The hospitals say that complying with the rule, which requires employees to compensate workers when there are last-minute schedule changes, would mean a collective $30 million loss. Meanwhile, Chicago-area chains have been reconfiguring themselves to become specialty hospitals. Other hospital news comes out of California, Massachusetts and Kansas, as well.
Happy Friday! As you all know, when I come across an outrageous medical mystery story I like to drag you all down with me because horrified misery loves company. This week’s offering: A man in Kentucky went into his doctor complaining of eye irritation. And what did his doctor pull out of his eyeball? That’s right! A tick. (You’re welcome.)
Quickly moving on! Here’s what you might have missed during this very hot week.
The tensions in the Democratic presidential field that have been brewing for a while erupted into verbal sparring between Sen. Bernie Sanders (I-Vt.) and former Vice President Joe Biden. The mini-war seems to be more than just your typical political posturing — both men have deep personal stakes in the issue (which, if you haven’t noticed, voters care a lot about right now). Sanders’ “Medicare for All” plan is nearly synonymous with the man himself, while Biden experienced firsthand the blood, sweat and tears it took to actually get the health law passed.
Earlier in the week, Biden dropped his own health plan, which could be summed up as the Affordable Care Act on steroids. And his promise that went along with the reveal — “If you like your plan … you can keep it” — was a blast-from-the-past that highlights all the advantages (the health law is quite popular at the moment) and pitfalls (that promise when President Barack Obama made it was ranked PolitiFact’s “Lie of the Year”) of taking this particular path.
It also nudged Biden and Sanders into a collision over their philosophical differences that played out in public at various events this week. Neither candidate pulled punches, but Sanders, in particular, had some tough words for his rival. “Unfortunately, he is sounding like Donald Trump,” he said. “He is sounding like the health care industry, in that regard.”
On that note, Sanders called on the Democratic candidates to join his pledge not to take donations from the health industry or pharma. Though he didn’t name names, it seemed to many like another jab at Biden.
Biden also took shots of his own, calling Medicare for All costly and complicated, and insinuating that those looking to get rid of the health law are no better than Republicans.
Whatever the outcome of this particular scuffle, it highlights that, in a crowded field, candidates are looking for things to set them apart. And in this particular election cycle, looks like it’s health care.
Meanwhile, the health law faced off against an unlikely foe this week: Democrats. Lawmakers in the House delivered what is in all intents and purposes a death blow to the “Cadillac tax,” a cost-containing provision that at one point in time was looked at as crucial to the law’s success. (The Senate hasn’t voted on it yet, but Republicans are not exactly fans of the tax, so its fate seems decided.)
But as hell has not frozen over, it’s not as if the Democrats are suddenly jumping on the GOP bandwagon to dismantle the law. The tax was disliked by unions (a key constituency) and some liberal-leaning economists. Rep. Joe Courtney (D-Conn.), the author of the repeal bill, even (subtly) called it, the “Middle Class Health Benefits Tax Repeal Act.”
As a side note, you should be following Noam Levey’s great series on the ways Americans are hurting in the wake of the high-deductible revolution.
The Democratic field’s fireworks over candidates’ philosophical differences weren’t the only ones on display this week. Dr. Leana Wen was ousted from her position as head of Planned Parenthood after only eight months in the role. Although there have been reports about managerial styles, Wen has hinted that the friction comes from her desire to view the organization through a public health prism. During a time when the abortion wars grow only more intense, Wen’s strategy to emphasize abortion as part of a larger part of improving women’s health felt out of step to some.
As if underscoring that very tension, the ousting came as the Trump administration announced that the changes to family planing funding, often called a “gag rule” by critics, would be enforced immediately, now that it has the court’s go-ahead.
After a yearlong legal battle, The Washington Post and HD Media, which publishes the Charleston Gazette-Mail in West Virginia, obtained information from a Drug Enforcement Administration database that shows how 76 billion oxycodone and hydrocodone pain pills saturated the country as the opioid epidemic was gaining steam. Just six companies distributed 75% of the pills from 2006 to 2012, sending millions of pills into tiny rural towns with only a few thousand residents. The numbers reveal a trail of bright, screaming red flags that were overlooked as the country barreled toward a crisis point.
There was some rare good news on the opioid front this week: For the first time since 1990, fatal drug overdoses actually fell. There are (of course!) caveats, though: Experts still see worrying trends when it comes to synthetic drugs such as fentanyl.
Everyone in Congress and the administration is really, very, extremely angry about high drug prices … and yet pharma is still racking up the wins on Capitol Hill. Stat has a great read on exactly what’s going on with the industry’s influence, and looks at a new strategy from drugmakers, who seem to be targeting a pair of vulnerable Republicans to get their way.
In a landscape where everyone is jonesing to cut costs, why is it so breathtakingly easy to scam insurers? Some investigators estimate that fraud eats up 10% of all health care spending. Consumers’ gut reaction is that insurers would, of course, be stepping in to police these bad actors. But they don’t seem to have any desire — or, at least, not enough — to actually act. Maybe that’s because consumers are the ones getting stuck with the losses.
Speaking of, a former VA employee who was supposed to help veterans navigate insurance for their kids who had spina bifida used the position to collect millions in kickbacks, prosecutors allege.
A lot of very cool (or at least interesting) news came out of the Alzheimer’s Association International Conference this week. A look at highlights:
And in the miscellaneous file:
• What’s it like to be a Border Patrol agent? Because access to them can be tightly controlled, it’s rare to hear about their experiences. This story contains a chilling, yet fitting musing: “Somewhere down the line people just accepted what’s going on as normal.”
• It’s one of health care’s biggest challenges: weaning people off the habit of going to the ER instead of a primary care doctor. Well, New York City is going to invest $100 million a year to try to do just that.
• More than 200,000 kids in Tennessee were either cut or slated to be cut from insurance because the state’s unwieldy system heavily relied on hard-copy forms.
• Do service dogs actually help veterans with PTSD? Although there are plenty of heart-warming anecdotal stories about the benefits, doctors in the VA are hesitant to recommend them over treatment that has been shown to work because there’s little hard science on their benefits. The thing is, the VA is supposed to be doing research on it. Yet, for some reason, it’s been lagging, despite the burgeoning mental health crisis among veterans.
• A look at law enforcement in Alaska, where violence against women is gaining national attention, shows that dozens of convicted criminals have been hired as cops for these communities. In one small village, every single policeman on the force, including the chief, has a criminal record of domestic violence.
That’s it from me! Try to stay cool and make sure to hydrate this weekend!
Juul Labs, the nation’s leading manufacturer of e-cigarettes, has hired as its medical director a prominent University of California researcher known for his work on the dangers nicotine poses for the adolescent brain.
The company said the hire will support its efforts to stem a teen vaping craze the Food and Drug Administration has labeled an epidemic. But critics see a cynical tactic taken straight from the Big Tobacco playbook.
Dr. Mark Rubinstein, a pediatrician and formerly a leading researcher with UC San Francisco’s Center for Tobacco Control Research and Education, took up the post of executive medical officer at Juul last week, a move first reported by Politico. Rubinstein has done signature research on teen addiction and how nicotine, which is present in high levels in e-cigarettes, affects adolescents. He has spoken openly of the potential risks of vaping for children.
In a statement, Juul said Rubinstein would oversee research on underage use of vapor products, guide the company’s youth prevention programs and policy positions, and help form links with the public health community. The company declined to make Rubinstein available for an interview. It says the move is part of its effort to reduce teen vaping while it continues to provide an alternative to smoking for adults.
Colleagues of Rubinstein, however, said they were disturbed by the move and skeptical of Juul’s motivations. At the heart of their concerns is whether Juul is willing to lose the giant base of teen users who have helped fuel the company’s meteoric rise and hefty market share.
