Category Archives: Health

Medicare Part D: A First Look at Prescription Drug Plans in 2020

December 24, 2019

courtesy of NAELA eBulletin:

During the Medicare open enrollment period  from October 15 to December 7 each year, beneficiaries can enroll in a plan that provides Part D drug coverage, either a stand-alone prescription drug plan (PDP) as a supplement to traditional Medicare, or a Medicare Advantage prescription drug plan (MA-PD), which covers all Medicare benefits, including drugs.

Click here for the entire article and the issue brief

Medicare Premiums to Increase By Almost $10 a Month in 2020

December 24, 2019

After small or no increases the past couple in of years, Medicare’s Part B premium will rise sharply 2020. The basic monthly premium will increase $9.10, from $135.50 a month to $144.60.

The Centers for Medicare and Medicaid Services (CMS) announced the premium increase on November 8, 2019. Not everyone will pay the whole increase, however. Due to a “hold harmless” rule around 70 percent of Medicare recipients’ premiums will not increase more than Social Security benefits, and Social Security benefits are increasing only 1.6 percent in 2020. This “hold harmless” provision does not apply to about 30 percent of Medicare beneficiaries: those enrolled in Medicare but who are not yet receiving Social Security, new Medicare beneficiaries, seniors earning more than $87,000 a year, and “dual eligibles” who get both Medicare and Medicaid benefits.

Meanwhile, the Part B deductible will go from $185 to $198 in 2020, while the Part A deductible will go up by $44, to $1,408. For beneficiaries receiving skilled care in a nursing home, Medicare’s coinsurance for days 21-100 will increase from $170.50 to $176. Medicare coverage ends after day 100. CMS attributed the sudden steep rise in Part B premiums and deductibles on the increased costs of physician-administered drugs.

Here are all the new Medicare payment figures:

  • Part B premium: $144.60 (was $135.50)
  • Part B deductible: $198 (was $185)
  • Part A deductible: $1,408 (was $1,364)
  • Co-payment for hospital stay days 61-90: $352/day (was $341)
  • Co-payment for hospital stay days 91 and beyond: $704/day (was $682)
  • Skilled nursing facility co-payment, days 21-100: $176/day (was $170.50)

So-called “Medigap” policies can cover some of these costs.

Premiums for higher-income beneficiaries ($87,000 and above) are as follows:

  • Individuals with annual incomes between $87,000 and $109,000 and married couples with annual incomes between $174,000 and $218,000 will pay a monthly premium of $202.40.
  • Individuals with annual incomes between $109,000 and $136,000 and married couples with annual incomes between $218,000 and $272,000 will pay a monthly premium of $289.20.
  • Individuals with annual incomes between $136,000 and $163,000 and married couples with annual incomes between $272,000 and $326,000 will pay a monthly premium of $376.00.
  • Individuals with annual incomes above $163,000 and less than $500,000 and married couples with annual incomes above $326,000 and less than $750,000 will pay a monthly premium of $462.70.
  • Individuals with annual incomes above $500,000 and married couples with annual incomes above $750,000 will pay a monthly premium of $491.60.

Rates differ for beneficiaries who are married but file a separate tax return from their spouse. Those with incomes greater than $87,000 and less than $413,000 will pay a monthly premium of $462.70. Those with incomes greater than $413,000 will pay a monthly premium of $491.60.

The Social Security Administration uses the income reported two years ago to determine a Part B beneficiary’s premiums. So the income reported on a beneficiary’s 2018 tax return is used to determine whether the beneficiary must pay a higher monthly Part B premium in 2020. Income is calculated by taking a beneficiary’s adjusted gross income and adding back in some normally excluded income, such as tax-exempt interest, U.S. savings bond interest used to pay tuition, and certain income from foreign sources. This is called modified adjusted gross income (MAGI). If a beneficiary’s MAGI decreased significantly in the past two years, she may request that information from more recent years be used to calculate the premium. You can also request to reverse a surcharge if your income changes.

Those who enroll in Medicare Advantage plans may have different cost-sharing arrangements. CMS estimates that the Medicare Advantage average monthly premium will decrease by 14 percent in 2020, from an average of $26.87 in 2019 to $23 in 2020.

For Medicare’s press release announcing the new premium and deductible amounts, click here.

