Class-Action Lawsuit Seeks To Let Medicare Patients Appeal Gap in Nursing Home Coverage
By Susan Jaffe | Kaiser Health News | August 12, 2019 | This KHN story also ran on 
and
Medicare paid for Betty Gordon’s knee replacement surgery in March, but the 72-year-old former high school teacher needed a nursing home stay and care at home to recover.
Yet Medicare wouldn’t pay for that. So Gordon is stuck with a $7,000 bill she can’t afford — and, as if that were not bad enough, she can’t appeal.
The reasons Medicare won’t pay have frustrated the Rhode Island woman and many others trapped in the maze of regulations surrounding something called “observation care.”
Patients, like Gordon, receive observation care in the hospital when their doctors think they are too sick to go home but not sick enough to be admitted. They stay overnight or longer, usually in regular hospital rooms, getting some of the same services and treatment (often for the same problems) as an admitted patient….
(Photo courtesy of Betty Gordon)
But observation care is considered an outpatient service under Medicare rules, like a doctor’s appointment or a lab test. Observation patients may have to pay a larger share of the hospital bill than if they were officially admitted to the hospital.Medicare’s nursing home benefit is available only to those admitted to the hospital for three consecutive days. Gordon spent three days in the hospital after her surgery, but because she was getting observation care, that time didn’t count.
There’s another twist: Patients might want to file an appeal, as they can with many other Medicare decisions. But that is not allowed if the dispute involves observation care.
Monday, a trial begins in federal court in Hartford, Conn., where patients who were denied Medicare’s nursing home benefit are hoping to force the government to eliminate that exception. A victory would clear the way for appeals from hundreds of thousands of people. [Continued at Kaiser Health News, Next Avenue or Salon]
Social Security Error Jeopardizes Medicare Coverage For 250,000 Seniors
By Susan Jaffe | Kaiser Health News | June 6, 2019 | This KHN story also ran on 
At least a quarter of a million Medicare beneficiaries may receive bills for as many as five months of premiums they thought they already paid.
But they shouldn’t toss the letter in the garbage. It’s not a scam or a mistake.
Because of what the Social Security Administration calls “a processing error” that occurred in January, it did not deduct premiums from some seniors’ Social Security checks and it didn’t pay the insurance plans.
[Continued at Kaiser Health News or NPR ]
Home Health Care Providers Struggle With State Laws And Medicare Rules As Demand Rises
“We can send prescriptions to the pharmacy, including [for] narcotics,” says Marie Grosh, a geriatric advanced practice nurse practitioner and the owner of a medical house calls practice in a Cleveland suburb. “We can order lab work, x-rays, ultrasounds, EKGs [electrocardiagrams]; interpret them; and treat patients based on that. But we’re just not allowed to order home care—which is absurd.”
By SUSAN JAFFE | Health Affairs | June 2019 | Volume 38, Number 8
When Christine Williams began working as a nurse practitioner some forty years ago in Detroit, Michigan, older adults who couldn’t manage on their own and had no family nearby and no doctor willing to make house calls had few options besides winding up in a nursing home.
Not anymore.
Home check: Nurse practitioner Marie Grosh visits Leroy Zacharias at his home in a Cleveland suburb, He has Parkinson disease, and Grosh says he would be living in a nursing home if he couldn’t get medical care at home. (Photo by Lynn Ischay.)
“The move towards keeping seniors in their homes is a fast-galloping horse here,” says Williams, who settled in Cleveland, Ohio, more than a decade ago. “We don’t have space for them in long-term care [facilities], they don’t want to be in long-term care, and states don’t want to pay for long-term care. And everybody wants to live at home.”
But despite the growing desire for in-home medical care for older adults from nearly all quarters, seniors’ advocates and home health professionals claim that rules set by the Centers for Medicare and Medicaid Services (CMS) along with state regulations have created an obstacle course for the very providers best positioned—and sometimes the only option—to offer that care. [Continued here]
US Planned Parenthood leadership shake-up
Volume 394 Number 10195 27 July 2019
WORLD REPORT Planned Parenthood’s board of directors decided to remove Dr. Leana Wen her after only 8 months, igniting a public debate about how the prominent women’s health-care organisation should best protect a woman’s right to abortion.[Continued here]
US Congress wants to take the surprise out of medical bills
Volume 393 Number 10191 29 June 2019
WORLD REPORT A Texas high school teacher gets an unexpected hospital bill for $110,000 that his health insurance policy doesn’t cover. What can Congress do about it? [Continued here]
Trump administration limits fetal tissue research
Volume 393 Number 10189 15 June 2019
WORLD REPORT The move could threaten medical research advances, say scientists, as acquisition of new fetal tissue for research is substantially hindered. Susan Jaffe reports.
“Many discoveries now in clinical practice and wide research use have come from human fetal tissue”, said Irving Weissman, director of the Stanford Institute for Stem Cell Biology and Regenerative Medicine. “For these, there was—and still is—no substitute for human fetal tissue.”
…Anti-abortion groups praised the new policy, which would “separate federal research funding from the abortion industry”, said Melanie Israel, a research associate at the conservative Heritage Foundation… Yet how the new Trump research policy would reduce abortions is still unclear. “They are conflating pro-life issues and abortion with research”, said Jennifer Zeitzer, public affairs director at the Federation of American Societies for Experimental Biology. “But there’s no evidence that women are getting abortions so they can donate fetal tissue for research.” [Continued here.]
Legal battles over abortion heat up in the USA
Volume 393 Number 10184 11 May 2019
WORLD REPORT Changes to Title X, several legal challenges, and a change to the Supreme Court composition could mean drastic changes for access to abortion in the USA. Susan Jaffe reports.
