The “Public Charge” Proposed Rule and Access to Medical Care

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And you thought medical jargon was unintelligible!? (Linked to full rule on DHS website).

Only one more day stands between me and freedom from anatomy! Although, as our awesome lecturers have reminded us, anatomy is a key component of the actual practice of medicine. If you don’t know cardiac anatomy, how can you listen to the various valves of the heart, one of the most basic exams in clinical medicine?

Since histology ended a week ago, most of my time has been spent with a Netter’s atlas in the anatomy lab learning the cranial nerves and all their innervations. My free time consists of going to the grocery store and maybe an episode of The Office before bed. But there is one recent JAMA article that I did take a moment to read and feel needs to be shared. 

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Health Policy Hangs in the Judicial Balance

In case we haven’t met, hi–I’m Molly and I’m a huge fan of School House Rock. Thanks those VHS’, I grew loving the checks and balances built into our government–the legislative branch creates the laws, the executive branch enforces the law, and the judicial branch interprets laws as constitutional or unconstitutional. Today we’re going to focus on the Supreme Court, the ultimate arbiter of the judicial branch. It is comprised of nine Justices with a lifetime appointment who hear and rule on cases that question federal constitutional issues or conflicts between states.

If you’ve been on social media, any news site, or turned on the T.V., you know that Judge Brett Kavanaugh has been nominated to fill the current Supreme Court vacancy. But we’re not going to delve into the allegations of sexual assault against him or the Judiciary Committee majority’s complete disregard for process, order, or even common decency today. No, we’re going to talk about the impact that one person, Judge Kavanaugh, can have on the entire U.S. health care system.Health care has certainly been on the agenda at #SCOTUS in nearly every recent decade as the federal government as gotten more involved in that policy area since creating the Medicare and Medicaid programs in 1965. But even dating back to Jacobson v. Massachusetts in 1905, when the Supreme Court upheld the authority of states to enforce compulsory vaccination to protect the public health, SCOTUS has been involved in health issues.

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A Tale of Medicare Payment Models: From Volume to Value

Yes, it costs a lot of money to become a doctor. And yes, you will likely get paid a lot of money once you are a doctor. So it was surprising that a recent survey of internal medicine providers found that nearly two-thirds of respondents lacked familiarity with MACRA, the Medicare Access and CHIP Reauthorization Act of 2015, which fundamentally alters how doctors are paid for caring for Medicare beneficiaries.

In 2017, Medicare spending accounted for 15 percent of all federal spending and is projected to increase to 18 percent by 2028. Medicare benefits payments cost $702 billion in 2017 (up from $425 billion in 2007). Add in our aging population (by 2035, there will be more Americans older than 65 than kids under 18) and costly medical advancements that can sustain and prolong life, and we’re looking at a serious problem. [The solvency of the Medicare trust fund is a hot issue on the Hill.]In one attempt to rein in Medicare spending, MACRA shifts a growing percentage of physician payment from a volume-based model to a value-based model. MACRA has four main provisions: (1) repeal of the sustainable growth rate (SGR), which determined Medicare Part B reimbursement rates; (2) change how Medicare rewards providers for value over volume; (3) streamline various quality programs under the Merit-based incentive program (MIPS); and (4) give bonus payments for participation in eligible alternative payment models (APM).

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Impact of Proposed Medicare Payment Changes on Chronic Care Management

In 2015, Medicare beneficiaries (65 and older) accounted for only 15% of the population but 34% of annual healthcare expenditures. Medicare spending steadily increases as beneficiaries age, in part due to the management of multiple chronic conditions (MCC) that require primary and specialist care, medication, and/or hospitalization, among other health expenses. MCC, or comorbidities, affect nearly one in four Americans. Chronic conditions include physical conditions (i.e. arthritis, cancer, hypertension, high cholesterol) and mental/cognitive conditions (i.e. dementia, depression, substance abuse) that last longer than one year and require continual medical attention and/or impact daily activities. According to a recent RAND report, 81% of those over 65 have MCC, including nearly two-thirds of Medicare beneficiaries.

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The Marketplace Olympics

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 Choosing a plan on the Marketplace is like the Olympics. After completing the Herculean task of actually selecting the best plan, you get rewarded with a medal. Or in this case, metal. Bronze. Silver. Gold. Plus an additional metal, platinum! All plans offered on the Marketplace must meet the Essential Health Benefits (EHB) standards created by the ACA.

The metal level refers to the amount of health care costs covered by the plan, called the actuarial value (AV).The ACA specifies that plans offered on the Marketplace must be at one of four levels of actuarial value: 60% (bronze), 70% (silver), 80% (gold), 90% (platinum). For example, a silver plan has an actuarial value of 70%, which means that the plan will pay 70% of the of the health care expenses, while enrollees will pay the remaining 30% through a combination of deductibles, copays, and coinsurance. The ACA also requires that plans have a cap on out-of-pocket expenses for enrollees. The current limits are $7,350 for an individual plan and $14,700 for a family plan. These out-of-pocket maximums are adjusted annually based on premium increases. Bronze plans typically have lower monthly premiums and higher out-of-pocket costs when an enrollee seeks care. In contrast, platinum plans typically have the highest monthly premiums and lowest out-of-pocket costs.

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