Home Care Costs Rise Sharply in Annual Long-Term Care Cost Survey

December 24, 2019

When it comes to long-term care costs, the charges for home care are now rising faster than those for nursing home care, according to Genworth’s 2019 Cost of Care survey. In the past year, the median annual cost for home health aides rose 4.55 percent to $52,624, while the median cost of a private nursing home room rose only 1.82 percent to $102,200.

Genworth reports that the median cost of a semi-private room in a nursing home is $90,155, up 0.96 percent from 2018, and the median cost of assisted living facilities rose 1.28 percent, to $4,051 a month. But home care services had sharper increases. The national median annual rate for the services of a home health aide rose from $22 to $23 an hour, and the cost of adult day care, which provides support services in a protective setting during part of the day, rose from $72 to $75 a day, up 4.17 percent annually.

Alaska continues to be the costliest state for nursing home care by far, with the median annual cost of a private nursing home room totaling $362,628. Oklahoma again was found to be the most affordable state, with a median annual cost of a private room of $67,525.

The 2019 survey, conducted by CareScout for the sixteenth straight year, was based on responses from more than 15,178 nursing homes, assisted living facilities, adult day health facilities and home care providers. Survey respondents were contacted by phone during May and June 2019.

As the survey indicates, long-term care is growing ever more expensive. Contact your elder law attorney to learn how you can protect some or all of your family’s assets from being swallowed up by these rising costs.

For more on Genworth’s 2019 Cost of Care Survey, including costs for your state, click here.

For Seniors, Financial Woes Can Be Forerunner to Alzheimer’s

November 18, 2019

courtesy of NAELAeBulletin:

By Deborah DiSesa Hirsch
HealthDay Reporter
TUESDAY, Oct. 29, 2019 (HealthDay News) — Unpaid bills, overdrawn accounts, dwindling investments: When seniors begin experiencing fiscal troubles, early dementia or Alzheimer’s disease could be an underlying cause, researchers say.In the early stages of the disease, people with undiagnosed Alzheimer’s are at high risk of making foolish and dangerous decisions about their finances, mostly because families may not know they need help, researchers say.

“Individuals often aren’t diagnosed early enough, and it’s a perfect storm,” said study author Carole Gresenz, a professor of health systems administration at Georgetown University in Washington, D.C.

“They’re vulnerable to large reductions in liquid assets because they’re not making wise decisions about their finances, savings and checking accounts. This can also reduce net wealth,” added Gresenz.

Ruth Drew, director of information and support services for the Alzheimer’s Association, pointed out that Alzheimer’s destroys the brain.

“As the disease progresses, everyone with Alzheimer’s will reach a point where they need help with their finances and ultimately assistance with daily tasks and around-the-clock care. We have certainly spoken to people whose finances were significantly affected,” she said.

In some cases, people responsible for making major financial decisions, either at work or at home, were unaware of their own mental decline, added Drew, who wasn’t involved with the study.

“Others around them either did not notice or did not feel they could alert the family until there was already significant financial impact,” she said. “By the time we met them, family members were facing the challenges of caring for a person with far fewer financial resources than expected.”

The new study linked Medicare fee-for-service claims data and the national Health and Retirement Study of Americans over the age of 50 for the years 1992 to 2014. The health and retirement study included questions about households’ financial assets and liabilities.

The sample included nearly 8,900 U.S. households, of which nearly 2,800 included someone with Alzheimer’s or related dementia. In these households, the financial “head of the household” had the thinking disorder in 73% of them.

Gresenz said declining financial skills associated with Alzheimer’s may mean unpaid bills, overspending on credit cards or paying too little attention to investments and other forms of wealth. Impaired money sense also makes the elderly more vulnerable to fraud and scams.

The bottom line: “Living in a house with early-stage AD puts both the patient and family members at heightened risk of a large reduction in liquid assets — money that’s easily accessible, like checking, savings, money markets, bonds and stocks,” Gresenz explained. “One reason this is so concerning is that these core financial outcomes are occurring just prior to a time when they will have substantial costs placed on them.”

Alzheimer’s costs $341,000 on average from diagnosis to death, the Alzheimer’s Association says. Families pay 70% of this out of pocket.

Alzheimer’s disease affects 5.5 million people in the United States and 50 million worldwide, the researchers noted. As the U.S. population ages, prevalence of Alzheimer’s will rise, with a near tripling by 2050, they said.

