How can they cut medicare effectively

[wvugurl26]

That $48 billion is just for Medicare. Doesn't include the federal government share for improper Medicaid payments. Also excludes Part D. Going into the 6th year of the program they still don't have a good system for estimating the Part D overpayment number. Part C estimate is said to be worthless. Conservative estimates put the number at $70 billion when you include Part D. That $48 billion number is not all fraud. That is the improper payment number which could be a lot of things including fraud.

The price for the drug to prevent labor represents the costs to get the drug approved by the FDA. While it has been previously mixed up by specialty compounding pharmacies there was no quality control to ensure one batch of the drug was the same as the next. Right or wrong getting drugs through the FDA channels cost money. Is it an absurd increase based on ingredient costs? Yes, but now that drug can be available to anyone not just those with a compounding pharmacy. The development and approval process, manufacturing and distributing in accordance with FDA guidelines is expensive. We have to pay for policing the industry somehow.

Dark law specifically prevents Part D plans from covering ED drugs for men. Some got by in the early years of the program bc of faulty computer edits now supposedly fixed. They can be covered for female patients, I forget what its used for. Apparently has an accepted off label use for females.

Medicare Advantage plans vary from one to another. I am almost positive deductibles also vary. They offer a different range of services so premiums and deductibles won't be the same. If they have an included drug benefit you should be able to search their drug formulary the same way you would for a stand alone Part D plan.

The best thing they can do to balance the federal budget and get Medicare costs under control is stop this ridiculous pay and chase model. The unicorn that is the ACOs will not be our saving grace. Cracking down on fraud will. No one pays a bill without verifying its legit. We might not pay great attention to our bills most of us at least glance at them to make sure it appears legit. I am tired of hearing the whining about delaying payments and doctors and hospitals couldn't survive the payment delay. Tough luck, the federal government should not be in the business of funding your operating cash flow. And that is exactly what it is. I'm sure lots of industries wish they could get their operating cash flow needs funded interest free from the federal government.

The providers have whined and beyotched and moaned for years about it but Medicare is finally doing it albeit starting with a small portion, the durable medical equipment. It is about time bc a lot of those billions get funneled to offshore accounts and we can't do a damn thing to recover it. When filing fradulent claims with Medicare and Medicaid ranks up there with selling coke and pot as the choice criminal activity to make money you have to change the system.

I'm sick of hearing we need to cut things that are legitimately needed. Cut down on the outright FRAUD and you will damn near balance the budget right there. IBM has offered up the software (free to boot!) on numerous occasions and they get turned down every time. Clearly our software isn't getting the job done but we turn down help? We can't afford to. And I'm stepping off the soapbox now.

[wvugurl26]

Pat my understanding is you should get the plan negotiated price for drugs in the deductible phase but you'll have to pay the whole price till you meet the deductible. Once you get to $300 or whatever the number is this year, then you should just pay the copays until you get to the coverage gap if you get there. In the gap this year you get a 50% discount on the insurer's negotiated price for a brand name drug.
If the negotiated price for premarin is $57 in the coverage gap you'd pay $28.50 but the entire $57 will count towards your Troop spending and moving you along to the catastrophic coverage stage. The remaining 50% is covered by a rebate from the Premarin manufacturer.
Also the legislation that created Part D specifically makes it illegal for the federal government to negotiate drug prices as it does with Medicaid. Auditing how the insurers and their pharmacy benefit managers (if they use them) negotiate drug prices is a nightmare bc they consider the information proprietary.
And I'm really stopping now.

[april47]

I took Premarin for about 18 years after my total hysterectomy because the doctor said I needed it because I would be miserable without it. About 4 years ago, because of the internet, I did some research and found out that it was made of pregnant horse urine and the horses were very much mistreated. They inseminated them to keep them pregnant but were kept in the stalls and never let out. If the baby lived, they were shipped overseas for food. I don't know how much of this was true but it made me sick to think of it. I quit taking Premarin and guess what. No hot flashes and NO problems.

