. . >> until then, a discussion on medicare part b as part of the health-care debate. this is from this morning's "washington journal." journal" continues. host: we continue our series on health care.

we will introduce you to bruce vladeck who was the health care finance industry head -- that government agency is not known for the centers for medicare and medicaid services. he is joining us to discuss medicare part a b. how would you describe medicare part b? guest: it is the part that covers physician services and a broad range of other outpatient services. it is a voluntary program in principle. when people turn 65 they are certified for social security disability. you have a choice of whether to enroll. the overwhelming majority of those eligible do because it is such a good deal. it is financed, one-quarter of the costs are financed by premiums beneficiaries pay themselves, about $100 per month

generally deducted from people's social security checks. the balance comes out of general federal revenue. about half of all payments under part b are to physicians over office visits or house calls. another chunk is paid to a patient services. the whole range of other diagnostic and treatment services, laboratories, x-rays, durable medical equipment, people who need wheelchairs or assistive devices in their homes -- a whole array of other services and goods are covered under part b. host: was the thinking behind part a and b when it was first developed? guest: an interesting historical story, the great advocates of medicare who by 1965 had been working for 15 years to get something enacted made a

conscious political decision to start with something very modest. the medicare proposal of the democratic party was just for inpatient hospital insurance and related post-hospital, nursing home care. in 1965 the republican party knowing that something would pass decided they had to come up within alternative. -- with an alternative. the camera with the program described as voluntary that would focus primarily on paying doctors. when i got to the ways and means committee its chairman said and what we do them both? so, he took the republican and democrat bill and stapled them together. that is why it medicare has had two parts ever since. host: who determines the rates paid to doctors under medicare part b?

guest: in effect the congress does. there is an elaborate process that has widespread participation by representatives of all the medical specialty societies to establish the relative prices, what the surgeon gets paid as opposed to what a general practitioner gets paid. the details and level of payment are determined in law by congress. host: does a general practitioner in montana get paid the same as one in new york city? guest: no, because part of the formula is supposed to account for the cost of maintaining a medical practice. about half of the physician fee is not based on what they take time, but what it costs to run their office or practice. rents in new york city are substantially higher than in

montana. those differences are built into the formula. host: is that where the national coverage determination comes into play? guest: no, that coverage speaks specifically to what medical procedures for tests medicare will pay for. technology is changing. medical practice is changing. medicare like every other insurer must decide if and when it will pay for some new treatment or approach. historic late, in medicare most of those decisions were made initially at the local level by the carriers, the private companies who under contract to the government manage the program. each had a medical director and they in turn had advisory committees.

when something you came along they would decide whether medicare should cover its -- when something new came along. there is an effort and reason years to have greater uniformity in national decisions. there is an elaborate process. the problem is that when you have a very publicly open, broadly representative, scientifically based process it takes a long time. the number of decisions that can give made through the mechanism are not large enough. there is still a lot of reliance on medical directors and individual regions -- in individual regions of the country. host: you referred twice to the elaborate process of setting rates. where does it start? guest: it starts with the legal framework that enacted into law

something called a resource- based relative value scale developed by a group of physician and social science experts based primarily at harvard in the late 1980's. they undertook this study to compare the value of something one physician did to something another did. in 1990 congress wrote into law that the scale should use. they also provided for a process of regular updating. as medical technology changes and new treatments become available, as new approaches receive consensus approval within the medical community, there is a committee that operates, but it is run largely by the medical

profession who meet regularly. once a year the make changes in the code. they add new categories of service. there is an extensive, prolonged process to get a new procedure from the time it is first approved by specialty society or the fda through the experts into the payments system. host: do doctors lose money on medicare patients? guest: no, the question is whether they earn as much from taking care of medicare patients as from privately-insured patients or those to pay out of pocket. that really depends where they are. their ratio of what medicare pays for certain positions services to with the prevailing price is in the private

insurance market varies dramatically from one part of the country to another. in some parts of the country medicare pays substantially less than private insurers do. in other parts it pays a similar amount. in a few parts medicare actually pays more than private insurers. it varies. it is a national program, but local insurance markets varied substantially. host: of the $460 billion or so that medicare spends every year, what portion comes from medicare part b? guest: just over a quarter at the moment. that is a little misleading because another 25% of the cost of medicare is paid to medicare advantage plans which we will

