Shedding New Light On Hospice Care

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Woman and caregiverEarlier this year, Kathy’s 86-year-old mother was hospitalized in Colorado after a fall. As she rushed to her side, Kathy asked for a consultation with a palliative care nurse.

“I wanted someone to make sure my mother was on the right medications,” Kathy said.

For all her expertise — Kathy Brandt advises end-of-life organizations across the country — she was taken aback when the nurse suggested hospice care for her mother, who has advanced chronic obstructive pulmonary disease, kidney disease and a rapid, irregular heartbeat.

“I was amazed — really?” Kathy said, struggling with shock.

It’s a common reaction. Although hospices now serve more than 1.4 million people a year, this specialized type of care, meant for people with six months or less to live, continues to evoke resistance, fear and misunderstanding.

“The biggest misperception about hospice is that it’s ‘brink-of-death care,’” says Patricia Mehnert, a longtime hospice nurse and interim chief executive officer of TRU Community Care, the first hospice in Colorado.

In fact, hospice care often makes a considerable difference for those with months to live. “When someone is further out from death, we can really focus on enhancing their quality of life,” says Rachel Behrendt, senior vice president of Hospice of the Valley, which serves the Phoenix metropolitan area.

New research confirms that hospice patients report better pain control, more satisfaction with their care and fewer deaths in the hospital or intensive care units than other people with a similar short life expectancy.

What should seniors and their families, the largest users of hospice care, expect? It’s fairly well understood that patients forgo curative therapies in favor of comfort care when they enter hospice. Here are additional features:

Four Levels Of Care

Hospice providers are required to offer routine care in patients’ homes (this includes seniors who reside in assisted living or nursing homes); continuous care at home for people with out-of-control symptoms such as pain or breathing problems; inpatient respite for families that need a break from caring for a loved one; and general inpatient care for medical crises that cannot be handled in any other setting.

With continuous care, a nurse must be on-site in the home for at least eight hours a day, helping to bring symptoms under control. Usually, this will happen in one to three days. Respite care has a maximum limit of five days.

Some hospices have their own general inpatient facilities and “it’s a common misconception that patients are sent to inpatient hospice to die,” says Jean Cohn, clinical manager at Montgomery Hospice’s inpatient facility, Casey House. “In fact, we’re frequently fine-tuning patients’ regimens in inpatient hospice and sending them back home.”

Intermittent Care At Home

Routine care at home is by far the most common service, accounting for about 94 percent of hospice care, according to the latest report from the National Hospice and Palliative Care Organization.

While services vary depending on a patient’s needs, home care typically involves at least one weekly visit from a nurse and a couple of visits from aides for up to 90 minutes. Also, a volunteer may visit, if a patient and family so choose, and social workers and chaplains are available to address practical and spiritual concerns.

Hospices will provide all medications needed to address the underlying illness that is expected to cause the patient’s death, as well as medical equipment such as hospital beds, commodes, wheelchairs, walkers and oxygen. Typically, there is no charge for such gear, although a copay of up to $5 per prescription is allowed.

What families and patients often do not realize: Hospice staff will not be in the home every day, around the clock. “Many people think that hospice will be there all the time, but it does not work that way,” Brandt says. “The family is still the front line for providing day-to-day care.”

In assisted living, patients or their families may have to hire nursing assistants or companions to provide supplemental care, since hands-on help is limited. In nursing homes, aides may visit less often, since more hands-on help is available on-site.

Self-Referrals Are Allowed

Anyone can ask for a consultation with a hospice. “We get many self-referrals, as well as referrals from family and friends,” says Behrendt of Hospice of the Valley. Usually, a nurse will visit and do a preliminary assessment to determine if a person would qualify for hospice services.

To be admitted, two physicians — the patient’s primary care physician and the hospice physician — need to certify that the person’s life expectancy is six months or less, based on the anticipated trajectory of the patient’s underlying illness. And re-certification will be required at regular intervals.

A Person Can Choose Their Physician

A person has a right to keep their primary care physician or they can choose to have a hospice physician be in charge of their medical care.

At JourneyCare, the largest hospice in Illinois, “we prefer that the patient retains their primary care physician because that physician knows them best,” says Dr. Mark Grzeskowiak, vice president of medical services.

These arrangements require close collaboration. For instance, if a nurse observes that a patient with heart failure is experiencing increased shortness of breath, JourneyCare staff will get in touch with that patient’s primary care physician. The physician is responsible for altering the treatment plan; the hospice is responsible for implementing that plan and giving clear instructions to the patient and family.

Concerns About Medications

“There’s a misconception that a person is going to be medicated to a highly sedated state in hospice,” says Dr. Christopher Kerr, chief executive officer and chief medical officer for Hospice Buffalo Inc. in upstate New York. “The reality of our primary goal is to increase quality wakefulness. Managing these medications is an art and we’re highly experienced.”

Family caregivers are on the front line since they are responsible for administering pain medications such as morphine. “Absolutely, there’s a great deal of fear and anxiety around all the issues associated with giving medications,” says Cohn of Montgomery Hospice. “We try to reassure caregivers that the doses we start with are very small, monitor how the patient reacts, and go deliberately slow.”

