Kaiser Health News reported that nursing home industry groups are cheering Medicare’s move to  increase coverage and payments to nursing home, home care and physical therapy bills for patients.   “For decades Medicare’s guidelines cut off coverage of ”skilled” nursing and home care services if patients weren’t shown to be improving. The care in question might have been physical therapy for stroke victims, home nurse visits for those with Alzheimer’s or post-hospital nursing home care for diabetics. Once their conditions plateaued or started deteriorating, Medicare would stop paying.”

The Obama administration and the Center for Medicare Advocacy agreed to a settlement that would change the rules.  The change doesn’t affect reimbursement for personal care, physical assistance and other “non-skilled” care that accounts for a large portion of home health and nursing home spending.


The Washington Post reported that the average premium for basic Medicare drug coverage will stay the same next year, $30 a month. That’s the third year in a row of little or no change. In addition, Medicare recipients with high prescription costs are saving an average of $629 apiece thanks to a provision of the new health care law that gradually eliminates a coverage gap called the “doughnut hole.”


There have been lots of polls taken about how Americans feel about the Affordable Care Act.  The amazing thing is that a majority of Americans do not approve of the law despite a majority liking most of the provisions of the law.  The easy explanation is that many Americans are misinformed about the law and/or wanted the law to go further (i.e. Medicare for all or public option or universal health care coverage).  A good portion of the opposition to the healthcare law is because Americans want more reform, not less of it.  Polls found that a large number of Americans – including about one-third of Republicans and independents who disagree with the law – oppose it because it does not go far enough to fix healthcare.

Recently Reuters/Ipsos reported on a recent poll that they took on this issue and the results are fascinating.  Strong majorities favor most of what is in the law but 56 percent of people are against the healthcare overhaul in general and 44 percent favor it.

Support for the provisions of the healthcare law was strong:

82 percent favor banning insurance companies from denying coverage to people with pre-existing conditions;

61 percent are in favor of allowing children to stay on their parents’ insurance until age 26;

72 percent back requiring companies with more than 50 employees to provide insurance for their employees.

The Guardian also had an article on the polls and Americans lack of understanding of the health care reform bill.  “Most Americans may not like Obamacare as a whole, but they seem to like it as long as it doesn’t include the mandate. Only 34% of respondents in the CBS poll approved of Obamacare as a whole, but 51% either wanted the bill kept intact or only wanted the mandate eliminated. A Fox News poll similarly discovered that only 40% of Americans favored the healthcare bill as a whole, but 51%, again, wanted to keep either the whole law or most of the law minus the mandate.”

“Yet, only 34% of the general population opposes Obamacare because it goes too far; 13% of Americans asked actually oppose it because it is too timid. When you combine those who oppose it for not going far enough with those who favor it, a majority, 56%, actually wants Obama’s healthcare bill or something more far-reaching.”

“Only 51% of adults in an April 2012 Kaiser poll responded that they had enough information to understand how the law would impact them personally. A March CBS poll gave pretty much the same result. How can Americans judge a healthcare law that will make a difference in lives, if they don’t comprehend how it will?”



Vermont Gov. Peter Shumlin made history earlier this year when he signed into law legislation that would make his state the first state to lay the groundwork for a single payer health care system.  Vermont begins building a single-payer health system that will move many state residents into a publicly financed insurance program and pay hospitals, doctors and other providers a set fee to care for patients.   "Under the plan, single payer coverage will be a right and not a privilege, and will not be connected to employment," he wrote in a recent blog post. "This is groundbreaking. But our success in guaranteeing coverage depends on our ability to control health care costs, so our plan is focused squarely on that goal."

Now, another governor is looking to take advantage of flexibility in Obama’s health care law in order to establish a single payer system in his state. Gov. Brian Schweitzer (D-MT) announced that he will be seeking a waiver to set up his own universal health care system in his state modeled after the single payer Canadian health care system.

Gov. Brian Schweitzer will ask the U.S. government to let Montana set up its own universal health care program.  The popular second-term Democrat would like to create a state-run system that borrows from the program used in Saskatchewan. He said the Canadian province controls cost by negotiating drug prices and limiting non-emergency procedures such as MRIs.

Here are some of the issues involved:

Green Mountain Care would be a state-funded-and-managed insurance pool that would provide near-universal coverage to residents while reducing health care spending.   The law allows for either a completely public system or a public-private venture where the state could contract out some administrative functions to private insurers. Employers with self-insured plans (usually large companies) would be able to keep their current health coverage.