talk about more. about half the payments eventually go to physicians. from part b from legal and accounting sense it is about a quarter of the cost. host: we want to hear from you. we are discussing medicare parts b, the health insurance, medical insurance portion of medicare. we have divided our numbers a little differently today. if you are 64 or under, the first line. if you're 65 or over, the second phone number. healthcare professionals particularly we want to hear from also. that is the third line. bruce vladeck is our guest. he was head of the agency during the clinton administration that is now known as the medicare and medicaid services. we're also joined by mary agnes

. how is medicare part b debate going in congress with regard to reform? guest: they're looking at various things. bruce mentioned a possible change in the payments to insurers to help pay for reforming the they are also looking at possibly reducing payments to some medicare part b providers, skilled nursing facilities and such. there is data out there that indicates perhaps they are overpaid. i'm sure there would disagree. there could be savings from those payments. also, in the house democrats' bill that would pay more for primary-care services provided by doctors and other

practitioners. they are looking at closing those holes in the prescription drug benefit. they're looking at way beenco- payment for some preventative measures. host: besides dr. payments, the nurse practitioners and home health care is paid by part b? guest: yes, and there is some concern that maybe there is too much spending on home health- care services. the advisory board to congress has indicated that the sector does not necessarily need more money. host: who sits on that medicare advisory board? guest: you have people from academia, people in the medical professions. you also have hospital administrators. they try to have a cross section of experts. the present those used twice per year to congress. host: in the current debate,

which groups are quite active? guest: of course, it really all of them. the hospitals are concerned about what reform might do for them. physicians are concerned. all these providers whether home health agencies, skilled nursing facilities, durable medical equipment -- they are all concerned. they're concerned about how it is financed and hiking get more people covered. how can you make it more efficient? it is all part of the debate. host: bruce vladeck, if someone signs up for medicare part b, again, what are their premiums every month? are there out of pocket expenses? guest: the me begin backers. the out of pocket expenses is a real problem with medicare

program not so by any proposed legislation -- let me begin back worwards. it is about $96 per month for it unless they are high in come in which case the pay more. there is an annual deductible in which most services have the 20% signsco-pimm a. medicare pays 80% of the approved price and the beneficiaries must pay the balance. -- the services have the 20% co-payment. if you spend more than $2,000 per year or so out of pocket, over that the insurance pays 100%. there is nocap in medicare and neck to be a problem for many beneficiaries.

as a result, the limitations in part b, and high out-of-pocket expenses -- most you can afford to get some kind of supplemental insurance. some have a private retiree health insurance that fills in those holes. some and roll it in medicare advantage plants which frequently have lower out of payment -- out of pocket payments -- and some enroll in that. host: let's go to calls. ava, from orlando fla., on our 65 and over line. caller: thank you. the dirty little secret is that you can get any insurance if you're 65 or over except medicare.

believe me, i know and do not trust the system. i got caught in the system. i got disabled and had to go on medicare. i have enough on my plate, so i chose to go to the advantage plan. this obama scheme will take money away from me. i'm using mybrain and trying to save the taxpayers' money -- i am using my brain. i had nearly died three times. host: thank you for calling in with your personal experience. mike, in la grange, texas. caller: yes, it is ridiculous what medicare pays for the hardware. i have a machine that medicare

pays $75 per month for this machine. i founded on the internet where it retails for $239. they have been paying $75 per month for about 10 years. it is the same thing with wheelchair's. it is ridiculous. you're just giving money away. i cannot understand. host: bruce vladeck, medicare part b is for this durable medical equipment, right? guest: yes, and i could not agree more caller. every administrator in the agency going back to the 1980's has tried to change what medicare pays for durable medical. medical we have proposed changes in fees and -- what medicare pays for

durable medical equipment. we have proposed changes in fees and changes in bidding. every single time live executive-branch under both parties to eliminate those overpayments, the congress has prevented it. my former colleagues continue a used to drive me crazy on a particular issue of pain for in- home oxygen where medicare pays about three times as much as the veterans administration or some private insurers for machines to provide people with it. i used to run around the office modern that we're pain $300 billion per year for air. yet every effort for the last 20 years or so to reduce medicare

