Medicare

Oct. 1 is a big milestone for the Affordable Care Act.

That’s when open enrollment begins for the ‘‘marketplaces,’’ the insurance exchanges where individuals and small businesses will get health coverage under the 2010 law.

Renard Murray is well aware of the upcoming calendar.

Murray is the regional administrator for the Centers for Medicare & Medicaid Services in both the Atlanta and Dallas (Texas) regions.

He will be in charge of the federally run insurance marketplace in Georgia and six other states in the Southeast. And Murray, who hails from Louisiana, will be working with the exchanges in the Dallas region, which consists of Texas, New Mexico, Louisiana, Arkansas and Oklahoma.

Georgia Health News interviewed Murray recently about the planning for the marketplaces, the public perception of the Affordable Care Act (often known as Obamacare), possible problems with its implementation, and the South’s health challenges.

Q: You’re in charge of the exchanges in two regions now?

A: With the Affordable Care Act, it’s basically region-based. So in the Atlanta region, we are running federally facilitated marketplaces in seven of eight states. The executive person in each region is basically running the marketplace for that region –– open enrollment, quality, and its operational components. I’m running the Atlanta region marketplaces.

I’m supporting the Dallas region as well, but not really leading it. It’s still a lot of work.

Texas has the largest number of uninsured among states with federal facilitated marketplaces, and Florida is second. It keeps us busy. But it’s exciting work, because when you think about the mission of getting the uninsured people insurance that they’ve never had before, it’s keeping us excited. Individuals with pre-existing conditions who were denied coverage can now get coverage. That keeps us excited.

Q: Which states in your region are running their own marketplaces?

A: The only one running its own [in the Atlanta region] is Kentucky –– they have a state-based marketplace. We stand ready and available to provide support, assistance, guidance, recommendations to Kentucky as well, even though they’re operating their own marketplace.

Q: And the Dallas region?

A: The only one in the Dallas region running its own marketplace is New Mexico.

Q: How’s the planning for the marketplaces going?

A: It’s going very well. We’re partnering with our federal partners [such as] the Department of Labor, the Department of Education. They have similar interests in getting people insured. There’s overlap.

The Department of Labor operates the COBRA benefit. Individuals are becoming unemployed, but may not afford COBRA coverage, but they qualify for the marketplace. From the federal perspective, we are working with more than a dozen of our federal partners.

We are also working with stakeholder groups –– the hospital associations, the geriatric associations, the various associations that deal with individuals who might be uninsured. We’re trying to get them to understand what the marketplace is.

We are driving people to our website, Healthcare.gov, which has posters, pamphlets, YouTube videos, self-help things –– things that can educate your constituencies in terms of what the marketplace means. We’re developing it in Spanish as well. We want to reach all populations.

Q: Are you working with health insurance companies as well?

A: This is work we recognize we have to do. We haven’t really started engaging insurance companies directly at the regional level. I’m not saying it hasn’t happened nationally at the headquarters level. Here, we have had several conference calls and trainings already, and I’m sure insurance company members have participated.

We’re trying to get people more interested in becoming [insurance] navigators to ask questions and be informed on what the navigators will be doing. We’re giving stakeholders information on what to expect with education, what the marketplace means. We want to make sure that we’re getting it right. We’re asking stakeholders to give us ideas and information that will help us build this correctly.

Q: Will the information technology to launch the marketplaces in October, or definitely by January, be ready?

A: I would say yes. There’s been a lot of work that has been going on with states. There’s been testing in building that [IT] hub. In addition to that, we’re also developing a network of call centers that can help individuals, so a person can call, speak to a counselor who can help them.

I’m pretty confident that our IT infrastructure is going to be pretty solid so that we’ll be able to facilitate marketplace enrollments beginning October 1.

Q: There’s a lot of confusion among consumers about how this marketplace is going to work –– questions such as: Am I eligible for credits? How is this going to help me? Am I going to lose my insurance?

A: Let me use an analogy for you. Fifteen to 20 years ago, we’d go to a travel agent to take a trip. The travel agent would come up with options, you’d pick a flight, you’d go there, you’d have a good time.