Gresenz said families need to be involved as early as possible.

“It’s always a good idea to check in on loved ones and make sure that the vital financial activities of the household bills are happening, maybe checking credit scores. Even if there are not yet any obvious signs, making sure there’s a safety net,” she said.

“There’s also a role for financial institutions, which could play an important part in protecting elderly individuals,” Gresenz added.

Drew said that when it comes to Alzheimer’s and dementia, it’s never too early to put plans in place.

To older adults themselves, Drew said, “Talk to your financial planner early. When you’re setting up financial plans, put in provisions that say who the trusted people are in your life.” That way, if you start to show symptoms of mental decline, “your banker or financial planner will know who those trusted people are, and will have the paperwork that authorizes them to share their concerns.”

The study was published Oct. 25 in the journal Health Economics.

Researchers find high-intensity exercise improves memory in seniors

November 18, 2019

courtesy of NAELAeBulletin: 

Researchers at McMaster University who examine the impact of exercise on the brain have found that high-intensity workouts improve memory in older adults.

The study, published in the journal Applied Physiology, Nutrition and Metabolism, has widespread implications for treating dementia, a catastrophic disease that affects approximately half a million Canadians and is expected to rise dramatically over the next decade.

Researchers suggest that intensity is critical. Seniors who exercised using short, bursts of activity saw an improvement of up to 30% in memory performance while participants who worked out moderately saw no improvement, on average.

“There is urgent need for interventions that reduce dementia risk in healthy older adults. Only recently have we begun to appreciate the role that lifestyle plays, and the greatest modifying risk factor of all is physical activity,” says Jennifer Heisz, an associate professor in the Department of Kinesiology at McMaster University and lead author of the study.

“This work will help to inform the public on exercise prescriptions for brain health so they know exactly what types of exercises boost memory and keep dementia at bay,” she says.

For the study, researchers recruited dozens of sedentary but otherwise healthy older adults between the ages of 60 and 88 who were monitored over a 12-week period and participated in three sessions per week. Some performed high-intensity interval training (HIIT) or moderate-intensity continuous training (MICT) while a separate control group engaged in stretching only.

The HIIT protocol included four sets of high-intensity exercise on a treadmill for four minutes, followed by a recovery period. The MICT protocol included one set of moderate-intensity aerobic exercise for nearly 50 minutes.

To capture exercise-related improvements in memory, researchers used a specific test that taps into the function of the newborn neurons generated by exercise which are more active than mature ones and are ideal for forming new connections and creating new memories.

They found older adults in the HIIT group had a substantial increase in high-interference memory compared to the MICT or control groups. This form of memory allows us to distinguish one car from another of the same make or model, for example.

Researchers also found that improvements in fitness levels directly correlated with improvement in memory performance.

“It’s never too late to get the brain health benefits of being physically active, but if you are starting late and want to see results fast, our research suggests you may need to increase the intensity of your exercise,” says Heisz.

She cautions that it is important to tailor exercise to current fitness levels, but adding intensity can be as simple as adding hills to a daily walk or increasing pace between street lamps.

“Exercise is a promising intervention for delaying the onset of dementia. However, guidelines for effective prevention do not exist. Our hope is this research will help form those guidelines.”

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This work builds on earlier research from Heisz’s lab that found physical inactivity contributes to dementia risk as much as genetics.

Changes associated with Alzheimer’s disease detectable in blood samples

November 18, 2019

courtesy of NAELAeBulletin:

Researchers have discovered new changes in blood samples associated with Alzheimer’s disease. A new international study was conducted on disease-discordant Finnish twin pairs: one sibling suffering from Alzheimer’s disease and the other being cognitively healthy. The researchers utilised the latest genome-wide methods to examine the twins’ blood samples for any disease-related differences in epigenetic marks which are sensitive to changes in environmental factors. These differences between the siblings were discovered in multiple different genomic regions.

Development of the late-onset form of Alzheimer’s disease is affected by both genetic and environmental factors including lifestyle. Different environmental factors can alter function of the genes associated with the disease by modifying their epigenetic regulation, e.g. by influencing the bond formation of methyl groups in the DNA’s regulatory regions which control function of the genes.

By measuring methylation levels in the DNA isolated from the Finnish twins’ blood samples, the researchers discovered epigenetic marks which were associated with Alzheimer’s disease in multiple different genomic regions. One of the marks appeared stronger also in the brain samples of the patients suffering from Alzheimer’s disease. The link between this mark and Alzheimer’s disease was confirmed in the Swedish twin cohorts.