“We are the department of life…from conception until natural death, through all of our programmes”, US Department of Health and Human Services (HHS) secretary Alex Azar said earlier this year…. The government’s anti-abortion efforts have ignited lawsuits from Maine to California. Eventually, one or more of these cases are expected to reach the Supreme Court. With its newest arrival—Justice Brett Kavanaugh, whose nomination by Trump was championed by abortion opponents—the Supreme Court’s ideological balance has now shifted towards a conservative majority [raising] opponents’ hopes that a sympathetic court will diminish, if not overturn, Roe v. Wade...
Late last week, lawyers for the HHS appealed decisions by two federal court judges in Oregon and Washington state to temporarily halt new administration rules that would limit the information about abortion services that federally funded health-care providers can tell their patients.
“We are fighting back in the courts, we are fighting back in Congress and in state legislatures all across the country”, said Planned Parenthood president Leana Wen, noting that one in four women in the USA will have an abortion in their lifetime. “The public is with us when it comes to defending access to safe legal abortion, which people understand is part of the full spectrum of reproductive health care, which is health care.” [Continued here.]
Doctors arrested in US crackdown on illegal opioids
Volume 393, Number 10182
27 April 2019
WORLD REPORT The multiagency operation hit five states and led to the arrest of 60 people. Perpetrators face up to
50 years’ prison sentence if found guilty. Susan Jaffe reports.
Arrests of 31 doctors, pharmacists, and other health care professionals for allegedly prescribing and distributing illegal opioids affected some 28,000 of their patients. That’s why Department of Justice officials are working with state health departments, the Centers for Disease Control and Prevention and the Department of Health and Human Services to help patients by “… bringing enforcement and [opioid addiction] treatment closer together…than ever before,” says Benjamin Glassman, the US attorney for the southern district of Ohio. [Continued here.]
Scott Gottlieb steps down from US FDA leadership
Volume 393, Number 10176
16 March 2019
WORLD REPORT The announcement came as a surprise, prompting many to ask: Can the US FDA commissioner’s policies continue without him? Susan Jaffe reports.
Unlike some government agencies that can toil peaceably in relative obscurity, the FDA is frequently in the headlines. It is responsible for ensuring the safety of products that account for about 20 cents of every dollar US consumers spend—or US$2·5 trillion annually. …When Gottlieb became commissioner in 2017, the agency had an estimated 1000 vacancies which has now risen to 1400.[Continued here.]
US lawmakers seek cuts in prescription drug prices
Volume 393, Number 10175
9 March 2019
WORLD REPORT A committee brought together Senators and drug company representatives to discuss why drug pricing in the USA is so high, but little progress was made, Susan Jaffe reports.
A much-publicized Trump Administration proposal allows — not requires — pharmaceutical companies to pass large rebates on to Medicare patients. Savings as much as 30 percent for seniors depend on companies’ voluntarily cutting prices but several top drug makers tell Senate committee they can’t promise to do so. [Continued here.]
CMS lost $84M in two years for ineligible nursing home stays
IG investigators said such improper payments are accumulating year after year.
By Susan Jaffe | Modern Healthcare | February 20, 2019
The CMS pays millions of dollars a year to nursing homes for taking care of older adults who don’t qualify for coverage, according to an investigation by HHS’ inspector general.
The IG’s report, released Wednesday, includes steps the CMS should take to fix the problem; but in a written response, CMS Administrator Seema Verma rejected some key recommendations. [Continued here.]
USA sets goal to end the HIV epidemic in a decade
Volume 393, Number 10172
16 February 2019
WORLD REPORT The unexpected announcement in the State of the Union address could set the start of a realistic agenda to end HIV/AIDS in the USA, provided funds are secured. Susan Jaffe reports.
Nearly an hour into his 90 min State of the Union address, President Donald Trump called for a government-run health-care programme “to eliminate the HIV epidemic in the United States within 10 years”.
Although the president has promised to get rid of the Affordable Care Act (ACA) along with its health insurance marketplaces and Medicaid expansion, these and other policies did not appear to dampen his enthusiasm. [Continued here.]
House Drug Price Hearing Takes Aim at Industry
By Susan Jaffe | Contributing Writer | MedPageToday | January 30, 2019
WASHINGTON — Pharmaceutical companies were pummeled during Tuesday’s hearing of the House Committee on Oversight and Reform. The panel’s first hearing of the 116th Congress examined the reasons for rising drug prices and follows committee chairman Elijah Cummings’ (D-Md.) launch of an aggressive investigation into pharmaceutical pricing issues.
“For the past decade I’ve been trying to investigate the actions of drug companies for all sorts of drugs — old and new, generic and brand name,” Cummings said. “We have seen time after time drug companies make money hand over fist by raising the prices of their drugs often without justification…” [Continued at MedPageToday]
NYC guarantees health care to all
Volume 393, Number 10169
26 January 2019
WORLD REPORT The mayor of New York City is not counting on Congress for solutions to its health-care problems, Susan Jaffe reports.
By encouraging patients to seek primary and preventive care instead of more expensive emergency care, city officials expect to save money and keep people healthy.
“From this moment on, in New York City, everyone is guaranteed the right to health care—everyone”, declared New York City Mayor Bill de Blasio as he unveiled his so-called NYC Care plan this month. People who cannot pay or are ineligible for health insurance—including undocumented immigrants—will be able to get the most comprehensive and affordable health coverage in the country, at little or no cost, the mayor said, speaking in both English and Spanish. “This is a way of getting people health care here and now, regardless of what happens on the state or the federal level”. [Continued here.]