Stanford University professor Bonnie Halpern-Felsher, who researches teen vaping and writes curriculum on teen prevention, helped train Rubinstein at UCSF. She said she was both incensed and disappointed when she heard about his move.
“Even if you believe in harm reduction,” she said, “to go work for a tobacco company … to me goes against everything that anybody doing control should believe in.” She said she is particularly concerned that a specialist on the effects of nicotine in adolescents has gone to work for the industry. Last year, Altria, one of the world’s largest cigarette makers, bought 35% of Juul for $12.8 billion.
Stanton Glantz, director of the Center for Tobacco Control Research and Education, concurred, saying he was “shocked and depressed” by Rubinstein’s decision to leave UCSF for Juul. He sees Juul’s early social media campaigns as evidence the company has intentionally marketed to teens. Research supports this claim, though the company denies it and has shut down its Facebook and Instagram presence.
Not everyone shares their skepticism. Dr. Neal Benowitz, a UCSF professor who has studied addiction and smoking cessation for decades, frequently published with Rubinstein. He said he is hopeful that e-cigarettes can help people quit smoking and wants them to remain on the market while more research is done. He was shocked by the job change but said that if anyone can help figure out strategies to reduce youth vaping, it’s Rubinstein.
Rubinstein’s hire comes as Juul works to gather evidence to submit to the FDA that its devices offer more public benefit than risk. If it fails to convince the agency, Juul could be prohibited from selling most of its products.
Under the Trump administration, the FDA, which has oversight of all tobacco products, originally gave e-cigarette manufacturers until 2022 to file applications for approval for their devices, but a federal judge recently advanced the deadline to 2020. Juul has been wooing prominent researchers in the lead-up to the deadline, but with limited success amid concerns about the company’s goals.
“Part of Juul’s strategy is to create credibility and buy influence by hiring everybody who would take their money. We shouldn’t be fooled: Juul created the youth e-cigarette epidemic and refuses to take responsibility for it,” said Vince Willmore, spokesman for the Campaign for Tobacco-Free Kids.
Some believe it will be a tall order for the companies to show that e-cigarettes are a net benefit, given what is known about the risks of teen vaping and how few studies there have been on their long-term efficacy to help people quit smoking. Others see the FDA’s relatively lenient approach to the industry so far as a sign it may take a more favorable view of the products.
The FDA last year labeled teen vaping an “epidemic,” noting federal survey data showed nearly 1 in 5 high school students had tried vaping in 2018. While not as harmful as older tobacco products, e-cigarettes contain high doses of nicotine and a variety of carcinogenic chemicals, according to Rubinstein’s research. When it comes to vaping, Juul is by far the biggest seller in the U.S., capturing an estimated 70% of the e-cigarette market.
Anti-tobacco activists contend Juul increasingly is drawing on the tactics of tobacco companies to push back against regulation of its products. They point to a recent Juul campaign to overturn restrictions on e-cigarettes and flavored tobacco in San Francisco, where the company is based.
Last month, a Juul-backed ballot proposal gathered enough signatures to make the city’s November ballot. The bill’s supporters claim it would strengthen regulations around adolescent access to tobacco products, while ensuring the devices are available to those who want to quit smoking. Opponents, including the city’s former attorney, say the measure would take away local control and peel back existing bans on flavored tobacco products and the sale of e-cigarettes until they are approved by the FDA.
“To us, Juul is Big Tobacco 2.0,” said John Schachter of the Campaign for Tobacco-Free Kids, asserting the company is using deceptive legislation to maintain the sale of its products.
Benowitz of UCSF disagreed with the comparison, saying he sees a big difference between Juul, whose products show legitimate potential to help people addicted to cigarettes, and the tobacco companies that predate it.
One question at the core of the concerns over Rubinstein’s move is whether research and prevention should come from within the industry. An internal research program is problematic, said David Michaels, a professor at George Washington University who has studied corporate attacks on the science underpinning environmental protection. “I understand why scientists are concerned about a program like this, and I think they should be,” he said.
E-cigarette manufacturers, not taxpayers, should fund research of their products, Michaels said, but the research must be completely independent of the company. Tobacco companies have long used scientists to manufacture uncertainty and defend products that have harmed public health, he said, and the research they produce in-house will always be called into question.
Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
In Defense Of Opioid Prescribers
Articles such as this one are leaving elderly patients with debilitating pain and also hospice patients struggling to get adequate pain control (“Surgeons’ Opioid-Prescribing Habits Are Hard To Kick,” June 21). After seeing my father in agony in hospice care this year, I am upset by this opioid-induced fear of prescribing. Also, leaving post-surgical patients in pain by not prescribing enough pain medication is a shame in this day and age. The anti-opioid movement pendulum has swung way too far to the opposite side. I watched my dad suffer needlessly in hospice care because the nurse practitioner (who, by the way, never once visited my father) would balk anytime we begged for them to relieve my father’s uncontrolled pain. I am angry. I am sorry. But things need to change in the health care field. Medical practitioners are more scared of getting in trouble than they are helping patients in pain.
— David Colegrove, Powell, Ohio
Data shows that for most common surgical procedures, such as laparoscopic appendectomy or cholecystectomy, the right duration of opioid use is a day or at most two days of IR medicine. Yet many patients get sent home with much more than that https://t.co/04zmZVkqli
— Scott Gottlieb, MD (@ScottGottliebMD) June 21, 2019
— Dr. Scott Gottlieb, Washington, D.C., former commissioner of the Food and Drug Administration
You are engaging in the worst kind of public shaming with this investigation of opioid prescribers (“Opioid Operators: How Surgeons Ply Patients With Painkillers,” June 20). I remember when my dad had bypass surgery and he was in a lot of pain. I look at these numbers and wonder how many patients didn’t have someone to get the prescription filled. We are attacking the wrong people. The overdoses are caused by illegal heroin and fentanyl. I have been on these medications a long time for intractable pain. I have never taken more than prescribed and nearly all patients like me do the same. If I have been taking the same dose for six years, I would say the odds of an overdose are slim to none. Learn the difference between physical dependence and addiction.
— Dennis Ewing, San Antonio
The tone of this article and tweet borders on slander. Inaccurate unfair criticism. There is NO DOUBT Surgeons have changed their prescribing habits and patients (as first comment proves) are not homogenous.
— Edward T Chory (@DrEdMDBFD) July 7, 2019
— Dr. Edward Chory, Lancaster, Pa.
Your project entitled “Opioid Operators” is ridiculously inflammatory. I hope you get sued by the same doctors you are “exposing.” You have no idea what each individual patient needs because you aren’t there.
In addition to being wracked with the pain of complex regional pain syndrome (CRPS) 24/7, I am also the caregiver to my husband, who has end-stage renal disease. Taking away pain medication when 99% of the pain patients who use it never abuse it is a crime. It will have no effect on addiction. It will just kill people who are already frail from having to combat pain from incurable disorders.
— Bijoux Faraj, Concord, Calif.
I’m legit SHOCKED that 10 pills is the Johns Hopkins recommended # for minimally invasive gallbladder removal. I got ~120 pills~ of generic oxycodone and that was barely enough.
— madi alexander (@MadiLAlexander) June 24, 2019
— Madi Alexander, Arlington, Va.
Why do groups constantly put “information” out to the public that fits their narrative? This story about opioids is nothing more than a reason to bash doctors who prescribe pain medication to people in pain. Why not investigate why doctors prescribe this medication to patients? I have had chronic pain for 25 years. These stories have caused my medication to be all but taken away. How about running a “rebuttal” to that story and let the “other side” speak?
— Dennis Shivers, Lake Ronkonkoma, N.Y.
