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.

Current Advantage and Prescription Drug Plan customers are not affected

The Centers for Medicare and Medicaid Services brought sanctions against Cigna-Healthspring January 21.

Cigna-Healthspring cannot enroll new beneficiaries into its Medicare Advantage and Prescription Drug plans. They are also prevented from marketing efforts. Cigna supplement plans are not involved in the suspension. The sanctions will be removed when the problems are solved, which will be decided by Medicare.

The sanctions are a result of Cigna’s poor responses to customer complaints and appeals, and problems with the Part D formulary and benefits. These problems led to difficulty obtaining and denials of treatment and medications, and increased costs.

What about those in the plans?
Current members of Cigna-Healthspring Advantage and Prescription Drug Plans are not affected. Coverage will remain and the hope is that Cigna, under the oversight of Medicare, will solve the problems that led to the sanctions.

If you’ve experienced problems with your Cigna-Healthspring plan, file a complaint with them or with Medicare. Fill out the Medicare Complaint Form here, or learn more about complaints on

How long will this last?
The sanctions will be withdrawn when the problems are fixed. That could last as long as six months, a year, or possibly into 2017. Cigna must submit a plan to correct the issues to Medicare by January 29.

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Change will save millions by preventing fraudulent claims

Prior authorization will now be necessary before Medicare will cover medical equipment such as wheelchairs and prosthetics. Prior authorization has always been required, but now it will be earlier in the process.

Fraudulent billing for these types of equipment costs Medicare millions. They expect to save big: $10 million in the first year, $200 million within five years and $580 million within ten years. In 2014, “the error rate among durable medical equipment billing was 53.1%, which accounted for $5 billion in improper payments that year.” Not all of those were intentionally fraudulent, but this new rule intends to correct many of those cases.

What is prior authorization?
Before an insurance company will cover something- a prescription or procedure- they will need to talk to your doctor and determine if they will cover it. If not, they could cover a substitute, change the dosage, or provide an alternative.
In this case, before Medicare will cover a piece of medical equipment, they will need to talk to your doctor earlier in the process than they previously had.

What equipment is affected?
The Master List of equipment that requires prior authorization includes items with “a high rate of fraud or unnecessary utilization.” They are also items that have an average purchase cost over $1,000 or an average rental cost over $100.
After 10 years, items are removed from the list. They will also be removed if the prices fall before then. In addition to wheelchairs and prosthetics, equipment like oxygen supplies, orthotics, and braces are listed.

Are there any concerns with this plan?
Some groups are concerned that the new rule will increase wait times for equipment that patients need ASAP.

To read the Centers for Medicare and Medicaid Services’ press release on the change, click here.

For more information on the prior authorization process, see this article from Healthcare Finance.

Approving new applications could significantly lower the cost of drugs

The question is how to reduce drug prices. The solution could be found in the Food and Drug Administration.

In recent months, politicians and organizations have written to the FDA, calling for the Office of Generic Drugs to reduce their overloaded system holding thousands of applications for new medications. Each of these 3,000 applications, called ANDAs (Abbreviated New Drug Applications), is a submission for a new generic drug.

Why is this important?

Generic drugs can cost up to 80% less than brand drugs. Of all prescriptions filled in the U.S., 86% are for generic drugs. Introducing new generics into the marketplace could increase competition and bring down prices across the board.

Is this a new problem?

The FDA will always have a backlog of new applications, says The Office of Generic Drugs has been receiving more applications than it can feasibly look over.

However, other groups have noticed the problem getting worse. The Healthcare Supply Chain Association (HSCA) wrote in a letter to the FDA that approval time for generic drugs increased almost a full year from 2012 to 2014. They also said the Administration has approved fewer generic drugs each year for the last three years.

More generic drug applications are being submitted likely because so many patents are expiring. Drug patents originally issued in the 1980’s and 1990’s are nearing their end, opening up the opportunity for generic versions to exist.

Has anything been done?

In the last few months, the issue has gained traction. Senator David Vitter (R-LA) wrote a letter to the Acting Commissioner of the FDA urging the Administration to reduce the backlog of generic drug applications.

Democratic Presidential candidate Hillary Clinton also wrote to the FDA, calling for expediting pending applications and clearing the backlog.

For more on the FDA’s generic drug applications, see this article from the Wall Street Journal.

Click here to learn more about the FDA’s drug approval process.

Did you know that lung cancer is the second most common cancer in men and women?

The American Cancer Society estimates that in the United States in 2014 there will be:

  • 224,210 new cases of lung cancer (116,000 men and 108,210 women)
  • 159,260 deaths from lung cancer

For seniors in particular, the largest demographic that faces lung cancer diagnosis, screenings for lung cancer offer the greatest opportunity for early detection and treatment, which in turn increases the possibility of survival. An interesting article from NBC News published yesterday discusses a proposal by Medicare to pay for this life-saving testing as a means for prevention similar to colonoscopies and mammograms.

“Experts project that the screening test, which costs $250-$300, may prevent as many as 20 percent of future deaths from lung cancer, making it akin to mammograms and colonoscopies in terms of saving lives.”

Check out the entire article from NBC News here.

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