hospitals requiring payment upfront

The South Florida Sun-Sentinel on Tuesday examined how across the U.S., “some insured patients are being asked by hospitals to pay larger portions of their bills upfront — and sometimes hospitals will not do the procedures until they get their copayments.” Although hospitals must provide emergency treatment without receiving upfront payment, elective or scheduled procedures, such as angioplasty or chemotherapy, “can be withheld depending on a patient’s ability to pay,” according to the Sun-Sentinel.

A voluntary survey conducted by the Internal Revenue Service in 2006 found that 14% of 481 not-for-profit hospitals nationwide required an upfront payment or payment plan before a patient was admitted. Hospitals maintain that the slow economy and rising health care costs have resulted in many unpaid medical bills and the practice is needed to offset such costs. However, patient advocates contend that requiring payment before services are delivered can cause stress on already vulnerable patients who might have life-threatening illnesses.

Hospital officials in Florida say that patients are being asked to pay larger amounts upfront as insurance companies require patients to make higher out-of-pocket contributions to their care. David Smith, CFO for Memorial Regional Hospital in Florida, said, “As the economy worsens, employers are having a harder time affording insurance for their employees, they’re increasing the patient portions, and patients’ benefits actually decrease”

medicare reimbursement with generic drugs

When a drug goes generic, the price plunges. But the formula Medicare uses to pay for certain drugs is slow to reflect that price drop, which means the program winds up overpaying for months.

Read all about it in this report out today from Health and Human Services’ inspector general.

drug pricesThe report looks at irinotecan, a cancer drug (sold by Pfizer under the brand name Camptosar) that went generic in February of this year. In March, Medicare was paying $126 per dose of the drug. During the same month, the average generic price was $41, the report found. Even factoring in sales of the branded version, the average price during the month was only $52.

Irinotecan is covered by Medicare Part B, which pays for medicines injected at the doctor’s office and oral cancer drugs. The program likely overpays for other new generics, the report found.

The problem is that Part B uses a backward-looking formula to calculate what it should be paying for the drugs. So when new, lower-priced generics hit the market, Medicare is still basing its payment on prices calculated when only the branded drug was available. During the current quarter, Medicare is paying about $75 for irinotecan — way down from what it was paying in March, but still far above the average price.

The report suggests that Medicare figure out a way to “address pricing discrepancies arising from newly available generic drugs.” That may include pushing for a change in the laws that govern what Medicare pays for drugs, the report suggests.

Legislation to make referrals more transparent

Senate Finance Committee ranking member Chuck Grassley (R-Iowa) recently introduced legislation (S 3343) that would require physicians to disclose their financial ties to imaging services ordered under Medicare when making self-referrals, CQ HealthBeat reports.

The legislation is intended to reduce physicians’ incentives for referring patients to imaging providers in which the doctor has a financial stake by requiring them to disclose such ties. The bill would require physicians to provide beneficiaries with a written list of alternative providers when referring imaging services, such as MRIs, CT and PET scans. The measure also would require the list to specify which providers are in proximity to the beneficiary’s home. The legislation is based on recommendations from the Medicare Payment Advisory Commission after the Government Accountability Office found that Medicare imaging spending increased about 200% between 2000 and 2006. The Congressional Budget Office did not score the measure, but a Grassley aide said it could reduce Medicare spending.

Mo Zilly, director of government relations for the Medical Imaging and Technology Alliance, said that MITA would support the measure because it improves transparency. However, she said it does little to reduce overuse of imaging services in Medicare and instead shifts costs from one provider to another.

Grassley had included a similar provision under Medicare legislation on which he worked with Finance Committee Chair Max Baucus (D-Mont.) that failed to receive consideration. Ultimately, the new Medicare law did not include the imaging disclosure provision (Parnass, CQ HealthBeat, 7/29).

telemedicine reimbursement approved

Final Victory for Telemedicine Reimbursement
Congress Overrides Presidential Veto on H.R. 6331

Telemedicine achieved final victory in its quest to add new originating sites for
Medicarereimbursement on July 16 when Congress overrode President Bush’s veto of H.R. 6331.
Under this new law, as of January 1, 2009, skilled nursing facilities, in-hospital dialysis centers and
community mental health centers will be originating sites for Medicare reimbursement.

H.R. 6331, a large Medicare bill that addresses many issues including averting scheduled cuts in physician
fees, has been highly controversial due disagreements over spending cuts necessary to offset new
expenditures in the legislation. The bill originally passed the House on June 24 by a vote of 355 to 59 and
passed the Senate on July 9 by a vote of 69 to 30. On July 15, President Bush vetoed the bill. Later that
day Congress overrode the veto making the bill law. The House vote was 383 to 41, and the Senate vote
was 70 to 26.

NEXT STEPS: The law goes into effect January 1, 2009, but the Center for Medicare and Medicaid
Services (CMS) needs to issue regulations detailing how it will be implemented. ATA will work with
CMS as they develop these regulations, and will keep the membership informed as this process
unfolds.

