U.S. watchdog finds $6.7 billion in questionable Medicare payments to insurers

By Chad Terhune

(Reuters) – A U.S. government watchdog is raising fresh concerns that health insurers are exaggerating how sick Medicare patients are, receiving billions of dollars in improper payments as a result.

Health insurers selling Medicare Advantage plans to seniors and the disabled received an estimated $6.7 billion in 2017 after adding diagnoses to patients’ files that were not supported by their medical records, according to a report released on Thursday by the U.S. Health and Human Services (HHS) Inspector General’s Office.

Inspectors found that Medicare Advantage insurers had added diagnoses for diabetes, heart disease and other conditions in 99.3% of chart reviews of patient information, even though they did not appear in records from doctors, hospitals or other medical providers. Insurers deleted incorrect diagnoses less than 1% of the time, they found.

The additional diagnoses boosted government payments to insurers by an estimated $6.9 billion, while the deleted information trimmed payouts by nearly $200 million, producing a net benefit of $6.7 billion for the companies.

“We could not see any services with the diagnosis and that raised a number of concerns,” Linda Ragone, a regional inspector general in Philadelphia and co-author of the report, said in a phone interview. “There is a vulnerability here that needs to be addressed.”

The report highlighted a group of 4,616 Medicare Advantage enrollees for whom insurers added a diagnosis that resulted in a higher payment, even though there was no record of the person receiving any medical services during the year under review.

Medicare Advantage plans are privately-run alternatives to traditional Medicare. They served 22 million people – or 1 in 3 of those eligible for the government healthcare program – at a cost of $210 billion in 2018.

The report did not identify specific insurers. UnitedHealth Group Inc <UNH.N>, Humana Inc <HUM.N> and CVS Health Corp <CVS.N> through its ownership of Aetna, are among the biggest sellers of Medicare Advantage plans. Together, the three companies have 54% of the market, according to the Kaiser Family Foundation.

America’s Health Insurance Plans (AHIP), an industry trade group, said the rate of improper payments in the Medicare Advantage program has been decreasing.

“Everyone agrees that Medicare Advantage payments must be fair and accurate, and we continue to work with (Medicare) to improve payment accuracy,” said AHIP spokeswoman Kristine Grow.

The U.S. government pays Medicare Advantage insurers based on a risk score for each enrollee. The formula pays more for sicker patients, creating a financial incentive for insurers to inflate risk scores.

The U.S. Centers for Medicare and Medicaid Services (CMS) should be doing more to prevent insurers from exploiting this vulnerability, the inspector general said.

In a Nov. 1 letter to the inspector general’s office cited in the report, CMS challenged the $6.7 billion estimate of payments linked to chart reviews as too high. The agency agreed with the report’s recommendations for increased oversight and audits.

CMS in a statement said it is “committed to ensuring that Medicare Advantage plans submit accurate information to CMS so that payments to plans are appropriate.”

Prior to these findings, Medicare estimated it had made $40 billion in overpayments to insurers from 2013 to 2016 due to diagnoses submitted by health plans not supported by medical records.

(Reporting by Chad Terhune; Editing by Bill Berkrot)

Trump to unveil order aiming to boost Medicare health program, woo seniors

By Jeff Mason

WASHINGTON (Reuters) – U.S. President Donald Trump will unveil an executive order on Thursday aimed at strengthening the Medicare health program for seniors, seeking to improve its fiscal position and offer more affordable plan options, administration officials said.

The order, which Trump will discuss during a visit to a retirement community in Florida known as the Villages, is the Republican president’s answer to some Democrats who are arguing for a broad and expensive expansion of Medicare to cover all Americans, proposals that Republicans reject.

It follows measures rolled out in recent months by the administration designed to curtail drug prices and correct other perceived problems with the U.S. healthcare system, though policy experts say those efforts are unlikely to slow the tide of rising drug prices in a meaningful way.

The Medicare program covers Americans who are 65 and older and includes traditional fee-for-service coverage in which the government pays healthcare providers directly and Medicare Advantage plans, in which private insurers manage patient benefits on its behalf.

Seniors are a key political constituency in America because a high percentage of them vote, and Florida is a political swing state that both parties woo in presidential elections.