[Deleted]

Thanks dave... i'll look to that... i don't even think that is exactly what i'm talking about...

anne... i haven't read that book, i'll put it on my list... but i've read lots of others... and i've read reports from states on the excessive drugging that goes on in their foster care systems, and deaths and other side effects (increased suicide to ... lactating boys anyone?) ... which can occur... little kids on 9 high powered psych drugs... .... heartbreaking...

[wvugurl26]

It is heartbreaking oped and is being looked into. Without going into details its very complicated to audit and a very sensitive subject to boot. I wish it was easier to fix but there's a hard road in front of us to change this. Especially considering a lot of the abuse goes in the foster system so that means you have to change each state's foster and medicaid rules. No one is giving up but realistically it will take away to change it. There's no shortcut or magic wand
oped if you happen to have links on reports from any of the states that you can share I'd be happy to look at them. I have a 2006 report from Texas that I'm working off now. I thought the Texas legislature had commissioned a new study but I have yet to find the results and it was supposedly due last November. You can PM me if you don't want to post them here.

[chiver78]

Apr 4, 2011 19:44:42 GMT -5 @patstab said:

My mom was in a nursing home only a few months. I did have a feeding tube put in over the objection of the doc, but it didn't do any good. Mom wanted to live, the doc was mad at me and telling me that before she went into the surgical suite to get ready. I said I can't let her starve to death and she raised up and said I wouldn't let you starve to death. So we had it done.

But it did no good, she had a lot of issues. I put notes on the bed, and wall and said don't lay her flat as that stuff will come up and choke her. I also told the nursing station. I went in one day, there she was signs all over and she was laying flat. Of course, she had pneumonia. She also had lost so much weight the ambulance attendant just picked her up in his arms and laid her down. I had a hard time with this but in the ER room, I told the doctor, do not treat her make her comfortable. He said I'm not sure I could help her if we did. They had already tried to put in IV's, take blood, she was bruised all up and down her arm. I said stop. She was 84. She went up to her room and I was with her the next day, she squeezed my hand, gave a sigh not long after and died. That was enough I would not put her through more. And 10 years later I still wake up with guilt over it. After I did that is when I started having insomnia. I know you couldn't help her, maybe live a few more days or weeks. But to me it was torture for her keeping her alive. She was almost blind, could not breath, in her esophagus she had aphasia and hadn't been able to swallow anything for years very well, she was always choking because the swallow reflex was gone, her lungs looked like someone that had worked in a coalmine. She had no quality of life whatsoever. There were more issues yet I made the decision to let her die, hardest thing I have ever done. My husband keeps telling me I did what I needed to do, but it was awful.

hugs. my family growing up included my Nana - Mom's mom - from the time I was a year old, she lived with us. she passed in '04, after a couple trips to the hospital where she couldn't process the oxygen coming in from regular breaths. she ended up on oxy tanks and, after an ugly fall, in the ER. sadly the night she picked to go to the ER, it was full. she was up all night before they found her a bed in the hospital, and she was given sedatives to sleep after having been up all night. her medical history says she never processed sedatives well (she got a bit loopy ), but it wasn't a documented allergy or anything. well, a couple days later, she was still sort of lucid before slipping into a haze that she never recovered from. that last period of lucidity, I remember being there with my mom. the staff brought in a lunch tray, and we helped Nana have lunch. I distinctly remember her apologizing for not being able to speak clearly, that she was still 'all there' as she said, even though the words weren't quite there. mom left to go run errands, and I helped Nana finish lunch. by the time she finished, she was so into the haze that I really couldn't understand the words, but still knew she was in there somewhere. she passed the next night.

Mom was her medical POA; Dad, my sis, and I all knew her wish of a DNR. any of us could have made the call, but thankfully Mother Nature put her solid foot down. I was the last one there with her while she still knew what was going on. I can still see the room, and the lunch tray. I know you know what your mom wanted, just like I knew what Nana wanted. it is definitely hard, but your mom is still with you...and she knows that you honored her wishes.

[Deleted]

Is that Strayhorn's stuff?