payments for oxygen has run into a large lobbying campaign from the supplier industry, generally organized to frighten beneficiaries to say that if you let this go ahead congress will cut off yourair supply. congress has stepped in to prevent reductions in oxygen payment every single time. host: mary, are there talks about cuts for medical equipment in the current debate? guest: last year it they had the entire system to set up competitive bidding. vendors were selected and in congressional pressures stopped it. representatives of the sector put a lot of pressure on congress saying that you heard beneficiaries with this step. critics say that your hurt and fishers. the obama administration and

others are interested, but you can expect a strong political. host: can you both talk about the political aspect of the medical guest: fee structure please go ahead, bruce. there is always a local concern and pressure within congress. it is sort of a zero sum game. there is a stress between urban and rural areas. it plays out in the debate over medicare reimbursement. host: bruce vladeck? guest: a basic problem in american politics, the political scientist talk about this and have for years -- if you're the average taxpayer or member of congress, medicare's overpayment for oxygen which is egregious but it may cost you an extra $5 or $10 per year out of pocket as a taxpayer, for the oxygen

suppliers it is their entire livelihood. whenever the issue comes up before congress the people who benefit from government payments are much more involved in vocal than the average citizen who has lots of other things to worry about and for whom it is a relatively small piece of a big puzzle. i used to say that medicare spent so much for oxygen and $1 billion went to provide for this, and someone to lobbying, and so on. host: here is a message from twitter. could you both talk about medicare and whether or not it leads to inefficiencies in the

health care system? guest: we have had as a matter of policy and still do, including in president obama's proposals and bills that passed the house, an unwillingness to really take on the sellers in the marketplace and in the sense that the only way to get more effective control over the rate of health care costs is to give the buyers relatively more power. look at other countries which have universal coverage and lower-cost and many of them still rely heavily on private insurance. all except for britain. what is different is that they

basically legally provide a mechanism by which the big paris, both government and private sector, can negotiate -- the big payers, negotiate with the sellers of the services. in the u.s. most insurance companies do not have enough clout to tell physicians what they can charge or negotiate with them. you have the following political cycle that occurs with medicare every year. the physicians, hospitals are able to basically charge what they want to the private health insurers. that creates a gap between what private insurers pay and what medicare pays. there are enormous pressures politically on medicare to catch up. as long as we have half or more of the business in a market

where the sellers can charge any price they want, it will be hard to control costs. guest: there is very little coronation of care in the fee- for-service sector. there is a lot of concern that cents is paid by the service, you're simply providing an incentive to provide more services. that drives of cost. there is discussion concerning the coordination of care. how to do the better and how it could reduce costs. host: judy is a health-care professional in washington. caller: good morning. thank you for c-span and for this subject. i have been waiting for it. i have been in the medical care business since 1973. and the certified procedural and diagnostic coder as well as a medical practice management person. i discovered from the time i

began dealing with all the insurance carriers that things are going fairly well until the cpt system came into a fight. there are over 10,000 procedural terminology coats -- came into effect -- in determining what doctors will get paid for what. i remember whennother thing came into effect, and prior to that time the fees were based on the locality. if one doctor charge $50 for a procedure and another charged $40 for the same, then the powers that be would look at this and decide that it must be $40 and pay everyone that. but is an 80/20 plan.

i also found that medicare, when it approved the medicare qualified hmo's which now call medicare advantage, that is when everything went to pot. i believe that through the hmo plans because they have a gatekeeper and try to corning care, they actually reduce care. the get incentives for not doing certain things. you know that that is true. -- they get incentives for not doing certain things. it seems that in order to revise medicare -- i do not think medicare per se is the problem. i think our seniors deserve that care. i think that part a works well. i do not believe in what they call the -- i am sorry, the

diagnostics, the drg's. that is how hospitals get their payments. they are restricted in what they can actually do. they come up with clever ways of going above that. i remember when durable medical equipment was not covered at all. host: what kind of reforms would you like to see to medicare part b? and i have a follow up with you. caller: first of all, my thought on the whole health care reform is that medicare part b should go back to c for service in that durable medical equipment should be revised. it is ridiculous for an equipment company to charge