The order is designed to show Trump’s commitment to keeping Medicare focused on seniors, administration officials said ahead of the announcement.

The order pushes for Medicare to use more medical telehealth services, which is care delivered by phone or digital means.

One administration official, who described the order to Reuters, said that would reduce costs by cutting down on the number of expensive emergency room visits by patients; lower costs would help strengthen the program’s finances.

The order directs the government to work to allow private insurers that operate Medicare Advantage plans to use new plan pricing methods, such as allowing beneficiaries to share in the savings when they choose lower-cost health services.

It also aims to bring payments for the traditional Medicare fee-for-service program in line with payments for Medicare Advantage.

Trump’s plans contrast with the Medicare for All program promoted by Bernie Sanders, a Democratic socialist who is running to become the Democratic Party’s nominee against Trump in the 2020 presidential election.

Sanders’ proposal, backed by left-leaning Democrats but opposed by moderates such as former Vice President Joe Biden, would create a single-payer system, effectively eliminating private insurance by providing government coverage to everyone, using the Medicare model.

“Medicare for All is Medicare for none,” said Seema Verma, the administrator of the U.S. Centers for Medicare and Medicaid Services, on a conference call with reporters, calling the proposal a “pipe dream” that would lead to higher taxes.

Sanders has argued that Americans would pay less for healthcare under his plan.

The White House is eager to show Trump making progress on healthcare, an issue Democrats successfully used to garner support and take control of the House of Representatives in the 2018 midterm elections. Trump campaigned in 2016 on a promise to repeal and replace the Affordable Care Act, his predecessor President Barack Obama’s signature healthcare law also known as “Obamacare,” but was not successful.

In July, the U.S. Department of Health and Human Services (HHS) said it would propose a rule for imports of cheaper drugs from Canada into the United States. A formal rule has not yet been unveiled.

The administration also issued an executive order in June demanding that hospitals and insurers make the prices they charge patients more transparent, as well as another in July encouraging novel treatments for kidney disease.

Trump considered other proposals that did not reach fruition.

A federal judge in July shot down an executive order that would have forced drugmakers to display their list prices in advertisements, and Trump scrapped another planned order that would have banned some of the rebate payments drugmakers make to payers.

The administration is also mulling a plan to tie some Medicare reimbursement rates for drugs to the price paid for those drugs by foreign governments, Reuters reported.

(Reporting by Jeff Mason; Additional reporting by Caroline Humer and Carl O’Donnell; Editing by David Gregorio)

Medicare hospital fund reserves likely to be exhausted in 2026: U.S. report

FILE PHOTO: U.S. Administrator of the Centers for Medicare and Medicaid Services (CMS) Seema Verma (C) is joined by Concerned Women for America CEO Penny Nance (L) at the White House in Washington, U.S., April 13, 2017. REUTERS/Jonathan Ernst/File Photo

(Reuters) – Medicare’s hospital insurance fund will be depleted in 2026, as previously forecast, and Social Security program costs are likely to exceed total income in 2020 for the first time since 1982, according to a government report released on Monday.

The report from the board of trustees for Social Security and Medicare also projected that Social Security funds could be depleted by 2035, leading to potential reductions in expected payouts to retirees and other beneficiaries.

U.S. healthcare costs are expected to be a hot topic during the 2020 presidential campaign, with uncertainty around possible cost-cutting solutions already weighing on healthcare stocks this year.

Senator Bernie Sanders, among a large field of contenders for the Democratic presidential nomination, has unveiled a “Medicare-for-All” plan that would eliminate private insurance and shift all Americans to a public healthcare plan.

However, Republicans have denounced the proposal as impractical and too expensive.

“At a time when some are calling for a complete government takeover of the American health care system, the Medicare Trustees have delivered a dose of reality in reminding us that the program’s main trust fund for hospital services can only pay full benefits for seven more years,” Seema Verma, administrator for the Centers for Medicare &amp; Medicaid Services (CMS), said.

The report said costs associated with the Medicare Supplementary Medical Insurance (SMI) trust fund, which covers drug costs in Part B and D in the program for seniors, are likely to grow steadily from 2.1 percent of gross domestic product in 2018 to about 3.7 percent of GDP in 2038, given the aging U.S. population and rising costs.

