Image: The Hill
Image: The Hill

In a weekend interview with The Washington Post, President-elect Donald Trump offered some surprising news, declaring he is nearly finished with his plan to replace President Obama’s Affordable Care Act. Trump, who is less than a week away from beginning his four-year presidential term, did not reveal the specifics of his health care replacement but vowed his plan would “have insurance for everybody.”

Trump continued, “There was a philosophy in some circle s that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”

While Trump did not elaborate on the details of his plan, he did reveal that it’s formulated down the to the “final strokes.” He said he is waiting for his secretary of health and human services, Rep. Tom Price (R-Ga.), to be confirmed before he releases the specifics.

While he was tight-lipped about most aspects of his plan, which will replace most aspects of Obamacare, he did make his intentions to target pharmaceutical companies well known. He revealed that drug companies will be forced to negotiate on Medicare and Medicaid prices. Trump also declared his plan will have lower deductibles because he plans to fight pharmaceutical companies over drug prices. “They’re politically protected, but not anymore,” he said

In developing his replacement plan, Trump acknowledged that he paid attention to critics who say that repealing the Affordable Care Act would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion.

“We’re going to have insurance for everybody,” Trump said. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people” He also insisted that Americans “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

Last week, Congress took a big step toward dismantling the ACA by approving a budget resolution that would begin repealing the healthcare law. According to House Speaker Paul Ryan (R-Wis.), the budget vote gives Congress “the tools we need for a step-by-step approach to fix these problems and put Americans back in control of their health care.”

While Trump seems all but ready to reveal and implement his replacement plan, there will likely be months of debate and Congressional infighting before the law is passed. However, Trump has warned Congress that he will use the power of his presidency (and social media) to let the American people know that Washington politicians are delaying the implementation of his replacement plan. He noted, “The Congress can’t get cold feet because the people will not let that happen.”

To learn more about President-elect Trump’s comments about his forthcoming Obamacare replacement plan and his declaration to fight pharmaceutical companies over drug prices, visit and contact Tommy Chamouris. Tommy and his staff are committed to protecting senior citizens and helping them navigate through the “Medicare maze”—at no additional cost. See our ad on page 1 of Boomer magazine.

23975375121Since Trump’s election last November, there has been a lot of speculation over how the President-elect will overhaul and revamp America’s healthcare industry.

With his recent appointments of Seema Verma to serve as the Administrator of the Centers for Medicare and Medicaid Services, and Georgia Representative Tom Price as head of the U.S. Department of Health and Human Services, there is more clarity on Trump’s vision; and, despite the hysteria, many within the health industry are encouraged by what could be in store.

Throughout the election, Donald Trump declared he would “repeal and replace” the Affordable Care Act. Now that he’s elected, it seems highly likely that Trump will deliver on his promise. Although many predicted this would be a nightmare scenario, it seems that hospitals and health insurers are pleasantly surprised with the President-elect’s first steps.

Trump’s appointments of Rep. Price and Verma, along with his recent softening on some aspects of the Affordable Care Act, is a signal to some insiders that instead of chaos, he is preparing an orderly transition to replace Obama’s health program with a plan that healthcare companies may want.

Rep. Price is an orthopedic surgeon who has drafted legislation to replace the ACA. Meanwhile, Verma has close ties to Vice President-elect Mike Pence and helped design his ACA Medicaid expansion model, Healthy Indiana Plan 2.0. She has also advised several states on how to add elements such as health savings accounts and employment requirements to their programs. If both are confirmed, experts predict more power will be granted to states in crafting individual insurance plans and Medicaid programs.

“Pence and Trump have made a big deal about giving the states more flexibility and autonomy in managing their Medicaid programs and [Verma] would appear to be the perfect person, given her expertise, to manage that rollout of more state flexibility,” said Robert Laszewski, president of Health Policy and Strategy Associates.

Of course, some have been critical of Trump’s choices and his declaration to repeal and replace the ACA. There is a fear that millions of Americans will instantly lose health insurance and there will be even more uncertainty surrounding Medicare and Medicaid. However, lawmakers, including House Majority Leader Kevin McCarthy, have indicated that although they will work to repeal the ACA immediately, there will be a two-year transition period to phase out the law and citizens currently insured by the program won’t be left without a safety net.