Tough: they need to prescribe fewer #opiates and then, believe it or not, be AVAILABLE for patients who might need a refill, and actually talk to or examine them!! (They don’t like to be bothered…that is the problem!)#opioidcrisis
— peter grinspoon (@Peter_Grinspoon) June 22, 2019
— Peter Grinspoon, Boston
Boggled By Mind Games In ACA Court Battle
I want to congratulate Julie Appleby (“DOJ Lawyers Try New Tricks To Undo Obamacare. Will It Work?” July 12) for distilling what I consider to be one of the worst oral presentations by the Department of Justice I have ever seen or heard (I listened to the entire audio of the oral arguments). I say this as a health care attorney of some 46 years who was also brought to D.C. to counsel members of Congress on the Affordable Care Act as it was being developed.
The positions taken by DOJ counsel floored me — viz a viz, that the outcome of the case should apply to only the plaintiff states and not the rest of the country; or that the entire act is inseverable from the mandate provision, but since the act is “complicated” (really? of course it is), it would have to be worked out which provisions could remain in effect — for only the plaintiffs? for the entire country?
Scholars on both sides of the ACA agree the decision of the lower court was anathema to sound judicial foundation and precedent. The critical fact is that the 2017 Congress — not the one that passed the ACA in 2010 —eliminated the tax/penalty to zero and kept the rest of the act in place. Judges do not eliminate laws unless there are clear expressions from the legislature in its legislation to do so, or the language of the act is so ambiguous as to require judicial interpretation of the words used. With the ACA, there was no expression of inseverability related to zeroing out the individual mandate … despite the DOJ telling the appeals panel there was.
Finally, Judge Kurt Engelhardt, a member of the panel hearing the case and a Donald Trump appointee, questioned why the House could not pass another bill that kept the worthy features of the ACA in the event the current law remains unconstitutional. The role of appeals jurists is to probe the strengths and weaknesses of all sides during oral argument, not ask foolish questions, considering Mitch McConnell controls the Senate, the majority of the House is blue and, of course, Trump presently remains president. As I have written for over a decade before it was in vogue to do so, health care is a right for all Americans, and the ACA is the embodiment of this philosophy ingrained within the fabric of our country. To even posture a new health care bill given the current political environment is glaring fool’s gold.
— Miles J. Zaremski, Highland Park, Ill.
Caring For Survivors Of Sexual Assault
I just read Michelle Andrew’s story about the staggering, and often re-traumatizing, hospital bills that survivors of sexual assault frequently receive after getting a forensic exam in a hospital setting (“Despite Federal Protections, Rape Victims Still Get Billed For Forensic Exams,” July 12). At The SAFE Alliance in Austin, Texas, we operate a community-based sexual assault clinic called Eloise House, where survivors can receive a private exam and evidence collection as well as free medical care after experiencing an assault.
We’ve found that this free, trauma-informed model eliminates many barriers for people who’ve experienced an extremely traumatizing situation by eliminating emergency room wait times and creating an environment that feels more like a home than a hospital. Our advocates work alongside our forensic nurses to offer emotional support, explain the steps of the exam process, answer questions about what the reporting process may look like if the survivor chooses to report, assist with safety planning and much more. Since we opened the clinic in 2015, we’ve served over 2,000 survivors of sexual assault in Central Texas.
I hope that one day every community has access to a clinic like Eloise House, to make the healing process even a little easier for survivors of sexual assault. Thank you for reporting on this little-known issue.
Emma Rogers, Austin, Texas
As Rural Areas Lose Hospitals, Misplaced Priorities?
I’m getting more discouraged as people exclaim how well our economy is doing when there are losses in our communities such as the closing of rural hospitals (“Have Cancer, Must Travel: Patients Left In Lurch After Hospital Closes,” July 1). Similar reductions and losses are occurring in education, infrastructure and environmental protection, to name a few. This contrast must be reported so citizens can better understand these upside-down priorities are hurting all of us — except for the ultra-rich. This downward spiral will ultimately catch up with them, too, as they will then end up paying for the resultant problems this “ignore-ance” will create.
— Victoria Mosse, Joseph, Ore.
This was the closest hospital for my in-laws. Long distances for cancer treatment are all too common in rural America. My dad had 60 miles each way to get to his radiation appointments in another part of Kansas. https://t.co/Gle9TrvtTd
— Mark Fleury (@ME_Fleury) July 1, 2019
— Mark Fleury, Washington, D.C.
Hospitals in rural areas are closing. Americans are not being treated with human dignity and care. And ignorant people of this country have the audacity to care about immigrants? I have no respect for the immigrants coming here for all the freebies of medical care and housing while Americans are being treated like second-class citizens.
— Debra Schaal, Hobe Sound, Fla.
Terrible things happen when rural hospitals close. But in many states, these are preventable tragedies. Why hasn’t Kansas expanded Medicaid, which would save many hospitals? Why doesn’t this story ask? Big miss. @SJTribble https://t.co/HAcmG0Waha
— Jim Tananbaum (@JTananbaum) July 1, 2019
— Jim Tananbaum, San Francisco
Preventing Falls For A New Generation
Your piece “More Seniors Are Dying In Falls. Doctors Could Do More To Reduce The Risk” (June 27) addresses an important yet rarely discussed epidemic that has become increasingly deadly over the past decade. According to the Centers for Disease Control and Prevention, fall deaths among seniors increased by 31% from 2007 to 2016 — a trend slated to worsen over the next few years as more baby boomers enter retirement. Falls are now the No. 1 cause of injury for older Americans, resulting in 800,000 hospitalizations every year and $50 billion in health care spending.
As a physical therapist (PT), I’ve seen the effectiveness of some of the treatment strategies mentioned in this article. But, while fall risk assessments and personalized patient plans are important preventive tactics, one important factor that wasn’t mentioned in the article is the value of telehealth in reducing seniors’ risk of falling.
Telehealth appointments and virtual fall risk assessments can be incredibly beneficial, particularly for patients with age-related disabilities and limited mobility. Telehealth services provide valuable opportunities for seniors to receive professional PT in the comfort and privacy of their own homes. In turn, this reduces access barriers — particularly for patients in rural and underserved areas — and helps seniors who struggle with transportation issues get the care they need. In fact, one of the initiatives mentioned in your article included a strong telehealth component, which improved compliance with and the effectiveness of PT-prescribed fall prevention exercise regimens. Because falling once doubles the chances of falling again, it is critical to empower America’s seniors with care that makes them stronger, steadier and more flexible.
With an increasingly graying U.S. population, this problem demands a novel and comprehensive response. Having helped countless patients reduce their fall risk, I believe that telehealth PT, together with other solutions mentioned in your article, will play an important role in addressing this epidemic. By embracing evidence-based practices such as telehealth PT, we can seize the opportunity to prevent falls, reduce Medicare spending and, ultimately, save lives.
— Nikesh Patel, PT, DPT, physical therapist and executive director of the Alliance for Physical Therapy Quality and Innovation, Washington, D.C.
Great tips fr @judith_graham on #fall prevention. Doctors Could Do More To Reduce The Risk. https://t.co/gsklcP5QIW via @khnews
Would add using hiking poles when walking on uneven surfaces.
And trifocals are G-d’s gift to orthopedists.
I also rec some sort of medical alert system
— Judy Stone (@DrJudyStone) July 6, 2019
— Dr. Judy Stone, Cumberland, Md.
— Wendl Kornfeld (@WendlKornfeld) July 1, 2019
— Wendl Kornfeld, New York City
While Fact-Checking Debates, Check The Moderator’s Attitude
While the facts were somewhat interesting, the elephant in the room was the rigged, wildly biased phrasing of host Lester Holt’s “Medicare for All” question: “Who here would abolish their private health insurance in favor of a government-run plan? Just a show of hands …” On this point, I’m surprised and disappointed KHN didn’t deconstruct that framework (“PolitiFact & KHN HealthCheck: ‘Medicare For All’ Emerges As Early Divide In First Democratic Debate,” June 27).