[cronewitch]

The chairs have some retail value our company has bought two used ones for one employee. We don't allow her to walk outdoors at work because she keeps falling and getting hurt. She fell this weekend she said she tripped on air, she was using a cane but it went flying so know she racked up her knee and is brused. She isn't on Medicare or Medicaid, she doesn't need a chair but we are afraid of L&I claims since she fell several times walking on the dock. The dock has bolt heads holding on some steel plates and the planks are uneven.

[cronewitch]

My ex let his grandfather die. He had a bad stroke and the doctor told his wife that it was gods will that he should die. He was not responding for a couple of days and had oxygen. His wife was in the hospital when the had the stroke so had just gone home and he was being put in a nursing home before he had the stroke because she couldn't take care of him.

We called the undertaker to ask what to do because his wife couldn't do anything and we didn't know what to do. They said call when he dies and then bring his funeral suit to the funeral home and they would take care of things.

So my ex was in his room when he stopped breathing but he didn't call anyone to revive him. He took his wrist and waited until his pulse stopped before slowing walking to the nurses station.

He was senile and in a wheel chair before the stroke and his wife had a radial mastectomy a few days before, they were married 62 years and she couldn't take care of him after her surgery. Sometimes death is the right answer.

[Deleted]

"We don't allow her to walk outdoors at work because she keeps falling and getting hurt. She fell this weekend she said she tripped on air"

I have a friend with MS who has to be very, very careful, and has taken a few bad spills in her time... Is there an underlying problem?

[cronewitch]

"We don't allow her to walk outdoors at work because she keeps falling and getting hurt. She fell this weekend she said she tripped on air"

I have a friend with MS who has to be very, very careful, and has taken a few bad spills in her time... Is there an underlying problem?

She has lots of problems the latest is mini seizures, her work is not acceptable so she is being replaced. She is forgetting basic things like last week where the light switch is for an office she has been in 14 years. We made her get her head examined and they gave her medicine but it isn't helping. I am doing her work and my work until we can find someone, she is 64 but acts 80.

[Deleted]

Apr 4, 2011 16:14:09 GMT -5 oped said:

But lots of that stuff is done today because 1) there is no legal paperwork drawn up and emotional next of kin end up asking for things that the person himself would not want and/or 2) there is no legal paperwork drawn up and the doctor and facility are covering their backsides...

My Ex died last year of liver and kidney failure. He was 64 and had been abusing alcohol for decades. It fell to DS to make the decision about whether to stop all the medical intervention and put him in hospice care. Fortunately, everyone (including my Ex's sister) agreed. Up to that point they were giving him dialysis and transfusions. He died a few days after they put him on the hospice floor, but that would have happened eventually no matter what they did.

I've been told since that in these cases there's frequently some guilt-ridden relative who hasn't visited the patient for years who insists that everything possible be done. The hospitals need a legal way to override that when there's no hope of recovery.

[Deleted]

Apr 4, 2011 20:50:03 GMT -5 april47 said:

I took Premarin for about 18 years after my total hysterectomy because the doctor said I needed it because I would be miserable without it.

I think a lot of people never question long-term med use. DS was on Adderall for a couple of years and it genuinely helped him get his act together, but a couple of years with a good psychologist helped him learn other ways to manage his ADD and he quit taking it. Of course, insurance didn't pay for the psychologist. We did. DH once put all of his elderly mother's prescriptions in a bag and took them to her doc- he cut out about half of them, including Premarin.

I'm 58 and on no prescriptions at all. I threw out a cholesterol-lowering drug because I got raging tendinitis in my elbows. The tendinitis is gone and I control cholesterol through diet and supplements. I never started on Premarin or anything similar. I'm very happy with that decision.

[Deleted]

Apr 6, 2011 6:58:38 GMT -5 Lady Gaga Gaga Snerd said:

I think a lot of the problem with pills, is that it absolves people of taking responsibility for their health.

My father (still in decent shape at age 80) once commented on the high-cholesterol selections a friend of theirs was making at a restaurant. Her reply: "well, I can just take a higher dose of Lipitor".

[Deleted]

Apr 6, 2011 7:41:19 GMT -5 Lady Gaga Gaga Snerd said:

Personally, I think the whole cholesterol craze is so much crock and bull.