The marketplace will be very similar to the transition of moving from travel agents to Travelocity or the other sites [that offer travel assistance via the Internet]. Individuals who would normally go to insurance companies to shop for insurance will go now into a marketplace.

At a one-stop location, they can decide which health plan is the best option for them. Their children can be eligible for CHIP through the marketplace, or Medicaid. Individuals with incomes less than 400 percent of the federal poverty level will also quality for a tax credit.

It sounds like it’s overwhelming, but nonetheless, it puts at the fingertips of consumers the ability to choose a plan that works the best for them. Just like it did for Medicare Part D. There are gold, silver, bronze, platinum plans –– they can choose which coverage is best for them in the marketplace.

It sounds it may be a little bit overwhelming, but they’ll have more ability to manage my own choice health care, instead of going to an agent.

Q: You mentioned Medicare Part D, the prescription drug benefit that debuted in 2006. There were hiccups when that started. Do you anticipate similar glitches?

A: Yes, there were a few hiccups along the way in Part D, but the good thing is we learned a lot of lessons.

We’re applying those lessons to the marketplace . . . We’re looking at our processes now so when people apply October 1, we have procedures and processes already developed [to help them] based on lessons we learned from Part D.

Q: Many of the states in your regions are not expanding Medicaid programs. How much of a problem will that be?

A: Let’s look at it historically. When the law was signed in the ’60s [establishing] Medicaid, several states said, ‘We’re not going to do Medicaid.’ Maybe less than a handful of states said they weren’t going to do it. Here we are [nearly] 50 years later, and we have Medicaid programs in every state. I can’t predict what states will do, [but] Medicaid expansion may follow the same path.

Q: So you believe states will eventually expand their programs?

A; It depends on the Legislature of a state and what they decide to do. I think states will start to re-examine their options, realize the availability of federal funds, and then decide what’s best for the state, based on whatever the governor and Legislature decides to do.

Q: Many critics of the ACA say it’s too costly for states to expand Medicaid.

A: I can’t speculate what a governor is looking at in terms of cost, because what he or she may be using for analysis may be based on some other types of decision points. On the point of reimbursement for Medicaid expansion, all I can tell you is that in the first three years, we’re looking at 100 percent federal reimbursement. The plan has been laid out in terms of Medicaid reimbursement rates for expansion over the next 10 years.

Governors are making a decision based on what he or she anticipates is going to be the growth of cost of the Medicaid program over that time.

Q: Opponents also question whether the federal government can deliver what it’s promising, given the current budget crunch.

A: I’ll use another analogy. You buy a car, you expect it to last five years with a five-year warranty. You have a major breakdown in the fourth year. The warranty is still there; it hasn’t expired. The regulation [says Medicare expansion] will be 90 percent [federally funded] 10 years down the road, and it will be 90 percent.

Q: You’ve heard a lot of criticism of Obamacare. What are the biggest misconceptions about it?

A: The biggest misconception is people basing their comments and decisions on what they’re hearing from a neighbor or someone else who hasn’t read the regulations and doesn’t know what’s going on. I try to debunk the myths and direct people to Healthcare.gov, the official site.

Don’t base what you’re hearing from a media outlet. Base it on what you’re hearing from the federal government. If you have questions, you can contact the Department of Health and Human Services, the Centers for Medicare and Medicaid Services, or if you have a tax question, contact the IRS. . . . We have a team here at CMS that can address those questions.

Healthcare.gov gives information on not just how the marketplace will work but how the Affordable Care Act itself works, how it affects women, affects seniors, affects Asian-Americans . . .

We also have a mobile app, so that individuals can access [the marketplace] from their smartphones, and people can sign up for information. When the marketplace website is launched, you can access it . . . and start the enrollment process.

Q: The states in your region have physician shortages. There are fears that the ACA will aggravate these shortages.

A: I’m not that concerned about that. I hear the comments and the rhetoric about not having access.

Some of the things we’ve done [include] HRSA, with the Medical Service Corps, looking to expand the availability of primary care positions in medically underserved areas.