The researchers observed that the strength of the mark was influenced not only by the disease, but also age, gender and APOE genotype, which is known to associate with the risk of developing Alzheimer’s disease. Furthermore, the mark was stronger in those twins with Alzheimer’s disease who had been smoking.

The function of the gene where the mark is located is still not well understood. The gene product is suspected to inhibit activity of certain brain enzymes that edit the code translated from DNA to direct the formation of proteins. In a previous study conducted on mice, it was noticed that removing this genomic region caused learning and memory problems which are central symptoms of Alzheimer’s disease.

One of the leaders of the research group, Docent at the University of Turku, Riikka Lund explains that even though the results offer new information about the molecular mechanisms of Alzheimer’s disease, more research is needed on whether the discovered epigenetic marks could be utilized in diagnostics.

“The challenges of utilizing these marks include for example the variation of the DNA methylation level between individuals. More research is also needed to clarify potential impact of the marks on disease mechanisms and to identify the brain regions and cell types affected,” Lund says.

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The study was conducted in cross-disciplinary and international collaboration between the researches at University of Turku, Hospital District of Southwest Finland, University of Helsinki, Aalto University, Karolinska Institutet, Jönköping University, and University of Southern California. The research results have been published in the esteemed journal Clinical Epigenetics.

Original publication: Mikko Konki, Maia Malonzo M, Ida K. Karlsson, Noora Lindgren, Bishwa Ghimire, Johannes Smolander, Noora M. Scheinin, Miina Ollikainen, Asta Laiho, Laura L. Elo, Tapio Lönnberg, Matias Röyttä, Nancy L. Pedersen, Jaakko Kaprio, Harri Lähdesmäki, Juha O. Rinne, Riikka J. Lund. Peripheral blood DNA methylation differences in twin pairs discordant for Alzheimer’s disease. Clinical Epigenetics. 2019 September 2;11(1):130. https://dx.doi.org/10.1186/s13148-019-0729-7

Medicare would cover dental and vision if these bills pass Congress

November 18, 2019

courtesy NAELAeBulletin:

by Sarah O’Brien

  • Right now, Medicare’s 60 million beneficiaries can only get dental, vision and hearing coverage through supplemental options such as Advantage plans or standalone insurance policies.
  • Original Medicare — Part A hospital coverage and Part B outpatient care — excludes those services except in limited circumstances.
  • Allowing Medicare to negotiate with drugmakers as outlined in one of the bills would save the government $345 billion from 2023 through 2029, according to an estimate from the Congressional Budget Office.

Medicare beneficiaries would get dental, vision and hearing coverage if several bills now before Congress pass.

In addition, the government would get authority to negotiate prices with drugmakers and create a cap for Medicare out-of-pocket spending on prescription drugs. All have cleared the necessary committees over the last couple of weeks and now await full House action.

“There have been proposals over the years that would do this, but in the past they haven’t gone anywhere,” said David Lipschutz, associate director at the Center for Medicare Advocacy. “It looks like this time something could get passed in at least one chamber of Congress.”

The bills (summarized further below) are generally supported by Democrats and opposed by Republicans. This means that even if the measures get approved in the Democrat-controlled House, they would would face an uphill battle in the Republican-dominated Senate.

Roughly 10,000 baby boomers turn 65 each day and can sign up for Medicare. While the program’s 60 million beneficiaries can access dental, vision and hearing through supplemental options such as Advantage plans or standalone insurance policies, original Medicare — Part A hospital coverage and Part B outpatient coverage — excludes them except in limited circumstances.

Some of the Advantage plans now include comprehensive dental coverage as part of the plan or as an optional supplemental benefit, said Elizabeth Gavino, founder of Lewin & Gavino in New York and an independent broker and general agent for Medicare plans.

However, those benefits also might be limited to the carrier’s dental network or require prior authorization that the treatment is medically necessary, Gavino said.

H.R. 3: Includes provisions to allow the Medicare program to negotiate with drugmakers, cap out-of-pocket spending by beneficiaries on prescriptions at $2,000 and expand the low-income subsidy program, which helps cover Part D premiums and out-of-pocket costs.