 Supporters say that a single-payer system is friendly to consumers and providers and will help reduce the rate of health-care cost increases. A Commonwealth Fund report concluded that such a system could cut health care spending by 25 percent after it is fully implemented. After adding coverage for the uninsured and expanding other services, including dental care, the system would save Vermont households and employers nearly $200 million in the first year alone. Savings would come primarily from lower administrative expenses, reduced fraud and abuse, greater delivery system integration and malpractice reform. The report also found that the system would create about 3,800 new jobs and increase the state’s total economic output by more than $100 million in 2015.

Dr. David Himmelstein, a professor at the City University of New York’s School of Public Health and a proponent of a national single payer system, said: "If they follow through like they say they would, it would be a fabulous thing, an enormous gift to the nation."

Meanwhile, some single-payer advocates believe that the new system does not go far enough. Himmelstein said that the law should be more explicit about not having copayments and deductibles and make a greater commitment to global budgeting, in which providers pay for a patient’s healthcare with a set fee for the year.


Detroit Free Press had an interesting and informative article about the different coverages that Medicare provides.  Medicare is a federal insurance plan that provides basic coverage for medical care to seniors and people with certain physical disabilities. 
There are different types of Medicare policies. Two are basic plans:

Part A: Coverage for hospital care, limited nursing home stays and some home health care. Most people who have been employed get Part A coverage without having to pay a monthly premium. Recipients, however, do have out-of-pocket expenses, such as co-pays.

Part B: Coverage many seniors purchase from Medicare for other physician and outpatient services, some home health care and some medical equipment. Enrollment typically is automatic once you qualify for Medicare. Recipients pay a monthly premium plus a typical 20% co-pay and other out-of-pocket costs.

In addition to the plans above, you can purchase the following policies from insurance companies on your own:

Part C: Also known as Medicare Advantage, these are plans that usually provide more comprehensive coverage for prescription and generic drugs and sometimes dental and vision care, contributions towards gym memberships and diet-related programs and other care. Medicare Advantage plans include all Part A and B coverage, so you don’t need the two basic plans if you have a Medicare Advantage policy.

Part D: Also known as a stand-alone prescription drug plan, these policies pay for outpatient prescription and generic drug coverage. If you don’t sign up immediately for one of these plans when you reach age 65, you face penalities ranging from a few dollars to more than a $100 a month.

Medigap: Also known as Supplemental Medicare, these plans pay for additional physician and outpatient care services, but often not prescription coverage, necessitating the purchase of a Part D plan. While these plans typically have not required a co-pay, new plans being offered in 2011 are introducing small co-pays such as $2 to $50 for a doctor’s or emergency room visit, a trend likely to continue in the future.



Poll Shows Beneficiaries Largely Unaware of New Measures to Close “Donut Hole”

Medicare’s Part D prescription drug coverage continues to enjoy strong support among the nation’s seniors, with a new survey showing that 84 percent of beneficiaries are satisfied with their coverage and more than 80 percent saying their Part D premiums and co-payments are affordable.

The survey of 1,243 Medicare beneficiaries conducted by KRC Research was commissioned by the Medicare Today coalition, an alliance of more than 400 national and local organizations committed to providing seniors and near-retirees with reliable information on Medicare benefits and program changes.

“The Medicare Part D program continues to defy its doubters,” said Mary R. Grealy, president of the Healthcare Leadership Council and co-chair of Medicare Today. “At its outset, critics said health plans wouldn’t participate in Part D, but today seniors have ample choices of affordable plans. They said the program would cost too much, but the last Medicare trustees report reported costs are 41 percent below initial expectations. And they said seniors would find the program too confusing, but it remains enormously popular.”

In fact, the KRC Research survey found that 94 percent of Medicare beneficiaries say they understand how their plan works and they know how to use it. And, among the beneficiaries who do not have Part D coverage, only six percent said it’s because the program is too complicated.

With the Medicare Part D open season – during which beneficiaries have the ability to move from one coverage plan to another – beginning on November 15 and continuing until the end of the year, the KRC Research survey found that 65 percent of beneficiaries feel no need to shop around for another plan while 31 percent said it is very likely they will compare their current plan’s costs and benefits with available alternatives. This, Ms. Grealy said, indicates that the majority of consumers are finding value in their current prescription drug plans.

Ms. Grealy said the survey research underscores the need for both public and private sectors to continue outreach to the Medicare beneficiary community with information about the Part D program. She noted that only one in five seniors are aware that eligible beneficiaries who have drug spending that places them in the so-called “donut hole” will receive a 50 percent discount on brand-name prescription drugs beginning next year.

“Seniors on limited incomes need to plan their spending and budget their resources and it’s important they know about these changes. Congress and the nation’s pharmaceutical companies have taken significant steps to reduce out-of-pocket spending for these ‘donut hole’ seniors and we need to raise awareness of these changes,” she said. She also stressed that work must continue to reach out to low-income beneficiaries who can receive Medicare prescription drug coverage at little or no cost.