Last week, the latest voter poll from The Washington Post and ABC News included a Medicare for All question so carefully crafted it could serve as the gold standard for questions that strive to eliminate respondent bias on emotionally charged issues. It asked: [Would you support or oppose M4A] “if there was no private insurance option available?” This phrasing removes the actor: No one is abolishing or taking away anything. It’s the passive voice put to exquisitely good use to avoid bias: “… if there was no private insurance option available.”
Also, notice pollsters’ use of the word “option.” It implicitly frames private insurance as something expendable. It’s an option. Not a requirement, not written in stone. I give big kudos to the pollsters for this careful, and truthful, framing.
And while we’re on the subject of wording: The day before the first debate, an NPR commentator prospectively boiled it down to a struggle between “pragmatists” and “progressives.” Obviously, progressives advocate for substantive change such as Medicare for All — which by implicit definition is not “pragmatic.”
Current public policies that leave us with upward of 500,000 medical-related bankruptcies a year and 36,000 annual deaths attributed strictly to lack of health care coverage are somehow blandly acceptable as “pragmatic.” Needless to say (but I’ll say it anyway), this is an affront to both logic and morality.
— Ira Dember, Houston, founder of FairNow.org
Ensuring The Robust Right To Appeal
On behalf of the California Association of Health Plans, which represents 46 public and private health plans that collectively provide health care coverage to over 26 million Californians, we would contend that the “Asking Never Hurts” column “Did Your Health Plan Deny You Care? Fight Back” (July 15) mistakenly implies that California’s long-standing system for handling grievances, complaints and medical reviews is somehow confrontational, contentious and unknown. The fact is that California has had a robust framework of consumer protections for decades — long before the Affordable Care Act created similar consumer rights at the national level. Our system of resolving disputes balances maintaining a functional and affordable health care system while giving enrollees and providers an opportunity to appeal.
If a patient’s claim is denied by their health plan, the patient has the right to appeal with their health plan, and the right to an independent medical review by the state regulator if they disagree with the health plan’s decision. Independent medical reviews are conducted by a team of providers that have no affiliation with the health plan, and the decision of the independent medical review is binding.
Health plans ensure enrollees are aware of their existing consumer protections under California law, and we provide a comprehensive list of covered services when they are medically necessary. This happens millions and millions of times without dispute. When there is a difference of opinion, health plans want to get it right.
Every Californian deserves to have the peace of mind that they have access to an independent appeals process should they need it. California’s health plans work hard to provide consumers with that peace of mind as we continuously strive to improve outcomes for patients and provide accessible, high-quality, affordable care for all Californians.
— Charles Bacchi, president and CEO of California Association of Health Plans, Sacramento
A Handy Takeaway From Your Podcast
I heard the “An Arm and a Leg” podcast recently (“Forget The Shakedown. To Get Paid, Hospitals Get Creative,” June 12). Great stuff!
Then I dislocated a bone in my foot and went to see an orthopedist at SportsMED Orthopedic Surgery & Spine Center in Huntsville, Ala. Doc ordered an Aircast AirSelect brace. The brace shop said my insurance covered it 100%. That was good, so I had them fit it. My foot felt better right away, more stable. Then, as I’m ready to leave, I’m told I have to sign a digital pad with only a signature space. “What is it you want me to sign?” I asked.
Turns out it was a form stating I agreed to pay all costs that may be later billed and not covered by insurance (which they could not tell me what that would be). Long story short — forget about my insurance covering it 100%. After checking with Blue Cross Blue Shield, I learned my out-of-pocket cost could have been $378.
If I had come in with no insurance, it would only be $110, and a variety of other permutations of random pricing all “the fault of my insurer, not their pricing,” per their insurance supervisor. Having heard your podcast, I checked Amazon — an identical Aircast was $78 with free shipping. So, I limped out and ordered it on Amazon. At least I knew how much I would pay. The person before me left with a knee brace for his son for a $415 insurance copay.
— Lisa Moore, Huntsville, Ala.
Out In The Open About Well-Thought-Out Exit Strategies
This is a topic (“In Secret, Seniors Discuss ‘Rational Suicide,’” June 25) that should be public, not sequestered in private. My 87-year-old father and I have had this conversation, and it’s not taboo in our family. Thank you for talking about it.
It’s sad that as a society we can’t face the fact that people want to have choice, especially on the quality of their life and remaining years — whether or not they have a terminal diagnosis. Just because medicine could possibly prolong our lives doesn’t mean we want it to do so.
— Laura Palmer, Denver
Would love to know if the individuals meeting to discuss this have their advance directives in place. That is a way to address fears of decline, I think. Nevada failed to move forward a death with dignity bill to a vote this Legislative session so it is a fraught topic.
— Homa S. Woodrum (@woodrumlaw) June 25, 2019
— Homa S. Woodrum, Carson City, Nev.
I think a point missed may be that many seniors are becoming increasingly distraught with the state of the world — not so much from depression, but from the pervasive hostility, anger, loss of traditional values, ignorance, lack of caring, political bickering and general “meanness” that is the world nowadays.
Together with my physical limitations that further limit my ability to find continued meaning in life, I am glad to say that I have an exit strategy in place that I can activate when the time is right. I think if the right to choose were available and supported, there would be (and likely will be, if current trends continue) more interest in having this option more easily available.
— Dr. Bill Saunders, Snohomish County, Wash.
This goes for anyone who has a debilitating disease.
— Rich Meyer (@richmeyer) June 25, 2019
— Rich Meyer, Naples, Fla.
I’m 65, healthy, happy and enjoying life. 25 years from now I hope to be 90, healthy, happy, and enjoying life. I might also be 90, bed-bound, in daily pain, and emotionally spent. These days it’s not uncommon to outlive our bodies. I’ve seen. I get it. https://t.co/HOLTmWL7mi
— Duane Blackwell (@DuaneBwell) June 25, 2019
— Duane Blackwell, Alexandria, La.
No More Band-Aid Solutions On Surprise Medical Bills
An approach to solving this problem is to set standard costs for all procedures (“Bill Of The Month: A Year After Spinal Surgery, A $94,031 Bill Feels Like A Back-Breaker,” June 17). Using Medicare reimbursement as a benchmark, set national reimbursement rates adjusted for regional cost of living. Set the rates as Medicare plus a percentage and require all providers to accept those rates. This would do away with the need for networks.
Standardize insurance plans using the Medicare Part B concept. There can be a variety of plans, but each insurer must offer the exact same coverage for a specific plan. Then the purchaser can make an informed comparison among plans. If the goal is to lower medical costs, standardization, along with best practices is probably the best approach.
We need to drive out the unnecessary costs and eliminate the annual 160,000 unnecessary deaths and estimated 100 million medication errors in the U.S. hospital system. The unnecessary annual death total is greater than annual opioid deaths, gun violence deaths and automobile accident deaths combined.
This will be a long struggle because of the entrenched financial interests, but we need to draw a line in the sand.
— Michael Hausig, San Antonio
#MedicareforAll. Fulfilling the Hippocratic oath.
— Kerri Barber, One of the Squad (@ACA_Sherpa) June 17, 2019
— Kerri Barber, Chicago
Not Anti-Vaccine, Just Against This Legislation
I oppose Senate Bill 276 in California (“A Proposal To Make It Harder For Kids To Skip Vaccines Gives Powerful Voices Pause,” June 14). I have a child who nearly died from seizures after being administered the DTaP vaccine [to guard against diphtheria, tetanus, and whooping cough, or pertussis]. That reaction is a CDC-acknowledged adverse event. Stop calling everyone who opposes this bill “anti-vaccine activists.” While some people might characterize themselves as “anti-vaccine,” most people are simply parents who did vaccinate their child until they were seriously harmed. To call us “anti-vaccine” activists and ignore that fact is extremely deceptive.