$32.90 for the use of water per month you can buy over the counter for $139, but people are caught up -- for the use fo a walker. when you are in the hospital there are coordinators' of car . the patients are often elderly and do not understand. if you took away the hmo portion of the medicare part b and put it back to a fee for service, and make it instead a 75/25 plan with a more reasonable deductible. right now the deductible is about $500 for hospitals. i cannot remember where it is right now for part b -- what is

it? guest: about $140. host: what is it that you do? guescaller: i am a procedural ad diagnostic specials. i have a boeing co. and do electronic billing and practice management -- i have a billing company. it was started in 1989 when billing was just in its infancy. host: who are your clients? caller: i have a physician's, durable medical equipment, and first assistant nurses. host: thank you for calling. let's see if we can get some response, beginning with bruce vladeck. guest: a couple of points, if i can. first on the cpt coding system

now used by medicare and most other insurers, i agree with the callers criticisms. host: what is cpt? guest: common procedural terminology, and it is the allegra said of coats that says if you have to removal -- and it is itset of codes that says if it is the removal of a wart it is .17 and so on.. it is owned and copyrighted by the american medical association. every one of them generates a royalty to the ama. it is a major source of the association's income.

ever since medicare began to use cpt in the late 1980's, every effort to replace it with something more streamlined and modern and effective has been energetically resisted by the largest physicians' group in the country. so, we ought to replace it. part of the political deal in effect between congress and the ama over the last 20 years is that there would accept some aspects of the fee schedule they did not care for as long as the government was committed to continue to using the coding system they owned. it is time that the changes. . .

as the caller mentioned, someone offers them all these services. people need a way to navigate that. do i need this, do i not need this? i think is going to play out in the debate. host: there is a lot of talk about fraud and waste. at what is the talk on capitol hill, and what is your view? guest: we have seen story after story about medical equipment, providers and miami as a hotbed for that. it there has been a lot of discussion and investigation. this will continue to be part of the debate. maybe bruce can talk about this. to quantify how much waste, fraud, and abuse is in medicare. there is in medicare, and

it's of great interest to finance the health reform bill, as more of us grow into the medicare population, it will be more expensive and take more of the government spending to pay per -- for the program. and waste and abuse plays into medicare now and into the future. host: bruce vladeck? guest: it's hard to tell how much waste is in the program, one's person waste is part of the medicare. medicare spends so much money that a small portion is still a lot of money. we have no idea how much fraud and abuse there is in the rest

of the medical market. but we have no reason to suspect that it's less proportionately in medicare, and could be more, because the penalties are less severe than in a government program. the answer is that no one knows, it's clearly in the billions of dollars, because one percent of medicare is $4 billion. and we need to do a better job of not just protecting and prosecuting but preventing it in the first place. and interestingly congress is willing to spend more money on prosecutors and reluctant to invest in the companies that

they have to prevent fraud at the onset. host: that caller said she wanted to see a fee-for-service plan to come into effect, do you agree with her? guest: i don't understand the question, three-quarters of medicare servers is under part "b" and i understand she was being critical of the hmo's and there is a lot of emotion around the quality of service provided by the advantage plans as opposed to the fee-for-service system. and i hate to tell advocates of either side, we have a lot of data of the managed care and those in the fees for service are not that great, doctors are

doctors which ever service they are in. host: jamie, we have on the line of 65 or older. >> caller: i have a question, why doesn't medicare pay for physicals. when i called about physicals, they said they don't pay for them. that's question one, i am anemic and i have to take this here shot that costs $4,300, and it's run by the government, i can't get it whether on medicare or 60 or 40, why does the government choose to run that shot? and the other thing i would like to know, the inhome care

that's gone to people. is there a lot of waste there? and sometimes people don't know that can get inhome health care through medicare, they are not told that by their doctor, ok. and the other thing i wanted to ask, which i have never heard in all the conversations in the health care system being discussed, is where does workers' comp fit in this at all? and i will take my answers offline. host: thank you, bruce, you want to start? guest: i didn't understand the question of anemia, could you restate that? host: the caller is gone. could you talk about physical.