Cost projections for Part D drug spending, which covers prescription medicines obtained at the pharmacy, are lower than in last year’s report because of slower price growth and a trend of increasing manufacturer rebates, CMS said.

Part B primarily involves specialty drugs administered on an in-patient basis.

Trustees project that the SMI fund for Part B and Part D will remain adequately financed into the indefinite future because current law provides financing from general revenues and beneficiary premiums each year to meet the next year&rsquo;s expected costs.

The Trump administration in January proposed a rule that would overhaul the use of rebates in government-run healthcare plans, potentially ending a decades-long system under which drugmakers provide large discounts off the list price of their medicines to benefits managers and insurers rather than to consumers.

(Reporting by Tamara Mathias in Bengaluru; Editing by Bill Berkrot)

U.S. charges hundreds in major healthcare fraud, opioid crackdown

U.S. Attorney General Jeff Sessions addresses a news conference to announce a nation-wide health care fraud and opioid enforcement action, at the Justice Department in Washington, U.S. June 28, 2018. REUTERS/Jonathan Ernst

By Nate Raymond

(Reuters) – The U.S. Justice Department on Thursday announced charges against 601 people including doctors for taking part in healthcare frauds that resulted in over $2 billion in losses and contributed to the nation’s opioid epidemic in some cases.

The arrests came as part of what the department said was the largest healthcare fraud takedown in U.S. history and included 162 doctors and other suspects charged for their roles in prescribing and distributing addictive opioid painkillers.

“Some of our most trusted medical professionals look at their patients – vulnerable people suffering from addiction – and they see dollar signs,” U.S. Attorney General Jeff Sessions said.

The arrests came as part of an annual fraud takedown overseen by the Justice Department. The crackdown resulted in authorities bringing dozens of unrelated cases involving alleged frauds that cost government healthcare programs and insurers more than $2 billion.

Officials sought in the latest crackdown to emphasize their efforts to combat the nation’s opioid epidemic. According to the U.S. Centers for Disease Control and Prevention, the epidemic caused more than 42,000 deaths from opioid overdoses in the United States in 2016.

In a report released on Thursday, the U.S. Department of Health and Human Services’ Office of Inspector General said about 460,000 patients covered by Medicare received high amounts of opioids in 2017 and 71,000 were at risk of misuse or overdose.

Those figures were slightly down from 2016, but the report said the high level of opioid use remained a concern. The report said almost 300 prescribers had “questionable prescribing” that warranted further scrutiny.

Many of the criminal cases announced on Thursday involved charges against medical professionals who authorities said had contributed to the country’s opioid epidemic by participating in the unlawful distribution of prescription painkillers.

The cases included charges in Texas against a pharmacy chain owner and two other people accused of using fraudulent prescriptions to fill bulk orders for over 1 million hydrocodone and oxycodone pills that were sold to drug couriers.

“The perpetrators really are despicable and greedy people,” U.S. Health and Human Services Secretary Alex Azar said at a press conference.

The Justice Department also announced other cases unrelated to opioids, including schemes to bill the government healthcare programs Medicare, Medicaid and Tricare as well as private insurers for medically unnecessary prescription drugs and compounded medications.

(Reporting by Nate Raymond in Boston; Editing by Chizu Nomiyama and Tom Brown)

Companies need older workers: here is why

FILE PHOTO: Office workers take their lunch at a food court in Sydney, Australia May 4, 2018. REUTERS/Edgar Su/File Photo

By Mark Miller

CHICAGO (Reuters) – The demographic trend is no secret: the populations of the United States and other major industrial countries are getting older, and fast. That means workforces are aging too, but employers are doing surprisingly little to prepare to meet the challenges or adapt to employees’ needs.

In the United States, the 65-and-over population will nearly double over the next three decades to 88 million by 2050 from 48 million, according to the U.S. Census Bureau.

By 2024, one in four U.S. workers will be 55 or older, according to the U.S. Department of Labor, more than double the rate in 1994 when 55-plus workers accounted for just 12 percent of the workforce.

Many workers will face a financial need to keep working past traditional retirement ages, while others will want to work in order to stay engaged, notes Jonathan Rauch, a senior fellow at the Brookings Institute and author of “The Happiness Curve: Why Life Gets Better After 50.”