H.R. 4650: Would add preventive and screening dental services, including oral exams and cleanings under Part B. It would also cover procedures such as tooth restorations and extractions, bridges, crowns, root canal treatments and implants and dentures. Beneficiaries would chip in the standard 20% for basic treatments and 50% for major treatments.

H.R. 4665: Would add routine eye exams to coverage through Part B, with beneficiaries generally paying 20% of the cost. It also would provide some coverage — $100 — toward contact lenses or eye glasses.

H.R. 4618: Would provide coverage under Part B for hearing exams and hearing aids, with beneficiaries contributing 20%.

This expanded coverage also might come with a cost. While some Advantage plans have no premium, the average is expected to be $23 in 2020, according to the Kaiser Family Foundation. Although down from $27 this year, any amount paid for a premium is on top of what Medicare enrollees pay for Part B: $135.50 is the standard for 2019 and forecast to be $144.30 next year. (Higher earners pay more).

Roughly 22.2 million, or 37%, of Medicare beneficiaries have Advantage plans. The remainder stick with original Medicare, which they can pair with a supplemental policy (i.e., Medigap) and a standalone Part D plan for prescription drug coverage (which also is typically included with Advantage plans).

“The majority of people on Medicare still choose to be in [original] Medicare, so having an expansion of benefits would accrue to everyone,” Lipschutz said. “It would be a significant improvement to the program and fill holes that have been there since its inception.”

The Congressional Budget Office has not yet released an estimate on how the three bills that expand benefits would impact Medicare’s budget. It did, however, offer a preliminary estimate of $345 billion in government savings from 2023 through 2029 if negotiating with drugmakers were allowed under the fourth bill.

At the same time, though, the budget office report notes the bill’s negative effects may include reduced spending on research and development.

In 2018, Medicare spent about $740 billion on 59.9 million beneficiaries through its hospital, outpatient care and prescription drug benefits, according to the latest report from the program’s trustees.

Total Medicare costs are expected to rise to 5.9% of gross domestic product by 2038, up from 3.7% in 2018, the report says. The more immediate concern among opponents of the measures now headed for a possible House vote is that the trust fund for Part A (hospital coverage) is anticipated to be depleted in 2026 unless Congress acts before then. At that point, the program would be able to fund 89% of promised Part A benefits, the trustees report says.

“We are … considering four bills that expand Medicare benefits as this important program is facing bankruptcy and have no responsible way to pay for them,” said Kevin Brady, R-Texas, in his opening remarks during a hearing on the bills in a recent House Ways and Means Committee, where he is the lead Republican.

Don’t Let Medicare Open Enrollment Go By Without Reassessing Your Options

November 18, 2019

Medicare’s Open Enrollment Period, during which you can freely enroll in or switch plans, runs from October 15 to December 7. Don’t let this period slip by without shopping around to see whether your current choices are the best ones for you.

During this period you may enroll in a Medicare Part D (prescription drug) plan or, if you currently have a plan, you may change plans. In addition, during the seven-week period you can return to traditional Medicare (Parts A and B) from a Medicare Advantage (Part C, managed care) plan, enroll in a Medicare Advantage plan, or change Advantage plans. Beneficiaries can go to www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to make changes in their Medicare prescription drug and health plan coverage.

According to the New York Times, few Medicare beneficiaries take advantage of open enrollment, but of those that do, nearly half cut their premiums by at least 5 percent. Even beneficiaries who have been satisfied with their plans in 2019 should review their choices for 2020, as both premiums and plan coverage can fluctuate from year to year. Are the doctors you use still part of your Medicare Advantage plan’s provider network? Have any of the prescriptions you take been dropped from your prescription plan’s list of covered drugs (the “formulary”)? Could you save money with the same coverage by switching to a different plan?

For answers to questions like these, carefully look over the plan’s “Annual Notice of Change” letter to you. Prescription drug plans can change their premiums, deductibles, the list of drugs they cover, and their plan rules for covered drugs, exceptions, and appeals. Medicare Advantage plans can change their benefit packages, as well as their provider networks.

Remember that fraud perpetrators will inevitably use the Open Enrollment Period to try to gain access to individuals’ personal financial information. Medicare beneficiaries should never give their personal information out to anyone making unsolicited phone calls selling Medicare-related products or services or showing up on their doorstep uninvited. If you think you’ve been a victim of fraud or identity theft, contact Medicare.

