Congratulations to The Center for Medicare Advocacy (http://www.medicareadvocacy.org/default.htm) in achieving a great victory for Medicare Recipients. All their hard work paid off with Congressional passage of the the Medicare Improvements for Patients and Providers Act of 2008 over a Presidential Veto.

Both the Senate and the House of Representatives voted on Tuesday, July 15, 2008, to override the presidential veto of H.R. 6331, the Medicare Improvements for Patients and Providers Act of 2008.  In addition to staving off cuts in Medicare reimbursement to physicians, the Act also makes modest improvements for Medicare beneficiaries.  For further details on how H.R. 6331 affects beneficiaries, visit http://www.medicareadvocacy.org/Reform_08_07.10.HR6331.htm.

H.R. 6331, the “Medicare Improvement for Patients and Providers Act of 2008,”

Both the Senate and the House of Representatives voted on Tuesday, July 15, 2008, to override the presidential veto of H.R. 6331, the Medicare Improvements for Patients and Providers Act of 2008.

Most press reports describe H.R. 6331 as a bill that cancels the pay cuts to doctors that went into effect on July 1, but the bill also contains improvements for Medicare beneficiaries.  While these improvements are much more modest than the improvements included in legislation passed by the House of Representatives last year, they are still significant and will provide relief to many older people and people with disabilities.

A Summary of Provisions in H.R. 6331 Relevant to Medicare Beneficiaries

As indicated, H.R. 6331 contains a number of provisions that make improvements for Medicare beneficiaries.  The Center will issue an Alert that discusses the provisions in more detail if and when H.R. 6331 is enacted into law.

Relevant sections provide:

1.      Provisions for Low-Income Individuals

* QI program:  Extends the QI program through December 31, 2009, and increases funding for the program.
* Low-income subsidy (LIS) and Medicare Savings Program (MSP):  Effective 2010, increases the assets test for MSP to the LIS asset level for full subsidy individuals.  This change includes indexing the MSP asset test for the first time since the program was authorized in 1986.
* MSP applications:  SSA is directed to provide LIS applications and information about MSPs to individuals potentially eligible for such subsidies, to provide assistance with applications, and to share LIS application information with states such that the receipt by the state of such information initiates an application for MSP.
* Out -of -pocket expenses:  Limits cost-sharing for beneficiaries who are dually eligible for Medicare and Medicaid and who enroll in Special Needs Plans to the cost-sharing under Medicaid.
* Late enrollment penalty:  Eliminates the Part D late enrollment penalty for LIS-eligible individuals.
* Eliminates estate recovery:  Eliminates the authority for states to collect from estates of deceased beneficiaries the amounts paid to MSP recipients.
* Changes to definitions of income and resources for LIS: Exempts value of life insurance policy (resources) and in-kind support and maintenance (income).
* Judicial review of LIS decisions:  Provides for a right to federal court review
* Translation of model form:  The model MSP application must be translated into languages most frequently used by Medicare beneficiaries and made available to states.
* Assistance to SHIPs and Area Agencies on Aging: Provides additional funding, some of which is targeted to LIS outreach.

2.      Part A and Part B Provisions:

* Extension of exceptions process for therapy caps:  The process is extended until December 31, 2009.
* Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS):  Delays for 18 months implementation of the competitive bidding acquisition process for DMEPOS, which went into effect in 10 areas on July 1, and modifies the competitive bidding process.
* Improvements to preventive services:  The Secretary can use the national coverage determination process to add coverage of new preventive services.  The “Welcome to Medicare” physical is extended from 6 months to 1 year, and the deductible does not apply.
* Mental health services:  Decreases over 6 years the coinsurance for mental health services to the 20% coinsurance rate for other Medicare services.
* Chronic obstructive pulmonary disease and other conditions:  Includes coverage of intensive cardiac rehabilitation programs and repeals transfer of ownership of oxygen equipment
* Medigap: Requires implementation of modifications made by NAIC to the standard Medigap plans.  The modifications contain restructuring of current benefit packages.

3.      Part C and Part D Provisions:

* Prohibitions and limitations on marketing of Medicare Advantage (MA) and prescription drug (PDP) plans:  Prohibits door-to-door sales, cold calling, cross selling of non-health-related products.  Requires limitations on commissions and gifts, and requires agents to abide by state appointment laws.  Some provisions would be effective in time for the 2008 Annual Enrollment Period.
* Phase-out of indirect medical education (IME):  Phases out an adjustment to MA payment rates for IME, but continues to pay teaching hospitals directly for their higher patient care costs.

NOTE:  This provision is the only adjustment to Medicare Advantage payment rates. It adopts a recommendation of the Medicare Advisory Payment Committee (MedPAC) to eliminate these duplicate payments.

* Private Fee-for-Services (PFFS) changes:  Requires PFFS plans in counties where there are two HMOs or PPOs to form networks of providers, beginning in 2011. Also requires PFFS plans, effective 2010, to have the same quality improvement programs as local PPOs.
* Special Needs Plans (SNPs): Extends the authority of SNPs and the moratorium on new SNPs through December 31, 2010.  Includes new eligibility and care management requirements and quality reporting standards.
* Coverage of barbiturates and benzodiazepines: Permits coverage under Part D of barbiturates (for certain conditions) and benzodiazepines, effective January 1, 2012.
* Protected classes of drugs: Codifies current guidance concerning coverage of “protected classes” of drugs under Part D and authorizes modification of the protected classes through rulemaking.
* Medically accepted indication for drugs:  Authorizes Medicare to revise the compendia used for identifying medically accepted indication for Part D drugs, and provides that the criteria for anticancer drugs covered under Part D should be the same as the criteria for anticancer drugs covered under Part B.

The Center for Medicare Advocacy will provide provide further analysis of H.R. 6331.
[i] Senator McCain was not present for the vote.

