Susan Jaffe – Page 19 – Washington, D.C. reporter specializing in health policy and aging issues

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By Susan Jaffe | June 28, 2013 | KAISER HEALTH NEWS

The Commission on Long-Term Care held its first meeting Thursday on Capitol Hill with some members acknowledging that their late start adds to their challenges in offering Congress recommendations on how to finance the expensive services for seniors and disabled Americans.

The panel is hobbled with a meager budget and staffing, and it is facing a three-month deadline for its report. Speakers at the meeting reminded the commission that the effort is daunting.

The commission heard a litany of statistics from four experts who explained how the nation’s growing population of seniors will become more dependent on long-term care services. But the rising cost of those services threatens to deplete individuals’ savings and add to the nation’s budget problems because of the expenses borne by Medicare and Medicaid. MORE

Appeals, Long term care, Medicare Advantage, Medicare costs, Physical therapy

FAQ: Medicare Beneficiaries May See Increased Access To Physical Therapy Or Some Other Services

By Susan Jaffe | June 25, 2013 | Kaiser Health News in collaboration with

For years, seniors in Medicare have been told that if they don’t improve when getting physical therapy or other skilled care, that care won’t be paid for. No progress, no Medicare coverage — unless the problem got worse, in which case the treatment could resume.
This frustrating Catch-22 spurred a class-action lawsuit against Health and Human Services Secretary Kathleen Sebelius. In January, a federal judge approved a settlement in which the government agreed that this “improvement standard” is not necessary to receive coverage.

“This will help a lot of older or disabled people who clearly need the skilled care and aren’t getting it because they will not get better,” said Margaret Murphy, associate director of the Center for Medicare Advocacy, which helped bring the lawsuit. “The settlement recognizes that Medicare will pay for care to maintain their condition and prevent backsliding.”

Yet providers may not know about the settlement yet and may still be telling patients, incorrectly, that Medicare won’t cover treatment if there’s no improvement. MORE

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By Susan Jaffe | June 21, 2013 | KAISER HEALTH NEWS in collaboration with

Within days, the company that handles an average of more than 60,000 calls daily about Medicare will be deluged by new inquiries about health insurance under the Affordable Care Act.

The six Medicare call centers run by Vangent, a company based in Arlington, Va., will answer questions about the health care law from the 34 states that opted out of running their own online health insurance marketplaces or decided to operate them jointly with the federal government.

The Department of Health and Human Services estimates that Vangent’s call centers will receive 42 million calls about the federal marketplaces this year, a daily average of up to 200,000; plus answer 2,400 letters and 740 e-mails, and host 500 Web chats daily. Customer service representatives will take consumers through the process — from shopping for a plan to enrolling.

Running the 800-Medicare call centers may provide valuable experience, but Vangent’s track record reveals that it was slow to adapt when changes in the Medicare program caused dramatic spikes in demand.

“It’s going to be huge,” said Bonnie Burns, a training and policy specialist at California Health Advocates. “The number of calls they are likely to get will probably dwarf anything they saw in Medicare.” MORE

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Volume 381, Issue 9882, Pages 1975 – 1976, 8 June 2013

WORLD REPORT Health and science agencies in the USA have been operating on reduced budgets, enforced by sequestration, for just over 3 months Susan Jaﬀe reports from Washington, DC.

The automatic budget cuts known as sequestration that the US Congress approved in 2011 were intended to be so onerous that they would never happen. Lawmakers would surely find a more reasonable way to save at least US$1·2 trillion over the next decade before the cuts would begin in 2013. Instead, Republicans and Democrats could not agree on an alternative, and the first wave of cuts, totalling $85 billion through to September, 2013, are phasing in for most non-defence US Government operations. Everything from White House tours to the most promising cancer research have been limited by a lack of funding.

..Many services provided by the US Department of Health and Human Services (HHS) are affected, including programmes at the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), and medical research funded by the National Institutes of Health (NIH). Even the Affordable Care Act (ACA)—President Barack Obama’s landmark health reform law—will feel the impact, with supporters worried that enrolment for next year’s new health insurance coverage will have a difficult start in October. [FULL STORY AS PDF]

US sequester hits health and science programmes

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Seniors Sue Medicare To Close Nursing Home Coverage Gap

By Susan Jaffe | Connecticut Health Investigative Team Writer | May 3, 2013

…Today, lawyers representing 14 seniors, including 7 from Connecticut, will go to U.S. District Court in Hartford to ask a judge to eliminate the observation care designation because it deprives Medicare beneficiaries of the full hospital coverage they’re entitled to under Medicare, including coverage for follow-up nursing home care. More seniors are falling into the observation care coverage gap: the number of observation patients has skyrocketed 69 percent in the past five years, to 1.6 million nationally in 2011, according federal records.

