Eric Lewis’ plans of expanding his community hospital’s reach have been derailed.
As CEO of Olympic Medical Center, he oversees efforts to provide care to roughly 75,000 people in Clallam County, in the isolated, rural northwestern corner of Washington state.
Last year, Lewis planned to build a primary care clinic in Sequim, a town about 17 miles from the medical center’s main campus of a hospital and clinics in Port Angeles.
But those plans were put aside, Lewis says, because of a change in federal reimbursements this year. Medicare has opted to pay hospitals that have outpatient facilities “off campus” a lower rate — equivalent to what it pays independent doctors for clinic visits.
Therapy has taken center stage in the run-up to the new Medicare payment model for skilled nursing facilities, but a growing chorus has begun to frame the change as a return to the primacy of nurses in nursing homes — with a leading provider planning on adding 600 of them to meet the new priorities and expected demand.
As Signature HealthCARE’s senior vice president of data informatics and management information systems, Vinnie Barry and his team have taken the lead on preparing the provider for the Patient-Driven Payment Model (PDPM), set to take effect October 1. And as the Louisville, Ky.-based provider has crunched the numbers, a few clear trends have emerged: Moving forward, Signature plans to focus on honing its clinical capabilities and changing the way it markets its services to hospital partners in key regions.
While Barry expects Signature to see overall reimbursement gains as a result of the new incentives, he emphasized that the company is willing and ready to take a short-term earnings hit in order to properly staff up its facilities to eventually capture that new revenue.
Once, turning 65 typically meant retirement, Medicare and the inevitable onset of physical decline. It also often signaled the need to search for a geriatrician, a doctor who specializes in caring for the complex medical problems of the elderly.
But many of today’s older Americans are healthy, vigorous and mentally sound, with no urgent need to change doctors. They aren’t afflicted with age-related diseases or functional impairments. This raises interesting questions about when — and whether — those 65 and older need to make that switch.
Seeing a geriatrician “should never be age specific,” says Nir Barzilai, a longevity researcher at the Albert Einstein College of Medicine. “Biological age and chronological age are not the same. Asking what age to start seeing a geriatrician is not the right question. The right questions are: What conditions do you have? Are you mobile? Are you starting to get frail? Are you losing weight, or not walking well? Can you shop? Can you get to your apartment? Can you live by yourself?”
The federal government has taken a new step to reduce avoidable hospital readmissions of nursing home patients by lowering a year’s worth of payments to nearly 11,000 nursing homes. It gave bonuses to nearly 4,000 others.
These financial incentives, determined by each home’s readmission rates, significantly expand Medicare’s effort to pay medical providers based on the quality of care instead of just the number or condition of their patients. Until now, Medicare limited these kinds of incentives mostly to hospitals, which have gotten used to facing financial repercussions if too many of their patients are readmitted, suffer infections or other injuries, or die.
“To some nursing homes, it could mean a significant amount of money,” said Thomas Martin, director of post-acute care analytics at CarePort Health, which works for both hospitals and nursing homes. “A lot are operating on very small margins.”
Nearly half of all new Medicare enrollees are signing up for Medicare Advantage plans, which now account for about 35 percent of the entire Medicare market.
The other 65 percent of Medicare beneficiaries are in what’s called original Medicare, which consists of Part A (hospital, nursing home) and Part B (doctors, equipment, outpatient expenses). Those patients usually have a private Part D drug plan, and a quarter have a private Medigap supplement policy.
Medicare Advantage (MA) plans must cover everything that original Medicare covers, and they can’t discriminate against people who are ill or have preexisting conditions. Anyone, regardless of their health, can get an MA plan or switch to one during open enrollment, which continues through Dec. 7.
FOR MOST OF US, MAKING the move from private, employer-provided health insurance to Medicare is a daunting task. First, there’s the new lexicon: Medicare Advantage, Part B, Part D, Medigap – what do they mean? Then there’s the fear: “The Medicare decisions you’re about to make will affect your health care and out-of-pocket costs for the rest of your life,” says the Medicare information organization 65 Incorporated.