All: One of the most dynamic, frustrating and exhilarating aspects of our Democracy is the constant Ying and Yang of our political system. After experiencing the most repressive, regressive and poorly administered administrations over the last eight years in our history, a ray of sanity and hope appears on the political horizon.  The Republican attempt to Privatize the Medicare Program through Medicare Advantage Plans is a sin against God and the very fiber of what America stands for and hopefully we are experiencing its eradication.

http://www.nytimes.com/2008/07/11/opinion/11krugman.html?_r=1&th&emc=th&oref=slogin#secondParagraph

Op-Ed Columnist
Kennedy’s Big Day

By PAUL KRUGMAN
Published: July 11, 2008

It was the worst of days, it was the best of days. On Wednesday, Senate Democrats capitulated to the Bush administration on wiretapping — with Barack Obama joining the coalition of the craven.

Later that day, however, those same Senate Democrats won a huge victory on Medicare.

News reports stressed the cinematic quality of the event: Ted Kennedy, who is fighting a brain tumor, made a dramatic appearance on the Senate floor, casting the decisive vote amid cheers from his colleagues. (Only one senator was absent: John McCain.)

But the vote was bigger than the theatrics. It was the first major health care victory that Democrats have won in a long time. And it was enormously encouraging for advocates of universal health care.

Ostensibly, Wednesday’s vote was about restoring cuts in Medicare payments to doctors. What it was really about, however, was the fight against creeping privatization. Democrats finally took a stand — and, thanks to Senator Kennedy, seem to have prevailed.

The story really begins in 2003, when the Bush administration rammed the Medicare Modernization Act through Congress, literally in the dead of night. That bill established large de facto subsidies for Medicare Advantage plans — plans in which Medicare funds are funneled through private insurance companies, rather than directly paying for care.

Since then, enrollment in these plans has been growing rapidly. This has had a destructive effect on Medicare’s finances: the fastest-growing type of Medicare Advantage plan, private fee-for-service, costs taxpayers 17 percent more per beneficiary than Medicare without the middleman. It also threatens to undermine Medicare’s universality, turning it into a system in which insurance companies cherry-pick healthier and more affluent older Americans, leaving the sicker and poorer behind.

What does this have to do with cuts in doctors’ fees? Well, legislation passed a decade ago makes such cuts automatic whenever the growth in Medicare spending exceeds an unrealistically low target. This year, the automatic cuts would have reduced doctors’ payments by more than 10 percent, a pay reduction so deep that many physicians would probably have stopped taking Medicare patients.

In previous years, payments to doctors were maintained through bipartisan fudging: politicians from both parties got together to waive the rules. In effect, Congress kept Medicare functioning by expanding the federal budget deficit.

This year, the Democratic leadership decided, instead, to link the “doctor fix” to the fight against privatization and offered a bill that maintains doctors’ payments while reining in those expensive private fee-for-service plans. Last month, the Senate took up this bill — but Democrats failed by one vote to override a Republican filibuster. And that seemed to be that: soon after that vote, Senators Max Baucus and Charles Grassley had another bipartisan fudge all ready to go.

But then Democratic leaders decided to play brinkmanship. They let the doctors’ cuts stand for the Fourth of July holiday, daring Republicans to threaten the basic medical care of millions of Americans rather than give up subsidies to insurance companies. Over the recess period, there was an intense lobbying war between insurance companies and doctors.

And when the Senate came back in session, it turned out that the doctors — and the Democrats — had won: Senator Kennedy was there to cast the extra vote needed to break the filibuster, a number of Republicans switched sides and the bill passed with a veto-proof majority.

If the Democrats can win victories like this now, they should be able to put a definitive end to the privatization of Medicare next year, when they’re virtually certain to have a larger Congressional majority and will probably hold the White House.

More than that, however, advocates of universal health care, like Health Care for America Now, the new group headlined by Elizabeth Edwards, have to be very encouraged by this week’s events.

Here’s how it will play out, if all goes well: early next year, President Obama will send his health care plan to Congress. The plan will face vociferous opposition from the insurance industry — but the Medicare vote suggests that this time, unlike in 1993, Democrats will hold together.

Unless Democrats win even bigger than expected, however, they won’t have the 60 Senate votes needed to override a filibuster. What the Medicare fight shows is that the Democrats could nonetheless prevail by taking their case to the public, daring their opponents to stand in the way of health care security — so that in the end they get some Republicans to switch sides, and get the legislation through.

A lot can still go wrong with this vision. But the odds of achieving universal health care, soon, look a lot higher than they did just a couple of weeks ago.

All: I have been in the health care financing business for over 30 years and have never heard or read of a Annual Family Health Insurance Premium for $22,232 until today. This is ridiculous – you have to be wealthy to afford a premium at this amount. If this is what state high risk pools and individual insurance markets have to offer then — NO THANKS.

What is really going on here?? For an insurer, no less a state insurer, to propose that someone pay a $22,000 annual health insurance premium is ludicrous and ridiculous. LOOK – there really needs to be a federal, state and/or private investigation into the financial assumptions used to calculate and overall justification for a premium at this level.

Senator McCain and his right-wing conservative insurance supported republican consultants need to go back to the health care policy drawing board and come up with something better then this because this turkey is DOA.

http://www.nytimes.com/2008/07/09/us/politics/09health.html?_r=1&th=&adxnnl=1&emc=th&pagewanted=1&adxnnlx=1215612112-w0krbOJapF53LGEZzjGOvA

McCain Plan to Aid States on Health Could Be Costly

By KEVIN SACK
Published: July 9, 2008

PIKESVILLE, Md. — If Senator John McCain’s radical plan for remaking American health care is to work, he will have to find a way to cover people like Chaim Benamor, 52, a self-employed renovator in this Baltimore suburb. Mr. Benamor never found it necessary to buy insurance before having a mild heart attack last year and now, 13 years shy of Medicare, has little hope of doing so.

“What do you pay first? Do you pay the mortgage? Do you pay your child support?” asks Chaim Benamor. The $4,572 premium for a high-risk policy was more than he could afford on an income of about $35,000.

The heart attack left Mr. Benamor with a $17,000 hospital bill, $400 in monthly prescription costs and a desperate need for insurance. After being rejected by a number of commercial carriers, he turned to the Maryland Health Insurance Plan, one of 35 state programs for high-risk applicants whom no private company is willing to insure.