guest: medicare will first pay for a comprehensive exam, it does not pay for routine check-ups afterwards. it does pay for routine checks for breast cancer, and so forth, but it's a hole in the program and prior to 1965 private companies did pay for physicals, and when we try to get them covered, the budget feel it will cost too much money. it's a hole in the medicare system. host: inhome care, under part "b"? guest: most is paid under part "a," medicare pays inhome care only when a patient has a

particular medical need, and the inhome services address the particular inhome need. it's the definition of who should get the inhome and shouldn't. and it's the norm in the insurance industry and private and public, basically if you need a nurse in your home to administer medications or vital signs or physical therapy or speech therapy, medicare will cover it to an extent, and if you need those services it will cover those in the home. it's tied to a medical treatment for a specific illness, generally after a hospitalization.

host: and does workers' comp fit in this at all? guest: most are no longer working, but the law is specific, if you are entitled to health care payments or reimbursement under workers' compensation or under automobile insurance laws or tort laws, there is a very sophisticated way to make sure those insurance programs pay their share and medicare only pays the balance. and is there a very sophisticated operation which medicare collects back from the workers' comp company and auto programs, the share of the cost. host: we have a tweet from judy, it's about the money to get their laws passed by congress.

this must stop for change, who are the ones under reform? guest: well, the health care providers are powerful and anyone that provides in the medicare are powerful. all of these extremists are at play and here in washington. and we have ads and it's a fee for pitch now and know that congress is looking for reform. host: what is the kaiser health news? guest: this is a national, not for profit news service, our stories run on our website and all over the country. we are a program of the kaiser family foundation but independent of that. host: next we have richard, from new york city, a health

care professional. caller: yes, good morning, i am wondering as everyone harps on the medicare industry in terms of flaws. if you look at the overall pattern of medicare and the medicaid rates, i know is not a part of the discussion, but the current rates is so fraudulent, and no one seems to pay attention to that. host: richard, what do you do? caller: i am a surgeon. guest: i don't understand the comment that it's fraudulent. host: unfortunately he's gone. mary agnes, you want to touk to that? guest: of the congressional pressure involved, maybe that's

what the caller is talking to and has a disagreement and thinks they are too low. host: mary agnes, are doctors satisfied with medicare part "b" and the reimbursement schedules? guest: i think it depends on who you talk to, most physicians would like to make more money, the benefits feel that some doctors are happy. and the data from the med-pac show that beneficiaries do have impact which indicates that doctors still take the program. host: how influential is med-pac and how important? guest: i think they are

incredibly influential and when they come to congress and make recommendations, and we talk about the political pressures pushed back. sometimes congress doesn't always take their advice. there is discussion on capitol hill of elevating the med-pac and make recommendations to congress that would go into effect unless congress acted to stop them. so there is discussion to give med-pac more clout. host: bruce, was med-pac head of you? guest: we worked close with them, i was a member of a part of med-pac, we had respect of their work and we thought along similar lines about particular issues. and you know they do very good work. as some of their own members have said in recent months, one

of the reasons they are able to perform as effectively as they do, is because they are making recommendations and not final decisions. that has two implications, one, they are not subject to the legal requirements that occur in the american governmental system of people that have to make formal decisions. and second, they have somewhat greater freedom of action in saying what they think, as opposed to satisfying various constituencies. a superb group of med-pac does not show how they would perform if people had to adopt their recommendations. host: ed, good morning, on line under 65. caller: thank you for taking my

call, my wife and i are both in our 50's. my wife retired early and i am contemplating retiring. it's a scary proposition to do this these days with the cost of health insurance. during the presidential primaries, i heard governor richardson from new mexico talk about retirees and early retirees that retire in their 50's. the opportunity may be to buy-into medicare. and i know we are talking about medicare part "b," but i would like the opportunity to buy-into medicare as a whole. and the discussion of medicare having financial problem, if you have a younger group of people willing to buy in, instead of giving to the private insurance, i thought it would be a way to help medicare.