Yes, some researchers believe that the connection between high cholesterol and heart attacks is tenuous at best (although I think a low-fat diet is good for you anyway). The drug industry loves inventing problems and then selling expensive solutions.

[Deleted]

Apr 6, 2011 7:28:35 GMT -5 @athena53 said:

Apr 6, 2011 6:58:38 GMT -5 Lady Gaga Gaga Snerd said:

I think a lot of the problem with pills, is that it absolves people of taking responsibility for their health.

My father (still in decent shape at age 80) once commented on the high-cholesterol selections a friend of theirs was making at a restaurant. Her reply: "well, I can just take a higher dose of Lipitor".

I once worked with a student who was trying to get her parents to stop feeding her med (she was in high school) and was told that her psychiatrist's theory was, in response to the idea that MOST teenagers will show signs of depression or angst at some point... "well, if in doubt a little wellbutrin never hurt anyone" ...

[Deleted]

From what i've read, the ONLY real correlation in cholesteral and heart attack is for men over a certain age... i'm thinking 65.. its been a lot of years since i looked into that... problem is we have INDUSTRY writing guidelines... so instead we get even LOWER 'normal' ranges handed out...

[NomoreDramaQ1015]

I have a co-worker who has siblings who have high cholesterol. He said we are talking 400-500 level cholesterol (it's genetic). He laughs at the commericals for cholesterol drugs that say that 275 (or whatever) is "too high". He said those are the numbers his sibilings doctors are trying to get them down to!

[Deleted]

Apr 6, 2011 11:10:37 GMT -5 oped said:

I once worked with a student who was trying to get her parents to stop feeding her med (she was in high school) and was told that her psychiatrist's theory was, in response to the idea that MOST teenagers will show signs of depression or angst at some point... "well, if in doubt a little wellbutrin never hurt anyone" ...

Holy crap! Antidepressants are a miracle for the people who truly need them- and I know a few. Prescribing them "just in case" is criminal. But it's another example of how healthcare reimbursement works. They'll pay to keep you on mind-altering drugs for years rather than pay for talk therapy which will (many times) eliminate the need for meds.

[wvugurl26]

They'll pay to keep you on mind-altering drugs for years rather than pay for talk therapy which will (many times) eliminate the need for meds.

I think this is what's happening with the foster system and kids. They'd rather dope the kids up than fix the real issues. Fixing the actual problems they may have is going to be a long, hard road but putting them on 4 or 5 psychotropic drugs is easy.

[NomoreDramaQ1015]

They do it with blood pressure too. A doctor tried to tell my dad his blood pressure was "high" and my dad asked how can that be because the number is exactly the same as last year's and was considered "perfect". The doctor told him they had changed the requirements for "high" blood pressure in men. My dad told him to shove it.

[midjd]

Apr 7, 2011 5:45:48 GMT -5 Lady Gaga Gaga Snerd said:

And, those drugs are not benign. They have effects on your muscles, kidneys, and liver.

Exactly. Now they have the "see your doctor to make sure ___ is right for you, may cause kidney, liver, brain problems and death" disclaimers at the ends of these ads, but it doesn't stop many doctors from pushing these drugs.

My grandmother died of liver cancer in 1992 after taking one of the statin drugs for about a year. It was kind of ironic, really... she was a health nut, ate only fresh fruits/veggies, super fit, never smoked/drank, etc. She thought her cholesterol was a little high and decided to go on this med. 6 months later, she's legal-pad yellow, and 3 months after that, she's dead.

My grandfather is very anti-drug as a result, and is still kicking at 86 with no major health problems. Maybe it's just a foolish decision based on what I've seen in my own family, but I would be very reluctant to put myself on any long-term medication for something that can be controlled by diet/exercise/lifestyle changes. Meds can be lifechanging for the right people, but shouldn't be handed out like candy.

[resolution]

Apr 7, 2011 8:50:13 GMT -5 midjd said:

Maybe it's just a foolish decision based on what I've seen in my own family, but I would be very reluctant to put myself on any long-term medication for something that can be controlled by diet/exercise/lifestyle changes. Meds can be lifechanging for the right people, but shouldn't be handed out like candy.