We are activists now, that part is true. We had to become activists, because these organizations you mention in your article (such as the American Academy of Pediatrics) have done nothing to help our children. The AAP is a lobbying organization that receives funds from vaccine manufacturers. It lobbied against AB-2832 (Assemblyman Travis Allen), which was a one-sentence bill that would have put a link on the California Department of Health website to two “.gov” websites: the Vaccine Adverse Event Reporting Systems (VAERS), the database for serious adverse events after vaccination, and the National Vaccine Injury Compensation Program. The purpose was to help parents find this information when they need it. That the AAP lobbied against it says everything you need to know about their priorities when it comes to vaccines. They are not doing what is in the best interest of families. Clearly, their pharmaceutical company funding influences their lobbying.
In your story, Dr. Michelle Bholat’s concern about who would qualify for a medical exemption is exactly the same concern that parents opposed to this bill have. There is a good chance my child would not qualify for a medical exemption to the vaccine that nearly killed him, and he definitely would not qualify for an exemption to any others. If I had another child, I would not be able to get a medical exemption to the vaccine that nearly killed my son for that new baby. This bill puts our kids at serious risk for irreparable harm or even death.
— Kara Morales, San Diego
— Amesh Adalja (@AmeshAA) June 17, 2019
— Dr. Amesh Adalja, Pittsburgh
Something In The Water? Drink To Your Health!
A recently published article (“A Million Californians Don’t Have Clean Drinking Water. Where Do They Live?” June 28) cast some doubts concerning the safety of drinking water available out of the tap for Alpine County residents and visitors.
First, some background. There were 1,175 persons counted in the 2010 census in Alpine County. There are several hundred private wells in Alpine County, which are initially permitted by the county, but then managed by the owner. The Environmental Health Program staff of the Alpine County Public Health Department regulates about 40 small public water systems, including the Markleeville Water Co., Woodfords Mutual Water Co., Diamond Valley Elementary School and numerous campgrounds. Two large water systems are regulated by the California State Water Resources Control Board: Kirkwood Meadows Public Utilities District and Lake Alpine Water Co., along with the Grover Hot Springs State Park. The definition of a “large” water system is one with more than 200 connections.
The greatest risk to the public’s health from drinking water is bacterial contamination, which is controlled by disinfection. The surface water used by the large water systems is disinfected with chlorine. Byproducts of the disinfection process include trihalomethanes (TTHM) and haloacetic acids (HAA5). Managers work to achieve the ideal balance between enough chlorine to provide water free of bacterial contamination, and at the same time keeping levels of byproducts lower than the maximum contaminant level (MCL) as required by the State Water Resources Control Board.
Conclusions in the article were drawn from a review of state compliance data dating prior to 2018 and refer only to the Lake Alpine Water Co.
- The data source stated that the Lake Alpine Water Co. serves a population of 625. This includes 125 residents and 500 transients (skiers, visitors at the Bear Valley Lodge, and condos); thus, the original statement “more than half of residents” was incorrect. The data source states that Lake Alpine Water Co. serves 487 service connections. This includes 294 single-family residences, 179 multiple-dwelling units (lodge, condos), 12 commercial, and two irrigation systems. So, essentially correct, but includes water provided to visitors.
- The data shows that the Lake Alpine Water Co. was out of compliance with levels of total haloacetic acid exceeding the MCL, the latest violation on 12/31/17. However, what it does not show is that corrective action was promptly performed, with compliance obtained in January 2018. Quarterly testing during the past 18 months has shown continued compliance, and an official Return to Compliance (RTC) status will be achieved in the near future. There have not been any other violations or enforcement actions taken.
- The Water Board has never issued an order that “residents can’t drink water flowing from their taps,” as the article stated— anywhere in the county.
- In the past 25 years of records and memories, water systems in Alpine County have not exceeded MCLs for either nitrates or arsenic — anywhere in the county.
My conclusion: Drink up (water)!
— Dr. Richard O. Johnson, health officer for Alpine County, Calif.
(Editor’s note: Thank you for your salient points. The article has been revised to reflect your concerns.)
When doctors told Frances Faulkenburg she had sleep apnea, she was more than ready for relief from her tired-all-the-time existence. She used to fall asleep at red lights while behind the wheel. At night, she’d wake up gasping for air, heart pounding. Her husband told her she snored.
But Faulkenburg, 47, couldn’t tolerate the CPAP machine her doctor prescribed.
“I just could not get used to the face mask covering both my nose and mouth,” said Faulkenburg, who lives in Oviedo, Fla.
“It was claustrophobic.”
CPAP, or continuous positive airway pressure, is often one of the first solutions doctors suggest for sleep apnea. With this disorder, a person’s breathing stops and starts so frequently during the night that it can lead to or exacerbate health problems. The National Sleep Foundation estimates that more than 18 million American adults have sleep apnea.
A CPAP machine blows a stream of air into the back of the throat to let people breathe easier. It prevents muscles in the back of the throat from narrowing, which can constrict the airway, causing snoring or disturbed sleep.
Yet Faulkenburg quit using her CPAP and went back to feeling sleepy and tired all the time.
Many people have a negative reaction to the machines and are tempted to do the same. The big whoosh of air in your throat. The restrictive mask on your face. It can be a lot to adjust to. Studies suggest that from one-third to more than 50% of patients either stop using their CPAP machine or never bother to fill their prescription. They quit for a variety of reasons, but mostly because the device can be cumbersome and uncomfortable. Sometimes, they quit because of confusing or stringent health insurance restrictions.
But the health effects of untreated sleep apnea can be serious. People struggle with anxiety, tiredness and low productivity. There’s even an increased risk of high blood pressure, heart attack and stroke.
Mary Mertens, a respiratory therapist at the Cleveland Clinic, helps patients work through problems with their CPAP machine. Patients often complain that the volume of air the machine puts out feels too intense.
“Think about it as sticking your head out of a car window with your mouth open at 60 mph versus 25 mph,” said Mertens. “The high pressure can be very overwhelming.”
So Mertens’ team goes to people’s homes to help troubleshoot problems. That includes explaining sleep apnea and how a CPAP can help.
“Picture the air passage at the back of their throat like a garden hose with no water in it. The hose collapses down,” said Mertens. That’s what happens when a person with sleep apnea is sleeping.
“When we put a CPAP on somebody, it’s like turning the water on for the garden hose,” she said. “The hose then pops open and stays open.”
At the Cleveland Clinic, about 70% of patients in the Respiratory Home Care program keep using their CPAP, Mertens said.
Follow-up is key. Mertens’ team checks in with patients during the first three to five days, again between 30 and 45 days and again between 60 and 90 days.
Faulkenburg, the patient in Florida, first tried a CPAP 15 years ago but never checked back with her pulmonologist when she was struggling. And, she said, the physician never contacted her. Then several people in her social circle died in their sleep — all of them right around her age. Those stories shook Faulkenburg, and she decided to try her CPAP again.
“I got a mask that covered just my nose, which let my mouth stay closed. That ended up being the whole issue,” she said. “I sleep so good, I can’t sleep without my CPAP now.”
Dr. Indira Gurubhagavatula, a sleep medicine physician at the University of Pennsylvania Health System, said the look of the device alone can be alarming.
“One of the first things that I hear is that the thing itself is intimidating — they see the tubing and mask and it’s blowing air in their face — they have real concerns: ‘Am I actually going to sleep better with that thing?’