Here are more resources for navigating the Open Enrollment Period:

  • Medicare Plan Finder, which helps you find a plan to match your needs: www.medicare.gov/find-a-plan
  • Medicare coverage options: https://www.medicare.gov/medicarecoverageoptions/
  • The 2020 Medicare & You handbook, which all Medicare beneficiaries should have received. The handbook can also be downloaded online at: medicare.gov/forms-help-resources/medicare-you-handbook/download-medicare-you-in-different-formats
  • The Medicare Rights Center: www.medicareinteractive.org
    Your State Health Insurance Assistance Program, which offers independent counseling: https://www.shiptacenter.org

House Calls Provide Better Care and Save Money. Why Don’t More Use Them?

October 8, 2019

Only a fraction of older adults eligible for home-based primary care are being served
By  Beth Baker  September 13, 2019

Margaret Birt, then 62, had routine surgery in 2006. But in the recovery room, she had complete cardiac arrest. Initially in a vegetative state, Birt regained much of her cognition. Her life, however, was never the same. She was left with no physical capabilities, needing constant care.

Rather than ending up in a nursing home, though, Birt lives at home in Wheaton, Ill. with her husband, Maurice. She receives primary medical care there, covered by Medicare, from Dr. Thomas Cornwell and his team at Northwestern HomeCare Physicians. They perform exams, chest x-rays and blood draws — all in the comfort of Birt’s home. “We’re very fortunate,” says her husband. Cornwell is also CEO of the Home Centered Care Institute, dedicated to mentoring and training home-based providers.

In addition to her Medicare-covered primary care, Margaret Birt requires 24-hour help from caregivers that the couple must pay for out-of-pocket. Without the generous long-term care policy purchased years ago, Maurice Birt says, he would be bankrupt.

House Calls: A Cost-Saving Measure

“Home-based primary care focuses first on a vulnerable and disenfranchised population, often older adults with multiple chronic conditions who also experience problems with basic activities of daily living [such as walking or dressing],” says Dr. Bruce Leff, director of The Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine. “They are what payers refer to as ‘high need, high cost.’”

Prior to January 1, 2019, health providers had to document the medical necessity for why a house call was needed instead of an office visit. Medicare has since eliminated this requirement. Now it is at the provider’s discretion where a patient is seen, explains Cornwell.

“The main difference is house calls could not be done prior to this year for the convenience of patients who could easily get to the office. Now they can. Having said this, most house call programs have as their mission to serve patients who otherwise cannot get to a provider’s office,” notes Cornwell.

It may seem counter-intuitive, but giving these vulnerable patients individualized primary care at home saves money for the nation’s health care system, according to studies by Department of Veterans Affairs and the Centers for Medicare and Medicaid Services (CMS), among others.

“Now there is strong evidence that home-based care results in better care outcomes and better experience of care by patients and by caregivers, who often have a lot put upon them,” says Leff, who is working with colleagues to develop quality standards for home-based primary care. “It also has a pretty robust effect on reducing health care costs.”

The John A. Hartford Foundation (a Next Avenue funder) awarded Leff and colleague Dr. Christine Ritchie, in partnership with the Home Centered Care Institute and the American Academy of Home Care Medicine, a $1.5 million grant to foster and expand home-based primary care.

“What we’re focusing on is a population who is really in need,” says Brent Feorene, executive director of the American Academy of Home Care Medicine. “Even if the adult son could get mom to the doctor’s office, the average primary care practice is not equipped to handle the patients. The doctors don’t have time, and often [the patients] have psychosocial issues.”

Patients with dementia may experience fear and anxiety at a doctor’s office, for example, and be disruptive to others in the waiting room.

At least 2 million older adults would benefit from home-based primary care, according to Health Affairs. Because these patients have difficulty getting to an office visit, they frequently end up in emergency rooms or hospitals. Per-patient savings range from $1,000 to $4,000 annually through reduced hospital and nursing home stays, emergency room trips and specialist visits, according to research cited by the American Academy of Home Care Medicine.

According to the American Academy of Home Care Medicine, the CMS Independence at Home Demonstration, part of the Affordable Care Act, estimated that Medicare would save $10 to $15 billion total over a 10-year period if home-based primary care were extended nationally to those on Medicare who are homebound.