It is interesting how our family history influences these kinds of decisions. My family history is the opposite, the whole family on my dads side has 300+ cholesterol. The ones that have treated it are still alive and the ones that didn't treat it died of heart attacks in their 30s-50s. My grandfather died when dad was 7, before any drug therapy was around. My dad is 72 and he has been on every kind of diet, supplement and powder with limited success until the statins came out.

So in my 30s the dr found my cholesterol to be 326, normal BMI and very active with a low fat diet. I have taken the statins and lowered it to 200. It is scary when I read about potential side effects and read the debates over whether the cholesterol is dangerous or not, but in the end seeing my family history has convinced me that it is right for me. I have been to three doctors to see if there is any lifestyle changes or new supplements I can try to get off of them and the response is consistent that it is genetic and i am already doing what i can do. So although I agree they are not right for everyone, I am glad they are available because it does seem to make a difference in my immediate family.

[midjd]

Kari, I think you and your family members are probably the perfect candidates for these drugs - and I am glad they are working for you. I have a friend with genetically high cholesterol who watched his father pass away at age 32 - statins have saved him from what he used to think of as a death sentence.

The problem with my grandmother was that her cholesterol was never that high in the first place - she was just a hypochondriac who hated the thought of having "high" anything. She never should have asked for statins, and the doctor never should have given them to her. This was before every other commercial on TV was for some drug or another, I'd imagine this phenomenon has only gotten worse since then.

[Gardening Grandma]

I agree with patstab about raising the premiums.

The current budget proposal by Paul Ryan does something along that line. Seniors would be given vouchers for a flat amount. Then they'd use the vouchers to buy their own insurance on the market. Reminds me of the Part D clusterf***.
It would be a nightmare for the elderly trying to sort that out. And, of course, the vouchers would not cover the full cost of the premium. It's just a way to put more of the cost onto the backs of seniors.

One thing they could do is allow folks 55 and older to opt into Medicare. The pool would then have younger (presumably healthier) participants in it, so the risk level (and therefore costs) would go down.

[Sum Dum Gai]

Raising the premiums sucks, but realistically they need to either ration care, raise premiums, or find the money from elsewhere in the budget. There aren't many other options. The one silver lining is that Medicare is one of the few programs with so much outright fraud that it's probably cost effective to do something about that, so that will help a little.

[Sum Dum Gai]

You blame the insurance industry, I personally blame medical advances. Fifty years ago we didn't have the technology to keep people alive as long as we do now. Some of it is practically miraculous and does truly heal people. A lot of it is simply prolonging death, stretching the process out for it's own sake, with no improvement whatsoever in the quality of life of the patient. It's also wicked expensive. If we, as a society, would accept the fact that we aren't immortal and accept death when it's inevitable anyway it would save a LOT of money.

[Gardening Grandma]

Other countries have medical advances as well. Yet they manage to have healthcare for all without bankrupting their systems.... Oh wait.... They don't have profit driven insurance companies. Patstab is,again, spot on.

[shanendoah]

Let me start with the caveat that I work for a managed care organization, and I work for this company not just because it pays the bills but because I believe in managed care. Just so you all know where I'm coming from.

Medicare should not be paying suggested retail price for medications, which is what we're doing now. However, you don't have to let Medicare negotiate based on its own buying power. You could simply require that drug companies give Medicare the best negotiated rate for that drug in that locality. So if Blue Cross has neogtiated the best rate on insulin, Medicare pays what Blue Cross pays, etc.
This is actually why so many companies have Medicare Advantage plans. The insurance companies get paid a flat amount per Medicare member who signs up for their Advantage plan. Managed care (which all advantage plans attempt to do in some form or another) has a cost savings, but also, the insurance company is charged their negotiated prices for drugs, even though the flat fee from Medicare is determined based on what Medicare would pay for drugs.