Because most hospice stays are short — the median length is only 17 days — and because the diversion of painkillers from people’s homes is a risk, doctors have begun writing prescriptions for a week or two at a time, says Judi Lund Person, vice president of regulatory and compliance for the National Hospice and Palliative Care Organization. If concerns exist, hospices can have a lockbox for medications sent to the home.

Discharges Are Possible

Estimating when someone is going to die is an art, not a science, and each year hundreds of thousands of hospice patients live longer than doctors anticipate.

If physicians can document continued decline in these patients — for instance, worsening pain or a noticeable advance in their underlying illness — they might be able to re-certify them for ongoing hospice care. But if the patient is considered stable, they will be discharged, various experts say.

In 2015, nearly 17 percent of hospice patients were so-called live discharges, according to a report from the Medicare Payment Advisory Commission. Two days before a discharge, hospices are required to give the patient or family members a Notice of Medicare Non-Coverage. Expedited appeals of discharge decisions can be lodged with a Medicare quality improvement organization.

There are no regulatory requirements governing what hospices should do to facilitate live discharges. Some hospices will spend weeks helping patients make arrangements to receive medications, medical equipment and ongoing care from other sources. Others offer minimal assistance.

At The Very End

Almost 1 in 8 hospice patients do not get visits from professional staff during their last two days of life, according to a study published in JAMA Internal Medicine last year. And this can leave families without needed support.

Some hospices have responded by creating programs specifically for people who have a very short time left to live. “We’ve put together a special team for people who are expected to live 10 days or less because that requires a different kind of management,” says Ann Mitchell, chief executive officer of Montgomery Hospice. “Instead of a nurse for every 15 patients, a nurse on this team will have five to six patients and a social worker is available seven days a week.”

“One-third of our patients are here for less than seven days and often we receive them in a crisis,” says Kerr of Hospice Buffalo. “We’ve had to re-purpose our services to address the urgency and complexity of these patients’ needs and that means we have to be ever more present.” Across the board, Hospice Buffalo requires that patients be seen within 24 hours of an expected death.

Old-School Pharmacy Hand Delivers Drugs

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Grubbs PharmacyIf House Speaker Paul Ryan comes down with the flu this winter, he and his security detail will not be driving to the closest CVS for Tamiflu, a little-known perk for the powerful members of Congress. 

Instead, he can just walk downstairs and pick up the pills, open to every member of Congress, from Ryan and Majority Leader Mitch McConnell down to the newest freshman Democrat or Republican.

Nearly every day, for at least two decades, pharmaceutical drugs have been brought by the carload to the Capitol — an arrangement so under the radar that even pharmacy lobbyists, who regularly pitch Congress in their industry, are not aware.

The deliveries arrive at the secretive Office of the Attending Physician, an elaborate medical clinic where Navy doctors triage medical emergencies and provide basic health care for lawmakers who pay an annual fee of just over $600. Every medicine comes from Washington’s oldest community pharmacy, Grubb’s.

Mike Kim, the reserved pharmacist-turned-owner of the pharmacy, says he has become familiar with knowing the most sensitive details about some of the most famous people in Washington.

“At first it’s cool, and then I realize, I’m filling prescription drugs that are for some serious health problems (i.e. diabetes and Alzheimers). And these are the people who are running the country,” Kim says.

“It makes me kind of sit back and say, ‘Wow, they’re making the highest laws of the land and they might not even remember what happened yesterday.’

Kim’s tiny pharmacy — which, at its busiest, sends as many as 100 prescriptions to members in a day — is nestled among Capitol Hill’s stateliest row houses, less than four blocks from the Capitol building. Founded in 1867 and named for a previous owner, the pharmacy predates penicillin, the American health insurance system, and even the Lincoln Memorial.

The two-story nostalgic shop, with its bay windows and wood counters, is reminiscent of the past, though the computer systems and supplements inside are not far removed from a typical Walgreen’s or CVS counter — if all the inventory in a pharmacy of today were placed into the nooks and crannies of three small aisles and labeled with individual stickers. At Grubb’s, staff will even scoop Hershey’s ice cream into cones from a small counter in the corner, a modern-day nod to the marble-topped soda fountain once popular with the neighborhood kids.

The pharmacy mostly serves the staffers, lobbyists, and families who make their home in the quiet, leafy neighborhood just east of the Capitol building, though Grubb’s five drivers will deliver prescriptions across the entire city. Some 800 prescriptions leave its doors every day, filled by three dozen pharmacists, technicians, and support staff.

The relationship between Grubb’s and the Capitol has gone nearly unchanged for decades, even as congressional leaders have pushed again and again to overhaul the nation’s broader health care system.

For the most part, lawmakers get the same prescription delivery service as any other customer of Grubb’s. The pharmacy still bills each lawmaker’s insurance plan. Grubb’s keeps credit card information on file for co-pays and other purchases. There are no discounts, Kim says. No special treatment.

