11-30-2005
The nation’s largest health insurance program is in danger. A recent report released by the Medicare and Social Security trustees stated that the Medicare program will be broke by 2019. With the rapid decline in the number of workers per beneficiary, rise in national health care spending, aging baby boom generation, and the prescription drug benefit passed last year, Congress will be forced to soon make some really tough decisions regarding Medicare.
In 1965 Congress enacted the Medicare statute of the Social Security Act which covered the elderly without regard to income or medical history. In 1972, it added coverage for people with disabilities under the age of 65. The program covers forty-one (41) million Americans: thirty-five (35) million seniors and six (6) million non-elderly people with disabilities. In its entirety Medicare is a source of coverage for one in seven Americans.
A “trust fund” was established by Congress to financially support the Medicare program through payroll taxes and premiums. There is a Medicare tax with each paycheck a person receives to maintain the upkeep of those on Medicare. Unfortunately, according to Medicare trustees, the “trust fund” is a cookie jar with all sorts of hands in and out tapping all the money and replacing the goods with IOU’s the government issues to itself. If this sounds like funny math you are correct. Soon the program’s annual cost will exceed its income and Medicare will be broke and the federal deficit will continue to spiral out of control. If decisions are not made soon it will be only harder to make them in the future.
The breakdown can be seen in other areas as well. For instance, Medicare all too often will refuse to embrace the benefits of new technology. I would go as far as to say that the Part B section of Medicare is stuck in the mid-80’s, from definitions, to what technology a beneficiary actually needs. Approving older technology leads to greater cost to the system. New technology creates cost-effective options but as long as the DMERC’s deny or hinder new medical assistive technology the result will be a lower standard of care and a policy that suppresses innovation.
Part of the problem is the effectiveness in the program itself. Here is a quick course in the Medicare structure: Part A is a hospital insurance program covering inpatient hospital stays, skilled nursing facilities, and home health care service, and will make up 46% of the benefits in 2006. Part B, the supplementary medical insurance, covers physician and outpatient care, lab test, medical supplies, and home health. Part C, which is managed care plans, represents only 14% of benefit spending. Last, Part D, is a great unknown as it embodies the new prescription drug plan that will be applied to the nation in this year but the cost are expected to be high.
With the information above one fundamental collapse in the system is the lack of communication between Part A and Part B of the Medicare program. For example, a quadriplegic receives a power wheelchair under Part B coverage using the Medicare allowable and old technology and is denied certain seating system recommendations issued by the doctor, therapist and provider involved in the case due to cost. Part B may end up saving $10,000. The patient ends up with an out of date inappropriate chair. An ulcer develops and requires surgery to repair the damage done by the power wheelchair. The beneficiary checks into the hospital, covered by Part A, and spends 40 times the cost for the surgery and recovery that the appropriate wheelchair with new technology would have prevented.
The Part B chairs continue to be issued and the Part A coverage continues to pay for the result of a system that does not communicate with each other. Vanderbilt University recently tracked a Medicare beneficiary receiving an inappropriate chair that took three years and $365,000 to heal. With 80% of all quadriplegics receiving a pressure sore during his or her lifetime the system can not afford not to communicate to each other.
For a federal program that covers so many the lack of public participation in this arena is alarming. Congress will soon face the music and be forced to raise taxes, increase premiums, cut money from the federal budget, or confront the restructure of Medicare. Without a public outcry the manipulation of funds will continue. Election years are the time to enact such a battle cry and both candidates running for president are positioning to do battle over health care.
The main focus is the current gaps in coverage and the rising cost of health care. Congress was told the new Medicare Reform Act was to be at a cost of $395 billion but when the actual cost was released the Trustee’s reported a cost closer to $600 billion. If this is truly the case it is simply another factor eroding Medicare. Let’s take a look at the way the two candidates are spinning the Medicare problem:
The Bush administration made use of the report to re-iterate the need for controlling rising health care cost, spur more competition, encourage the use of cheaper generic drugs, preventive care, and that the new law will provide such savings in the future. Medicare Trustees report and blames large tax breaks, giveaways to prescription drug companies, and the fact that if you are 50 years old or younger Medicare will run out of money by the time of retirement.