He decided that the annual premium — $4,572 for a plan with heavy deductibles — was more than he could handle on an income of about $35,000. Yet his earnings were too high for him to qualify for state subsidies.

“I’d like to get it, but what do you pay first?” Mr. Benamor asked at his dining room table. “Do you pay the mortgage? Do you pay your child support? Do you pay your car insurance? Do you pay for your medicine?”

In late April, Mr. McCain, Republican of Arizona, announced that if elected president he would seek to insure people like Mr. Benamor by vastly expanding federal support for state high-risk pools like Maryland’s, or by creating a structure modeled after them. But as Mr. Benamor’s case demonstrates, even well-regarded pools have served more as a stopgap than a solution.

Though high-risk pools have existed for three decades, they cover only 207,000 people in a country with 47 million uninsured, according to the National Association of State Comprehensive Health Insurance Plans. Premiums typically are high, as much as twice the standard rate in some states, but are still not nearly enough to pay claims. That has left states to cover about 40 percent of the cost, usually through assessments on insurance premiums that are often passed on to consumers.

Health economists say it could take untold billions to transform the patchwork of programs into a viable federal safety net. The McCain campaign has made only a rough calculation of how many billions would be needed and has not identified a source for the fi-nancing beyond savings from existing programs. Finding the money will only get more difficult now that Mr. McCain has pledged to balance the federal budget by 2013, which already requires a significant reduction in the growth of spending.

Mr. McCain’s proposal stands in sharp relief to that of his Democratic rival, Senator Barack Obama of Illinois, who wants to require insurers to accept all applicants, regardless of their health. That is now the law in five states, including New York and New Jersey.

For those who can afford the premiums, or who qualify for subsidies in the 13 states that provide them, the high-risk programs can be a godsend.

Richard and Susan Logan, both of whom have battled cancer this decade, said they were grateful to have coverage for themselves and their daughter through the Maryland plan, even though it will cost $22,232 this year. They had been rejected by 25 commercial insurers, said Mrs. Logan, 57, a part-time billing clerk for a physician.

The Logans, who live in Gambrills, near Annapolis, estimate that without the high-risk pool, they would pay $40,000 a year for medication alone.

“The plan’s worth its weight in gold for that,” said Mr. Logan, 62, an aviation accident investigator. “Otherwise, we’d be paying for the medications out of our retirement.”

A fifth of the 14,000 participants in the Maryland plan receive subsidies that drop their premiums below the market rates charged to healthy people, said Richard A. Popper, the plan’s director. But many in the middle find the policies both unaffordable and intolerably restrictive, and Mr. Popper estimates that two-thirds of those eligible have not enrolled.

Almost all of the state pools impose waiting periods of up to a year before covering the health conditions that initially made it impossible to obtain insurance. In some states, fiscal pressures have forced heavy restrictions in coverage and enrollment. Florida, which has 3.8 million uninsured people, closed its pool to new applicants in 1991, and the membership has dwindled to 313.

An informal survey by the American Cancer Society recently found that only 2 percent of nearly 2,700 callers to its insurance hot line enrolled in high-risk pools within two months of being referred to them. “In most cases, we know they probably didn’t apply because they discovered high premiums or pre-existing condition clauses and just didn’t bother,” said Stephen Finan, associate director of policy for the group’s Cancer Action Network.

There is no census of the medically uninsurable. But in 2006, insurers turned down 11 percent of all individual applicants for medical reasons, including 22 percent of those 50 or older, according to America’s Health Insurance Plans, an industry trade group.

Finding a way to cover the sickest of the uninsured is critically important because 15 percent of the population is responsible for three-fourths of health care spending. Many wind up in emergency rooms, which cannot legally reject them, leaving hospitals with more than $30 billion in unpaid bills each year.

“You either find a way to slow enrollment through economic forces or you close the plan,” says Richard A. Popper. The Maryland plan’s director estimates that two-thirds of those eligible have not enrolled.

Mr. McCain’s proposal, which he calls the Guaranteed Access Plan, would be part of a market-based restructuring that is in many ways more fundamental than the universal coverage proposed by Mr. Obama.

With the goal of making the insurance marketplace more equitable and competitive, Mr. McCain would end the longstanding exclusion from income taxes of health benefits paid by employers. The 17 million nonelderly people covered by directly purchased insurance do not enjoy that advantage.

Mr. McCain would replace the exclusion with refundable health care tax credits of $2,500 per person and $5,000 per family in the hope of driving consumers into the individual insurance market. To help push down premiums, he would allow the purchase of policies across state lines.

Currently, those who buy insurance individually often face higher costs because their risks are not spread across broad groups of workers. Though insurers cannot discriminate against participants in group plans, they evaluate consumers seeking individual coverage case by case to determine if they are worth the risk of coverage, and at what price. Insurers contend that if they had to charge the same rates to all comers, many would wait until they were sick to buy policies.

The McCain campaign recognizes that in an invigorated individual market, even larger numbers of chronically ill people would go without the protection afforded by group coverage. High-risk pools would theoretically serve to fill the gaps.

Critics argue that, to date, insurers have benefited from the state pools as much as the uninsured. As long as premiums remain above market rates, the pools insulate commercial insurers from the greatest risks while giving customers little incentive to abandon their private policies.

“They are run in ways that protect the profitability of commercial insurers,” said Karen Pollitz, a professor at Georgetown University who has studied high-risk pools and who has served on the board of the Maryland plan. “They leave the illusion that there’s a safety net without there really being much of one.”

Mr. Obama’s plan differs from Mr. McCain’s in several ways. In addition to requiring insurers to accept all applicants, he would require that parents obtain insurance for their children. To make premiums affordable, he would create a Medicare-like government plan that would be open to all and pump up to $65 billion a year into subsidies. The money would come from repealing President Bush’s income tax cuts for those earning more than $250,000 a year.

When Mr. McCain unveiled his high-risk pool proposal, his chief domestic policy adviser, Douglas Holtz-Eakin, the former director of the Congressional Budget Office, estimated the federal cost at $7 billion to $10 billion. Mr. Holtz-Eakin said five million to seven million uninsured people would be singled out for coverage.