One plan, proposed by House Speaker Paul Ryan, will offer individual insurance with a form of Federal subsidies, provide block grant funding for Medicaid, create vouchers for Medicare coverage, and the eliminate the advance paid premium subsidies for individual insurance. Many believe Ryan’s plan will serve as the foundation of the eventual replacement plan. In the meantime, members in Congress have been already asking healthcare companies for input and advice on functional alternatives for the ACA.

While the future of healthcare under the Trump administration is still uncertain, the President-elect’s recent appointments and proposals have excited many healthcare professionals, including Kathleen Harrington, chair of Policy of Government Relations for the Mayo Clinic. Harrington is pleased with what she has heard so far from the administration over the past few weeks. She notes, “We are very encouraged with the approach we’re hearing so far from President-elect Trump in terms of having a focused review and removing certain parts of it.”

To learn more about Donald Trump’s recent appointments and his plans to reform America’s healthcare system, visit and contact Tom Chamouris. Tom and his staff are committed to protecting senior citizens and helping them navigate through the “Medicare maze”—at no additional cost. See our ad on page 1 of Boomer magazine.


More than half of the nation’s hospitals –a total of 2,597—will be facing record fines once the federal government’s new readmission penalties go into effect in the next two months.

Beginning October 1, hospitals having more patients than expected return within a 30-day period will be subject to record-high penalties. The penalties are based on the readmission rate for patients with six conditions: heart attacks, heart failure, pneumonia, chronic lung disease, hip and knee replacements and — for the first time this year — coronary artery bypass surgery.

While the same number of hospitals as last year will face penalty, the fines will increase by a 20 percent, as Medicare withholds more than half a billion dollars in payments over the next year. According to Medicare, the penalties are expected to total $528 million, about $108 million more than last year.

Proponents of the Hospital Readmissions Reduction Program (HRRP), which began in 2012, believe that these higher penalties will help hospitals identify best practices and develop a quality-improvement infrastructure that will address readmissions in the context of other priorities. Research conducted by the Centers for Medicare and Medicaid Services (CMS) supports this notion. Data shows that national readmission rates have dropped as many hospitals pay more attention to how patients fare after their release.

However, there are others who oppose these penalties because of the challenges faced by hospitals that treat large numbers of low-income patients. They argue that these patients may have recuperating because they can’t afford their medications or lack the social support to follow physician instructions.

The American Hospital Association published a report asking several physicians for their reactions to the HRRP. Doctors Karen E. Joynt, M.D., M.P.H., and Ashish K. Jha, M.D., M.P.H. candidly disclosed that “the growing body of evidence suggests that the primary drivers of variability in 30-day readmission rates are the composition of a hospital’s patient population and the resources of the community in which it is located—factors that are difficult for hospitals to change.”

Despite the continued debate, hospitals with more unplanned readmissions than expected will receive a reduction in each Medicare case reimbursement for the upcoming fiscal year, which runs from October 1 through September 2017. These payment cuts apply to all Medicare patients, not just those with one of the six conditions Medicare measured for readmission.

According to Kaiser Health News (KHN), starting in October, more than 2,500 hospitals will receive lower payments for every Medicare patient that stays in the hospital. “The average Medicare payment reduction is 0.61 percent per patient stay, but 38 hospitals will receive the maximum cut of 3 percent. A total of 506 hospitals, including those facing the maximum penalty, will lose 1 percent of their Medicare payments or more,” KHN reported.

It’s important to note that under the Affordable Care Act, a variety of hospitals are excluded from readmission penalties, including those serving veterans, children, and psychiatric patients. Despite the more than 1,400 hospitals exempt from these fines, KHN determined that 1,621 hospitals have been penalized in each of the five years of the program.

To learn more about the Hospital Re-admissions Reduction Program (HRRP) and its impact on you or your loved one, visit My Medicare Planner and contact Tom Chamouris. Tom and his staff are committed to protecting senior citizens and helping them navigate through the “Medicare maze”—at no additional cost. See our ad on page 1 of Boomer magazine.


Beginning Saturday, August 6, a federal law goes into effect requiring hospitals to tell their Medicare beneficiaries if they have not been formally admitted and why.

The NOTICE  Act is a nationwide law which addresses complaints from Medicare patients who were surprised to learn that although they had spent a few days in the hospital, they were receiving observation care and were not admitted. Observation care is when patients are considered too sick to go home yet not sick enough to be admitted into the hospital.

Often, seniors are unaware they have not been admitted because they are getting treatment and, in some cases, staying in the hospital overnight, yet they are subject to higher charges than admitted patients and do not qualify for Medicare’s nursing home coverage.