“The Capitol takes somewhat of a precedence just because of who we are servicing,” Kim says. “The member might be calling to say, ‘I’m about to leave in five minutes, where’s my drug? So [the clinicians at the Capitol] get into panic mode. I wouldn’t say they’ve ever become frustrated with us, but it’s a concern, ‘Oh my gosh, the member just called asking about their drug.’

Those busy moments are much more prevalent in winter, when lawmakers have been in session for a while and when they might be facing more late-night vote sessions, Kim says. During August recess, the Capitol pharmacy business — like much of Washington’s economy — slows considerably.

Most lawmakers know far more about the Office of the Attending Physician than about Grubb’s or its arrangement with Congress. In a STAT survey of two dozen House and Senate members from both parties, only one knew about the single pharmacy that delivers all their drugs: Congress’s only pharmacist, Rep. Buddy Carter (R-Ga.).

“It’s a great opportunity for us, as pharmacists, to showcase what we do because what we do is take care of patients,” Carter told STAT. “This is another example of how we go above and beyond our call of duty to help people in health care.”

Others were quick to praise the Navy doctors and nurses in the Office of the Attending Physician, which has at least one pharmacist and several technicians on its staff.

Lawmakers describe the Office of the Attending Physician as a modern space much like a regular doctor’s office — though the $3.7 million budget it enjoyed for 2016 suggests a relatively well-furnished space. It’s strictly off-limits to reporters.

The office is not without controversy. Its services — and the relatively low fees that members must pay for access — were thrust into a harsh spotlight in 2009, as Congress began to debate the Affordable Care Act and as reporters began to ask how lawmakers’ own care might color their perspectives on policy. The central issue is the cost: In 2016, lawmakers paid $611 for annual membership — a fee that, unlike most health care prices, has risen much slower than inflation. In 1992, the first year the office charged a fee, it was $520.

The Office of the Attending Physician itself was formed in 1928, after three members of Congress died in their offices within months of one another — more than 50 years after Grubb’s first opened its doors.

But the pharmacy services at the Capitol may go back even further — a 1911 text on senatorial privileges describes an “assortment of drugs and viands, tonics and recuperatives” on hand and “readily accessible” for lawmakers. Back then, reportedly, senators took tablet after tablet and vial after vial of quinine, pepsin, and calomel, “endless supplies of cough drops,” and something described as “dandruff cure.”

It’s not clear how long Congress has contracted with Grubb’s to provide private prescriptions, but a 1992 review of the OAP — hastened after one senator threatened to make his colleagues pay market prices for the free care they got at OAP — decreed that prescription pharmaceuticals for lawmakers should be obtained through private pharmacies and paid for by the lawmakers themselves, according to a memo shared with STAT by the Senate historian.

It’s not clear, either, just how many drugs the OAP keeps on hand, whether for members or emergencies. But Dr. Lee Mandel, a retired Navy physician who spent several years working for OAP in the 1980s, remembers a well-stocked pharmacy just off the main corridor under the speaker’s office.

“We provided some pretty comprehensive service, to keep the members doing their jobs so they didn’t have to go look for a doctor,” he told STAT. “As far as all medications, I don’t know — maybe the more exotic ones we didn’t — but we probably did stock [most drugs] on their behalf.”

Kim, 47, knows only that the OAP’s relationship with Grubb’s has existed since at least 1997, when he joined the staff part-time as he finished his training at Howard University.

Not much has changed since then, though enhanced security protocols after 9/11 ended the pharmacy’s practice of driving each prescription to an individual member’s office and collecting cash in-person. Now, the drivers — all of whom have undergone a Capitol Police background check — head straight to OAP.

After 20 years at Grubb’s, Kim himself is not nearly so starstruck by the lawmakers. Even when they stop by the shop in-person, he says they’re just like any other customer.

“I still remember John Kerry — it was literally the day after he lost [the 2004 presidential election], he came in and was just standing in line with everybody else,” Kim recalled. “I just remember seeing him standing in line and almost feeling sorry for him — one day he’s a superstar, he’s got his entourage and security detail, and the next day he’s just by himself, picking up his prescription.”

Though Kim himself is active in the National Community Pharmacists Association that lobbies on behalf of the industry, he said he usually does not push lawmakers to talk shop when they are in line as customers.

Although he isn’t lobbying Congress, Kim is still working to improve his relationship with OAP. He desperately wants the office to use an electronic system to route prescriptions to the pharmacy, rather than having their physicians call them in every time.

The “back to back” calls are slowing down the rest of his business, and he thinks it’s important to have a clearer record of what prescriptions are ordered than a phone call can provide.

Those frustrations aside, however, Kim is proud of the work he does for the powerful figures who dominate Washington’s attention.

“It’s definitely a special arrangement that no other pharmacy in the country has,” he says. “In other states, [a community pharmacy] may fill prescriptions for maybe one or two members. But at this location, we are servicing almost every member from all across the country. It’s very cool.”

Holistic Approach To Eliminating Opioids

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Each year, more than 300 patients with chronic pain take part in a three-week program at the Pain Rehabilitation Center at Mayo Clinic in Rochester, Minnesota. 

Their complaints range widely, from specific problems such as intractable lower-back pain to systemic issues such as fibromyalgia. By the time patients enroll, many have tried just about everything to get their chronic pain under control. Half are taking opioids.