More information on the KRC Research survey can be found at www.medicaretoday.org.

The Honolulu Advertiser had an article about the sentencing of CNA Mark Genetiano  He was
sentenced to only a year in prison and five years of probation for molesting four helpless elderly women in a retirement home. Genetiano pleaded guilty to six counts of third-degree sex assault, admitting that he assaulted two of the victims twice while working at the Kāhala Nui retirement home.

The victims ranged in age from 89 to 92 when the crimes took place in May and June of last
year. All four women suffered from Alzheimer’s disease or dementia and were "mentally defective, mentally incapacitated or physically helpless," prosecutors said.

According to a police report, three of Genetiano’s co-workers reported that he pinched the
patients’ breasts while they were changing clothes or in the bathroom. The co-workers said the women tried to fend him off by waving their arms and yelling at him to stop and that Genetiano laughed at them.  How do you properly compensate someone for that kind of experience?

In a somewhat related article in the Honolulu Advertiser, the authors discuss the lack of liability insurance among nursing homes in Hawaii.  This is common in the vast majority of states including South Carolina.

Industry officials believe as many as half the roughly 500 licensed care homes in Hawai’i don’t carry liability insurance, though no one has reliable data on that.  The percentage probably is much greater among Hawai’i’s unlicensed care homes, which industry leaders estimate number anywhere from a few dozen to close to 500.

Liability insurance protects the insured from claims made by others who suffer injury at the business. The breadth of coverage can vary significantly depending on the terms of the policy. But it also provides an avenue for the injured person to seek redress, particularly if the harm is caused by a hazard at the home or negligence.

Without liability insurance, an injured senior would have no recourse to pursue a claim — short of suing the caregiver, a costly and time-consuming process.  States should require nursing homes who accept taxpayer money through Medicare and Medicaid to carry minimum insurance.  A reasonable number would be $1 million per claim or 20% of gross revenue from Medicaid and Medicare.  There should be a reasonable consensus as to a proper amount.

Oregon, for instance, does not require liability insurance for homes with five or fewer residents, a state spokeswoman said, but facilities with six or more that take Medicaid patients must have coverage. In Washington state, all facilities that take Medicaid clients are required to have liability insurance.

Mandating basic coverage also would nullify the unfair advantage care-home operators without insurance have over all the others, according to Medy De Lara, president-elect of the alliance and a care-home owner for 24 years.  A bare-bones policy costs less than $700 per year for an entire facility.


A friend of mine who is interested in nursing homes sent me a link to Money-Driven Medicine: Patients for Sale.  I have not seen the movie but the trailer looks interesting.

Money-Driven Medicine provides the essential introduction Americans need to become knowledgeable participants in healthcare reform.   Based on Maggie Mahar’s acclaimed book, Money Driven Medicine: The Real Reason Health Care Costs So Much, the film offers a behind-the-scenes look at how our 2.6 trillion dollar a year healthcare system went so terribly wrong and what it will take to fix it.

The U.S. spends twice as much per person on healthcare as the average developed nation, fully one-sixth of our GDP – yet our outcomes, especially for chronic diseases, are very often worse.  The U.S. is the only industrialized nation that has chosen to turn medicine into a largely unregulated, for-profit business. 

In Money-Driven Medicine, Dr. Donald Berwick, president of the Institute for Health Care Improvement, explains: “We get more care, but not better care.” Our fee-for-service system channels resources into the high-tech, high-cost “rescue care” patients need after they become critically ill, while it skimps on the preventive primary care which could keep them out of the hospital in the first place. As a consequence, emergency rooms overflow while family practitioners are becoming an endangered species. Medical students explain that these perverse pay incentives drive them away from primary care into higher-paying specialties.

Medical ethicist Larry Churchill doesn’t mince words: “The current medical care system is not designed to meet the health needs of the population. It is designed to protect the interests of insurance companies, pharmaceutical firms, and to a certain extent organized medicine. It is designed to turn a profit. It is designed to meet the needs of the people in power.”

These businesses comprise the “medical-industrial complex” which has wrested power from physicians, turning healthcare into a commodity and patients into profit centers.   Although many uninsured and underinsured Americans receive too little care, the well-insured often get unnecessary, even risky care. More than two decades of studies by researchers at Dartmouth reveal that one-third of our healthcare dollars are squandered on useless tests and ineffective or unproven procedures no better than the less-costly ones they replace. The studies demonstrate that evidence-based, accountable care would be both more effective and less expensive. 

In Money-Driven Medicine frustrated doctors and outraged patients testify to the tragedies which can happen when profit trumps patients’ needs. Money-Driven Medicine will encourage health professionals and patients to work together to take control of American medicine back from the MBAs.