I

f your health care is covered by Medicare, like more than 55 million of your fellow Americans, where you live partly determines what Medicare will pay for. The process for deciding what items and services are covered from region to region needs reform.

In our work with physicians, patients, and medical technology companies, we have seen coverage decisions ignore medical evidence and Medicare program requirements. Ultimately, these decisions place people with disabilities and older Americans at risk. One local Medicare decision, for example, established an arbitrary utilization threshold for tests to evaluate chronic gastritis, which is associated with increased risks of ulcers and gastric lymphoma. Another poorly developed decision affects a diagnostic test used for the early detection of blinding vision disorders, such as glaucoma.

There are two pathways for determining what Medicare will cover. National coverage determinations, which are developed by the Centers for Medicare and Medicaid Services, apply to all Medicare beneficiaries. Local coverage determinations set Medicare coverage for a particular service in a specific geographical region. These take into consideration regional, geographic, and population-based differences. Patient demographics in South Carolina, for example, are different from those in Alaska.

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Local coverage determinations are made by seven Medicare administrative contractors that currently oversee 12 jurisdictions across the country, along with four durable medical equipment contractors servicing different regions. The contractors follow Medicare guidelines to decide on a local level what types of items and services should be covered on a case-by-case basis and how much Medicare will pay. Most coverage decisions are now made through the local process.

The organizations we lead are seeing firsthand how decisions made by some local contractors harm patient care. For example, local Medicare administrative contractors have created uncertainty among Medicare patients who have lost limbs about whether they will have access to the prosthetic care they need. One proposed local coverage determination would restrict an individual’s eligibility for prosthetics if he or she didn’t walk with a natural gait and limit him or her to 1970s- or 1980s-era technology. As a result, people with limb loss who currently receive quality prosthetic care would no longer be able to get the devices they need to remain active and independent. In other instances, administrative contractors have set arbitrary levels on the types and numbers of tests that can be performed each day in certain regions — risking the accuracy of a patient’s diagnosis.

We are increasingly alarmed by the extent to which Medicare administrative contractors are adopting local coverage determinations from another jurisdiction as a backdoor approach to deciding what to cover. This cut-and-paste process transforms what should be a local coverage determination to a national policy without the benefit of the more stringent national process. Such adoptions can limit thoughtful discussion and timely feedback from stakeholders and advocates who are able to offer unique expertise in response to a proposed coverage decision.

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Bipartisan legislation introduced in the House and Senate will make much-needed reforms to the local coverage determination process. The Local Coverage Determination Clarification Act of 2017 (S. 794 and H.R. 3635) prescribes six remedies to improve transparency and accountability in the process:

  • Hold open meetings where contractors discuss local coverage determinations and facilitate a meaningful dialogue with affected patients and key stakeholders.
  • Disclose in advance the evidence used to draft a local coverage determination so the public can review and respond to the rationale.
  • Require Medicare administrative contractors that want to adopt a local coverage determination developed in another jurisdiction to independently evaluate the evidence supporting the determination.
  • Create a meaningful reconsideration process that involves review by the secretary of Health and Human Services in limited circumstances separate from the Medicare administrative contractors that created the local coverage determination.
  • Appoint an ombudsman to help patients and providers file appeals, track data on appeals and actions taken by contractors, and recommend ways to improve the efficiency of the appeals process.
  • Protect and ensure an aggrieved party’s access to an administrative law judge.

We represent three of the more than 120 health care organizations that support this effort. We urge Congress to take up and pass this important legislation to help better patients’ lives through improved access to innovative technologies. America’s seniors deserve nothing less.

Scott Whitaker is president and CEO of AdvaMed, the Advanced Medical Technology Association. Jack Richmond is president and CEO of the Amputee Coalition. Bruce Williams, M.D., is president of the College of American Pathologists.

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  • The authors are describing Original Medicare only. Original Medicare, which is over 50 years old and based on the way healthcare was paid for in the 1940s and 1950s, needs to be completely reformed. Making these little one-off out of context changes just makes it worse and worse.

    Luckily Original Medicare is increasingly becoming the least likely choice for people on Medicare. Most people now fully signing up for Medicare for the first time (not counting the many people who sign up for Medicare because they have turned 65 but keep working and keep getting employer sponsored insurance) are choosing the modern choice, a public Part C Medicare health program. The are over 3000 plans in the Part C program, sponsored by a wide range of integrated health delivery systems such as Kaiser and Geissenger and non profits like some Blue Cross organizations and leading medical school affiliated groups. These plans provide a wide choice of benefits and costs to the beneficiary and save the Trust Funds money compared to what is spent on people with Original Medicare.

