Financing of Health Care for the Elderly: Who has the Money?

1. Financing of Health Care for the Elderly: Who has the Money? David Wilner, M.D., FACP, AGSF Coordinator, Geriatric Medicine Training Department of Medicine, St. Vincent Hospital @ WMC Clinical Associate Professor of Medicine, UMMS Associate Professor, GSN, UMMS Geriatrician and Medical Director, Summit ElderCare

2. Who Needs to Know? • The Doctor • Will your prescription be filled? • Can the patient afford the treatment? • Why doesn’t the patient move to a handicap apartment? • Why doesn’t the patient go into a nursing home?

3. CMS and MA data-2009-2010 • 23% of income went to health care services and premiums of those 85 and older (2003) • Lowest 20% earners pay 32% of income • In Massachusetts • 14% of population >65 (903,000 in 2010) • 36% self report a disability (325,000) • 25% need assistance with activities of daily living (81,000)

4. Data from CMS -2007

5. Monthly OOPC - original Medicare • Healthy: $515.90/month ($6,200 annually) • Part B premium 104.90 • Monthly Plan premium 0 • Inpatient Care: 35.00 • Outpatient prescription drugs: 228.00 • Dental Services: 35.00 • All other services: 100.00 • Diabetic: $651-700 (was 701-750) • CHF: $ 851-900 (was 750-950) • Heart Attack: $951-1000 (was751-1,000)

6. Medicare • What is Medicare?

7. Medicare • Federal Program of Health Care for the Elderly • CMS (Center for Medicare and Medicaid Services)- formerly HCFA • Started in 1965 • Not intended to be comprehensive • Entitlement Program • Parts A-B-C-D

8. Medicare • Part A • Pays for Inpatient Care, SNF, Hospice, Home Health Care • Acute hospital charges for up to 150 days • Pt pays $1,184 deductible per benefit period • Pt pays $296/day days 61-90 and $592 days 91-150 (once in lifetime) • Pt pays 0 for hospice care and home health care services • Inpatient Rehabilitation up to 100 days • Pt pays $148 per day for days 21 days -100 days • Home Nursing (VNA) on a case payment basis • Hospice • Financed by a 2.9% payroll tax (split between employer and employee)

9. Medicare • Part B • Pays for Doctor services and Outpatient Care and some prevention • Physician Services • Laboratory • Hospital outpatient • Outpatient PT/OT/ST • Ambulance • Vaccination: Pneumococcal, Influenza • 75 % from General Tax Revenues • ~25% from premiums • Base is $104.90 per month in 2013 if income <85,000 • premium is progressive based on income with max $335.70 per month for income over $214,000 • $147 deductible per year 2013 • Medicare pays 80% of fee and pt pays 20% (20-40% for mental health)

10. Medicare • Part C • Private Medicare Advantage plans, such as Medicare HMOs, SNPs, PPOs, PACE • Provides Parts A and B and usually D as a combined product

11. Medicare • Part D • Drug Coverage started January 2006 • Voluntary Participation • Monthly premium: each plan has a different package but income >$85,000 adds up to 66.60/month. • Maximum out of pocket expense for an individual • Pt pays first $310 is a common plan feature • Pt pays a copayment of next $2700 in drug costs • Pt then pays all of next months of drug costs until she has spent $4,700 except for 50% discount on brand name drugs under 2010 health care reform (accountable care act) • Pt pays 5% of next drug costs, unlimited

12. Medicare Eligibility • Age 65 or over- 39.6 million in 2010 • Or on Social Security Disability for over 24 months- 7.9 million in 2010 • Or receiving dialysis treatment • Patient or Spouse paid Social Security Taxes • 10,000 persons/day turning 65 in U.S.

13. Covered Medicare Preventive Services • Lipid Panel screen every 5 years • Colon Cancer Screening every 2-10 years • Annual Mammograms • PSA and DRE • Bone Density Testing every 2 years • Glaucoma Screening every 1 year • Diabetes screening twice a year • Smoking cessation counseling • Vaccination: Hepatitis B, Influenza, Pneumococcal, Td post injury • PAP every 2 years • Welcome to Medicare Exam (within first 6 months) then q 12 mo (since 2011) • AAA screening once (in former smokers) • Depression screening annually • HIV screening annually

14. Noncovered Medicare Services • Outpatient Prescription Drugs • Unless the patient elected Part D coverage • Hearing and Vision Services • Dental Care • Hospital Care over 210 days • Nursing Home Care • Maintenance Home Care • Not: EKGs, PFTs, CXRs if “screening/baseline”

15. Medicare Supplements • HMO • FCHP Senior Plan • Tufts Medicare Preferred • HMO Blue • BC/BS Medex • AARP Medicare Complete • Medicaid • Indemnity: Cigna, Aetna

16. Medicare Supplements • Cover 20 % patient responsibility • Cover deductibles • May cover some medication expenses if you choose part D coverage and pay the premium • Tier co-payments • May offer extras: eyeglasses, health club discounts

17. Cost of Medicare Supplements 2013 • Medicare Advantage Plans 2013 • FCHP $~0-202/month • Tufts $~0-196/month • Copayments cost ~$10-20 per visit • Blue cross $23-183/month • AARP: $20/month • Only 60% of patients have supplements • Medicare Advantage (tufts) annual estimated OOPC $597-5278 Source: http://www.mass.gov/ocabr/docs/doi/consumer/healthlists/medigap-11.pdf

18. Other Help to pay for Medicare Supplements • Veterans Administration (VA) • Medicaid • For indigent/ low income • 13% of those age 65 and over in MA • Less than $2,000 in bank

19. Medicine Costs • Self Pay • Insurance with Co-Pays • State Programs • Medicare Part D benefit • Indigent Drug Programs from Pharmaceutical Companies • Generic vs. Brand Name • Newer Drugs vs. Older Drugs

20. Medicine Costs HTN, Hyperlipidemia, GERD, DM2, Depression, Dementia, CAD

21. Nursing Home Costs • Considered Custodial Care, not Medical • $7,000-$10,000 per month • 70% paid by Medicaid in MA • 14% Self Pay and other • 3% VA • 1% Private Insurance • 14% Medicare (Rehab)

22. Nursing Home Costs • 50% of all persons 65 and older will use a Nursing Home • 46% of stays are for less than 12 months • 21% stay more than 4 years accounting for 2/3rds of days and costs • Women have a threefold higher lifetime risk of admission (they live longer and are more often alone)

23. Who has Money?

24. Elderly Finances • Income from • Social Security • Pension • Savings • Bank Accounts • Investments • Current Employment • Reverse Mortgage

25. Elderly Finances • No mortgage • Subsidized Rent in Elderly Housing • Reduced Taxes as lower income • Fewer Expenses: Clothing, Housing, Transportation, Taxes, School • Higher Medical Costs

27. Now you know a little about where the money comes from and where it goes! Follow the Money