Yikes – that’s a lot of pressure! Take a deep breath, because with some research and careful consideration, you can find a Medicare plan that works for you. Here are the steps you should take to make the right choice.
1. Check your timing. “Timing is one of most important decisions a person can make,” says Diane Omdahl, co-founder and president of 65 Incorporated. Many people need to enroll during the Initial Enrollment Period, which is the seven months surrounding one’s 65th birthday – including the three months before, your birthday month and the four months after. Patients may be responsible for late penalties and lapses in coverage if they don’t qualify for a Special Enrollment Period, which allows you to enroll outside your 65th birthday window or during open enrollment, for unplanned events like losing a job and associated health insurance coverage.
Drugstore chain Walgreens is partnering with health insurer Humana to open senior-focused care centers.
They plan to open two locations inside Walgreens stores this fall in the Kansas City, Missouri, area with primary care services, pharmacies and other services like a Humana representative to answer seniors’ Medicare questions.
Humana will run the clinics through its Partners in Primary Care business. The unit already opened four independent centers in the area last year. The partnership is just the latest example of health insurers trying to become more consumer-facing businesses.
The annual Medicare fall open enrollment period, also known as the annual election period, is a time when people with Medicare can choose or alter their Medicare coverage. It runs from Oct. 15 to Dec. 7 of each year.
Finding the right Medicare plan to fit your needs, reviewing deductibles and understanding the prescription drug coverage gap, or “donut hole,” can be confusing when you don’t know where to look for information.
According to Paula Muschler, operations manager for Allsup, a private company that advises Medicare beneficiaries on their coverage options, the Affordable Care Act launched in 2014 has created confusion for enrollees. Medicare beneficiaries, she says, often ask about Obamacare (another name for the Affordable Care Act) and want to know: “How does this affect me?”
In 2000 about 10% of the world’s population were aged 60 or over. By 2015 that had risen to 12%. United Nations projections indicate that will have increased to 16% by 2030, and jumped to 22% by 2050. The percentages may not seem alarming but to put this into perspective let’s look at the following: by 2025, the world’s population is set to be 8 billion, of which approximately 15% or 1.2 billion will be elderly. Essentially, that is almost equivalent to the population of the second most populous country in the world – India! Another alarming statistic is the projected decline in the working-age population (25-59) between 2030 to 2050 meaning that there will be fewer people to support the growing elderly population – financially and otherwise!
But why does this matter so much? The answer is medical costs! Healthcare expenditure on the elderly is a growing concern, as it accounts for a higher share of expenditure compared to other age groups.
Nurse anesthetists often receive guidance from physician anesthesiologists, yet bill their time as if they are making decisions alone, according to a recent study(1) of more than 9,000 cases published online in Anesthesia & Analgesia. The study suggests a frequently used billing code — called the modifier QZ — gives a false impression that many nurse anesthetists practice without the supervision of physician anesthesiologists.
“Our findings show that using the modifier QZ as a surrogate for nurse anesthetists working without the supervision of a physician anesthesiologist is incorrect,” said Amr Abouleish, M.D., M.B.A., study co-author and professor of anesthesiology at the University of Texas Medical Branch, Galveston. “These findings invalidate the underlying premise of several previous studies that used the modifier QZ to determine how often nurse anesthetists provide unsupervised care. Therefore, the conclusions of those studies are not scientifically accurate.”
Nurse anesthetists have two coding options for billing their clinical care for Medicare patients: modifier QX and QZ. The modifier QX is used in a very specific situation – when the physician anesthesiologist provides a high level of care to the patient. In contrast, modifier QZ is used in several different clinical situations including supervision of the nurse by physician anesthesiologist, supervision of the nurse by another physician, and the nurse working without supervision, as well as a high level of care with limited documentation. For the modifier QZ, it is impossible, based on the above, to know from billing claims how care was provided.