    Forget these half baked ideas

    • You sound like an employee of a Part C company. Don’t knock original Medicare. Original Medicare can get better if the “leaders” in Washington stop using our dollars to subsidize the private Medicare Part C plans. For every $1.00 we spend for our Medicare your private company gets 30 cents of that money in the form of cash or “kick-backs” from Original Medicare!! That’s what needs to stop. We in the original Medicare have been subsidizing the private companies doing the Advantage plans for too long. I guess that’s why they are called “advantage”–taking advantage of the Original Medicare dollars. After all, some Part C private plans don’t charge any premium charge at all. How can that be–where is their profit coming from? It doesn’t take too much to figure that one out.

    • Pete Brac writes:

      “You sound like an employee of a Part C company. Don’t knock original Medicare. Original Medicare can get better if the “leaders” in Washington stop using our dollars to subsidize the private Medicare Part C plans. For every $1.00 we spend for our Medicare your private company gets 30 cents of that money in the form of cash or “kick-backs” from Original Medicare!! That’s what needs to stop. We in the original Medicare have been subsidizing the private companies doing the Advantage plans for too long. I guess that’s why they are called “advantage”–taking advantage of the Original Medicare dollars. After all, some Part C private plans don’t charge any premium charge at all. How can that be–where is their profit coming from? It doesn’t take too much to figure that one out.”

      Pete Brac sounds like a typical leftist.
      1. He or she begins with a personal insult of someone he or she knows nothing about. I am not an employee of anyone. I have been semi-retired for 15 years after years of working for myself in a business having nothing to do with health care or insurance. I spend a lot of times correcting lies like his or hers about Medicare.
      2. Next typical leftist Pete Brac segues to The Big Leftist Lie. Stalin, the patron saint of the left, would be proud of Pete. The actual facts lettered A, B and C follow;
      — anyone can look the numbers I give up by referencing Table II.B.1 of the Annual Medicare Trustees report from the last 8-10 years (prior to that the same information is available in the Trustees’ reports but the table numbering scheme differed).
      — You can look up the non-number facts in the booklet called “Medicare and You, 2018” and other government sources:

      A. For people born after 1940, Medicare — all four Parts — is completely funded by the people who receive the benefits, both in terms of the dollar value of payroll and income taxes paid into the Part A and B Trust Funds respectively over a lifetime but also in terms of monthly premiums (unless you are poor, in which case it is free or disabled in which case you did not fully fund your benefits). People born before 1940, especially before 1900 did get a taxpayer subsidy (larger the earlier you were born)
      B. The public Part C program is Public. That is what the Part in Part C means. There is no such thing as a “private Medicare Part C plan.” The only thing remotely “private” in Medicare are group retirement plans that a decreasing percentage of retirees get instead of or on top of Medicare Part B OR the expensive individually purchased Medicare supplements you see in TV ads all the time from organizations like AARP. About 20% of people on Medicare, mostly rich people, use these expensive private supplements. People on public Part C, about a third of the people on Medicare, mostly poor people, cannot buy private supplements.
      C. The $1.00/$.30/kickback statement by Pete Brac is pure crap created out of thin air (the way Stalin says to do The Big Lie) and the facts are just the opposite. Since 2011, primarily because PPACA and a later law eliminated special Part C deals for union members and the rural/inner-city poor, the average per-person cost of someone on Part C has been — as intended by the Democrats that “invented” Part C in 1995 — from 5% less to 1% less than a person on traditional Medicare depending on year. The Part C program has basically achieved the original Democratic idea. (From 1997 to 2006, the per capita cost also averaged 5% less per person because it was set by law but between 2006 and 2012 the per person cost averaged 5% more because of the special Part C deals for union members and the rural/inner-city poor that have now been eliminated).

      Notice that Pete Brac supplies no sources. Another typical leftist trick

    • Separate from Pete Brac’s leftist lies about the costs of public Part C Medicare health plans, people reaching Medicare age need to know that Part C provides amazingly better financial protection than traditional Medicare in terms of an annual out of pocket spending protection feature, almost always an annual physical exam, typically integrated self-administered drug coverage, and often dental and vision care coverage — all things not included in traditional Medicare (precisely because it is “traditional,” the way Blue Cross and Blue Shield worked 60 years ago). In other words, it is like the insurance you have had in your working lives the last 40 years.

      However Part C is accepted by only a minority of doctors and other providers. So if you have a favored provider and he or she does not accept Part C, you are out of luck. Typically Part C plans are sponsored by large integrated health delivery systems such as Kaiser or Baystate Health here in Massachusetts or non-profits orginally associated with teaching hospitals (such as Hopkins or Tufts here in Massachusetts). If your favored provider is not associated with such an organization, you probably have no choice but the expense and confusion of traditional Medicare

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