Medicare ‘cost-savings’ rules pushing costs onto patients (2013)

[ND-Dem]

I thought this was interesting in light of the Administration's new plans for Medicare:

THE COST OF Medicare, the top driver of runaway entitlement outlays, seems to be stabilizing at last. For the past three years, Medicare inflation has moderated to an annual average of 3.9 percent. But if you look more deeply, a lot of these supposed savings are actually a shift in costs to patients. As Congress and the administration devise new ways to restrain Medicare, this disguised form of rationing is likely to worsen.

I had a vivid glimpse of this trend in my own family this past winter. In late February, my mother, age 99, had a bad fall. She was taken by ambulance to the closest hospital, Mass. General...My mother ended up staying four days. A couple of days in, we got an unpleasant financial surprise. Even though she was placed in the MGH’s maxillofacial inpatient unit, where she got excellent care, my mother was classified as being there “for observation” — meaning that she was considered an outpatient for billing purposes. This meant that the bill — over $20,000 — was coded under the Medicare outpatient category (Part B) with a 20 percent patient co-pay. Being classed as an outpatient also disqualified my mother from any Medicare benefits in a rehab facility or skilled nursing home after she was discharged.

In order to cut costs — actually shift them, partly to hospitals and partly to patients — Medicare applies extreme financial pressure on hospitals to book admissions as outpatients whenever possible. This shifts them from Medicare Part A (the hospital program) to Medicare Part B, which is designed to cover only doctor bills. The hospital gets paid a lot less and the patient gets stuck for a lot more.

"While the big players spend a small fortune to game the system, patients remain in the dark."

Medicare does this through outside, for-profit vendors known as “recovery audit contractors,” who are paid based on how much they save Medicare. They achieve savings by punishing hospitals after the fact if a patient who might have been booked as an outpatient is classified by the admitting doctor as an inpatient. The contractor only gets paid when it overturns a medical decision — which sure seems like a gross conflict of interest.

http://www.bostonglobe.com/opinion/2013/07/18/medicare-disguised-form-rationing/W6sF7dkTW08oGOlSekzlFI/story.html

[virgogal]

1. I'm on Medicare. This info has been around for quite a while.

[ND-Dem]

4. not a one-time thing. point is: the cost-cutting/shifting continues

[MiniMe]

2. This has been known for a while

AARP published something on it which I read. I know when my mom was going through some end of life care in 2013, I made sure that they officially admitted her and not for observation. I don't think the ER docs knew about the rules, but I was happy to tell them. I was lucky, and I didn't end up having a problem, but I was glad that I knew about it and could make sure that they admitted mom as an inpatient.

[ND-Dem]

3. point is: the cost-cutting/shifting continues

[Recursion]

5. It's one of the ways we extended the Trust Fund's life from 2017 to 2032 (nt)

[aint_no_life_nowhere]

6. I recently received bills totalling more than $100,000.00 and Medicare paid zero

meaning I was completely on the hook. It was for the cost of the anti-biotic Ertepentam (Invanz) for my mother administered in the hospital. She received 14 doses through IVs over seven days at more than $9,000 a dose. My mom's doctor prescribed it as a last resort for my mom's infection from the extremely lethal bacterium klepsiella pseudomonas. It's a "super bug" with supposedly a very high mortality rate and my mother had to be isolated from others in the hospitals (nurses and CNAs coming into her room had to wear masks, gloves, and anti-bacterial smocks). Anyway, Medicare sent my mom the summary of benefits and indicated they would pay none of the costs and gave us a certain time to appeal. I called Medicare twice. The first time I called, they could not find the claim according to the claim number. A few weeks later, I called again and asked them to find the claim and to explain why they would pay zero. They finally found my mom's file and said they could not pay because that substance, ertapentam was something they didn't pay for. I asked them why because I needed to find some basis to appeal their decision. We went around and around and around and around for 15 minutes of me asking the idiot on the other end of the phone why Medicare wouldn't pay for this. His answer was because Medicare doesn't pay for this. That was it, over and over. "I understand that medicare doesn't pay for it, but why? Why won't you explain this?" "I have explained it. Medicare won't pay for this because they won't pay for this". I may have been speaking to a paid contractor for all I know, but it was through the 1-800 Medicare phone number.

I asked to talk to a supervisor who was a little less rude and dismissive but he basically said the same thing: Medicare won't explain to the public why they won't pay for this anti-biotic and can only state the reason as they don't pay for this.

I called Tricare For Life (my mom has military insurance through my dad in addition to Medicare). They were like night and day. They talked to me AT LENGTH with utter courtesy. They explained to me that they had recently agreed to pay for the Ertapenam IVs and would send my mother a full explanation. There was a gigantic difference in the way in which they treated the public compared to Medicare, at least in my experience.

[ND-Dem]

8. I'm glad to hear you got some satisfaction (& hopefully some payment?) through Tricare.

[Generic Other]

7. I took my mother out of the hospital when they pulled this on her

They were planning to empty her savings when she had medicare AND Tricare. They did not want to let me take her, but since they had not admitted her, they had no choice. I drove her to a military hospital. They charged her nothing.