“It is a big ask to go to bed with this thing strapped to their faces,” she said.
Gurubhagavatula said people who feel claustrophobic should wear their CPAP mask during the day while reading or watching TV. That can help the nerve endings in the face get used to the mask.
“It’s just like breaking in new shoes or new jeans,” said Gurubhagavatula. “Once it’s broken in, it’s less of an issue.”
Pulmonologist James Rowley, a sleep medicine physician at Detroit Medical Center, said the air pressure from the CPAP can cause a runny nose, nasal congestion or dry mouth. He said he can help by adjusting humidity settings on the machine or prescribing an antihistamine.
Medicare and private insurance companies require patients to use their CPAP very consistently — often at least four hours every night and for 70% of nights each month. Sometimes the usage is monitored.
Patients who don’t comply may end up paying out-of-pocket. That’s the topic of this week’s episode of the podcast “An Arm and a Leg.” Kaiser Health News co-produces the podcast.
Prices vary, but a fully equipped machine typically costs from $500 to $3,000, with the national average around $850. After that initial investment, masks, hoses and filters need to be replaced two or three times a year. And users have the ongoing cost of maintenance supplies — wipes and brushes to keep the machine parts clean.
Gurubhagavatula said she has patients whose machines have been taken away because they couldn’t follow the insurance company rules.
“They may have child care or elder responsibilities that makes their sleep disrupted. Or they sleep in chunks of time because they work certain shifts,” she said. “The rule is arbitrary because using the machine, even if part time, is beneficial.”
Nate Wymer, 44, said his machine is lying around his home somewhere in Holly Springs, N.C., but he hasn’t seen it in years.
“When I had the mask on I had to think about breathing out of my nose,” said Wymer. “That’s not something I normally do. After a couple of nights, I just couldn’t do it.”
“My doctor never really followed up from what I can remember, so I back-burnered it,” said Wymer. “But, if you get in front of somebody, actually talk to them and make sure everything is going OK, that would have been nice.”
On Wednesday, Alexis Conell will mark seven years since she received the kidney transplant that saved her life, but the 53-year-old Chicago woman isn’t exactly celebrating.
Although the federal government paid most of the costs for her 2012 transplant, a long-standing Medicare policy halted coverage three years later for the drugs that keep her body from rejecting the organ.
So when Conell lost her job suddenly last September, she also lost her health insurance — and her ability to afford the 16 daily medications she needs to survive.
“I was terrified,” she said. “All you’re thinking is, ‘I don’t want to lose my kidney.’”
For nearly a half-century, Medicare has covered patients, regardless of age, who have end-stage renal disease, including paying the costs of kidney transplants and related care, which run about $100,000 per patient.
But coverage ends after 36 months for those younger than 65 who don’t otherwise qualify for the program — and that includes payment for the vital immunosuppressive drugs that cost thousands per patient each month.
Last week’s announcement of a Trump administration overhaul of kidney care in the U.S. has reanimated an effort by federal lawmakers and kidney care advocates to extend drug coverage.
“After a transplant, patients should not have to worry about whether they can afford the treatment needed to keep their transplanted kidney,” Rep. Ron Kind (D-Wis.) said in a statement.
For years, Kind has been among a bipartisan coalition in Congress championing legislation targeting kidney immunosuppressive drugs — to no avail.
The sticking point was price. A 2009 estimate by the Congressional Budget Office pegged the cost at $400 million over 10 years if the government were to extend lifetime drug coverage to those patients.
Two recent federal projections show that Medicare could actually save money — between $73.4 million and $120 million over a decade — by expanding payment for anti-rejection medications to help decrease the need for patients to get additional transplants or dialysis. Depending on financing, savings could reach $300 million in that period, suggested an estimate by the Centers for Medicare & Medicaid Services.
Armed with this data, a bipartisan coalition led by Kind and Rep. Michael Burgess (R-Texas), a physician, is expected to introduce legislation by August that would narrowly extend Medicare’s Part B program to provide drug coverage for kidney transplant patients who have no other option.
“We must ensure patients have access to immunosuppressant coverage to ensure the success of their transplant, which will keep costs down by decreasing the need for a re-transplant or further dialysis,” said Kind.
Sens. Richard Durbin (D-Ill.) and Bill Cassidy (R-La.) are poised to introduce their own legislation, sources told KHN on background.
The efforts in Congress will hinge on whether the CBO agrees that paying for the medication would save the government money, advocates said. Even the new estimates by CMS suggest that changing the program would increase costs initially, with savings apparent only after a decade.
Dr. Emily Blumberg, president of the American Society of Transplantation, said there appears to be high-level support for change now. In championing the overhaul of U.S. kidney care policy, Health and Human Services Secretary Alex Azar has cited a personal tie, noting that his father suffered from kidney failure and received a transplant in 2014.
More than 56,000 Americans with functioning kidney transplants don’t have Medicare coverage, according to data from the U.S. Renal Data System. About two-thirds pay for their medications through private insurance, Medicaid or other government programs, experts said.
But about one-third of those patients may have no other source of drug coverage, which can lead to missed doses, jeopardizing their new kidneys. A 2010 study found that nearly 70% of U.S. kidney transplant programs reported deaths or organ losses directly related to the high cost of anti-rejection drugs.
If Medicare drug coverage had been extended in 2015, it would have averted at least 375 kidney transplant failures that year alone, the latest analysis showed.
When transplants fail, patients can die — or they must return to dialysis — paid for by Medicare at a cost of about $90,000 per year, with a poor prognosis.
“It’s a no-brainer that you should do this both from a moral and ethical and, now it sounds like, cost perspective,” said Dr. Robert Gaston, a nephrologist at the University of Alabama-Birmingham who co-authored a call for coverage in an Institute of Medicine report two decades ago.
Conell battled end-stage renal disease for years before receiving her kidney transplant. When she lost her job abruptly last fall, she had to cancel scheduled medical appointments and lab tests.
She drained her savings, then nearly ran out of medication before she found a pharmaceutical firm program that provides the drugs she needs at a deep discount.
“If I had to pay full price for them, it would easily be $3,000 or more per month,” Conell said.
When her unemployment benefits ended in April, Conell qualified for Medicaid, which covers her drugs for now. The stress has been unrelenting, said Conell, who spent a day last week in the emergency room with dangerously high blood pressure.
“I was trying to look for a job, worried about paying my bills. Ultimately, I’m worried about losing my kidney,” she said, adding that the long-delayed legislation could solve the problem. “I think they should pass it, like, yesterday.”
Can’t see the audio player? Click here to listen.
When Eric Umansky discovered that the machine that helps him breathe at night was “transmitting” his sleep habits to his insurance company, he was not happy. He was also less than pleased to learn that his insurer wanted to use that information to avoid paying for the treatment his doctor prescribed.
Irked, Umansky — who’s a journalist — recruited an investigative reporter in his newsroom to get to the bottom of the story. Later, both men spoke with podcast host Dan Weissmann.
Episode 6 of “An Arm and a Leg” uncovers some surprising rules and regulations designed to get consumers to shoulder a bigger share of the cost of medical equipment.
Season 2 is a co-production of Kaiser Health News and Public Road Productions.
To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.
To hear all Kaiser Health News podcasts, click here.
Health insurers that treat millions of seniors have overcharged Medicare by nearly $30 billion the past three years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.
Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their patients are or by charging Medicare for treating serious medical conditions they cannot prove their patients have.
Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed, or backed off, efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat over 22 million seniors, more than 1 in 3 people on Medicare.
Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 — just a tenth of what it estimates the plans overcharge the government in a given year.
At the same time, the Department of Health and Human Services Inspector General’s Office has launched a separate nationwide round of Medicare Advantage audits.