Benefits to Patients and Families

For patients with chronic conditions, in addition to the convenience of home-based primary care, “The biggest benefit is that the care is very well coordinated,” says Dr. Zia Agha, chief medical officer of West Health, a research and policy center focused on improving care delivery to older adults.

“You have a team of providers who are working together to provide services to you. There is a tremendous emphasis on delivering palliative care. We see a lot of these patients where mom used to be in the ER or hospital ten times a year, and now she has not had a single hospital admission,” says Agha. “That is the biggest advantage, to be helped at home and have the right care to allow them to have quality of life, and not be on aggressive medical services.”

Geriatrician Dr. Carla Perissinotto, medical director of UCSF Care at Home at the University of California, San Francisco, stresses that home-based primary care is person-centered by definition. “When you are in someone’s home, you [as the doctor] are not the center, it is the person,” she says. “It is on their territory. You have to be comfortable with a change in the dynamic.”

For example, she says, “In the clinician’s office, you very clearly know as a patient where you’re supposed to sit. When I go into someone’s home, I wait for them to tell me where to sit.”

She recently had a medical resident ask her what to do about a patient who was stuck in the hospital and becoming increasingly delirious, begging to go home. The hospital did not want to keep him and no nursing home would take him.

“I said, ‘Has anyone thought of taking him home?’” says Perissonotto. “’I can see him at home, we can get home physical therapy. Has anyone applied for in-home support services?’” Two days later, he was back at home where he and his wife have lived happily for 18 months.

“We’re spending billions and no one has asked, what are the barriers to being at home? That’s not rocket science,” Perissinotto says.

“I see this is mostly a high-touch field. But in order to provide quality care, you have to have high-tech capability,” Cornwell adds. “With my smartphone, I can do an EKG within a minute. We have x-ray services, lab services, ultrasound in the home to check things like blood clots in the legs or abdominal pain. I can have more done in the home with smart technology than most can do in the office. It’s having the technology that enables truly quality care.”

Obstacles to Expanding At-Home Care

Despite the growing evidence that home-based primary care is superior in terms of cost and quality for those with complex needs, only a fraction of eligible older adults are being served.

Huge swaths of the country have no home-based primary care, especially in rural areas in Idaho, Montana, the Dakotas and other states.

Most people who are homebound live at least 30 miles from a home-based practitioner. Experts point to two major obstacles: reimbursement and lack of physicians.

Providers of primary care at home, including physicians, nurse practitioners and physician assistants, see roughly six to 10 patients a day, compared to office-based physicians who see up to 25. Providers receive a modest amount more per house call (Medicare pays $10 to $30 extra), which usually does not cover the time spent driving or coordinating the care of these complex patients. In the traditional payment model, this has meant much lower salaries for home-based practitioners (unless they are subsidized by a health system), making it hard to attract doctors to the field.

But that is changing. The fee-for-service model is giving way to value-based payments, a flat-fee per patient for primary care, including home-based. Here, high-quality care is incentivized and more complex cases receive higher reimbursement. In January 2020, providers in 26 regions may voluntarily opt for this method of payment. Medicare also recently eased some of the record-keeping burdens on physicians making house calls by not requiring them to justify every home visit.

Beyond the reimbursement challenges, many doctors barely know of the field’s existence. Residency programs often do not require rotations in home-based medicine or even in geriatrics.

“When I say I’m a geriatrician, I don’t get ‘Wow, you must be brilliant’ like I would if I said ‘I’m a neurosurgeon,’” says Perissinotto. “A lot of it is how we as a society value older adults. And it’s exposure. We have to explain it’s very challenging work and it’s amazing.”

“If you’re going into medicine not with a procedural focus [such as surgery], but to have a relationship with the patient for many years, you find a home in home-care medicine,” says Feorene. “You’re seeing the patient’s surroundings, you get to know the elder’s story. We’re often there in the last three years of life, and we’re making a difference in that final chapter. For those providers looking for a Marcus Welby relationship with the patients, this delivers in spades.”

The field is growing. Feorene’s organization, the American Academy of Home Care Medicine, has 900 members, half of them physicians, one-quarter nurse practitioners and physician assistants and the rest being social workers and nurses.

Nurse practitioners are “flocking to the field,” he says.

To spread the word and develop best practices, the Home Centered Care Institute in 2017 created a national network of Centers of Excellence that includes the Cleveland Clinic, University of California, San Francisco and four others.