The law states that starting August 6, “Medicare patients receive a form written in ‘plain language’ after 24 hours of observation care but no later than 36 hours.” The form must explain the reason a patient was not admitted and how that decision will affect Medicare’s payment for services and the patient’s costs. This information must be provided verbally to patients and a doctor or hospital staff must be available to answer any additional questions.

According to a Kaiser Health News analysis, claims for observation care have skyrocketed in recent years. Since 2006, the total number of claims has increased 91 percent, and long observation (stays of 48 hours or more) have increased by 450 percent.

“We are in complete agreement with the notion that the patient should certainly know their status and know it as early as possible,” said Sean Cavanaugh, Deputy Administrator at the Centers for Medicare and Medicaid Services, about the legislation.

However, some are worried that the law does not require hospitals to explain exactly why a patient is getting observation care instead of being admitted. Rep. Lloyd Doggett (D-Texas), who co-sponsored the bill, said that the plain language form does not comprehensively explain “the difference between Medicare’s Part A hospitalization and nursing home benefit and Part B, which covers outpatient services, including doctor’s visits, lab tests and hospital observation care.”

Also, a study by Brown University, which was published in Health Affairs, documents the increased use of observation status for Medicare beneficiaries, and notes that, “Although observation services are often appropriate, the extended use of such services could have unintended consequences for some Medicare beneficiaries by limiting access to skilled nursing care and subjecting them to higher out-of-pocket spending.”

While the goal of the new law is to educate beneficiaries, patients who are concerned about the potential costs associated with observation status, may elect to return home and leave the hospital against medical advice, which could be dangerous to their health.

Others, particularly medical professionals, believe another flaw is that the form does not sufficiently explain a doctor’s decision to either admit or provide a patient with observation care. This is a concern because if Medicare auditors find that hospitals erred by admitting patients who should have been in observation care, Medicare pays nothing, leaving patients to pay hospital and nursing home bills worth thousands of dollars.

Ultimately, once the NOTICE Act goes into effect, patients and their families should address hospital admission status vigilantly. The patient or the patient’s family must determine the hospitalization status as quickly as possible and challenge an observational placement if they think that the status is incorrect; waiting too long may mean an expensive bill.

To learn more about the NOTICE Act and how you can prepare for its implementation, visit My Medicare Planner and contact Tom Chamouris. Tom and his staff are committed to protecting senior citizens and helping them navigate through the “Medicare maze”—at no additional cost. See our ad on page 1 of Boomer magazine.


After a successful program at YMCAs nationwide, Medicare will cover programs that help prevent diabetes among those with prediabetes.

What is Prediabetes?
Prediabetes is the condition when blood sugar levels are higher than usual, but not high enough to be considered diabetes. One in three adults has prediabetes in the United States, and 90% don’t know they have it. Without action, about 15-30% of those with prediabetes will develop Type 2 diabetes within 5 years.

What will Medicare cover?
If approved, Medicare will pay for certain “lifestyle change programs,” where a trained counselor leads a class focused on preventing Type 2 diabetes with eating habits and exercise. These programs were implemented in YMCAs across the country with a federal grant with a CDC-approved curriculum.

The YMCA programs saved Medicare $2,650 per person enrolled in the program over 15 months. Participants lost about 5% of their body weight, which significantly lessened the likelihood of diabetes.

Need convincing? Here are more results:
In one of the first studies on healthy eating habits and exercise on diabetes, the results were so strong that the study was ended early. About 3,000 participants between ages 25-75 were randomly sorted into three groups. Group 1 was treated with a healthy diet and exercise. Group 2 was treated with metformin, and Group 3 was given a placebo medication.

Groups 2 and 3, with medication, reduced their risk of diabetes by 31%. Group 1, with diet and exercise, reduced their risk by 58% and the patients lost at least 7% of their body weight. Those age 60 or older, reduced their risk by 71%. These rates of reduction have been seen in studies since.

The program will likely be covered by Medicare soon, as it doesn’t require congressional approval.

prediabetes-inforgraphicThis infographic is f

You can take the CDC’s quick test online
to see your risk of prediabetes here.

For more on the YMCA prediabetes program,
see this New York Times article.

Doctor stethoscope examLet’s take a look at what Medicare covers in regards to whether your doctor’s appointment is a Physical Exam or a Wellness visit.  The NIH, The National Institute of Health defines the physical exam as when a doctor / health care provider studies your body to determine if you do or do not have a physical problem. This exam would include inspection, feeling the body with hands or fingers, listening to you take a deep breath, while touching your back, sticking out your tongue, and checking your reflexes. Any tests resulting from this physical exam will not be covered under the cost of the exam.

