Susan Jaffe

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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]

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November 9, 2012, 6:17 pm

By SUSAN JAFFE

Medicare beneficiaries battered by Hurricane Sandy have one fewer problem to worry about: Federal officials have extended the Dec. 7 deadline to enroll in a private medical or drug plan for next year for those still coping with storm damage.

The extra time also applies to any beneficiaries who normally get help from family members or others to sort through dozens of plans, but who have been unable to do so this year because they live in areas affected by the storm. Neither beneficiaries nor those who provide them assistance will be required to prove that they experienced storm damage.

Medicare officials have not set a new deadline but have encouraged beneficiaries to make their decisions soon if possible.[MORE]

More Time to Enroll in Medicare If You Live in Storm Areas

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Susan Jaffe | November 5. 2012 | Kaiser Health News produced in collaboration with

Medicare officials are trying a novel approach during this open enrollment season to gently nudge a half million beneficiaries out of 26 private drug and medical plans that have performed poorly in the past three years. It begins with letters informing seniors they are enrolled in a plan that received low ratings.

The effort marks the first time that Medicare officials have tried to steer beneficiaries away from some private drug and medical plans, while still allowing them to operate. Officials have also warned the plans that they might be canceled in the future. [More] [List of the 26 plans and areas served available here].

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A new law passed in July to strengthen the work of the US Food and Drug Administration may hit some serious barriers to implementation. Susan Jaffe reports from Washington, DC.

WORLD REPORT Volume 380, Issue 9852, Pages 1458 – 1459, 27 October 2012

The massive drug and medical device safety bill that won extraordinary near-unanimous support in the US Congress—despite a budget crisis and a contentious political campaign—is facing major challenges less than 3 months after President Barack Obama signed it into law in July. And in the process, prospects may be fading for additional reforms. [MORE]

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By Susan Jaffe

October 15, 2012, 6:00 AM KAISER HEALTH NEWS

Today, Medicare beneficiaries can begin choosing their drug and medical coverage for 2013, and most seniors are expected to stick with the same policies they have already, despite price changes and a rating system that shows some plans may be better than others. Seniors have been reluctant to change plans, even if there are cheaper or better-rated alternatives, according to recent studies and seniors advocates. Beneficiaries also tend to stay with the same insurers: This year more than a third of those in Medicare Advantage plans, which provide medical and drug coverage, chose policies from just two insurers, UnitedHealthcare or Humana.

The ratings are based on information reported by the plans, from Medicare records, and a yearly survey of some beneficiaries. Participation in the surveys is voluntary and anonymous but insurers are concerned that too many seniors opt out. [more]

Enrollment Season Opens For Medicare Advantage And Drug Plans

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Volume 380, Issue 9848, Pages 1133 – 1134, 29 September 2012

WORLD REPORT Comprehensive domestic health-care reform is one of the top defining issues in the campaign, overshadowing global health. Susan Jaffe reports from Washington, DC.

President Barack Obama and his rival Republican Mitt Romney would agree that the American health-care system is unsustainable, providing some of the world’s most expensive and yet fragmented care. But as they campaign for the presidency, the two candidates offer profoundly different solutions.

“The Affordable Care Act helps make sure you don’t have to worry about going broke just because one of your loved ones gets sick”, said Obama, describing his signature legislative achievement at a recent campaign stop in Colorado. “I don’t think a working mom in Denver should have to wait to get a mammogram just because money is tight”, he continued. “That’s why we passed this law. It was the right thing to do.” [more, as PDF]