Cornwell urges consumers to ask their physicians and health systems to support home-based primary care and the new value-based payment programs.

“It would be wonderful to have a groundswell,” he says.

Beneficiary Advocates Raise Alarms Concerning Roll-Out of New Medicare Plan Finder and Revision of Medicare Marketing Rules

October 8, 2019

Washington, DC ─ Justice in Aging, Medicare Rights Center, Center for Medicare Advocacy and the National Council on Aging sent a joint letter to Seema Verma, Administrator of the Centers for Medicare & Medicaid Services (CMS), on August 27, 2019, urging the agency to address concerns regarding changes to the Medicare Plan Finder (MPF) tool and the 2020 Medicare Communications and Marketing Guidance (MCMG).

The four organizations expressed appreciation for CMS’s efforts to update these resources to better support beneficiary decision-making, while raising concerns that the revisions may instead have the opposite effect. The groups urged CMS to mitigate adverse consequences by closely monitoring the roll out and functionality of the new MPF tool, providing enrollment relief as needed, and by rescinding the updated MCMG in its entirety.

Earlier today, CMS unveiled long-awaited updates to MPF—the federal government’s primary enrollment assistance tool for Medicare Advantage and Part D plans. While the new site includes a number of improvements, the groups are concerned that its late-August launch date may not give third-party assisters, like State Health Insurance Assistance Programs (SHIPs), adequate time to learn the new tool before Fall Open Enrollment begins. And that coupled with recent legislative and regulatory changes set to take effect this year, the truncated MPF launch timeline may generate demand for enrollment assistance that these chronically underfunded programs are unable to meet.  Further, CMS has stated that there will be no back-up system in place or ability to revert to the current “legacy” system during the upcoming Fall Open Enrollment period.

The Medicare Communications and Marketing Guidelines (MCMG) is a set of rules that govern the selling and promotion of Medicare Advantage and Medicare Prescription Drug plans. Revised each year, these guidelines help ensure that people with Medicare have accurate information about a plan’s costs and benefits as well as adequate protections against inappropriate marketing practices. The 2020 revisions, however, effectively disregarded the regular process for stakeholder input and introduce changes that primarily ease the burden on plans and downstream entities while at best doing little to benefit or protect consumers and at worst increasing the likelihood consumers will experience harm.

Apparently in direct conflict with current law, the revised MCMG weaken the distinction between “marketing” events, which are designed to steer or attempt to steer beneficiaries toward a plan or limited set of plans; and “educational” events, which are designed to inform beneficiaries about Medicare Advantage, Prescription Drug, or other Medicare programs. In addition, the revisions removed several disclaimers required of plans, including a short one alerting Spanish speakers of the availability of translations of certain important plan communications. The burden on plans of including the two-line notice was miniscule, but the need to alert limited-English proficient beneficiaries that they can receive help is great.  Further, the revision failed to include provisions outlined in the draft version that would have limited the aggressive marketing of plans referred to as D-SNP look-alikes. These Medicare Advantage plans, which are not subject to the oversight that CMS and states impose on plans designed to serve the complex needs of dual eligibles (people with both Medicare and Medicaid), are being marketed almost exclusively to this population. CMS has itself identified this marketing as a significant problem but abandoned its proposal to address its concerns in the guidelines.

Kevin Prindiville, Executive Director of Justice in Aging stated: “CMS’s harmful updates to the Marketing Guidelines are a step backward, leaving consumers more vulnerable to aggressive marketing tactics and making it more difficult for them to request important health information in their language. The hasty roll out of plan finder changes will only add to the challenges of this year’s Open Enrollment season.

Judith Stein, Executive Director of the Center for Medicare Advocacy, noted, “The revisions to the Marketing Guidelines cater to Medicare private plans and those who sell them, rather than being in the best interest of Medicare beneficiaries, those who assist them, or in furtherance of an equitable Medicare program. CMS should rescind these changes, and should ensure that beneficiaries are not hindered by a delayed roll out of a completely new Plan Finder format, with no back-up system in place.”

Frederic Riccardi, President of the Medicare Rights Center, stated: “Based on our experience assisting people with Medicare and their families, we know how challenging it can be for beneficiaries to make the best coverage decision for their unique circumstances. CMS must ensure that its tools and resources are developed, distributed and updated in ways that maximally support this decision-making process.”

Read the letter here.