In this 40-year-old program, that’s a deal breaker. Participants must agree to taper off pain medications during their time at Mayo.

More than 80 percent of the patients who enroll stay for the entire program, said Wesley Gilliam, the center’s clinical director, and many previous opioid users who finish the treatment report six months later that they have been able to stay off opioids. Just as important, he added, they have learned strategies to deal with their pain.

But such a program is not for everyone. Insurers might disagree that the intensive, interdisciplinary approach is medically necessary for some patients or simply not cover the program’s billing codes, he said. Mayo’s insurance team is sometimes an advocator on a patient’s behalf if they are a good candidate for treatment, however,  success is not assured.

Mayo’s program is not the only one to address the emotional, social and psychological aspects of pain, and other programs also focus on reducing patients’ reliance on addictive medications to manage their pain. But as our nation weathers an opioid epidemic, there are too few programs like these around the country to address the need, Gilliam says.

Gilliam, is a clinical psychologist with a specialty in behavioral pain management and talks about the program.

Q: How do pain medications work? By blunting the pain?

They blunt some of the pain. Opioids are very effective for acute problems, but they were never designed to be used chronically. They are not effective in the long term.

Opioids are central nervous system depressants. They soothe people who are in distress. Many people are not demonstrating improved functioning when they take opioids; it’s calming their nerves and it’s chemical coping.

Q: In treating pain, does it matter what may be the cause or it’s severity?

Pain is pain. The fundamental approach to self-managing it does not change based on the cause or severity of the pain. 

Q: How is someone chosen for a program such as yours?

Virtually all of our patients have tried and exhausted primary and secondary treatment options for pain.

[In] primary care, a patient has a complaint and a treatment plan is developed. It generally involves encouraging the patient to be active, to stretch, maybe the doctor initiates a non-opioid medication like a non-steroidal anti-inflammatory or an antidepressant.

If the patient continues to complain of chronic pain, the primary care provider will step up to level two and refer someone to a neurologist or maybe a pain psychologist or pain anesthesiologist.

If patients do not respond, they start to think about step three, which is a pain program like Mayo.

Q: How does the Mayo program work?

People come to us every weekday from 8 a.m. to 4 p.m. for three weeks.

We do not take a medical approach. It’s a biopsychosocial approach, [which] acknowledges not only the biological aspect of pain, but also recognizes that psychological and social variables contribute to how people experience pain.

That is not to say that pain is imagined, but rather how people experience pain is influenced by mood, anxiety and how that person’s environment responds to the person’s symptoms.

A more medical approach tends to focus on targeting and eliminating symptoms at the expense of the recognition of individual differences.

Q: What does that mean for the patient who’s in pain?

People need to accept that they have pain and focus on their quality of life. Some approaches reinforce in patients that the only way you can function is if you reduce your pain, as measured on a pain scale from zero to 10.

We focus on how to get a person back into their life by focusing on function instead of eliminating symptoms and pain. When I refer to functioning, I mean getting back into important areas of their life such as work, social activities and recreation. If a person is waiting for pain to go away, they are never going to get back into their life. When that happens, people get despondent, they get depressed.

Q: So how do you help people manage pain?

When a person is in chronic pain and it’s poorly managed, the nervous system can get out of whack. Their body behaves as if it’s under stress all the time, even when it’s not. Their muscles may be tense and their heart and breathing rates elevated, among other things.

With meditation and relaxation exercises, we are trying to teach people to learn how to relax their bodies and hopefully kick in a relaxation response.

If I have low-back pain, for example, during periods of stress, muscular tension is going to exacerbate the pain in my back. We focus on helping people to disengage from their symptoms.

By learning to relax in response to stress, muscular tension can be diminished and the experience of pain eased. This does not require a medication or a procedure, just insight and implementation of a relaxation skill.

Relaxation/meditation training is one component of a much broader treatment package. All aspects of our treatment — cognitive techniques for managing mood, anxiety and anger, physical therapy, occupational therapy — are all designed to settle the nervous system.

Q: Does insurance typically cover the program? 

Insurance companies may want to see patients complete more conservative treatment approaches before approving an interdisciplinary pain rehabilitation program like ours.

There are patients whose policies do not cover our billing codes. If we deem a patient as a good candidate, we will write letters saying they should be accepted.

There are a very select few who have paid out-of-pocket for our program. This is a significant minority, however. The program can cost up to $40,000 for someone with other complicated medical problems in addition to chronic pain.

There are studies that show these programs do save money over the long term in health care costs and reduced health care utilization.

If we are going to manage this chronic pain problem, we have to look at it for what it is: multifaceted. You cannot just treat the symptom, you have to treat the whole person.

Protecting Our Future Health

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Portrait Of Female Owner Of Gift Store With Digital TabletAre you a ‘glass half full’ or a ‘glass half empty’ sort of person? Scientific research shows ‘you are how you feel’. And, depending on your attitude towards life, you could be helping or hurting your well being. 

Google “optimism” and find: “hopefulness and confidence about the future or the successful outcome of something.”