“People are getting to their sixties with another 15 years of productive life ahead, and this is turning out to be the most emotionally-rewarding part of life,” Rauch said. “They don’t want to just hang it up and just play golf. That model is wrong.”

A survey of human resource professionals by the Society for Human Resource Management in 2016 revealed a short-term mindset along with a lack of urgency among employers in assessing and planning for aging workforce.

Just 35 percent of U.S. companies have analyzed the near-term impact of the departure of older workers and just 17 percent have considered longer-term impactions over the next decade, according to the survey.

Most employers do not have a process for assessing the impact beyond one or two years, and the majority said they do not actively recruit older workers at all.

Alex Alonso, senior vice president of knowledge development at Society for Human Resource Management, thinks employers have sharpened their focus in this area since the survey was conducted.

“In most boardrooms, there is urgency around the topic these days, but the conversation is around how to sustain the enterprise, with a focus on how to manage a multi-generational workforce,” Alonso said.

Age discrimination, while difficult to prove, persists. Yet research over the past decade has gone a long way toward debunking stereotypes about older workers – that they are less productive and energetic, and less able to learn or solve problems.

But the bias continues.

Forty-one percent of companies around the world surveyed by Deloitte Consulting said they considered aging of their workforces a competitive disadvantage. The finding varied by country.

“It’s somewhat of a cultural issue,” said Josh Bersin, a principal at the consulting firm.

Employers such as Deloitte Consulting are starting to wake up to the issues as the labor market tightens, Bersin said. “I spend a lot of time with human resource departments around the world, and they are starting to realize that one of best talent pools they can recruit from are the people they already have.”

ALTERNATIVE CAREER ROUTES

Leading-edge employers are starting to think about creating alternative career routes for older workers that feature more flexible assignments and schedules, creating opportunities for them to mentor younger workers and offering phased retirement.

Deloitte, for example, now has a new set of professional career paths available for employees who are not on the track to become partners but have important specialized knowledge.

Among major manufacturers, automaker BMW is often cited as an innovator in valuing the skills and experience of older workers. The company has implemented changes to its production lines aimed at improving ergonomics of its work environment and promoting age-neutral language in the workplace.

The Columbia Aging Center at the Mailman School of Public Health in New York City has been honoring “age smart” employers for the past three years. Winning companies actively recruit and promote older workers, provide flexible work schedules and mentorship opportunities.

For example, one company honored this year, accounting firm PKF O’Connor Davies, actively hires older accountants when other firms compel them to retire. Of the firm’s 700 workers, more than 250 are over age 50. The firm offers flexible work options, including shorter work weeks.

“We’re definitely seeing growing concern about the drain of human capital among larger companies, and interest in new models for older workers that retain them longer,” said Linda Fried, dean of the Mailman School and head of the school’s Aging Center.

Fried acknowledges that some employers worry about the higher compensation and healthcare costs associated with older workers. She has proposed changing Medicare’s rules to accept older workers, allowing them to shift away from employer health plans. Other researchers have proposed incentivizing employers by creating a 40-year cap on the total years of work requiring payroll tax contributions to Social Security.

Changing attitudes also will be important.

“There is a lot more talk in business circles about the human capital value of older workers, but we’re still in early innings,” said Paul Irving, chairman of the Center for the Future of Aging at the Milken Institute. “It takes time for things to percolate.”

(Reporting by Mark Miller; Editing by Lauren Young and Matthew Lewis)

Soaring costs, loss of benefits top Americans’ healthcare worries: Reuters/Ipsos poll

An examination room is seen at an onsite health clinic at the Intel corporate campus in Hillsboro, Oregon, U.S., April 25, 2018. REUTERS/Caroline Humer

By Maria Caspani

(Reuters) – For over a year now, Americans have listed healthcare as the most important problem facing the country, according to Reuters/Ipsos polling.

When asked what concerns them about U.S. healthcare, this is what they had to say:

TOTAL COST OF HEALTH INSURANCE

Sixty-five percent of Americans said in the poll that they are “very concerned” about the overall cost of health insurance, including premiums, deductibles and copays.

This concern is consistent throughout the country: A majority of both millennials and baby boomers, whites and minorities, Democrats and Republicans were worried about healthcare costs.