Medicare Part B covers a Welcome to Medicare Visit and Annual Wellness Visits. Your Welcome to Medicare Visit is called an Initial Preventive Physical Exam (IPPE) This benefit is available for a single visit once you are eligible for Part B within the first year of your enrollment.

Services completed by your provider during your IPPE include recording and evaluating your medical history, current health condition and prescriptions. Checking your blood pressure, vision and weight. Making sure your health screenings and any shots are up-to-date, and ordering any further tests. There is no copay for this visit, and Part B does not apply to the cost of the visit. After the visit you may have to pay a co-payment for recommended services, and your Part B may apply.

Your Annual Wellness Visit is developed to provide you with a personalized prevention plan. This visit would include an assessment for future health risks and any preventive measures that may be needed. Your provider will compose a list of risk factors and treatment options just for you. There is no co-payment for your Annual Wellness visit, and they are not a part of your Part B deductible. However, you may have to pay a share of the cost for recommended tests or services.




Don’t get caught in a Medicare Pickle, let Pickle Man help you.

Get ready for a long read. Last week, the Obama Administration announced a five-year program to test alternative payment models for Medicare Part B drugs. The program will try new methods relating to drug prices, patient outcomes and physician payments starting next year.

Currently, Medicare pays doctors an extra 6% of the price of the drug they administer, which gives providers a bigger payment when they choose medications that cost more. This can lead to prescribing more expensive drugs, which sometimes differ from cheaper drugs only in price.

What is a Part B Drug?
Not all prescriptions are filed under Part D. Drugs that beneficiaries don’t take on their own, like those that are administered by injection or infusion at a doctor’s office, fall under Part B.


This image is from

What will the program do?
There will be two phases. The first phase, which would go into effect later this year, would decrease Medicare’s additional payment from 6% to 2.5%, and use a flat payment of $16.80 per drug per day. The Centers for Medicare and Medicaid Innovation are looking to see how these changes affect the way doctors prescribe medications.

The next phase, which could begin as soon as early next year, will include a series of value-based purchasing options, based on price and effectiveness of drugs. Each strategy will be tested in a different geographic area:

  • Decreasing or ending cost-sharing for Part B drugs, so that beneficiaries may access effective drugs more easily
  • Creating tools for providers to choose drugs with evidence of their effectiveness and other information
  • Options for different payments based on the effectiveness of a drug
  • Using a benchmark, or standard rate or payment, for similar drugs
  • Connecting patient outcomes with drug prices by partnering with drug companies

What are people saying?
The Obama Administration, Centers for Medicare and Medicaid Services and advocates say that the decision for which drug to prescribe should be made with factors such as effectiveness, quality, the patient’s need, and price.

Those against the payment models call it an “absurd experiment,” and believe that doctors know what’s best for the patient, and should be free to prescribe without government oversight. Some doctors in certain specialties are concerned about losing major percentages of their profits.

Comments can be submitted on the program until May 9th.

Will any group be negatively affected?
Some specialists will be more impacted than others by the program. Oncologists, Ophthalmologists, and Rheumatologists, who make a significant profit with Medicare’s drug payments, would see the biggest change in money earned. Primary Care and Family Practice Physicians would see a 44% rise in Part B drug payments, as they typically prescribe and administer cheaper drugs than other specialists.

my medicare planner

This image is from


To read more about the Part B payment program, see this NPR article.

The full proposition of the program is available online at the Federal Register.

Last year, Medicare beneficiaries continued to save billions on prescription drugs since the 2010 introduction of the Affordable Care Act. These are the total savings:

  • 10.7 million beneficiaries have saved $20.8 billion on prescriptions with discounts.
  • Average savings per person: $1,945.

These are the numbers for 2015 alone:

  • 5.2 million beneficiaries saved more than $5.4 billion with discounts.
  • Average savings per person: $1,054.

The savings are 12% higher than in 2014, and twice as many beneficiaries saved money:

  • 5.1 million beneficiaries saved $4.8 million with discounts.
  • Average savings per person: $941.

Medicare beneficiaries are also being healthier by taking advantage of their plan resources.

  • Nearly 40 million beneficiaries used “at least one preventative service with no copays or deductibles” last year.
  • About 9 million Medicare Advantage beneficiaries, and 6 million with Medicare supplements, had an annual wellness visit last year.

