1. FAST FACT
In 2008, Medicare private health plans cost taxpayers on average 12.4 percent more than the corresponding cost of care in Original Medicare, with excess subsidies to these plans totaling $8.5 billion, according to a recent Commonwealth Fund report. (The Continuing Costs of Privatization: Extra Payments to Medicare Advantage, (http://www.kintera.org/TR.asp?a=8oICJRMxGfIHLYJ&s=fsKML1MFKgKYL3NOF&m=g…) Commonwealth Fund, September 2008)
2. OIG: OVERSIGHT LACKING FOR DRUG PLAN MARKETING
Part D prescription drug plans regularly fail to abide by guidelines that ensure marketing materials are accurate and understandable, and the Centers for Medicare & Medicaid Services (CMS) is falling short in its oversight of plan marketing materials, according to the Health and Human Services Office of Inspector General (OIG).
CMS established guidelines for materials that promote prescription drug plans (PDP) to ensure that people with Medicare have adequate information about the basic benefits and services, fees and other charges before they decide to enroll.
To help ensure accuracy and expedite the review process for certain marketing materials, CMS provides model documents which are uniform texts with standardized language that include pertinent information. The OIG found that 85 percent of marketing materials used by drug plans failed to meet at least one of CMS's guidelines, ranging from details about benefits, to font size for footnotes. For instance, 79 percent of advertisements that named a specific pharmacy as one that accepted a prescription drug plan neglected to mention that the plan was also accepted at other pharmacies and stores.
Although CMS reviews some marketing materials before they are disseminated, over half of marketing materials (including advertising and formularies) are approved under CMS's "file & use" certification system. In these cases, CMS reviews the materials retrospectively. However, at the time of the OIG's audit, CMS had not yet completed a retrospective review of any file & use submissions to determine whether they had followed the guidelines. The review of the 2006—submissions of marketing materials for 2007 plans--documents was not completed until April 2008, well past the period when these plans were in effect and much too late to protect consumers.
The OIG recommended CMS improve its oversight of marketing materials by revising their model documents and guidelines. Additionally, CMS should conduct more frequent reviews of the file & use marketing materials to ensure that these materials meet guidelines. CMS agreed to all of the OIG's recommendations and noted that it had already taken steps toward improvements.
3. NON-ENGLISH SPEAKING PEOPLE WITH MEDICARE RECEIVE IMPROPER CARE DUE TO LANGUAGE BARRIERS
The Centers for Medicare & Medicaid Services must do more to ensure that people with Medicare have access to interpreters in medical settings, according to a new report by the AARP Public Policy Institute. Language barriers between patients and doctors can result in poor access and quality of care. Lack of care or improper care is especially problematic in the Medicare population, since many people with Medicare have chronic, complex conditions.
Federal law requires that people with limited or no English proficiency have access to interpreter services. The Civil Rights Act, Supreme Court decisions, and a 2000 Executive Order all grant CMS the authority to require that Medicare providers and private Medicare plans provide appropriate interpreter services.
CMS has taken a few steps to ensure that people have access to language services, but can do more, according to the report. For example, AARP recommends that CMS establish demonstration projects that include language access components. Another recommendation calls for reimbursement of interpreter services in Original Medicare. State Medicaid programs can receive federal matching funds for providing interpreter services to enrollees; under current Medicare regulations however, neither hospitals nor doctors are required to provide such services, nor can they seek reimbursement for the services from Medicare.
According to the Office of Management and Budget (OMB), interpreter services would cost about $4.04 per visit through Original Medicare. Further, OMB estimates that any increased cost would likely be offset by savings that would result from fewer emergency room visits, elimination of unnecessary tests, and improved treatment.
AARP also recommends that CMS include questions about access to language services in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, which asks people with Medicare to evaluate their experience with a health care provider. This survey is currently available in only English and Spanish, and AARP recommends administering the survey in more languages.
4. GAO: ASSETS AND INCOME ARE BOTH IMPORTANT IN DETERMINING LOW-INCOME STATUS
A recent Government Accountability Office report shows that most people who are denied Extra Help -- the low-income subsidy for people receiving prescription drug coverage through a private Medicare drug plan -- have incomes above the limits ($15,600 for individuals and $21,000 for couples in 2008), and a much smaller percentage are denied assistance solely because they have assets above the limit ($11,990 for individuals and $23,970 for couples in 2008).
According to the GAO report, both a person's income and assets are considered when determining whether a person with Medicare qualifies for Extra Help, but a person's income is more often the reason why she or he is denied. The report shows that nearly half of applicants in 2006 and over two thirds of applicants in 2007 were denied Extra Help because their incomes alone were over the limit. This is compared to 34 percent of denials in 2006 and 19 percent of denials in 2007 that were attributed to assets only. In 2006, over 2 million people were denied Extra Help and 366,183 people were denied in 2007 because their income and/or assets were too high.
However, those denied Extra Help because their assets were over the threshold were sometimes over the limit by a small amount. In 2006, 3.6 percent of people who applied for Extra Help but were denied because of assets were beyond the threshold by less than $500 and 10.4 percent were beyond the threshold by less than $1,500. In 2007, 5 percent of applicants denied because of assets over the threshold were less than $500 beyond the limit and 12.4 percent were beyond the limit by less than $1,500.
The GAO will issue a second report that compares prescription drug use by people with Extra Help and those who were denied Extra Help because of their assets.
5. CASE FLASH: HOSPICE CARE RIGHTS AND EXTENSIONS OF CARE
Ms. F has Original Medicare Parts A and B. Six months ago, she was diagnosed with a fatal lung disease and her doctor told her that he expected she had less than six months to live. At that point, Ms. F decided that she would prefer to get hospice care to manage her pain and discomfort rather than seek treatment to cure her condition. Ms. F's son is now worried that Ms. F might have exhausted Medicare's hospice coverage, because she has outlived her doctor's initial prognosis, and is now entering her seventh month of hospice care. However, her doctor continues to state that her condition has not improved and that her prognosis has not changed.
Ms. F's son called the Medicare Rights Center hotline because he was concerned that either Ms. F would stop receiving hospice care soon or that she would be billed for the full cost of any hospice care she receives in the future. The counselor explained to Ms. F's son that as long as Ms. F's doctor certifies that she continues to be terminally ill, she is entitled to receive Medicare-covered hospice care for the rest of her life. Ms. F would be responsible only for a small copayment for outpatient prescription drugs and a small coinsurance if she were to receive inpatient respite care.
The counselor added that, going forward, Ms. F's doctor would need to recertify in writing every two months that she continued to qualify for Medicare-covered hospice care. If Ms. F felt comfortable with her current hospice agency, the counselor explained, she could keep receiving care from it for as long as it can still care for her, she continues to live in its service area, and she continues to qualify for the hospice benefit.