PRESCRIPTION DRUGS

Nearly three in four Americans use prescription drugs, and 58 percent said they are “very concerned” about the cost of paying for them, according to the Reuters/Ipsos poll. These drugs are expected to see the fastest annual growth over the next decade, rising an average of 6.3 percent per year, according to the U.S. Centers for Medicare and Medicaid Services (CMS).

CHOOSING CARE

Sixty-six percent of U.S. adults who took part in the survey said they were concerned about their ability to see a doctor of their choice going forward.

MEDICARE AND MEDICAID

About one in three U.S. adults said they were “very concerned” about losing benefits from government-run programs Medicare and Medicaid.

Enrollment in Medicare is expected to increase as baby-boomers reach retirement age, according to CMS projections, which will contribute to growing healthcare spending.

The poll also showed that 58 percent of Americans think Congress should keep the Affordable Care Act either entirely as it is, or with some fixes, while 24 percent think lawmakers should repeal it once an alternative law is passed and 18 percent want the ACA to be repealed immediately.

The Reuters/Ipsos poll surveyed 3,982 people in English in the United States from May 22 to June 3 and it has a credibility interval of about 2 percentage points.

For more Reuters polling, visit http://polling.reuters.com/

(Reporting by Maria Caspani, Editing by Chris Kahn and Chizu Nomiyama)

How Republicans can hobble Obamacare even without repeal

People march in a "Save Obamacare" rally in Los Angeles.

By Julie Steenhuysen

CHICAGO (Reuters) – Republicans may have failed to overthrow Obamacare this week, but there are plenty of ways they can chip away at it.

The Trump administration has already begun using its regulatory authority to water down less prominent aspects of the 2010 healthcare law.

Earlier this week, newly confirmed Health and Human Services Secretary Tom Price stalled the rollout of mandatory Medicare payment reform programs for heart attack treatment, bypass surgery and joint replacements finalized by the Obama administration in December.

The delays offer a glimpse at how President Donald Trump can use his administrative power to undercut aspects of the Affordable Care Act (ACA), including the insurance exchanges and Medicaid expansion that Republicans had sought to overturn.

The Republicans’ failure to repeal Obamacare, at least for now, means it remains federal law. Price’s power resides in how to interpret that law, and which programs to emphasize and fund.

Hospitals and physician groups have been counting on support from Medicare – the federal insurance program for the elderly and disabled – to continue driving payment reform policies built into Obamacare that reward doctors and hospitals for providing high quality care at a lower cost.

The Obama Administration had committed to shifting half of all Medicare payments to these alternative payment models by 2018. Although he has voiced general support for innovative payment programs, Price has been a loud critic of mandatory federal programs that dictate how doctors should deliver healthcare.

Providers such as Dr. Richard Gilfillan, chief executive of Trinity Healthcare, a $15.9 billion Catholic health system, say they will press on with these alternative payment plans with or without the government’s blessing. But they have been actively lobbying Trump officials for support, according to interviews with more than a dozen hospital executives, physicians and policy experts.

Without the backing of Medicare, the biggest payer in the U.S. healthcare system which Price now oversees, the nascent payment reform movement could lose momentum, sidelining a transformation many experts believe is vital to reining in runaway U.S. healthcare spending.

Price “can’t change the legislation, but of course he’s supposed to implement it. He could impact it,” said John Rother, chief executive of the National Coalition on Health Care, a broad alliance of healthcare stakeholders that has been lobbying the new administration for support of value-based care.

The move Friday to pull the Republican bill only reinforces the risk to the existing law, which Trump said on Friday “will soon explode.”

“It seems that the Trump Administration now faces a choice whether to actively undermine the ACA or reshape it administratively,” Larry Levitt, senior vice president at Kaiser Family Foundation, wrote on Twitter.

“The ACA marketplaces weren’t collapsing, but they could be made to collapse through administrative actions,” he added.

NEW PAYMENT PLANS AT RISK

The United States spends $3 trillion a year on healthcare – more by far than 10 other wealthy countries – yet has the lowest life expectancy and the highest infant mortality rate, according to a 2013 Commonwealth Fund report.

Health costs have soared thanks in part to the traditional way doctors and hospitals get paid, namely by receiving a fee for each service they provide. So the more advanced imaging tests a doctor orders or pricey procedures they perform, the more money he or she makes, regardless of whether the patient’s health improves.