ATA would again like to thank the many people who contributed to this success. ATA is extremely
grateful to our champions in Congress including Sen. Kent Conrad, ND; Sen. Max Baucus, MT; Sen.
Charles Grassley, IA; Sen. Debbie Stabenow, MI; Sen. John Thune, SD; Rep. Mike Thompson, CA; Rep.
Bart Stupak, MI; Rep. Kenny Hulshof, MO; and Rep. Earl Pomeroy, ND.

ATA also thanks those in the telemedicine community who worked so hard to get us this far. ATA is
grateful to all the members who responded to the ATA Action Alerts. Many ATA members worked hard
to get their senators and representatives to support this legislation, and ATA is grateful to those who made
individual efforts. In addition, many ATA members signed letters at the annual meeting in Seattle, and
many people also made Capitol Hill visits as part of the Telehealth Leadership Conference and on their
own. All these efforts contributed to this success.

ATA is grateful to our longstanding friend and ally, Bob Waters and the Center for Telehealth and e-
Health Law.

ATA is also grateful to other organizations who have worked to advance this legislation including the
National Council for Community Behavioral Healthcare and their representative, Al Guida, who has
worked so hard on the CMHC provision; the American Health Care Association; the National Association
for the Support of Long Term Care; the American Health Information Management Association; the
Center for Aging Services Technologies; the National Center for Assisted Living.

warning labels

FDA Issues New Rules on Product Warning Label Updates for Pharmaceuticals, Medical Devices

from kaisernetwork.org: Health Policy Daily Report

FDA last week issued new rules that aim to ensure medication warning labels provide clear and concise information to consumers, the AP/Denver Post reports. The new rule, which will take effect next month, states that pharmaceutical and medical device companies must rush out safety updates on products only if there is clear evidence of a risk not yet reviewed by FDA. The Pharmaceutical Research and Manufacturers of America supported FDA’s actions, saying the new rules provide clarity about drug warning labels, the AP/Post reports. However, consumer advocacy lawyers said the new rules provide legal protection to companies that withhold information on risks associated with their products. In addition, the American Association of Justice said the new rules require an unnecessary standard of scientific evidence before companies must update their labels (Perrone, AP/Denver Post, 8/24). Editorial Addresses NEJM Commentary on Pre-Emption
A Las Vegas Sun editorial agrees with the editors of the New England Journal of Medicine “who say that taking away consumers’ right to sue would also take away a strong incentive for the FDA and the pharmaceutical industry to be open about a drug’s potential for causing harm.” According to the editorial, the NEJM editors “state the obvious” that FDA and the pharmaceutical companies “haven’t always been completely open or correct in their labeling, even when the risk of lawsuits has been present.” The editorial concludes, “Preserving the right of consumers to sue will keep federal agencies and manufacturers more honest — and the public more protected”

Commonwealth study on the medical bill payments

A number of states have begun to consider legislation that would restrict access to physician prescribing information for data mining companies as part of a “backlash against pharmaceutical marketing efforts,” the AP/Arizona Republic reports. Data mining companies, such as IMS Health and Verispan, collect information on which medications physicians prescribe and the quantities in which they prescribe them and sell the data to pharmaceutical companies. Pharmaceutical company sales representatives use the information to target physicians who prescribe medications manufactured by competitors and determine the effectiveness on their marketing efforts.

According to IMS Health officials, without such information, pharmaceutical companies would have to hire more sales representatives. However, state lawmakers maintain that, in the 10 years after IMS began mining physician prescribing information in 1993, pharmaceutical companies tripled spending on marketing efforts and doubled their number of sales representatives.

As many as 18 states this year have considered legislation that would restrict access to physician prescribing information, and Maine, New Hampshire and Vermont have passed such laws. U.S. District court judges have struck down the Maine and New Hampshire laws as unconstitutional, and, in response to the court decisions, Vermont delayed the implementation of a similar law until 2009. The 1st U.S. Circuit Court heard an appeal of the lower court decision on the New Hampshire law earlier this year and likely will rule on the case this month. In the event that the appeals court overturns the lower court decision, “it could open floodgates to similar efforts nationwide,” the AP/Republic reports

legislative debate over physicians and data mining

A number of states have begun to consider legislation that would restrict access to physician prescribing information for data mining companies as part of a “backlash against pharmaceutical marketing efforts,” the AP/Arizona Republic reports. Data mining companies, such as IMS Health and Verispan, collect information on which medications physicians prescribe and the quantities in which they prescribe them and sell the data to pharmaceutical companies. Pharmaceutical company sales representatives use the information to target physicians who prescribe medications manufactured by competitors and determine the effectiveness on their marketing efforts.

According to IMS Health officials, without such information, pharmaceutical companies would have to hire more sales representatives. However, state lawmakers maintain that, in the 10 years after IMS began mining physician prescribing information in 1993, pharmaceutical companies tripled spending on marketing efforts and doubled their number of sales representatives.

