "dual eligibles" will be coordinated have yet to be determined. But there is a real opportunity for Medicare to save a fortune because the current lack of coordination is a study in bureaucratic inefficiency. 

As they are currently structured, Medicare and Medicaid do not offer an integrated system of care for dually eligible beneficiaries. Each program has historically been run completely separately, even though their coverage domains and populations overlap. This arrangement often forces dually eligible beneficiaries to navigate a confusing and poorly coordinated system of care (Scanlon, 1997). Fragmentation in administration and overlap in coverage also create incentives for cost shifting between the two programs. For example, States have incentives to have providers bill Medicare for as many services as possible since it is entirely federally funded, unlike Medicaid where States are expected to share in the costs.

CMS fact sheet (16 pages pdf)

Not mentioned at either Kaiser or CMS is another category I would call MULTI-eligible. These are military people who thanks to age and circumstance might be dual-eligible but thanks to their status as veterans also are covered by Tri-Care and/or Veterans Health Care. And there are some people for whom "coverage" is of no consequence because they are financially secure enough they have no need to worry.

I have been watching the health care system up close for the last seven years, first as an employee of a health care network with five hospitals and now as a non-medical caregiver for those who can afford to pay for private services beyond taxes and insurance. I have no idea how the accounting people in hospitals or nursing homes do their jobs but it is nothing like what I knew about in the world of business.