“We have a completely broken economy in healthcare,” said Blair Childs, senior vice president at hospital purchasing group Premier Inc. “Literally, all of the incentives in fee-for-service are for higher cost.”

Alternative payment models are designed to remove incentives that reward overtreatment of patients. Private insurers are on board, with Aetna Inc, Anthem Inc, UnitedHealth Group and most Blue Cross insurers announcing plans to shift half of their reimbursement to alternative payment models to control costs.

To promote the shift to alternative payments, the ACA created an incubator program at the Centers for Medicare Medicaid Services (CMS). The CMS innovation center is funded by $10 billion over 10 years to test payment schemes aimed at improving quality and cutting the cost of care.

The Obama administration’s decision to make some of these payment programs mandatory has drawn the ire of Price, a former U.S. senator and orthopedic surgeon. In response to a mandatory payment program for joint replacements last September, for example, Price charged that the CMS innovation center was “experimenting with Americans’ health.”

In his January 17 confirmation, Price said he was a “strong supporter of innovation,” but said he believed the CMS innovation center “has gotten a bit off track.”

TRUMP SETS WHEELS IN MOTION ON DAY 1

President Trump has already signed an executive order directing the HHS to begin unraveling Obamacare. In the early hours of his presidency, Trump directed government agencies to freeze regulations and take steps to weaken the healthcare law.

The order directed departments to “waive, defer, grant exemptions from, or delay the implementation” of provisions that imposed fiscal burdens on states, companies or individuals. These moves were meant to minimize the costs and regulatory burdens imposed on states, private entities and individuals.

David Cutler, the Harvard health economist who helped the Obama Administration shape the ACA, said Price could do all sorts of things to undermine the law.

“If he wants to blow it up, he can,” Cutler said in an email. But if they do, he added, “they alone will own the failure.”

(Editing by Edward Tobin)

U.S. healthcare costs to escalate over next decade: government agency

doctor holds hand of patient

WASHINGTON (Reuters) – The cost of medical care in the United States is expected to grow at a faster clip over the next decade and overall health spending growth will outpace that of the gross domestic product, a U.S. government health agency said on Wednesday.

A report by the U.S. Centers for Medicare and Medicaid Services (CMS) cited the aging of the enormous baby boom generation and overall economic inflation as prime contributors to the projected increase in healthcare spending.

Overall healthcare spending will comprise 19.9 percent of the economy in 2025, up from 17.8 percent in 2015, the report forecast. The pace of growth in U.S. spending on health is expected to pick up in 2017, increasing 5.4 percent over 2016. That compares with an estimated 4.8 percent spending uptick in 2016. Spending for 2016 was estimated at $3.4 trillion.

When the final numbers are in, the growth in prescription drug spending for 2016 is expected to have slowed to 5 percent from 9 percent in 2015. However, CMS has forecast growth of 6.4 percent per year between 2017 and 2025, in part because of spending on expensive newer specialty drugs, such as for cancer and multiple sclerosis.

The projections for 2016 to 2025 were made assuming that the Affordable Care Act (ACA), former President Barack Obama’s signature healthcare law widely known as Obamacare, would remain intact. It does not take into account likely changes to the law.

The Republican-led Congress and President Donald Trump have vowed to repeal and replace the ACA, but a viable replacement plan has yet to emerge.

Trump signed an executive order on his first day in office last month to freeze regulations and enable government agencies to take other steps to weaken Obamacare.

The ACA expanded Medicaid, the government health insurance program for the poor, in more than 30 states and set up private healthcare exchanges that enabled previously uninsured people to buy health insurance. After high enrollment between 2014 and 2015, Medicaid and private health insurance spending were expected to have slowed in 2016.

But spending on Medicare, the government health insurance program for the elderly, is expected to grow between 2017 and 2025 as a larger elderly population requires more medical services.

The overall insured rate of the population is expected to reach 91.5 percent in 2025, up from 90.9 percent in 2015, the report said.