Google “pessimism” and find: “a tendency to see the worst aspect of things or believe that the worst will happen; a lack of hope or confidence in the future.”

Which one better describes how you feel now, and for the future? If you answered “pessimism”, here’s some data that may help change your mind.

Unhealthy Outcomes For Unhealthy Minds

From a Harvard Medical School article citing various scientific studies:

  • 309 middle-aged patients were to undergo coronary artery bypass surgery. Before the procedure, each patient took a psychological evaluation to measure optimism, depression, neuroticism, and self-esteem. Researchers tracked each patient for six months after surgery. At that point, the researchers discovered those who were more optimistic from the initial evaluation were only half as likely to end up back in the hospital compared to the pessimists.
  • 298 angioplasty patients were followed over a six-month period, post surgery. As it turned out, the pessimists ended up back in the hospital at a 3 times greater rate than the optimists. 

But pessimism does not affect only cardiovascular health.

  • In 2006, scientists conducted a “sneaky” test. They wanted to see how personality styles (positive or negative) impacted viral symptoms. After concluding personality tests on 193 healthy volunteers, the scientists gave each volunteer a common respiratory virus. The results? Those displaying a “positive” personality style had less viral symptoms than the “negative” personalities.

With all being equal, it appears that “pessimism” affects overall health. What’s more eye-opening is how it affects longevity, too.

  • In the mid-1960’s, 6,959 students at the University of North Carolina took a comprehensive personality test.  Over the next 40 years, 476 died.  Of the deceased, the most pessimistic [according to the 1960’s test] had a 42% higher death rate than the most optimistic. And this is not just an American phenomenon.
  • A Dutch study followed 941 men and women, age 65 to 85 years old.  Those who were more optimistic at the beginning of the study had a 45% lower risk of death over the nine year follow-up period.

The University of Rochester Medical Center concurs with these studies.  They cite how researchers reviewed over 80 studies to see how pessimism affected physical health.  The review’s findings [from the 80 studies] showed that those who were more positive in life had betteroverall longevity, survival from a disease, heart health, immunity, cancer outcomes, pregnancy outcomes, pain tolerance and other health topics.”

Pessimism clearly affects our physical health. More and more studies show the more pessimistic, the worse our physical state.  This holds true for people who are already suffering from health ailments as well.

What’s the explanation?

How can our mindset influence our health risks? Much if it has to do with the physiological impact that negativity places on the body.  In short, stress from the negativity can wreak havoc on our cells. And that stress produces the negative outcomes.

When we are stressed, our body must tolerate more inflammation. That’s because the stress hormone, cortisol, courses through our veins and can wear down cells through inflammation. This inflammation creates a chain reaction of negative events in the body. It affects heart, bones, liver, skin, joint and pretty much all other physical problems.    

The reverse is also true.  Women with a more positive outlook had lower levels of inflammation (measured through C-reactive protein and interleukin-6 levels). These two inflammation measures predict the likelihood of heart attack and stroke. 

Both men and women had lower cortisol levels when they showed more optimism in a 2008 standardized test.  These results also considered possible influential variables such as age, employment, income, ethnicity, obesity, smoking and depression. 

We can truly “think ourselves” into poor health even while making other lifestyle choices.

How can we be more optimistic? 

Saying there’s an easy way might be a stretch. It all depends upon the mindset and the sort of thoughts in which we are already predisposed.  Nonetheless, when trying tips to be more positive, we can see and feel the difference in our life:

  1. Be Conscious Of  Our Thoughts. It’s difficult to fix something if not knowing it’s an issue.  That’s why it’s important to stop now and then, and take stock of our reaction to certain events (particularly the ones that do not go our way). If there’s a tendency to have a negative reaction to these events, there’s the opportunity to be more optimistic going forward. This is the path to better health!
  2. Try Thinking PositiveWhile it could feel odd to start, it doesn’t hurt to try thinking more positive. If someone cancels an appointment, it provides the opportunity of freedom to finish or do something else. 
  3. Stop Making Comparisons.  It’s natural to have the emotions of jealousy or anger when comparing ourselves to others. We all have different stories, different strengths and different roles in this world. Though the feelings are natural, they are not productive and will not help. Appreciate what we have and let it be a reminder that things could be worse. 
  4. Surround Ourselves With PositivenessThere’s always at least one friend who’s fun, cheerful and positive to be around. If so, it’s a good idea to spend more time together. Their positiveness can be infectious and rub off more than is realized. They will either consciously or subconsciously radiate happiness. Plus, it’s good to laugh more, too!
  5. Practice GratitudeThis is a great exercise. Sit down with a pen and paper.  Write down three things of gratefulness. Doing this everyday can make us feel better and experience the positive affects in life. 

 

 

 

Medicare Advantage vs Original Medicare + Medigap

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medicare-advantage-choiceAs health insurers struggle with shifting government policies and considerable uncertainty, one market remains remarkably stable: Medicare Advantage plans. 

However, this may or may not be good news for seniors as they select coverage for the year ahead during Medicare’s annual open enrollment period, October 15 to December 7, 2017.