Government lawyers will ask the judge to throw out the case because the seniors should have followed Medicare’s appeals process before going to court if they believed they were unfairly denied benefits.
And yet federal records and interviews with patients and advocates show that many observation patients who call Medicare about the billing problem hear something quite different – there is nothing that Medicare can do to help. MORE

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Advocates Head To Court To Overturn Medicare Rules For Observation Care

By Susan Jaffe | May 3, 2013 | KAISER HEALTH NEWS produced in collaboration with

Lois Frarie and her husband Wayne live in a Park Lane senior community home in Monterey, Calif. (Photo by Jay Dunn/The Salinas Californian for USA Today.)

After Lois Frarie, a 93-year-old retired teacher from Monterey, Calif., spent four days at a local hospital while being treated for a broken elbow and pelvis, she went to a nearby nursing home to build up her strength.

But her family was stunned to find out that they would have to pay thousands of dollars up front since two of the days she spent in the hospital were considered “observation care.” She wasn’t an admitted patient for at least three consecutive days and therefore she didn’t qualify under federal law for Medicare’s nursing home coverage.

Advocates for seniors say the distinction is not fair to patients.

They are taking their argument to federal court in Hartford, Conn., Friday for the first hearing on a lawsuit seeking to have Medicare eliminate the observation label. Government lawyers argue in court filings that Medicare considers observation care an outpatient service and if elderly patients think they should have been admitted to the hospital, they should file an appeal. [Continued in Kaiser Health News, and in USA Today PDF or online.]

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Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care

By Susan Jaffe | May 3, 2013 | KAISER HEALTH NEWS in collaboration with

Medicare officials have proposed changes in hospital admission rules that they say will curb the rising number of beneficiaries who are placed in observation care but are not admitted, making them ineligible for nursing home coverage.

“This trend concerns us because of the potential financial impact on Medicare beneficiaries,” officials wrote in an announcement April 26. Patients must spend three consecutive inpatient days in the hospital before Medicare will cover nursing home care ordered by a doctor.

…The reaction from patient advocates, doctors and hospitals has been swift and surprisingly unanimous: it’s a bad idea. MORE

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Volume 381, Issue 9872, Pages 1087, 30 March 2013

WORLD REPORT America’s new global health chief says “diplomatic discourse” will encourage countries to take ownership of US-funded health programmes. Susan Jaﬀe reports from Washington, DC.

In his first US public appearance since outgoing Secretary of State Hillary Clinton appointed Ambassador Eric Goosby to lead the new Office of Global Health Diplomacy in December, a gathering of policy experts, health-care advocates, and government officials asked him about its goals and challenges.

…Among the challenges for sustainability is the human resource deficit, Goosby explains. “The countries in which we work, virtually every one of them, do not have the tools to effectively manage and oversee programmes”, he says. “They have leadership that is well educated and ready but the minister of health then turns around to nobody to implement the idea.” [MORE] [PDF]

The USA and global health diplomacy: goals and challenges

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February 4, 2013, 7:49 am

By SUSAN JAFFE

Ellen Gorman, 72, a New York psychotherapist, can’t walk very far and gets around the city mainly by taxi, “which is really expensive,” she said. Twice since 2008 her physical therapy was discontinued because she wasn’t progressing. But after a knee replacement last year, she is getting physical therapy again, exercising with her therapist and building up her endurance by walking in the hallway of her Manhattan apartment building. Because of an action by Congress and a recent court settlement, Medicare probably won’t cut off Ms. Gorman’s physical therapy again should her progress level off — for as long as her doctor says it is medically necessary.

Congress continued for another year a little-known process that allows exceptions to what Medicare pays for physical, occupational and speech therapy. ….In addition, the settlement of a class-action lawsuit last month now means that Medicare is prohibited from denying patients coverage for skilled nursing care, home health services or outpatient therapy because they had reached a “plateau,” and their conditions were not improving. That will allow people with Medicare who have chronic health problems and disabilities to get the therapy and other skilled care that they need for as long as they need it, if they meet other coverage criteria. MORE

Therapy Plateau No Longer Ends Coverage

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By Susan Jaffe | December 17, 2012 | Kaiser Health News in collaboration with

Dan Driscoll used to be a smoker. During a regular doctor’s visit, his primary-care physician suggested that Driscoll be tested to see if he was at risk for an abdominal aortic aneurysm, a life-threatening condition that can be linked to smoking. The doctor said Medicare would cover the procedure. So Driscoll, 68, who lives in Silver Spring, had the test done and was surprised when he got a bill from Medicare for $214.