But in a recent interview, Mr. Holtz-Eakin emphasized that the projections “could change dramatically” depending on how the program was structured.

Mr. Holtz-Eakin and other McCain health advisers, including Thomas P. Miller, a resident fellow at the American Enterprise Institute, and Stephen T. Parente, a health economist at the University of Minnesota, said premiums would probably be capped at twice the standard rates. They said subsidies might be available to those making up to four times the federal poverty level, or $41,600 for a single person.

Financial incentives would probably be provided to those who effectively manage their diseases. No decision has been made about waiting periods for pre-existing conditions, the advisers said.

Mr. McCain’s proposal would represent a huge increase over the $50 million a year that Congress now appropriates in grants to the state pools, in a program that began in 2002. But several analysts questioned whether even $10 billion would be nearly enough, given that the states now spend about $2 billion to insure 207,000 people.

“I do not for a minute think it will cost 7 to 10 billion dollars a year,” Ms. Pollitz said. “It may cost 7 to 10 billion dollars a week.”

In an admonition for Mr. McCain, Maryland’s five-year-old plan, like others before it, has quickly become a victim of its growth. As enrollment expanded by 30 percent in each of the last two years, actuaries forecast insolvency as soon as 2010 and compelled the plan’s board to apply the brakes.

Over the last two years, it has raised premiums, deductibles and co-payments, increased out-of-pocket maximums, lowered the lifetime cap on payments and added a waiting period for pre-existing conditions, which rose to six months from two months on July 1. It also increased the amount applicants must pay to buy their way out of the waiting period.

At the same time, the plan is making more people eligible for subsidies. To keep it afloat, the state is raising the assessment on hospital bills that provides two-thirds of its financing.

“It’s not easy when you see there is strong demand for something and you need to temper that demand,” Mr. Popper, the plan’s director, said. “But you either find a way to slow enrollment through economic forces or you close the plan and no one gets in, which is a solution that no one wants.”

__________________________________________________________________________________________________________

I can see the conversation now between the hospital Billing Dept. of a major hospital and a patient with an unacceptable MedFICO Score. “Well Ms. USA, I am sorry to inform you that because of your low MedFICO Score, we will be unable to perform your Quadruple By-Pass surgery at this facility. I am sorry but that is hospital policy. However, I want you to know that we are here for all your medical needs, if you can afford to pay. Good luck finding another hospital and thanks for your interest.”

What a Humanitarian Disgrace!

http://consumerist.com/346422/medfico-in-development-its-fico-for-patients

The Consumerist

Health, fico, personal finance, credit scores, insurance, medfico, money, scary

MedFICO In Development, It’s FICO For Patients!

From the folks that brought you the credit score system in all it’s glory, here’s MedFICO! It’s a new business project underway with the goal of assessing patient’s ability to pay their medical bills. The system would gather patient’s bill payment history from hospitals around the country and then assign patients a score similar to a credit score. Critics are worried if the same problems with people getting erroneous information in their credit report and then having an insanely difficult time cleaning it up would also affect MedFICO. They also worry whether hospitals would use MedFICO to determine the level of care offered, like whether the person gets a hospital stay or not. FICO scores are now being used by some employers to screen out potential employees, would they use MedFICO to see who might take a bigger chunk out of the health benefits?

All: Why doesn’t someone just come out and tell the truth for a change? Here is the real story on the Medicare physician fee cuts. The Bush Administration has allowed the Insurer and HMO industries to overcharge the Medicare Trust Fund for the past eight years to the tune of Billions of US taxpayer dollars for services rendered to Medicare recipients, under a program known as Medicare Advantage Plans. The legislation that created these programs was passed when the Republicans controlled both the Congress and Administrative (Bush) branches of government.

Now that the Democrats control Congress they want to allow pre-determined and previously legislatively mandated physician physician fee cuts to take effect in order to force the Bush Administration to reduce the extravagant payments to Private Medicare Advantage Plans. Here is where the Republicans have out smarted themselves and find that they are between a rock and a hard place. A Republican controlled Congress passed the Medicare physician fee cuts (the rock) and also passed legislation (the hard place) to over pay the Insurer and HMO industry. When the Medicare financial costs run wild, which is what we are experiencing now, and the public demands cost containment what happens? NOTHING!

The Democratic Congress is not going to let the Republicans escape their legislative responsibility, even though the Bush Administration has stated that they will veto any legislation that REDUCES payments to Private Medicare Advantage Plans. So what is going to happen?

There probably is a compromise in there somewhere - Physicians get a fee cut of 5% not the original 10.6% and the Medicare Advantage Plans get their fees cut an unspecified % to make up the difference. But please, enough of the drama, just do it.

Doctors Press Senate to Undo Medicare Cuts
J. Emilio Flores for The New York Times

By ROBERT PEAR
Published: July 7, 2008

WASHINGTON — Congress returns to work this week with Medicare high on the agenda and Senate Republicans under pressure after a barrage of radio and television advertisements blamed them for a 10.6 percent cut in payments to doctors who care for millions of older Americans.

The advertisements, by the American Medical Association, urge Senate Republicans to reverse themselves and help pass legislation to fend off the cut.

How to pay doctors through the federal health insurance program is an issue that lawmakers are forced to confront every year because of what is widely agreed to be an outdated reimbursement formula. But the dispute, which showcases the continued potency of health care issues, has reached a new level of urgency this year. Some doctors are reassessing their participation in the program and powerful interests on all sides are in a lobbying frenzy.

Just before the Fourth of July recess, the House passed a bill to prevent the Medicare pay cut by a vote of 355 to 59. In the Senate, Republicans blocked efforts to take up the bill, so the cut took effect on July 1, as required by the formula. But the Bush administration has delayed processing of new claims to give Congress time to come up with a compromise.

Senator Harry Reid of Nevada, the majority leader, said he planned to force another vote this week, and Democrats pressed their case over the weekend in their national radio address.

Democrats need just one more vote to pass the bill, and they hope to win over Republicans who were hit by advertisements over the recess. The advertisements assert that Republicans have been protecting “powerful insurance companies at the expense of Medicare patients’ access to doctors.” The commercials were aimed at 10 Republican senators, including seven up for election this fall.