For 2018, 2,317 Medicare Advantage plans will be available across the country.

Medicare Advantage is an alternative to traditional Medicare. Administered by private insurance companies, the plans — mostly health maintenance organizations (HMOs) and preferred provider organizations (PPOs) — are expected to serve a record 20.4 million people next year, or slightly more than one-third of Medicare’s 59 million members.

Despite Medicare Advantage plans’ increasing popularity, several features — notably, the costs that older adults face in these plans and the extent to which members’ choice of doctors and hospitals is restricted — remain poorly understood.

Here are some essential facts to consider:

The Basics

Medicare Advantage plans must provide the same benefits offered through traditional Medicare (services from hospitals, physicians, home health care agencies, laboratories, medical equipment companies and rehabilitation facilities, among others). Nearly 90 percent of plans also supply drug coverage.

In general, HMOs require members to seek care from a specific network of hospitals and doctors while PPOs allow members to obtain care from providers outside the network, at a significantly higher cost.

Pros And Cons

Here’s a summarized list of the pros and cons for Medicare Advantage plans.

On the plus side, it cited they:

  • Put an emphasis on preventive care with in-network providers.
  • Provide benefits, such as vision care, dental care and hearing exams with, or sometimes without, an extra monthly premium.
  • Tout an all-in-one approach to coverage with in-network providers.
  • Have maximum annual out-of-pocket costs (HMO and PPO in-network $6,700) and (PPO out-of-network up to $10,000).

On the minus side, it cited they:

  • Have limited access to physicians and hospitals within plan networks.
  • Must get prior approval from a primary care physician before seeing a specialist.
  • Receive a set per-member monthly fee from the government and risk losing money if medical expenses exceed payments.
  • Have limits on care for members when traveling. Only emergency and urgent care is covered. 
  • Charge more than Original Medicare for short hospital stays, home health care or medical equipment.
  • Are locked in annually for a member with two exceptions: a special disenrollment period from January 1 to February 14 when a member can choose to return to Original Medicare; and an option to make changes during the annual enrollment period each year from October 15 to December 7.
  • Do not generally provide coverage for HMO out-of-network services.
  • Generally provide PPO out-of-network services with higher costs.
  • Portray the perception of costing less than Original Medicare. Actual costs depend on individual circumstances that are not easily calculated.
  • May not be effectively and consistently transparent [beyond zero or low premiums] in evaluating drug expenses, deductibles, co-insurance, hospitals, skilled nursing facilities and home health care.
  • Cannot easily determine which providers are in-network. Information is not on the Medicare website and directories are not accurate. Patients must call all their doctors about specific plans.

Notably, if someone enrolls in a Medicare Advantage plan when newly eligible for Medicare and stays with a plan past the Medicare Part B enrollment date, they may or may not health qualify for the other choice, a Medigap supplement plan.

Medigap policies cover charges such as deductibles, coinsurance and copayments that seniors with Original Medicare coverage are expected to pay out-of-pocket. 

Cost Perceptions

Seniors often first consider what they will pay in monthly premiums. In 2017, the average monthly premium for Medicare Advantage plans is $30. But nearly half of Medicare Advantage members are enrolled in plans that do not charge a monthly premium — so-called zero premium plans. 

To get a full picture of plan costs, which can vary annually and are in-network, seniors should look beyond premiums to drug expenses (including which drugs are covered by their plan, at what level and with what restrictions); deductibles (plans can charge deductibles for both medical services and drugs); what plans charge for hospital care (some have daily co-payments for the first week or so); and coinsurance rates for services such as home health care or skilled nursing care.

It’s really critical that people dig deep and find out about all possible costs they may incur in a Medicare Advantage plan before they sign. Part of the equation has to be what a person will have to pay [often more than expected] if they need extensive care.

Since 2011, Medicare Advantage plans have limited members’ annual out-of-pocket costs,  a form of financial protection. There is no similar limit in traditional Medicare. Yet, protection is not complete since out-of-pocket limits do not apply to drug costs, which can be considerable. 

Finding A Doctor

One way that Medicare Advantage plans try to control costs and coordinate care is by working with a limited group of physicians and hospitals. 

It’s not easy to determine who’s in-network for a Medicare Advantage plan. There’s no  streamlined way to search for information about provider networks across plans. Members must call all their doctors to ask if they are contracted in a plan [and refer to the plan number as well] because each insurance company may offer multiple plans in a market area.

Making matters even more difficult: Medicare Advantage plans can drop physicians or hospitals from their networks during the year, leaving members without access to trusted sources of care.

A new report discloses data about the size of Medicare Advantage plans’ physician networks for the first time. It finds that, on average, Medicare Advantage HMOs included 42 percent of physicians in a county in their networks while PPOs included 57 percent. Altogether, 35 percent of Medicare Advantage members are in plans with narrow physician networks, which tend to be the least expensive plans.

 

The Affordable Care Act?

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This year open enrollment for people who purchase their own private health insurance began Nov. 1st and ends Dec. 15th. 

That’s 45 days, six weeks shorter than last year — and only one of the big changes consumers need to consider. The Trump administration has cut back on marketing and funding for navigators to help people through the process.