In Medicaid, we’re reimbursing primary care physicians at the Medicare rate, enhancing more primary care for Medicaid recipients because we tend to have a gap there.

We’re getting more advanced practice nurses out there.

We’ll see a lot of people hopefully accessing primary care, instead of [going] to the ER . . . We’re developing medical homes that will provide primary care and coordinate care. Medicare is developing accountable care organizations. There’s telemedicine.

I think we’re going to have adequate access to services over the next several years.

Q: The South has many health needs and health disparities, along with high poverty and uninsured rates. How important is the ACA in addressing these problems?

A: It’s extremely important. States in the Southeast are among the highest in uninsured rates.

We’re working on other models. There’s a pilot project taking place in Alabama to focus on heart [care]. A lot of people in Alabama have congestive heart failure. African-Americans as well as [Hispanics], we’re targeting those ethnic groups [so they] get more informed about some things that can help prevent heart attacks and strokes.

Q: Do you hope the ACA will help solve these health problems?

A: It’s not going to be solved, but we’re going to make a tremendous dent in it. A lot of the things we’re focusing on, telling African-Americans, Asian-Americans, this is how the ACA can help you to deal with some of the health issues you’re having.

Each state has an office of minority health. There are connections with those state offices. We’re working with them to deal with some of the health disparities.

Q: Anything else you want to emphasize?

A: Even though the marketplace is upon us, we’re still going to administer the Medicare program, the CHIP program, the Medicaid program. We know the natural connections between those programs.

If you walk around the halls at CMS, you’re probably going to see some pretty exhausted people –– they’re doing both things at once. Nevertheless, we’re excited about the work coming from the Affordable Care Act.

A new group of coaches is coming to the Atlanta area, but their work won’t focus on athletics.

Starting next year, hundreds of Atlanta-area Medicare patients will each be assigned a ‘‘coach’’ to help guide their transition from hospital care to living at home. The goal is to prevent these patients from being readmitted to the hospital within 30 days after they are discharged.

The Atlanta Regional Commission (ARC) and six metro hospitals are participating in the coaching project, called the Community-Based Care Transitions Program. The ARC was selected by federal officials as one of the seven community organizations in the country to take part in the project, and it will receive funds for the coaches as well as providing other services for patients.

“This is a tremendous opportunity, combining the need to cut the cost of care with improving the quality of care,’’ says Cathie Berger, director of the Area Agency on Aging at the ARC.

Coaches will first meet with the Medicare patients in the hospital, and then make home visits after discharge, checking for problems with medication or other issues. If necessary, a coach can arrange for a patient to receive meals and transportation to a doctor’s appointment. Medicare will pay the ARC for these services, Berger says.

The transitions program was created by the federal health reform law of 2010, and is part of the national Partnership for Patients, which aims to reduce hospital readmissions by 20 percent.

A readmission is not only a bad sign for a patient, but it drives up the cost of medical care. And the high number of readmissions nationwide adds up to a huge expense.

While many return trips to the hospital within 30 days are unavoidable, it’s estimated that the avoidable readmissions cost Medicare $17 billion a year.

Georgia is in the middle of the pack among states in hospital readmission figures, Berger says.

Focusing on three types of patients

Despite increased attention to the issue, a Dartmouth Atlas study of Medicare patients found that readmission rates for hospitalizations that didn’t require surgery rose from 15.9 percent in 2004 to 16.1 percent in 2009.

“Lack of coordinated care between hospitals and caretakers such as nursing homes or home health providers can sometimes result in medical complications and costly, potentially avoidable return trips to the hospitals,’’ said Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services.

The six hospitals participating in the Atlanta Care Transitions Program are Emory University Hospital Midtown, Gwinnett Medical Center, Piedmont Hospital, Southern Regional Medical Center, WellStar Cobb Hospital and WellStar Kennestone Hospital.

Nancy Morrison of Sixty Plus, a Piedmont program for older adults and their families, says the Buckhead hospital has focused on post-discharge care of patients for several years. The new program, she says, “will give us a trained, professional coach who will be able to oversee the discharge and will see them in the home.’’

“We’re not reinventing the wheel,’’ she says of the project. “We’re just driving it.’’