“I didn’t accept that,” he said, because based on everything he had read from Medicare, he was sure this was a covered service. So Driscoll did something that seniors rarely do: He filed an appeal. Of the 1.1 billion claims submitted to Medicare in 2010 for hospitalizations, nursing home care, doctor’s visits, tests and physical therapy, 117 million were denied. Of those, only 2 percent were appealed.

“People lose, and then they lose heart, or they are too sick, too tired or too old, and they give up,” said Margaret Murphy, associate director of the Center for Medicare Advocacy, which has offices in Washington and Connecticut. “Or their kids are handling the appeal and they are too overwhelmed caring for Mom or Dad.” [Continued at Kaiser Health News and The Washington Post.]

How To File A Medicare Appeal Here are some basic steps for challenging Medicare coverage denials…. [Continued at Kaiser Health News.]

Appeals, CMS, Medicare costs

Seniors Need To Be Tenacious In Appeals To Medicare

By Susan Jaffe | December 17, 2012 | Kaiser Health News in collaboration with

Dan Driscoll used to be a smoker. During a regular doctor’s visit, his primary-care physician suggested that Driscoll be tested to see if he was at risk for an abdominal aortic aneurysm, a life-threatening condition that can be linked to smoking. The doctor said Medicare would cover the procedure. So Driscoll, 68, who lives in Silver Spring, had the test done and was surprised when he got a bill from Medicare for $214.

“I didn’t accept that,” he said, because based on everything he had read from Medicare, he was sure this was a covered service. So Driscoll did something that seniors rarely do: He filed an appeal. Of the 1.1 billion claims submitted to Medicare in 2010 for hospitalizations, nursing home care, doctor’s visits, tests and physical therapy, 117 million were denied. Of those, only 2 percent were appealed.

“People lose, and then they lose heart, or they are too sick, too tired or too old, and they give up,” said Margaret Murphy, associate director of the Center for Medicare Advocacy, which has offices in Washington and Connecticut. “Or their kids are handling the appeal and they are too overwhelmed caring for Mom or Dad.” [Continued at Kaiser Health News and The Washington Post.]

How To File A Medicare Appeal Here are some basic steps for challenging Medicare coverage denials…. [Continued at Kaiser Health News.]

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Insurance Commissioners Reject Calls To Limit Seniors’ Medigap Policies

By Susan Jaffe KAISER HEALTH NEWS in collaboration with Dec. 6, 2012

The nation’s insurance commissioners have some stern advice about proposals to shrink Medicare spending by asking seniors with supplemental Medigap policies to pay more out of pocket for their health care: Don’t do it.

The health law requires the National Association of Insurance Commissioners to advise the administration about whether seniors would use fewer Medicare services — and therefore, cost the government less money — if the most popular Medigap plans were less generous.

“Everything we’ve looked at has shown that increasing cost-sharing does stop people from seeking medical care,” said Bonnie Burns, a training and policy specialist at California Health Advocates who serves on an NAIC committee that has studied the issue for more than a year. “The problem is they stop using both necessary and unnecessary care.” [More in The Washington Post] or longer version from Kaiser Health News]

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By Susan Jaffe | KAISER HEALTH NEWS | December 4th, 2012 , 5:30 a.m.

If young adults can’t afford health insurance policies available in 2014 under the health care law, state insurance officials are worried they won’t buy them. And that could drive up the cost of insurance for the mostly older, sicker people who do purchase coverage. MORE

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Volume 380, Issue 9855, Pages 1727 – 1728, 17 November 2012

WORLD REPORT Implementation of the Patient Protection and Aﬀordable Care Act is unlikely to run smoothly despite the Nov 6 election result. Susan Jaﬀe reports from Washington, DC.

Just 3 days after President Barack Obama’s re-election preserved his signature legislative achievement, the Patient Protection and Aﬀordable Care Act (ACA), his administration reset a deadline for states to take a crucial step toward implementing it. The delay in the wake of the health law’s dramatic aﬃrmation—ﬁrst by the US Supreme Court and then at the polls—is another reminder that the way forward may still encounter obstacles, even if the most serious threat was eliminated on Nov 6. [MORE] [PDF]

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By Susan Jaffe November 15th, 2012 KAISER HEALTH NEWS

Health care providers who appealed to Medicare judges won more often than patients did, according to a report by the inspector general at the U. S. Department of Health and Human Services.

Hospitals, physicians, medical equipment suppliers and other providers also filed 85 percent of the cases decided by the administrative law judges in fiscal year 2010. Some providers get plenty of practice, with 96 “frequent filers” responsible for one-third of the 40,682 appeals submitted to the judges, the IG found. [MORE]