Here are some important factors to keep in mind if a person plans to enroll for 2018 coverage under the Affordable Care Act: 

The health law has NOT been repealed.

Despite the efforts of President Donald Trump and the Republican-led Congress, the Affordable Care Act is still the law of the land.

This means if people do not have insurance with an employer or a government program, they can still get coverage for a set of comprehensive benefits regardless of any preexisting conditions. It also means that if a person meets income eligibility requirements, they will be able to get help from the federal government to afford the premiums, and, possibly, deductibles and other out-of-pocket costs.

The “cost-sharing reduction” subsidies help hold down out-of-pocket costs for people with incomes under 250 percent of poverty (a little more than $30,000 a year for an individual). They will be available despite Trump’s decision to stop the federal government from reimbursing insurers for the required discounts. Most insurers are making up the difference by raising premiums.

Meanwhile, if a person receives premium assistance in the form of tax credits, this  assistance for coverage is not likely to be much higher, either. That’s because as premiums go up, so do federal premium subsidies.

The requirement for most people to have insurance — and most employers to offer it — is also still in effect.

Under the law, most households that earn enough to owe federal income tax are required either to have health insurance or pay a fine due with their taxes. The fine for not having insurance in 2017 (and 2018) is the greater of $695 or 2.5 percent of the taxpayer’s income. A person can claim an exemption from the fine if demonstrating they cannot afford insurance offered in their area.

The IRS has stated it will start rejecting returns filed in 2018 that do not indicate if the taxpayer had health insurance in 2017.

Larger employers (those with 50 or more full-time employees) are also required to offer coverage to their employees or pay a penalty. The coverage must be comprehensive and affordable.

The best advice for people to follow is to shop around. 

While it’s always been important to compare options, this year it’s more crucial than ever.

For starters, people should shop and choose a plan themselves so that the marketplace does not automatically renew a person’s existing coverage for 2018.  That’s because the auto-renewal date this year is expected to be Dec. 16, the day after the open-enrollment period ends. So, if a person is assigned a plan they do not like, they won’t be able to change it until the 2019 open-enrollment season.

Shopping allows a person to compare plans, including which doctors and hospitals are in-network, as well as premiums and co-payments, which can vary.

Cost will be a factor.

This year, premiums are going up, in some areas by double digits, due in part to the Trump administration’s mid-October decision to cut off cost-sharing subsidies to insurers.

But the premium increases may not affect all plans and “metal levels” — which is why people should compare prices.

Some states, for example, instructed insurers to load those additional costs only onto the “silver-level” plans (mid-level plans that cover about 70 percent of an average person’s medical costs). The policyholder covers the remaining cost in deductibles and co-payments.

Even though as a result of the state’s pricing decisions, “gold-level” plans (highest level plans that cover an average of 80 percent of costs) might, in some cases, have lower premiums than silver plans.

Of course, if a person receives a cost-sharing reduction — meaning lower co-payments and deductibles — because their individual income is below $30,150, they will need to stay in a silver plan.

Another factor to consider, however, is that the increased prices for silver plans may drive up a different subsidy — the tax credits that help people pay premiums. Those remain in place for people earning up to 400 percent of the federal poverty level. They could rise because they are tied to the cost of a benchmark silver plan in each region.

In some cases, the tax credit increase could be enough to make a bronze or gold plan have a very low or even zero monthly premium, according to a Congressional Budget Office analysis done before the administration took action. But, of course, consumers not receiving either type of subsidy could be faced with higher costs. All the more reason to comparison-shop.

Some experts suggest looking beyond the official federal and state marketplaces — whether directly checking out an insurer’s website, working through a broker or consulting a private online website — because some states ordered insurers to load additional costs resulting from the Trump order only onto marketplace plans. Therefore, plans off the marketplace might cost less.

Buyers should also beware. 

Outside of the official marketplaces there may be more insurers selling lower-cost, “short-term policies.” These policies are only for specific periods of time and are subject to insurance underwriting (must health qualify). Also, a person may carry a short-term policy for up to three (3) months per year without an Affordable Care Act penalty.

Sabrina Corlette, who studies the marketplace for Georgetown University’s Health Policy Institute, said that such plans, while less expensive, may not cover all benefits and might exclude coverage of preexisting conditions.

These plans also do not meet Affordable Care Act requirements for “minimum essential coverage,” so policyholders would still be liable for paying a tax penalty. “There are  some people taking advantage of consumer confusion,” warned Corlette, adding that shoppers who buy outside of state or federal marketplaces “should consult a reputable broker.”

Popularizing Prescription Drugs

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rx-bottle-and-cashLaura Ries was moved to action when she saw a TV commercial portraying a woman happily sharing time with her grandchildren after taking Lyrica, a prescription medication, for diabetic nerve pain of which her elderly mother suffers.

“The ad showed someone who was enjoying life again,” said Ries, president of a marketing strategy firm in Atlanta, who then researched the drug and spoke with her mother’s doctor. “This was very related to what my mom was experiencing.”

Her reaction was precisely the aim of ‘direct-to-consumer’ advertising: getting patients or their family members to remember a drug’s name and ask the doctor for a prescription.