The two-year Care Transitions program (if successful, it can be extended  longer) will focus on readmissions from three diagnoses: heart failure, heart attack and pneumonia.

Of the six metro Atlanta hospitals in the program, all performed at the U.S. average for readmissions of such patients except for Piedmont, which was better than the national mark for heart attack and heart failure patients, and WellStar Kennestone, which was worse than the national average on pneumonia patients, according to the Hospital Compare website run by CMS.

There’s a major added incentive for hospitals to perform better in preventing readmissions: Hospitals with high readmission rates will lose up to 1 percent of the Medicare billings starting next October. Those penalties will rise in following years.

Plenty of blame to go around

Reasons for readmission can start at the hospital level, with a discharge that’s done too soon or with inadequate planning, says Dr. Alan Bier, chief medical officer at Gwinnett Medical Center.

Medication problems are another frequent cause of readmission. A patient may not understand how to take a new medication, or may not have had the drug assessed for possible interactions with his or her other prescriptions.

Patients sometimes are at fault. Many don’t see a physician after they are discharged. “Often, people don’t follow up with medical appointments,’’ Berger says. The transitions program will aim ‘‘to get the patient involved in their own health care.’’

Coaching patients properly requires considerable effort, experts say. Just making phone calls to check on discharged patients is not enough to achieve real results, Bier says.

He adds that it’s important for patients to understand the red flags associated with their specific conditions, such as weight gain in heart failure patients. The coaches ‘‘can speak in a lay language’’ that the patients understand, Bier says.

Studies have shown that the help of coaches can reduce return trips to the hospital. The Archives of Internal Medicine published a Rhode Island study recently showing that in cases where a coach performed a hospital visit, a home visit and follow-up phone calls with a patient, the readmission rate was lowered to 12.8 percent, versus a 20 percent rate for a group that did not participate.

Hospitals involved say the coaching program can help them reduce readmissions. “It’s a win-win for both our patients and our organization,’’ says Amanda Bartlett, a spokeswoman for Southern Regional in Riverdale.

The Area Agency on Aging in the Akron/Canton area of Ohio has used transition coaches in a demonstration project as well as with a Medicare Advantage health plan.

The agency is also one of the seven organizations that will launch the program. The coaches are nurses or social workers who receive special training before they begin, said Gary Cook of the Akron/Canton agency.

“We see [discharged patients] in their home, hopefully within 72 hours,’’ Cook says.

“This is a true business solution to reduce Medicare costs,’’ he says.

Hospice Atlanta Chaplain Bob Hauert talks with a patient at the organization's 36-bed inpatient facility. For all the good work that such hospices do, the industry itself is concerned about rogue operators. Photo courtesy of Visiting Nurse/Hospice Atlanta

Care not properly coordinated. Failure to assess quality of care and improve it. Not properly evaluating and supervising health aides’ work.

Those are among the most frequent complaints cited by state regulators against hospice operators in Georgia.

In one case last year, a Fayetteville hospice organization faced having its permit revoked after Georgia regulators flagged the company for the state’s most serious violations — including two that either caused death or serious physical or emotional harm or posed an ”imminent and serious threat’’ to a patient.

Of course, hospice problems are not unique to Georgia. Regulatory issues and concerns about quality of care – some even expressed by industry groups – have continued to come up despite the generally benign public image of hospice care.

Hospice is a welcome choice for families who have a loved one with a terminal illness. It provides emotional support and pain management during a person’s final days, typically in the home. And hospice is a cost-effective alternative to expensive no-holds-barred medical procedures, saving the health care system thousands of dollars in end-of-life care.

As use of hospice has increased — to more than 1 million Americans and 33,000 Georgians a year — so has the number of organizations providing it. Georgia’s licensed hospice providers have doubled in the past 10 years.

The supply of hospices nationally rose 50 percent from 2000 to 2009, with an increase in for-profit businesses driving most of that growth. About 50 percent of hospice providers in the United States are for-profit businesses, but the percentage in Georgia is more like 75 percent, says Jennifer Hale, executive director of the Georgia Hospice and Palliative Care Organization.