Last year in Virginia, over 1 million people enrolled in Medicare Part B.

  • 76.2% of beneficiaries in Virginia used Medicare Part B Free Services.
  • 19.5% of beneficiaries in Virginia had an annual wellness visit.

Read the report on Medicare savings here.

For more on the numbers, see this Modern Healthcare article.

Difference can be hundreds of dollars

The formularies of Prescription Drug Plans show if, and how, the plan covers medications. A report by the Kaiser Family Foundation shows how the costs of on-formulary drugs differ between plans.

Of those listed, most generics’ highest cost will be $10, with the median cost hovering around $3-$5 dollars. Atorvastatin spans $0 to $20. Hydrocodone can cost up to $78- double the median cost of $36. Half of these drugs treat hypertension and high cholesterol.


This image is from the Kaiser Family Foundation.

The fluctuation in pricing is more severe with brand drugs. This list includes drugs that treat diabetes, asthma and other conditions. The highest cost of 60% of the top 10 brands is over $100. In the case of Spiriva, the highest cost is over ten times the lowest cost.

How is there such a difference?
The most important questions when looking at drug costs are:
  • Which tier is the drug in? 
  • What’s the cost to the customer per tier? 
  • Is the cost in copays (a flat cost for all drugs in a tier) or coinsurance (a percentage of the drug cost)?
These can make a big difference in the cost to the beneficiary.
This image is from the Kaiser Family Foundation.
What if it’s not on the formulary?
Then costs are even higher. If your drugs aren’t covered, there are alternatives: using websites that compare drug prices and looking into Canadian pharmacies.
This image is from the Kaiser Family Foundation.
✶ In the very near future, Tom will have Word Seek, Crossword and Sudoku books for clients. If you would like one, please respond to this email or call us at 804-788-1965 ✶

New tool shows the drugs with the highest costs for Parts B and D

Medicare has created an online dashboard to show which drugs have the highest spending among Part B and Part D plans.

In the interest of transparency, CMS aims to make public the trends surrounding drug spending by Medicare and Medicare beneficiaries. They hope to start a discussion about the costs of drugs and how they could be changed.

If a drug ranks high for spending, cost increase or cost to users, it was considered for the dashboard. Overall, the dashboard represents a large portion of total spending by Medicare. The Part D drugs show 33% of overall spending. The Part B drugs show 71%.

Below are three Part D charts and information on the drugs included. See Part B charts on the online dashboard (link below).

Trends in Medicare Part D Total Spendingfor the Top 5 Drugs in 2014.


  • Abilify: treats schizophrenia, bipolar disorder, and others.
    • Generic: Aripiprazole.
  • Advair Diskus: treats asthma and COPD.
    • Generic: None
  • Crestor: treats high cholesterol and high levels of triglycerides.
    • Generic: There is no generic version of Crestor, or Rosuvastatin Calcium. There are generic statin drugs, which are generic forms of other brand drugs, but no generic version of Rosuvastatin.
  • Nexium: treats GERD.
    • Generic: Esomeprazole Magnesium
  • Sovaldi: treats hepatitis C.
    • Generic: None





Annual Spending per User by Total Spending for Medicare Part D Drugs: 2014. 


  • Tracleer: treats pulmonary artery hypertension.
    • Generic: None
  • Gleevec: treats leukemia and other types of cancer.
    • Generic: Sales of the generic imatinib mesylate will begin in February. The drug was approved in December.
  • Olysio: treats hepatitis C.
    • Generic: None
  • Sovaldi: treats hepatitis C.
    • Generic: None
  • Copaxone: treats multiple sclerosis.
    • Generic: Glatopa
  • Humira: treats arthritis, Crohn’s disease, and others.
    • Generic: Adalimumab





Medicare Part D Drugs with Large Increases in Cost per Unit, 2013 to 2014.


  • Vimovo: PPI/ NSAID; treats arthritis, pain and other conditions.
    • Generic: Esomeprazole/ Naproxen
  • Captopril: ACE inhibitor; treats high blood pressure and kidney problems.
    • Generic: Already generic
  • Digoxin/ Digox: treats heart failure and heart rhythm disorders.
    • Generic: Digoxin; (Digox is a brand drug)
  • Prednisolone Acetate: treats eye conditions.
    • Generic: Already generic
  • Clobetasol Propionate: treats skin conditions.
    • Generic: Already generic

To see the online dashboard, click here.

To learn more about the online dashboard, see this article from the Washington Post.



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