But President Bush has vowed to veto the bill, so the fight — and the uncertainty — could continue for weeks.

Mr. Bush and many Republicans oppose the bill because it would finance an increase in doctors’ fees by reducing federal payments to insurance companies that offer private Medicare Advantage plans as an alternative to the traditional government-run Medicare program.

Insurance companies and the White House argue that the bill would hurt beneficiaries who rely on private Medicare plans. America’s Health Insurance Plans, a trade group, ran television advertisements last week, urging Congress to “stop cuts to Medicare Advantage.”

Medicare is just one issue on which Congress is stalled. The Senate has yet to finish work on a bipartisan bill to help homeowners facing foreclosure. Lawmakers are also struggling with legislation to regulate electronic surveillance and deal with soaring gasoline prices.

But the Medicare issue has been a sticking point for years. The question is how to rein in the rapidly rising cost of the federal health program. Members of both parties say they want to change the formula, which defines a “sustainable growth rate” for spending on doctors. But Congress is nowhere near agreement.

The pending bill offers a short-term fix. It would reverse the 10.6 percent cut and increase Medicare payments to doctors by 1.1 percent in January. Under the current formula, doctors would still face cuts of more than 5 percent a year from 2010 to 2012.

Despite the president’s veto threat, many House Republicans bolted and voted for the bill, putting added pressure on their colleagues in the Senate.

As the maneuvering goes on in Washington, doctors around the country have begun to reassess their participation in Medicare.

Dr. David D. Richardson, 40, an ophthalmologist in Los Angeles County, closed his practice last week to all but emergency patients and those needing surgery.

“I love practicing medicine,” Dr. Richardson said, “but I would lose more money by keeping my office open than by pulling it back to a skeleton crew. Just like a physician in the emergency room, I try to reduce the hemorrhaging.”

In Topeka, Kan., Dr. Kent E. Palmberg, senior vice president and chief medical officer of the Stormont-Vail HealthCare system, said its 70 primary care doctors were “no longer accepting new Medicare patients as of July 1 because of the draconian cut in Medicare reimbursement.”

Dr. Gerald E. Harmon, a family doctor in Pawleys Island, S.C., said he decided last week that he would not take new Medicare patients “until further notice.”

“This is not what we enjoy doing,” says a notice in his waiting room. “It is what we must do to maintain financial viability.”

Dr. Harmon said that Democrats had been more helpful on Medicare legislation, but that the two parties shared responsibility for the impasse.

“Rome is burning, and Nero is fiddling away, trying to get re-elected,” Dr. Harmon said.

Doctors have also entered the political arena. One made a direct appeal to Mr. Bush at a fund-raiser last week in Jackson, Miss. Dr. J. Patrick Barrett, a spine surgeon and president of the Mississippi State Medical Association, said he had told Mr. Bush that the Medicare pay cut would be “extremely detrimental to the health and welfare of the elderly population.”

In an interview, Dr. Barrett said: “I lose money whenever I operate on a Medicare patient. In the last week, a number of doctors have told me they will quit seeing new Medicare patients or will cut back on the amount of Medicare work they do.”

The A.M.A.’s advertisements focus on Senators John Cornyn of Texas, John E. Sununu of New Hampshire and Roger Wicker of Mississippi, among others.

Republicans defend their position in various ways. Mr. Cornyn said the bill provided only “a patchwork fix.” Senator Charles E. Grassley of Iowa said Democrats were playing “partisan games.”

Senator Jon Kyl of Arizona, the Republican whip, said, “Nobody wants to cut physicians’ pay.” But lawmakers disagree over how to cover the cost of remedial legislation.

More than 10 million of the 44 million Medicare beneficiaries are in private Medicare Advantage plans offered by companies like Humana, UnitedHealth and Coventry Health Care. Many of these plans offer extra benefits like vision and dental care. But independent studies have repeatedly found that the private plans cost the government more per person than traditional Medicare.

Expecting the battle to resume this week, Coventry Health Care, in an e-mail message dated July 3, asked insurance agents across the country to call Congress and oppose the pending Medicare bill, saying that it would be “harmful to beneficiaries.”

On the other side of the issue, military families have joined doctors and AARP, the advocacy group for older Americans, in lobbying for the bill.

Relatives of active-duty military personnel, military retirees and their dependents receive care under a federal program known as Tricare, which uses the Medicare fee schedule to pay doctors.

When Medicare reduces payments to doctors, fees under the military program are also reduced, and it becomes more difficult for military families to find doctors.

Congress is “playing chicken with your health care,” the Military Officers Association of America told its members in a bulletin last week.

Medicare receives 15 million claims a week for services paid under the physician fee schedule, so any change in payment rates has big implications.

Michael O. Leavitt, the secretary of health and human services, said he would try to “minimize the impact” of the cut by instructing Medicare contractors to hold claims for 10 business days.

Kerry N. Weems, the acting administrator of the Centers for Medicare and Medicaid Services, said doctors would not be paid at the lower rates “before July 15 at the earliest.”

However, Medicare officials said, that is simply what the law requires. Under existing law, claims cannot be paid sooner than 14 days after they are received. And if claims are filed on paper, rather than electronically, they cannot be paid sooner than 29 days after they are received.

http://www.nytimes.com/2008/07/07/health/policy/07medicare.html?pagewanted=1&_r=2&hp

thepolicycenter.org predicts that A Major Assault By The Health  Insurance Industry Will Be Launched To Privatize the Medicare System Before BUSH Leaves Office. How can we be so sure that this will happen? Because if I were a health insurer or HMO I would know that this is my last chance to significantly capture huge amounts of federal dollars before the opportunity door closes.  Insurers and HMOs have always been very opportunistic groups and they realize that the next administration will be a lot tougher on them then the present administration.