These are good points but neither has come up with a solid plan to reverse the wearing away of the Medicare program. Each candidate should break down the system as a whole and work from the inside out to fix the problems from within. For example, recently fraud became an issue in regard to durable medical equipment and Medicare coverage. CMS, under pressure, attempted to correct the situation that was getting out of hand but the perception was greater than the reality.
In September, 2003 CMS launched Operation Wheeler Dealer to combat fraudulent abuse by power mobility providers in the Medicare system. Wheeler Dealer, in effect, used the hammer of the federal government punishing both credible and unscrupulous providers with a policy that restricts. It is important to point out that it was the power mobility industry that alerted Medicare to the fraudulent practices to begin with through the Medicare hotline. It is important to point out that third party billing companies that Medicare contracts with was not doing their job identifying the fraud.
Further, in December, 2003 CMS issues a clarification of coverage policies in regard to power mobility for beneficiaries who are non-ambulatory. The definition of non-ambulatory is “… patients who are non-ambulatory are those who can only bear weight to transfer from a bed to a chair or wheelchair.” The non-ambulatory definition further restricts a policy that already provides unjust segregation with the interpretation of the Social Security Act “used in the patient’s home”. These policies are discriminatory and should be challenged if continued.
In March, 2004 CMS rescinded the clarification of coverage policies due to pressure socially, politically and economically during an election year. A CMS open door hearing was conducted to comply with the Benefits Improvement and Protection Act (BIPA) of 2000. Public participation has been a weak area when determining National Coverage determinations. This open door hearing, however; included consumer, advocate organizations, manufactures, providers, and therapist a like, but CMS has listened before without regard to the recommendations made.
In 2005 we saw action. A new NCD, LCD, Testing, Codes, and Allowables to try and pin point a policy that all can agree with in regard to power wheelchairs. Unfortunately, it is going to take another two years to shake everything out before we get final codes and policy. Everyday that goes by it is the beneficiary that takes the hit, but no hit is more harming than CMS’s “in the home rule”.
In 1965 Congress created the Social Security Act. It merged three bills from the Johnson Administration, AMA, and the House Republicans establishing Medicaid, and Medicare Part A and B. As part of a compromise the phrase “used in the patients home” was inserted into the language and final bill. There is no Congressional legislative report explaining the intent of the phrase. The absence of any legislative history does not award CMS a free hand to interpret this phrase as it chooses. To the contrary, the appropriate next step in determining if CMS’s interpretation is even permissible, is to examine the remaining text of the DME section and the purposes of the Medicare Act as a whole.
There is now a bill in Congress to address the issue. What CMS must do now is take into consideration the opinions set forth from public outcry and put in place a policy that will reflect health care in the 21st century and not the standards used in 1965 when the Social Security Act was passed. This means adopting a policy that clearly defines ambulatory between that of non-ambulatory. It means that the interpretation of “in the home” is discriminatory and a violation of the integrated setting clause of the Americans with Disabilities Act and out of line with the United States Supreme Court ruling in Olmstead vs. L.C. (1999) citing unjust segregation that people with disabilities must be provided with the least restrictive environment. Laws such as the ADA were passed to integrate not segregate.
This writer understands that it is “not that simple” to fix a program as big a Medicare over night but what we are asking for is a little common sense that fits with the year 2006. Medicare is very difficult to amend due to the senior population getting very nervous and angry when it is fooled with and that is understandable. Health care is as important as education, defense and the economy. When mistakes are made, and they will be made, listen to what the American people have to say and then incorporate policy to reflect their wishes. Keep Medicare alive and well for our future because we all one day will become elderly or disabled.