As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.
America’s Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it “fatally flawed.”
Insurer Cigna Corp. warned in a May financial filing: “If adopted in its current form, [the audits] could have a detrimental impact” on all Medicare Advantage plans and “affect the ability of plans to deliver high quality care.”
But former Sen. Claire McCaskill, a Missouri Democrat who now works as a political analyst, said officials must move past powerful lobbying efforts to hold health insurers accountable and demand refunds for “inappropriate” billings.
“There’s a lot of things that could cause Medicare to go broke. This would be one of the contributing factors,” she said. “Ten billion dollars a year is real money.”
Catching Overbilling With A Wider Net
In the overpayment dispute, health plans want CMS to scale back — if not kill off — an enhanced audit tool that, for the first time, could force insurers to cough up millions in improper payments they’ve received.
For over a decade, audits have been little more than an irritant to insurers because most plans go years without being chosen for review and often pay only a few hundred thousand dollars in refunds as a consequence. When auditors uncover errors in the medical records of patients they paid the companies to treat, CMS has simply required a rebate for those patients for just the year audited — relatively small sums for plans with thousands of members.
The latest CMS proposal would raise those stakes enormously by extrapolating error rates found in a random sample of 200 patients to the plan’s full membership — a technique expected to trigger many multimillion-dollar penalties. Though controversial, extrapolation is common in medical fraud investigations — except for investigations into Medicare Advantage. Since 2007, the industry has successfully challenged the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.
“The public has a substantial interest in the recoupment of millions of dollars of public money improperly paid to health insurers,” CMS wrote in a Federal Register notice late last year announcing its renewed attempt at using extrapolation.
Penalties In Limbo
In a written response to questions posed by Kaiser Health News, CMS officials said the agency has already conducted 90 of those enhanced audits for payments made in 2011, 2012 and 2013 — and expects to collect $650 million in extrapolated penalties as a result.
Though that figure reflects only a minute percentage of actual losses to taxpayers from overpayments, it would be a huge escalation for CMS. Previous Medicare Advantage audits have recouped a total of about $14 million, far less than it cost to conduct them, federal records show.
Though CMS has disclosed the names of the health plans in the crossfire, it has not yet told them how much each owes, officials said. CMS declined to say when, or if, they would make the results public.
This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 plans annually.
This spring, CMS announced it would extend until the end of August the audit proposal’s public comment period, which was supposed to end in April. That could be a signal the agency might be looking more closely at industry objections.
Health care industry consultant Jessica Smith said CMS might be taking additional time to make sure the audit protocol can pass muster. “Once they have their ducks in a row, CMS will come back hard at the health plans. There is so much money tied to this.”
But Sean Creighton, a former senior CMS official who now advises the industry for health care consultant Avalere Health, said payment error rates have been dropping because many health plans “are trying as hard as they can to become compliant.”
Still, audits are continuing to find mistakes. The first HHS inspector general audit, released in late April, found that Missouri-based Essence Healthcare Inc. had failed to justify fees for dozens of patients it had treated for strokes or depression. Essence denied any wrongdoing but agreed it should refund $158,904 in overcharges for those patients and ferret out any other errors.
Essence also faces a pending whistleblower suit filed by Charles Rasmussen, a Branson, Mo., doctor who alleges the health plan illegally boosted profits by overstating the severity of patients’ medical conditions. Essence has called the allegations “wholly without merit” and “baseless.”
Essence started as a St. Louis physician group, then grew into a broader holding company backed by prominent Silicon Valley venture capitalist John Doerr with his brother, St. Louis doctor and software designer Thomas Doerr, in 2007. Neither would comment on the allegations.
How We Got Here
CMS uses a billing formula called a “risk score” to pay for each Medicare Advantage member. The formula pays higher rates for sicker patients than for people in good health.
Congress approved risk scoring in 2003 to ensure health plans did not shy away from taking sick patients who could incur higher-than-usual costs from hospitals and other medical facilities. But some insurers quickly found ways to boost risk scores — and their revenues.
In 2007, after several years of running Medicare Advantage as what one CMS official dubbed an “honor system,” the agency launched “Risk Adjustment Data Validation,” or RADV, audits. The idea was to cut down on undeserved payments that cost CMS nearly $30 billion over the past three years.
The audits of 37 health plans revealed that on average auditors could confirm just 60% of the more than 20,000 medical conditions CMS had paid the plans to treat.
Extra payments to plans that had claimed some of its diabetic patients had complications, such as eye or kidney problems, were reduced or invalidated in nearly half the cases. The overpayments exceeded $10,000 a year for more than 150 patients, though health plans disputed some of the findings.
But CMS kept the findings under wraps until the Center for Public Integrity, an investigative journalism group, sued the agency under the Freedom of Information Act to make them public.
Despite the alarming results, CMS conducted no audits for payments made during 2008, 2009 and 2010 as they faced industry backlash over CMS’ authority to conduct them, and the threat of extrapolated repayments. Some inside the agency also worried that health plans would abandon the Medicare Advantage program if CMS pressed them too hard, records released through the FOIA lawsuit show.
CMS officials resumed the audits for 2011 and expected to finish them and assess penalties by the end of 2016. That has yet to happen amid the continuing protests from the industry. Insurers want CMS to adjust downward any extrapolated penalties to account for coding errors that exist in standard Medicare. CMS stands behind its method — at least for now.
At a minimum, argues AHIP, the health insurers association, CMS should back off extrapolation for the 90 audits for 2011-13 and apply it for 2014 and onward. Should CMS agree, it would write off more than half a billion dollars that could be recovered for the U.S. Treasury.
The American Hospital Association spoke out in support of CMS’ decision to hold off on releasing the ratings, which have long provoked push back from the industry over the methodology the agency uses.
Three years ago, Corey Walsh, who was in a relationship with a man who was HIV-positive, got a prescription for Truvada, a drug approved by the Food and Drug Administration to prevent infection with the virus that causes AIDS.
Walsh, then 23, was covered by his parents’ health insurance policy, which picked up the cost of the drug. But the price tag for the quarterly lab tests and doctor visits he needed as part of the prevention regimen cost him roughly $400, more than he could afford.
“I went back to my physician and said, ‘I can’t take this anymore because all these ancillary services aren’t covered,’” Walsh recalled. He ended up joining a clinical trial that covered all his costs.
Walsh’s experience with high out-of-pocket costs, whether for medication or related services, is common, advocates say. Last month, the U.S. Preventive Services Task Force recommended that clinicians offer prescription pre-exposure prophylaxis, or PrEP, to people at high risk of contracting HIV. The decision by the independent group of experts means that starting in 2021 most health plans are required to cover drugs that are recommended to prevent HIV, and patients can’t be charged anything out-of-pocket for the medication.
But the recommendation doesn’t apply to the other clinical and lab services people need if they’re on PrEP, according to task force officials.
In addition to the ancillary charges, other roadblocks persist for people who need PrEP from getting it.
“Eliminating cost sharing will undoubtedly expand access to individuals for whom affordability has been a significant barrier,” said Amy Killelea, senior director of health systems integration at NASTAD, an organization representing public health officials nationwide. “However, scaling up access to PrEP to individuals who need it most — including young, gay, black and Latino men — will require addressing other major systemic and structural challenges, such as stigma and provider awareness and willingness to prescribe PrEP to their patients.”
President Donald Trump has emphasized the need for more efforts to fight the HIV epidemic. In his State of the Union address in February, the president vowed to eliminate HIV transmission by 2030.
Currently, Truvada for PrEP, made by Gilead, is the only drug approved to prevent HIV. The once-a-day pill is at least 90% effective in some high-risk groups, including men who have sex with men as well as heterosexual men and women who have sex with HIV-positive partners, and 70% effective in people who inject illicit drugs.