Be forewarned, the worst of the Bush Administration is yet to come. Thank God that we only have 5 more months.

www.newsday.com/news/columnists/ny-bzsaul0627,0,4451877.column <http://www.newsday.com/news/columnists/ny-bzsaul0627,0,4451877.column>

Newsday.com
The battle to save Medicare
Saul Friedman
Gray Matters, June 26, 2008

Reader Jack Wajda, 69, of Orlando, a retired AT&T executive and financial planner, identifies the single greatest problem with the American health-care system as well as anyone. He writes: “To allow private for-profit insurance companies to decide whether and what type of care we receive is incomprehensible to me.”

If you’ve been reading my columns and mail in reaction to what I’ve written, that private insurers have the power to virtually run American health care is also incomprehensible to most doctors, nurses, technicians, as well as patients.

Don’t get me wrong. I have auto, homeowners and life insurance. The risk pools for these coverages are fairly predictable and we can largely depend on the insurance protection. But consider what happened on the Gulf coasts and even in parts of Long Island after recent hurricanes. Insurance was canceled or premiums raised sky high because of the slim possibility of another storm.

But one’s health should not be held hostage to the profit motive. Health is too important to be left to the insurance business. It is not like a car or a roof that can be replaced.

Yet that is how for-profit health insurance works. As long as you’re young and reasonably healthy, insurance companies are glad to take your money and cover your bumps, bruises and routine doctor visits. But if you’re really ill and your costs run into the thousands, your insurer will have second thoughts about your coverage. And if you’re elderly and more likely to suffer costly health problems, the risk pool suddenly becomes too risky for the profit-seeking health insurers.

Those costs are why the Republicans, who seek to replace Medicare with private insurance companies, took the first step toward that in 1995, with the assent of the Clinton administration, when Newt Gingrich’s Congress required Medicare to bring in private so-called Medicare HMOs. Gingrich, you recall, promised insurers that Medicare would “wither on the vine.” The HMOs bugged out on Medicare because they weren’t making sufficient profits. But they were replaced by “Medicare Plus Choice.”

Now, as Wajda correctly writes, taxpayers pay the private Medicare Advantage plans at least $9,000 a year more per patient than for traditional Medicare, with salespeople getting commissions. On top of that, the prescription benefit, Part D, has also been given to the insurance companies, which are earning high profits.

Medicare Advantage and Part D have been so confusing and corrupted by greedy sales practices and deception that even this administration has taken measures to crack down. But more important, the privatization of Medicare has come at great cost to the principles and the budget of our most popular public health-insurance program. As Judith Stein, of the Center for Medicare Advocacy, writes, private insurance is in danger of killing Medicare.

So will someone tell me why even Medicare’s well-wishers, including Sens. Barack Obama and Hillary Clinton, continue to look to the private insurers to strengthen the nation’s health-care system and cover the 47 million uninsured Americans? Both would subsidize the coverage for millions of Americans, but most of the insurance would be private. And many would not be covered. Sen. John McCain, who would slash spending for public health insurance, except for federal employees such as himself, would provide tax credits to purchase private insurance.

As columnist (and my former Newsday colleague) Marie Cocco writes, these proposals would not bring everyone into the system, and without universal coverage, the risk pool is bound to fail. Besides, patients and physicians would still be at the mercy of a profit-seeking business, with large administrative costs, bureaucrats checking and second-guessing your coverage, executive salaries, salespeople’s commissions and stockholders to satisfy.

Stein and other Medicare advocates have been lobbying to strengthen the program by canceling a potentially devastating 10 percent slash in physicians’ fee and easing the assets test to permit more of the near poor to take advantage of low-income programs. And Democratic lawmakers would pay for these changes by cutting the excessive payments to private Medicare Advantage plans.

But Mike Leavitt, the Secretary of Health and Human Services, who has been on the road telling audiences and reporters that Medicare is in financial trouble, has told Democrats that President George W. Bush will veto any bill that touches the fund for the private insurers.

As Democrats seek a Medicare bill that will pass, AARP has launched a nationwide advertising campaign to “Keep Medicare Fair.” AARP’s Andrew Nannis told me the organization favors the bill’s proposals to loosen the assets tests and cancel the physician cuts, without raising Medicare premiums. He added that AARP favors cutting the subsidies to private plans, but it’s not clear how hard their lobbyists are pushing for it. AARP’s insurer, UnitedHealthcare, is lobbying hard to retain the subsidies, which earns AARP $700 million a year in royalties.

Traditional Medicare is still the nation’s most popular health insurance, even among the young. Why not save the system with Medicare for all? Rep. John Conyers’ bill, HR 676, would cover every person for all health-care issues, and eliminate the expense of dozens of other programs, such as Medicaid, and the high overhead and profits of the private-insurance industry. The bill has 90 co-sponsors, and the support of organized labor, nurses and thousands of doctors. Take a look at the bill at thomas.loc.gov.

Copyright © 2008, Newsday Inc.

Just the other day I was thinking about what a wise physician told me some 20 years ago “Tom, there are people and groups out there that want to tear down the House of Medicine and hang all the physician’s ”. After 20 years, I guess that Guy Van Sickle, MD, CT State Medical Society (CSMS) prediction is finally coming to pass.

I know that I am showing my age but I remember when Physician reimbursement was not tied to Medicare reimbursement. In those days,  Medicare reimbursement was the lowest (and still is) payer and private payer reimbursement for physician services were plus (+) 10%, 20%, 25% more then the Medicare Rate. I guess we need to ask the Insurers, Regulators and the AMA how this happened.

I have often wondered what the health care financing marketplace would look like today if physicians had aggressively developed their own physician owned and controlled health insurance companies. They could have effectively leveraged the Health Insurer/HMO marketplace creating a much more competitive market then we have today.

I know one thing for sure: the physicians would not be hanging around the financing table waiting for the Insurers and Regulators to throw them their financial scraps. They could have been a major player at the financing table and the physicians would have been the one’s throwing their financial scraps to the Insurers and Regulators. Oh ……. the missed opportunities.
http://www.nytimes.com/2008/06/27/washington/27medicare.html

Doctors Face Payment Cuts for Patients on Medicare

By ROBERT PEAR
Published: June 27, 2008

WASHINGTON — Doctors face a 10 percent cut in Medicare payments next week, following the Senate’s failure on Thursday to take up legislation that would have averted the cuts.