host: mary agnes, discussion of that? guest: there is a discussion of that with a buy-in of if i -- of if i --55 or higher. there is a group that may not do this because of insurance they cannot afford, this is part of discussion on capitol hill, do you allow an early buy-in. host: go ahead. guest: could i comment, if you have mechanisms to ensure that everybody can buy insurance through a health care exchange, you don't need the early buy-in. the advantage of what is in the house bill as opposed to the early buy-in, again medicare

benefits are not as generous as they should be. but no question that early retirees and people in their early 50's and 60's that don't have employee based health insurance, are totally in enormous trouble, and they are the folks that would be the biggest beneficiaries of health care reform. the reason i believe that the current administration has not opposed it, because they know it would be the immediate attacked but the most efficient and least expensive way to get coverage to people that are 55-65 of people that can't get it in the private insurance market. host: rela, go ahead.

caller: thank you, i will cover this fast, the nursing home system is atrocious, and no one cares the fact that what medicare offers or is supposed to offer is not happening. i would like to see somebody walking around in different nursing homes without advising them they are coming, and this happens constantly. you know these people lay there in beds that are supposed to get physical therapy, it doesn't do any good to give someone physical therapy for six weeks and drop them. they are not getting the care that medicare supposedly ?g offers, it's like waste or something. i get so disgusted. i am well over 65 and hopefully i never end up in one of those places. but it's not just that,

medicare needs to look at health care for the elderly preventative. you know teeth, hearing, glasses, stomach, whatever. those are the problems coming up. and it's not covering certain things, i don't understand why the people we elect, appoint or pay their salaries, they don't seem to care. host: we will leave it there, when it comes to nursing homes and medicare part "b," bruce vladeck. >> -- guest: it's not a part "b" problem, but that covering the inspections of homes, has not increased in 20 years. with the increase of the facilities and the increased

requirements, as a nation this is a service that's gotten lost out on the pressures of the federal government on the desire to starve the beast, as a noted political commentator said, we are noting the problems of the facilities. and the kinds of problems that the caller talks about is a result of that. host: mary agnes carey, what is the role of doctor training? guest: they are paying from medicare to ñzhospitals for the transpositions. and that's part of the medicare program, that's how i understand it. host: bruce vladeck. guest: well medicaid paid the costs of the programs, when

medicare moved away from cost- payment in 1993, there was a provision for recognizing those costs and still does. that's only the direct medicare cost, and there is a lot of discussion and pressure of how medicare ought to do more of training the shape of health professionals. medicare is the only insurer that subsidizes health care. and we have problems with the trust funds and expenditures. again this is another area that's vital to the public, over the last 20 years as a result of tax cuts and other decisions of public policy. we have stopped spending money, and have a growing shortage of

physicians and nurses and other health professionals. and health reform is not going to fix that or medicare. it will only fix it as a nation, as we grow up and decide that it's a public responsibility to ensure the health care professionals. host: allen is a health care professional. what do you do? caller: thank you for taking the call, i have over 40 years of experience. i joined h.i. p. of new york, as a pre-paid private system. back then all the doctors were sal ride. -- salaried. and prior to medicare, it had problems because patients had to wait months to see doctors in some cases. and this is the model for the single payer that i am really

against. but going back to medicare, the insurance companies to me need to be addressed. now the federal health care benefit program has all insurance companies go through an accreditation process. this is a process where they are evaluated. not all insurance companies can sell to federal employees because they don't meet their standards. this is one of the best cost controls we could have. and also other measures to bring down the cost. i had one person in our community who told me about seven injections, and the doctor got $27,000 from medicare. and that rang a bell with me so fast. i did call a supervisor at medicare to find out what that

c.p.t. code was that allowed a physical with nerve-end injections to charge that kind of money. it was outrageous. host: allen, you are a doctor? caller: no, what i did, every piece of paper that came across from insurance companies and hospitals, like lagaurdia, at one time they came across my desk. medicare retentions and reform in 1993, and a pharmacist and drug committee and that was the team put together, and i was a member of that team. they saved $10 million in the first year. and for premium rates for h.i. p. for new york, there was enough for profit for insurance companies at that time and