Federal officials are monitoring the industry more closely after annual Medicare spending on hospice care quadrupled from 2000 to 2009. It has now surpassed $12 billion a year.

Amid the boom, industry trade groups have made the unusual call for more oversight of hospice providers.

Georgia does not have enough regulatory personnel to monitor the industry adequately, Hale says.  “There is a direct correlation between oversight and quality,’’ she says.

Consumers have no clear way to evaluate the quality of the services provided before picking a hospice, either in Georgia or elsewhere.  Unlike with hospitals and nursing homes, “there is nothing to allow consumers to compare quality,’’ Hale says. full story

Dr. Cody McClatchey, an Atlanta internist, says Medicare beneficiaries already have an access problem to physicians because of low payment rates. Photo courtesy of Piedmont Hospital

More than 80 percent of Georgia AARP members say they’re worried that doctors may stop treating older patients due to an impending Medicare pay cut to physicians, according to a new survey.

The survey of Georgia AARP members was released Thursday as physician groups and seniors gathered at a news conference at Atlanta’s Piedmont Hospital to urge Congress to halt a 25 percent Medicare pay reduction to doctors, scheduled to take effect Jan.  1.

That pay cut would force many physicians to drop out of the Medicare program, said leaders of doctors organizations, who advocated for a 12-month fix to the pay problem.

Inaction by Congress would have ‘’a disastrous effect on patients in Georgia,’’ said Dr. Sandra Reed, president-elect of the Medical Association of Georgia. “Some of our most vulnerable patients will struggle to find a doctor in their hour of need.’’

Medicare, the federal insurance program for people 65 and older and the disabled, covers more than 1 million Georgians, and 47 million people nationally. The program is expected to spend $519 billion this year and balloon to more than $900 billion by 2020. To help curb that spending growth, leaders of a deficit reduction panel are proposing requiring beneficiaries to pay a larger share of Medicare costs.

Costly concerns

The so-called ‘’doc pay fix’’ issue has flared repeatedly in Congress, with reimbursement cuts blocked several times in recent years. The most recent such action was a one-month extension of current rates passed in November. That postponement cost $1 billion over 10 years, and was offset by changes in Medicare reimbursement for outpatient therapy services.

The doctor pay formula stems from a 1997 budget-balancing law that requires physicians’ reimbursement rates from Medicare to be adjusted every year, in order to keep the program fiscally sound.

Physician groups and AARP are pushing for a permanent solution to the pay problem.  To eliminate the doctor pay formula would cost an estimated $250 billion to $300 billion over a decade.

AARP surveyed members in 13 other states about the physician payment issue. Republicans showed greater concern about the doctor pay issue than members of other parties in all those states, said Will Phillips, associate state director for advocacy for AARP Georgia. “Our members need peace of mind in accessing care. They need to know the docs are going to be there for them.’’

The survey of 800 Georgia AARP members aged 60 and older found that worry about doctors dropping out of Medicare cut across party lines – 77 percent of Democrats, 88 percent of Republicans and 80 percent of independents. Conducted in late November, the survey also found 83 percent of Georgia AARP members on Medicare were concerned they would have trouble finding a new doctor if their current physician no longer accepted Medicare.

Grim predictions

Many older Georgians already struggle to find a physician who will accept Medicare patients, said Dr. Harry Strothers, president of the Georgia Academy of Family Physicians. If the Medicare pay cuts are implemented, he said, one of every 10 family physicians ‘’will have to close their practices.’’

Added Dr. Ramon Suarez, past president of the Georgia Obstetrical and Gynecological Society: “Shame on the Congress, shame on the president, for putting access to care for seniors at risk.’’

AARP member Barry Reid, 71, of Tucker says he had a hopeless feeling when his endocrinologist stopped seeing him and other Medicare patients four years ago. “My doctor explained that he would be losing money to see us, ‘’ said Reid, who has diabetes. He said he managed to find another specialist to treat him.

Unless something is done, seniors’ access to physicians will worsen greatly, he said.

Lawmakers in Washington, Reid said, “owe us a solution.’’