Republican senators blocked efforts by Democrats to call up the bill, which was approved Tuesday in the House by an overwhelming bipartisan vote of 355 to 59.

In the Senate, supporters fell two votes short of the 60 needed to close debate. The vote was 58 to 40.

Senator Charles E. Schumer, Democrat of New York, said, “We have to pass this bill to avoid catastrophic cuts to doctors.”

Dr. Nancy H. Nielsen, president of the American Medical Association, said the cuts would force many doctors to “limit the number of new Medicare patients they treat.”

The bill would cancel the 10 percent cut scheduled to occur on Tuesday and would increase Medicare payments to doctors by 1.1 percent in January.

President Bush had threatened to veto the bill, in part because it would reduce federal payments to private Medicare Advantage plans, offered by insurers like Humana, UnitedHealth and Blue Cross and Blue Shield companies.

The 10 percent cut occurs automatically because of a statutory formula that reduces Medicare payments to doctors when spending would otherwise exceed certain goals.

Senator Mitch McConnell of Kentucky, the Republican leader, said: “We offered to negotiate. We offered to extend current law.” But, Mr. McConnell said, Democrats refused.

Lawmakers are leaving town this week for the Fourth of July holiday. When they return, they could increase doctors’ payments retroactively. But there is no guarantee.

The Senate majority leader, Harry Reid, Democrat of Nevada, said: “Senate Republicans are playing a dangerous game of chicken. The only losers will be Medicare patients, old people.”

Senator John Cornyn, Republican of Texas, said Democrats were scaring doctors and beneficiaries in an effort to score political points.

“We are looking at a partisan proposal,” Mr. Cornyn said. “We are being told that we have to take it or leave it, or the cuts will occur.”

More than 10 million of the 44 million Medicare beneficiaries are in private Medicare Advantage plans. Many of these plans offer extra benefits. But many studies have found that the private plans cost the government more per person than the traditional program.

Senator Richard J. Durbin of Illinois, the Democratic whip, said: “Who supports this bill? Doctors, consumer groups, pharmacists, hospitals. Who opposes this bill? The health insurance industry and the White House.”

But Senator Orrin G. Hatch, Republican of Utah, said the private plans provided a valuable option for retirees, especially in rural areas.

Senator John McCain of Arizona, the presumptive Republican presidential nominee, and Senator Edward M. Kennedy, Democrat of Massachusetts, who is ill, did not vote.

The jury is in - Delaying Necessary Medical Care Kills. If you want to commit suicide this is one of the best ways to do it. You can delay an oil change on your car, you can delay a payment on your credit card but if you delay needed medical it may be the last time you delay anything. Oh by the way, cost sharing and shifting also kills and consumer-directed health care is a death sentence for the poor and uninsured.

We knew 20 years ago that creating financial barriers to receive health care services kills, this is not a new but an old concept. Creating financial barriers for people to receive health care services MUST STOP. Do you know what happens when people delay needed medical care ? Well, they either die or their medical condition worsens and then the cost of their treatment quadruples. Cost sharing and shifting are inflationary health care financing concepts.

The health insurers and politicians are as dumb as rocks if they think that cost sharing and shifting are going to save anybody any money.

http://www.nytimes.com/2008/06/30/opinion/30mon2.html?_r=1&th&emc=th&oref=slogin

Editorial
Maybe I’ll Get Better on My Own

Published: June 30, 2008
While politicians have been debating endlessly over the best ways to reform the American health care system, the plight of American patients has rapidly worsened. A new national survey found that an alarming 20 percent of the population, some 59 million people in all, either delayed or did without needed medical care last year, a huge increase from the 36 million people who delayed or did not seek care in 2003.

As expected, people who have no health insurance — there are some 47 million of them — were most likely to make that difficult choice. But insured people also chose to go without care in ever-larger numbers.

According to the survey, the main reason is soaring medical costs, which have outstripped the modest growth in wages in recent years. High costs are deterring not only the uninsured from seeking care, but also many insured people who are struggling with higher deductibles, co-payments and other out-of-pocket expenses as their employers or health plans shift more of the cost burden to them.

Many patients with insurance said they went without care because their health plans would not pay for the treatment or their doctors or hospitals would not accept their insurance. Both insured and uninsured patients said they skipped treatments because they had trouble getting timely appointments, were unable to get through on the telephone, or could not make it to a doctor’s office or clinic when it was open. No doubt a weakening economy, high fuel prices, the home foreclosure crisis and general economic anxiety also played a role.

Sadly, previous gains in caring for low-income children have reversed, largely because their parents lost employer-sponsored coverage.

The telephone survey of some 18,000 Americans was conducted by the Center for the Study of Health System Change, a respected nonpartisan research group, and was financed by the Robert Wood Johnson Foundation. It relied on respondents’ views that they needed the care and did not explore what health consequences resulted.

Champions of so-called “consumer-directed health care” might argue that the market is working — people are wisely delaying or forgoing care of low marginal value. But it is disturbing that unmet medical needs increased the most for people in poor or only fair health — those most likely to get even sicker if they don’t get treatment.

The new survey further strengthens the case for universal coverage, with moderate cost-sharing provisions. All Americans should be able to get medical care when they need it.

People interpret and process information in many different ways, for
example, the article below from the SF Gate -  “Calif. HMOs raked in $4B in
profits”. To some, this is good news and a notice to buy more HMO stock, to
others this is bad news and demonstrates the hypocrisy in our health care
financing system  - insurers making billions while 47 million people remain
uninsured.

However, to me this article means something completely different - it describes a major health care financial wealth shift away from Physicians and patient care to Health Insurer Shareholder ROI’s. To me this is a very disturbing event - to take limited dollars from a financially distressed health care delivery system and convert these dollars into pure financial profit is unconscionable.

I do not begrudge Insurers from making a profit. However, the society must understand that for every health care dollar that is converted to profit a simultaneous decrease occurs in available health care dollars for patient care. Do you ever ask yourself - How many thousands of lives could have been saved if CA HMOs only had a $2 Billion dollar profit?