Spending on such commercials has grown 62 percent since 2012, even as ad spending for most other product types was flat.

“Pharmaceutical advertising has grown more in the past four years than any other leading ad category,” said Jon Swallen, chief research officer at Kantar Media, a consulting firm that tracks multimedia advertising. It exceeded $6 billion last year, with television picking up the lion’s share, according to Kantar data. Major network evening news and daytime drama programs are heavy with drug ads.

But the increase of drug advertisements has generated new controversy, in part because the ads inevitably promote high-priced drugs, some of which doctors say have limited practical utility for the average patient-viewer. For example, 60 capsules of Lyrica costs about $400 [the drug Ries asked about for her mother].

Critics, including the American Medical Association who called a ban in 2015, say ‘direct-to-consumer’ advertising inflates demand for new, more expensive drugs and encourages patients to ask their doctors for often marginal — and sometimes inappropriate — drugs that are stimulating high health care costs.

Such prohibition is unlikely. Previous efforts to push such an outcome have stalled, generally on free-speech arguments by the powerful drug lobby who declare that such ads provide valuable information to patients about treatment options.

Spending Zooms

One thing is certain: ‘direct-to-consumer’ advertising is big. And, as nearly everyone who watches TV knows, it’s getting bigger.

Some programs — the nightly news and sitcoms aimed at older Americans — get most of their advertising from drug companies. A Kantar analysis shows 72 percent of commercial breaks on the “CBS Evening News” have at least one pharmaceutical advertisement. Commonly, the ads target a range of conditions that generally affect this demographic. Sixty-two percent of commercial breaks during “General Hospital” include a drug ad.

“A lot of these ads target the caregivers and the children of older people,” said consultant Tom Lom, a former managing partner of Saatchi & Saatchi Consumer Healthcare, which has created ads for pharmaceutical giants.

Drug companies were on track to spend an estimated $6.4 billion on ‘direct-to-consumer’ advertising in the U.S. last year, up 5 percent from 2015, according to Kantar. In 2012, spending for pharmaceutical TV ads was the 12th-largest category. By last year, drug ads were sixth.

While substantial, the spending was less than the amount spent by automakers, retail and restaurants. Networks — ABC, CBS, NBC — along with cable channels like CNN — draw a lot of the pharmaceutical advertising.

According to Swallen, the effect of the ban on networks would be a daunting, 8 percent loss of total ad revenue, and its impact would be most evident for programming popular with viewers older than 60 ­— for instance, evening news shows. Similarly, cable networks such as the Hallmark Channel, which draw viewers from this demographic, would feel the pinch because they work on lower budgets.

Why Some Drugs Are Advertised

For years, the ‘direct-to-consumer’ industry was mostly focused on drugs that relieved chronic, typically non-fatal afflictions like heartburn (Nexium), allergies (Claritin) and high cholesterol (Lipitor).

More recently, Lom said, advertising has focused on more serious illnesses affecting seniors, such as Alzheimer’s disease. Ads for drugs that target constipation caused by other drugs — opioids — hit the scene last year, reflecting the large numbers of people taking painkillers.

In 2016, the top three ads based on total spending were Lyrica, $313 million; Humira, $303 million; and Eliquis, $186 million, according to Kantar Media.

The reasons why some drugs are advertised more than others vary, with drug companies evaluating which products are most likely to bring them the most revenue.

Drugmakers do not care “whether it’s a rare, expensive drug or a popular cheap drug,” said Amanda Starc, associate professor of strategy at Northwestern’s Kellogg School of Management. “They’re looking at the marginal return on advertising. A small number of customers spending a lot or a big number spending a little.”

How Advertising Plays To Consumers

The United States is one of two countries — the other is New Zealand — that allows ‘direct-to-consumer’ advertising, a long-standing practice that became more common in the mid-1980s after the FDA issued new rules. Most advertising was in print. But more television advertising began appearing when some of the rules were relaxed a decade later.

Lom said the ads give consumers a “head start” on knowing about drugs that might be available for their ailments, speeding up the consumer education process.

Surprisingly, 62 percent of physicians, for instance, said they would or might prescribe a harmless, even placebo, treatment to a patient who does not need it but demands it, according to a 2016 poll conducted by Medscape, an online physician education website.

Current rules require that if a drug is named in an ad, information must be included about side effects and adverse reactions. That makes it even more important that drug advertising be visually captivating — if not surprising, say consultants.

Meanwhile, the side effects are glossed over. “The ads describe the risks and at the same time play pleasant music — or show happy images — which helps to distract people from getting the message,” says Dr. Aaron Kesselheim, associate professor of medicine at Harvard Medical School.

Those that do advertise, however, appear to have a handle on the market. Ries, the brand consultant, says it wasn’t just the ad that helped her to remember Lyrica, but the name, too, which was easy to spell and pronounce.

Reis said her mother did take the Lyrica “and it’s helped.” That’s a good thing, says the brand guru who takes pride in looking out for her mother. “The ad spurred the conversation.”

But whether the advertising empowers patients or leaves them vulnerable is debatable.

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