As many as 18 states this year have considered legislation that would restrict access to physician prescribing information, and Maine, New Hampshire and Vermont have passed such laws. U.S. District court judges have struck down the Maine and New Hampshire laws as unconstitutional, and, in response to the court decisions, Vermont delayed the implementation of a similar law until 2009. The 1st U.S. Circuit Court heard an appeal of the lower court decision on the New Hampshire law earlier this year and likely will rule on the case this month. In the event that the appeals court overturns the lower court decision, “it could open floodgates to similar efforts nationwide,” the AP/Republic reports.

budget cuts considered for medicaid

A number of states in response to budget deficits have proposed changes to their Medicaid programs that could affect the eligibility of hundreds of thousands of residents or reduce reimbursements for health care providers, the Christian Science Monitor reports.

In February, California announced a 10% reduction in Medicaid reimbursements to providers that took effect in July, and the state in May announced more potential changes to the program that included a proposal to limit eligibility to residents with annual incomes less than 61% of the federal poverty level, compared with 107% currently. In New York, Gov. David Paterson (D) has proposed to freeze Medicaid reimbursement rates for hospitals for the remainder of 2008 and 2009. He also has proposed to reduce Medicaid reimbursement rates for hospitals by 7.2% over the next two years and impose a new tax on their revenue.

Meanwhile, Maine has added a $25 fee for adults who enroll in the state Medicaid program, and California, Arizona and other states have begun to require residents to re-enroll in their programs more often. In addition, New Jersey has reduced funds for charity care in hospitals, and Florida has frozen Medicaid reimbursements for nursing homes.

According to the Monitor, when “state lawmakers look at their budgets, the two largest expenditures are education and Medicaid,” and lawmakers often are “loath to cut education funding, especially during the school year.” Expenditures for Medicaid in 2006 reached $304 billion, a 48% increase from 2000, and enrollment in programs increased by 11% between 2000 and 2002 and by an additional 7% in 2003.

personal health record pilot

CMS in January 2009 will launch an online personal health records pilot program for Medicare beneficiaries in Arizona and Utah as part of an ongoing effort by the Bush administration to encourage use of health care information technology, The Hill reports. Under the program, the PHRs will include as much as two years of Medicare data. Medicare beneficiaries will have the ability to add information to their PHRs and share them with physicians, pharmacists and other health care providers.

Supporters maintain that increased use of PHRs and other health care IT can help reduce health care costs and medical errors and improve quality of care. HHS Secretary Mike Leavitt said, “This exciting pilot will be a major step forward in Medicare,” adding, “We believe that it will provide information that will empower consumers to manage their health”

hospitals an immigrants

The New York Times on Sunday examined how U.S. “hospitals are taking it upon themselves to repatriate seriously injured or ill immigrants because they cannot find nursing homes willing to accept them without insurance.” The article is the second in a series, titled “Getting Tough,” that examines efforts by government and other organizations to coerce undocumented immigrants to leave the U.S.

According to the Times, newly arriving documented and undocumented immigrants qualify for emergency medical care only under Medicaid, which “covers only a small fraction” of costs. In most states, the government does not provide funding for post-hospital care for undocumented immigrants, temporary immigrants and documented immigrants who have been in the U.S. for less than five years. Under federal law, hospitals receiving Medicare funds must transfer or refer patients to “appropriate” post-hospital care, the Times reports. According to the Times, the “hospitals are operating in a void, without governmental assistance of oversight, leaving ample room for legal and ethical transgressions on both sides of the border.”

Some hospitals choose to turn these immigrants over to the care of their home country; however, some immigrant advocates “see these repatriations as a kind of international patient dumping, with ambulances taking patients in the wrong direction, away from first-world hospitals to less-adequate care, if any,” the Times reports. Some hospitals say the only alternative to deportation is to keep these immigrants in acute-care hospitals indefinitely. According to the Times, “Hospital administrators view these cases as costly, burdensome patient transfers that force them to shoulder responsibility for the dysfunctional immigration and health care systems.” Lawsuit
The Times profiles Luis Alberto Jimenez, an undocumented immigrant who was injured in a car crash involving a drunk driver. Florida-based Martin Memorial saved Jimenez’ life twice. Then, after being unable to find a rehabilitation center willing to accept an uninsured patient, Martin Memorial cared for him for years at a cost of $1.5 million. The hospital then sought to return him to Guatemala, his home nation. Circuit Court Judge John Fennelly granted the hospital’s request to return Jimenez to Guatemala, which claimed it would provide care to him upon his return, the Times reports. Martin Memorial spent $30,000 for an air ambulance to transport Jimenez back to Guatemala.

The ruling later was overturned by the Fourth District Court of Appeals. The court said that there was no evidence to support that Guatemala would provide the appropriate care for Jimenez required under federal law and that Fennelly overstepped his bounds in a deportation issue that should have been handled by the federal government. According to the Times, “The decision has become what is known legally as a case of first impression on the issue of hospital repatriations.” Later appeals court rulings in Jimenez’ favor also ruled that the hospital can be sued for punitive damages and the cost of his medical care. The case is pending