since then they have gone bust. host: ok, thank you, bruce vladeck. guest: i can only imagine in the content of political discussions in the last month, how people would react of some committee in the federal government to establish a national formary of which drugs can be used and not. i don't think we are prepared as a nation to accept that. we don't as a nation, as a political choice regulate dietary supplements. we are just not there. on the issue of certifying or approving health insurance companies, as is done for the federal health employee government. that's what the house of representatives would do, it would n+÷set a high set of

standards for companies to participate in the new insurance exchanges and participate in the individual and small group market. and finally, i want to reassure the caller that h.i. p. is alive and well in new york.qo after their merger with group health, they have changed their name to amle health, but it's the same company and many of the same folks in management enrolled in the program and they are doing fine. host: and bruce vladeck, what are you doing today? guest: i am working as a consultant on policy and management issues, primarily with hospitals in the northeast and part of policy makers. host: and you are a senior

advisor of nexaria? guest: that's part of the senior policy hospital association and i can care that hat. host: steve, on the line of under 65. caller: yes, i recently got on social security disability, and i received $845 a month, they wanted to give me part "a" and "b" medicare, and were going to charge 94.65 a month for the part "b" premium, i have emphysema and i found out i would have to pay $175 a month for that coverage to pay for

i would have to pay almost $275 per month out of my $824. i had to tell them -- i had to refuse medicare part b because i could not afford to under and $75 a month -- $275 a month. they looked at me funny. i said i had been going to planning for the last three years. doctors there take care of me and give me my medications free. i thought, well, you know, they have been taking good care of me for the last three years. they have been giving me money, -- giving me all the medicines i needed. i actually could not afford the part b premium itself which was not so bad. but there is a 20% copiague.

. co-pay, that forced me to get a medicare supplement policy. host: mary agnes carey, you want to start? guest: one question for the caller, there are programs through medicare that can help people and offset those costs. people and offset those costs. maybe it could help those supplementals. that caused me concern of that siation. guest: if his whole income is $128 a month, he's eligible for the extra help in the medicare program, for low income assistance, that's administered by the state medicare agency. any programs that provide counseling to the seniors and disabled, and in iowa they

should be able to point him in the right direction, and those for the social security administration that didn't forward him, should be fired. while it's cumbersome, people should be able to get assistance with the premiums and co-payments. and while it's wonderful there is a free clinic in town, those will go out of business if patients who can get insurance, don't. i would encourage him to see if there is a way to get help with that so that he can use part "b". because by law he's entitled to those additional payments. host: finally on our 65 and older line, cheryl from michigan.

caller: i was going on the patients' responsibility and checking the bills from the doctors. my primary doctor overcharged me for an x-ray on my shoulder for $169 which i did not have. i didn't care medicare, i give them the chance to rectify that and he removed the charge. and i went to the foot doctor and i am a diabetic and have my nails done, and it was $59, but she had charged me for two other items for $59 each. so i called their offices and said, this did not happen. the charge should be $59, where did the other $118 come in? and they rectified that and took it off the bichlt -- bill.

and everyone should check their bills and at least try to do something about it. host: bruce vladeck, are there a lot of private contractors that work with medicare part "b"? guest: there is a lot of contractors over the last years to try to save money and get scale in the processing. but there are contractors that pay the bills and work with the physicians. there are separate contractors for seeking prevent, fraud and abuse. and other contractors whose focus is the quality of care. again it's a government health insurance program, bus -- but most of the day-to-day street administration is done by

contractors. host: finally what would you like to see done to part "b"? guest: i think it's important to fill in the holes and gaps, and the most would be the cap of pocket payments, so that no beneficiary would be bankrupted by the 20% they need. and i think in a saner world, we would in fact cover dental services, hearing aids, eye glasses for people that are 65 and older and for disabled people who need them to function. host: and mary agnes carey, what is the debate on capitol hill? guest: i think looking at payments to providers and talking about the issues of coordination of

>> he joins us again tomorrow as we continue our discussion about medicare on "washington journal." it is live every morning starting at 7:00 a.m. eastern. now we return to our live coverage from the john f. kennedy library in boston where senator ted kennedy's body is lying in repose. tomorrow morning, there will be a memorial service at the library. a funeral mass will be held at boston on saturday. his body will then be flown to arlington national cemetery. now, back to boston for live coverage from the kennedy library.

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