This article demonstrates to me that Physicians and Consumers/Patients have
lost FOUR (4) Billion Dollars in health care services and these dollars have been converted into Health Insurer Shareholder ROI’s. It is very, very sad to see a proud profession like the Medical Profession (Physicians): 1) slowly lose control over their revenue streams and thereby lose control over the quality of care they practice and their patient management decisions.

When are the Physicians in this country going to wake up and smell the Roses and take back health care control? Tom!

Study: Calif. HMOs raked in $4B in profits
By SHAYA TAYEFE MOHAJER, Associated Press Writer
Monday, June 23, 2008

(06-23) 22:42 PDT Los Angeles, CA (AP) –

Some executives at California health insurance providers paid themselves
handsomely while their companies were raking in more than $4.3 billion in
profits in the last year.

In addition, HMOs spent $6 billion on administrative costs, which include
hefty CEO salaries, according to a report by the California Medical
Association, which said the money could have gone toward driving down
premiums or better protecting the insured.
The annual report, which draws on expenditures reported to the state
Department of Managed Health Care, will be released Tuesday.
It found that annual salaries topped $1 million for chief executive officers
at providers like Aetna, Inc., CIGNA Corp., Health Net, Inc., UnitedHealth
Group and WellPoint Health Networks, Inc.
The medical association is sponsoring a bill to require health plans to
spend at least 85 percent of their annual income from the insured on health
care.
“This report really underscores what we have been saying all along, which is
there’s massive waste in the insurance industry,” said Sen. Sheila Kuehl,
D-Santa Monica, who authored the bill.
“Californians are literally going into bankruptcy because of rising
insurance premiums and having their benefits gutted simultaneously,” she
said.
The report found that if the bill were already in place, nearly $1.1 billion
dollars would have gone back to providing health care.
Of major providers, Indianapolis-based Anthem Blue Cross’ 4.1 million
members see the smallest proportion of their premiums returned, with 79
percent of revenue used toward medical care.
“One of the worst ratios is Anthem Blue Cross,” said CMA President Richard
Frankenstein. “They sent more than $1 billion back to Indiana last year and
I don’t think that’s where Californians want to see their premium dollars
go.”
Anthem Blue Cross said in a statement that as a for-profit business, it also
pays more taxes than the nonprofit HMOs included in the study, which
accounts for some of the difference in administrative costs.
“Anthem Blue Cross continually strives to reduce its administrative costs
while also delivering innovative products to its members,” the statement
said.
The report highlighted four major providers who already put more than 90
percent of revenue directly toward medical care: L.A. Care Health Plan (97.1
percent), CIGNA HealthCare of California (94.3 percent), Inland Empire
Health Plan (93.1 percent) and Kaiser Foundation Health Plan (90.6 percent).
“We’re a not-for-profit so there aren’t any shareholders who get dividends
or bonuses, so any net revenue is invested right back into facilities,
services, and keeping our rates affordable,” Kaiser spokeswoman Kathleen
McKenna said.

http://www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2008/06/23/state/n221615D33
.DTL&hw=health+care&sn=007&sc=935

Let’s push the pedal to the metal on Proxy  Votes supporting Universal Health Care Proposals. Why? Because the Wall  Street Journal, the mother of the insurance industry, Publicly Opposes this  initiative. If they vehemently oppose it then logic would have it that it is  an effective methodology for health care financing reform. This is strategy  is known as “reverse logic” and it has been used by the health insurers/HMOs  on us for years?

In order to achieve Universal Health Care and  Health Care Financing Reform you must focus on the Health Insurance  Industries most vulnerable pressure point – the Investor Community.

The  Wall Street Journal

REVIEW &  OUTLOOK

Politics by  Proxy
June 4, 2008

It’s  corporate proxy season, and as usual the shareholder activists are out to  make a splash. But this year there’s an important twist: The Securities and  Exchange Commission is helping them.

Unions have been trying for  years to force businesses to put their health-care policies on the  shareholder ballot. In the past, the SEC has objected by citing its  “ordinary business” rule, which says that shareholder votes are not the  place for establishing or changing a company’s business strategy or  compensation.

So this year the labor activists changed tack: They  asked for proxy space on the “principle” of universal health care. The idea  is that voting on general principles isn’t shareholder micromanagement and  so would evade SEC strictures. How universal health care would enhance  shareholder value is at best unclear, however. And in fact these proposals  are not about investment returns. They are about browbeating corporate  America into endorsing the union health-care agenda.

And sure enough,  the proposals at Boeing, General Motors, United Technologies and others were  essentially identical. They state that health care should be “universal,”  “continuous,” “affordable,” “sustainable” – these days, everything has to be  “sustainable” – and, well, “promote well-being.” None of this has anything  to do with running a company, but it is designed to echo through national  political debates and get business on record as supporting “universal”  (read: government) health insurance.

This should have been reason  enough for the SEC to throw the proposals out. Yet at every company where  they were offered, the SEC approved them. Our guess is that the staff is  blowing with the political winds and bowing to pressure from Democrats on  Capitol Hill. We’re also told the staff also proceeded on its own, without  the approval of SEC Commissioners. If that’s true, this is an abuse of  discretion by the staff, or an abdication by the Commissioners, or  both.

“If the staff did this without the commission’s knowledge,  that’s a commission run amok and that’s dead wrong,” former SEC Chairman  Arthur Levitt told us, adding: “It’s absolutely inappropriate.” And he  supports the proposals. The companies also deserve some blame, since  none of them tried to ditch the proposals for being trivial or  irrelevant.

This is a signal of what is likely to happen in far more  aggressive fashion if the SEC ever agrees to make proxy access easier, as  unions and Democrats on Capitol Hill are lobbying it to do. Instead of  focusing on business returns, the annual proxy will become another forum for  political debates and lobbying. Those debates, in turn, would take valuable  director time away from supervising management on key business issues – such  as compensation.

This year, the SEC reviewed 14 of these health-care  proposals. Given their success, we can expect more of them next spring.  Since the SEC staff is determined to play dumb about their political  purpose, the Commissioners will have to exercise some adult supervision to  prevent further politicization of shareholder proxies.

See all of  today’s editorials and op-eds, plus video commentary, on Opinion Journal.