More staff model hospitals and health care organizations. (My company does staff model as well as pay per service, so I've seen both sides.) We rarely hear good things about the VA, and many people blame the VA for problems at places like Walter Reed, even though that's an Army hospital, not a VA one. But study after study has shown that VA hospitals have some of the best outcomes for patients at the lowest cost per patient. A big part of this is the staff model. Their doctors are paid a salary, not a fee for service. They make the same amount of money regardless of how many surgeries, how many tests, etc. At the same time, they don't lose money on anything, either. This frees the physician up to focus on the best care for their patients.

Get the system set up for electronic medical records. Again, this is key to the VA's success. WIth electronic medical records, the VA can call up the medical records of a guy from WA who's vacationing in AZ instantly, and know what medications he's on, what treatments he's under gone, etc. Better information equals better outcomes.

Encourage people to have end of life discussions EARLY. Make sure people understand the laws regarding who makes decisions if they don't have the paperwork in place. This isn't any sort of "death panel" (though I'll address that in my next point), its medical and legal information that is important for people to know.
My father lives in MT. He knows he needs to get his end of life wishes set up NOW, because in MT, if anyone doubts any part of your mental compentency at the time your end of life documents were drawn up, the court will take over your care. Neither your wishes nor your family's wishes will be considered.
If you have more than one child, have a medical DPOA and let your kids know about it. In cases where there is no spouse, adult children are the next on the list to be given the power over your healthcare if you are incapacitated. If you have multiple adult children and no DPOA, the doctor/hospital is required to consult with every single child and get their permission before they can do anything. This makes it harder for your wishes to be followed while at the same time prevents care from being given in a timely manner.
This is information that people need to know. If doctors are being paid on a fee for service level, they should be paid for the time they spend having these conversations with their patients. (Doctors are usually more aware than run of the mill lawyers about a state's specific end of life legal policies.) Everyone, regardless of thier financial situation, should be given this information.
I will add that I think young adults needs this information as well, and also should set up DPOAs. My brother is not married. If something were to happen to him, our parents would be responsible for all decisions regarding his health care. Our parents have been divorced for over 20 years, and while they are perfectly capable of working together, not all divorced parents are. (And my step-mom would be mad that my father was talking to my mother throughout the ordeal, regardless of circumstances.)
The Terry Schiavo case made me talk to y husband and my parents regarding my wishes, so that I knew everyone was on the same page - ie pull the plug, unless you think you can get people to give you millions of dollars by fighting over it, and then wait until you're set for life before pulling the plug.

Allow "death panels", and by this I mean, adopt a system similar to that of England's system. Since they have single payer health care, the government does do a cost benefit analysis on all treatment. They have determined the "worth" of a year of high quality life and use a formula that takes into account the patients age, how long the treatment is likely to extend high quality of life, and the cost of the procedure. It means 20 year olds are more likely to get kidney transplants than 70 year olds, and I'm good with that.

The new Republican budget includes paying out lump (flat) sums of cash to states/insurance companies to turn all Medicare in to Medicare Advantage plans. I don't know all the details, but even though I'm a Democrat, I support it based on what I do know.

However, the biggest problem we face in getting any reforms passed is that the senior population is growing day by day, and they vote in record numbers. Taking anything away from them, even if it will then go toward their grandchildren, in incredibly unpopular and can result in a politician losing their job. Most politicians would rather hang on to their job.

EDIT: I mis-stated the Republican budget plan for Medicare. The plan is for vouchers for seniors, not money to the states or insurance companies. Yes, it would be a bit of a nightmare, but I'm not actually certain it would be worse than the current nightmare of trying to decide if staying on regular medicare is right for you, or if you should go to a MA plan. And if you go to a MA plan, which plan... I work in health care; I have an MBA, and I still spend close to a week every open enrollment period looking over the MILs coverage to make sure the plan she is on is still the appropriate plan.

[Sum Dum Gai]

Other countries have medical advances as well. Yet they manage to have healthcare for all without bankrupting their systems.... Oh wait.... They don't have profit driven insurance companies. Patstab is,again, spot on.

Other countries have tax rates that are twice as high as ours, obesity rates that are half what ours are, and they still ration care to a certain extent. If we double all taxes, kill all the fat people, and are willing to only get government approved procedures we wouldn't have a medicare problem either. Good luck running on that platform though.