(Reporting By Yasmeen Abutaleb; Editing by Tom Brown)

The facts about Social Security, Medicare may surprise you

An elderly lady walks in Copacabana in Rio de Janeiro

y Mark Miller

WASHINGTON (Reuters) – While the era of “alternative facts” dawned in Washington last week, experts from across the ideological spectrum gathered in the capital for a review of real facts about our two most important retirement programs: Social Security and Medicare.

The annual policy research conference of the National Academy of Social Insurance (NASI) focused on the group’s new report to the Donald Trump administration and Congress on the future of all our social insurance programs – those that cover retirement, but also those that protect the disabled, jobless, impoverished poverty and frail.

NASI is a consortium of many of the nation’s top social insurance researchers. The new report includes input from 80 experts in the field with a wide array of ideological and political perspectives. It describes the challenges facing these programs and provides a menu of solutions reflecting a variety of ideological perspectives.

As such, it reflects a set of consensus facts that should inform the looming debates about the future of social insurance at a time when these programs certainly will be under assault from budget cutters.

Here are a few facts on Social Security and Medicare that caught my eye:

FACT: Social Security benefits already have been cut. Raising the retirement program’s full retirement age to 70 is mentioned often as a way to solve the program’s long-term imbalance between costs and revenue. But did you know that Social Security benefits already are scheduled to be cut 24 percent? That is the average cumulative reduction in enrollee benefits by 2050 due to reforms passed by Congress in 1983, driven mainly by a gradual increase in full retirement ages from 65 to 67.

Since Social Security cannot deficit-spend as a matter of law, legislative reform will be needed by 2034 in order to avoid an immediate 21 percent cut in benefits. The reforms could include new revenue to the system, benefit cuts or a combination of both. Raising the retirement age to 70 would effectively cut benefit payouts by raising the bar on the age an enrollee must reach to receive her full benefit.

Raising the retirement age would whack benefits further, and we have much better options, including lifting the cap on wages subject to property taxes, or raising payroll tax rates very gradually.

FACT: Social Security matters to high-income households. We will hear calls to transform it into a means-tested program for the poor. But Social Security is the largest source of income for a majority of retired workers and their surviving spouses.

Eighty-four percent of all people over 65 and about 90 percent of surviving spouses over 65 receive income from Social Security, and for three-fifths of them, Social Security makes up at least 50 percent of their income. “Many upper middle class people assume that it’s mostly important for poor people, but that’s not the case,” said Benjamin Veghte, NASI’s vice president for Policy.

Proposals to restore solvency by means-testing Social Security would tear at a core design feature – its universality. At a time when a majority of households have not been able to save adequately for retirement, Social Security will remain critical.

MEDICARE: NO CAUSE FOR ALARM

FACT: Medicare is not facing a financial crisis. Politicians pushing Medicare reforms often claim that the program is teetering on the brink, but the NASI researchers conclude otherwise.

Let us start with the basics on how Medicare’s various “parts” are funded. Part A (hospitalization) is funded mainly by a 2.9 percent payroll tax split by employers and workers. For Parts B (outpatient services) and D (prescription drugs), 75 percent of funding comes from general federal revenue, with the remainder funded by enrollee premiums.

The Hospital Insurance trust fund that finances Part A can meet all its obligations through 2028, according to the program’s trustees. At that point, incoming revenue would cover 87 percent of expected costs, so there is a need to close the shortfall with additional revenue, less spending or a combination of the two.

But the NASI experts note that historical trustee projections regarding how soon the trust fund will become insolvent have varied widely – as little as two years, and as much as 28. “There’s no big cause for alarm in the current projection,” said Veghte.

Parts B and D cannot run out of money because they have permanent appropriations to cover whatever premiums do not. The cost of those programs will grow in the years ahead as the population ages, and as healthcare costs rise – especially prescription drugs. But that trend is not driven by Medicare itself, but by the cost of healthcare.

Overall Medicare spending is not out of control – per-enrollee outlays rose at an average annual rate of 5.5 percent, somewhat slower than the 6.3 percent average annual growth rate in private insurance spending per enrollee between 1989 and 2014. In addition, cost containment measures within the Affordable Care Act improved the outlook substantially, pushing the insolvency date out by 11 years.

“The problem really is healthcare cost, and how to control it,” said Veghte.

The 200-page report is exhaustive, thorough and authoritative. I encourage anyone interested in the facts on any of our social insurance programs to download it and read. You can find it here: (http://bit.ly/2kpgtNy)

(Editing by Matthew Lewis)

In-patient or not? Medicare requires hospitals to tell you

An entrance sign to a hospital is seen in Dallas, Texas,

By Mark Miller

CHICAGO (Reuters) – You are in the hospital for tests after experiencing dizziness. You are nervous about what the tests will show, but at least you do not have to worry about hospital bills – you have Medicare, so you can relax about healthcare coverage. Or can you?

Not if you are in the hospital under “observation status” – a Medicare designation applied to patients deemed insufficiently ill for formal admission, but still too sick to be allowed to go home. Observation status can result in thousands of dollars in higher costs – especially if you need post-hospital nursing care.

Medicare covers care in skilled nursing facilities, but only for patients who were first formally admitted to a hospital for three consecutive days.

Federal data shows that the number of Medicare patients classified as under observation has jumped sharply in recent years, and it has stirred a great deal of pushback from Medicare enrollees and advocacy groups. A new law – the Notice Act – requires hospitals to at least notify patients if they stay in the hospital more than 24 hours without being formally admitted. Patients will receive the warnings starting in January, but advocates argue the new protection does not go far enough.

“It does half of what we would like to see,” said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy. “The notice should also allow patients to appeal their status.”

Hospitals have been motivated to use the status to avoid costly penalties from Medicare for improper admissions under a well-intentioned effort by Medicare to control costs through a program that audits hospitals for possible overpayments. The program began during the George W. Bush administration.

The number of patients cared for under observation status doubled to nearly 1.9 million in 2014 compared with 2006, according to figures from the Centers for Medicare &amp; Medicaid Services (CMS). The majority (54 percent) were for observation stays of less than 24 hours; another 38 percent of the stays were 48 hours or less, CMS reports.

FACING HIGHER COSTS

The new notifications will require hospitals to inform patients orally and in writing if they are on observation status for more than 24 hours. The written notification, developed by CMS, is called the Medicare Outpatient Observation Notice (MOON). The MOON also explains the cost implications of receiving hospital services as an outpatient.

The costs of observation status can affect any enrollee on traditional fee-for-service Medicare. (Beneficiaries using Medicare Advantage, which provide all-in-one care, will also receive the MOON, but some Medicare Advantage plans will cover a stay in a skilled nursing facility without first requiring that patients have a three-day inpatient hospital stay.)

Medicare normally covers up to a maximum of 100 days of care in a skilled nursing facility following a hospital admission – it pays 100 percent for the first 20 days, and patients are responsible for a daily $161 co-pay for the next 80 days. But patients leaving the hospital for a nursing facility after an observation pay the full cost out of pocket.

RISING NURSING HOME COSTS

The cost of skilled nursing care is substantial, and rising quickly. This year, the national median monthly cost of a private nursing room is $7,698, according to a Genworth survey, and it runs much higher in states such as New York ($11,330 per month) and California ($9,338).

Medicaid would cover the stay if the patient meets the program’s low-income requirements (a status called “dual-eligible”). A commercial long-term care policy might provide some coverage, although many of these policies have “elimination” features (deductibles) that require patients to pay the first 90 days out of pocket.

Observation status also affects coverage of drug usage in the hospital. Medicare Part B would cover drug usage for the specific problem related to the hospitalization, subject to Part B’s typical 20 percent copay); for routine drugs that you take at home (say, a statin for high cholesterol), practices vary. Some hospitals allow patients to bring their own drugs from home, others do not, and charge much more than you would pay at a typical pharmacy.

Some – but not all – Part D drug plans will cover some of these prescription drug costs.

A broader fix to the observation status has garnered broad support from organizations ranging from AARP to the American Medical Association, elder law groups and Medicare advocacy groups. Legislation that has bipartisan support has been introduced in the U.S. House and Senate that would require that time spent in observation be counted toward meeting the three-day prior inpatient stay that is necessary to qualify for Medicare coverage.

“The bill is simple,” said Edelman of the Center for Medicare Advocacy. “Count the time in hospital, no matter what. If you are in the hospital for three midnights, you have met this requirement.”

(The writer is a Reuters columnist. The opinions expressed are his own.)

(Editing by Matthew Lewis)