Gilead estimated that 200,000 people now receive Truvada. The Centers for Disease Control and Prevention estimated that in 2015 there were 1.1 million people in the United States who could benefit from PrEP.
With a monthly price tag approaching $2,000, many private health plans have put the drug in a specialty drug tier with high copayments or coinsurance. Those payments will disappear when the task force recommendations take effect in 2021.
Truvada is generally covered in state Medicaid programs, as is the required clinical and lab work. But in the southern part of the country, where many states have not expanded Medicaid under the Affordable Care Act and HIV infection rates are high, there may be less access to the medication and other services.
Gilead offers a medication assistance program for uninsured people and a copay assistance program for those with private coverage that can fill gaps.
Gilead has submitted another HIV drug, Descovy, for FDA approval for PrEP, and a generic version of Truvada is expected next year.
It’s unclear how these options might affect people’s access to and ability to afford PrEP.
“Often it takes more than one generic for the price of a drug to drop,” said Jennifer Kates, a senior vice president at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)
The new preventive coverage requirement may lead to private insurers or Medicaid programs trying to limit access by imposing prior authorization requirements, some advocates worry. Insurers might, for example, require doctors to show that the patient is HIV-negative and meets the risk criteria before approving the prescription. That can have serious repercussions.
“Anytime there’s a delay at the pharmacy or on the provider’s end, patients will give up,” said John Peller, president and CEO of the AIDS Foundation of Chicago.
Citing fierce pushback from hospitals, California lawmakers sidelined a bill Wednesday that would have protected some patients from surprise medical bills by limiting how much hospitals could charge them for emergency care.
The legislation, which contributed to the intense national conversation about surprise medical billing, was scheduled to be debated Wednesday in the state Senate Health Committee.
Instead, the bill’s author pulled it from consideration, vowing to bring it back next year.
“We are going after a practice that has generated billions of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu (D-San Francisco). “This certainly does not mean we’re done.”
Chiu said he and his team would keep working on amendments to the bill that address the concerns of hospitals while maintaining protections for patients.
Hospitals focused their opposition on a provision of the bill that would have limited what they can charge insurers for out-of-network emergency services, criticizing it as an unnecessary form of rate setting.
“Balance billing,” better known as surprise billing, occurs when a patient receives care from a doctor or hospital — or another provider — outside of her insurance plan’s network, and then the doctor or hospital bills the patient for the amount insurance didn’t cover. These bills can soar into the tens of thousands of dollars.
In the absence of federal laws, many states have tried to formulate solutions to balance billing, but health policy experts suggest this issue would be best addressed by the federal government.
Congress is discussing different approaches but not without facing fierce opposition and lobbying from two influential groups: health insurers and providers, including doctors and hospitals.
Last week, the Senate Health, Education, Labor and Pensions Committee passed the Lower Health Care Costs Act, which would require insurers to pay providers no more than the median in-network rate in a geographic region for emergency and nonemergency care. But the American Hospital Association deemed the payment arrangement unworkable.
Getting buy-in from hospitals and other providers will not be easy.
“The system exists in a way that allows a subset of providers to stay out-of-network and charge very high rates,” said Christen Linke Young, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy. “They’re basically exploiting the system.”
Chiu’s bill would have prohibited out-of-network hospitals from sending surprise bills to privately insured emergency patients. Instead, hospitals would have to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles.
The bill also would have limited the amount hospitals could charge insurers for each service, and the amounts would have varied by region.
That’s the part hospitals opposed.
“We’ve said from the beginning that we are supportive of protecting patients. Unfortunately, the proponents of the bill inserted a completely unrelated provision regarding rate setting,” said Jan Emerson-Shea, a spokeswoman for the California Hospital Association.
Emerson-Shea said that if the state sets prices, health plans would have little incentive to negotiate contracts with hospitals. If this provision were removed, the hospital association would support Chiu’s bill, she said.
“That provision doesn’t need to be in the bill if the bill is really about protecting patients,” she said.
Chiu disagrees. Protecting patients from high costs and capping what insurers pay hospitals are “inextricably related,” Chiu said.
If this provision were removed, patients might still face high costs in the form of rising insurance premiums as insurers try to recoup their costs, Chiu said.
“It is useless to protect patients from receiving a bill on the front end if hospitals can turn around and price gouge consumers on the back end. It’s like closing your front door and leaving the back door wide open,” he said.
In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive nonemergency care.
Chiu’s bill was designed to close some of the loopholes. “It is disappointing it couldn’t get done this year” because more Californians will get hit with exorbitant balance bills in the meantime, he said.
The measure was prompted by the peculiar billing practices at Zuckerberg San Francisco General Hospital, located in his district.
Unlike most large hospitals, San Francisco General does not contract with private insurers. An investigation by Vox found that the hospital considered patients with private insurance out-of-network for emergency care and was slapping many of them with whopping bills. The hospital has since announced it has stopped balance billing patients.
Physicians who trained before the 2003 limits on work hours typically logged about 100 hours a week. When that was capped at 80 hours a week, some worried it wouldn’t be enough to properly train the doctors. But a new study finds that there were no difference in hospital deaths, readmissions or costs from the change.
Insulin is a vital drug that some 7.4 million Americans must take daily to manage their diabetes. But its price nearly doubled from 2012 to 2016, leaving some patients with no choice but to turn to black-market drugs or traveling to Canada, where insulin can be 90% cheaper. KHN senior correspondent Sarah Varney reports in collaboration with PBS NewsHour about the skyrocketing cost of insulin — and the trend’s deadly consequences.
This is a transcript of the story:
Sarah Varney: It’s early morning in downtown Minneapolis, and Quinn Nystrom is scrambling to arrange last-minute logistics for the trip to Canada.
Woman: A little nervous out there.
Quinn Nystrom: You and me both.
Varney: The caravan has drawn the media’s eye to a vexing problem that threatens her life and other Type 1 diabetics in the U.S., the exorbitant cost of insulin.
They will cross five states, picking up passengers along the way, all to buy insulin in Canada, where it costs 90% less.
Nystrom: Does everybody have their passport? Is everybody holding their passport up?
Varney: For Nystrom, this quest began years ago, when she was growing up in rural Baxter, Minn. She was diagnosed with Type 1 at 13 and hated being different from other girls at school. But when her parents sent her to a camp for kids with diabetes, she learned she wasn’t alone.
Nystrom: I didn’t get the choice to get diabetes, but I certainly had the choice of how I was going to react to getting diabetes.
Varney: She had dreams of finding a cure for diabetes. But about five years ago, as she was starting her career in public relations, she realized the real crisis: the price of insulin.
Nystrom: When I went to pick up that insulin, it started costing me $200 out-of-pocket, then $300 out-of-pocket. So I just started posting that on my social media and started to get a lot of responses.
Varney: So, Nystrom, once her senior class president and self-described rule-follower, took a different path. She now expedites transfers of black-market insulin.
Nystrom: Thank you so much. This is perfect.
Varney: In her refrigerator is a drawer of insulin donated by good Samaritans. Even with insurance, Nystrom herself pays up to $600 a month for two to three vials of NovoLog.
Nystrom: I don’t care if somebody steals my TV, but if they steal my insulin, I’m in big trouble.
Varney: Between 2012 and 2016, the cost of insulin nearly doubled. Nystrom meets people online who can’t afford insulin, like Abigail Hansmeyer, who turned to this black market a decade ago.
And with a special-needs daughter and a tight budget, a trip to Canada isn’t an option.
Abigail Hansmeyer: There’s costs for gas, food, you know, if you’re needing to stay overnight at the hotel. It’s not a solution for everyone. People that work full time, have children, it’s not a feasible thing. And this is certainly a band-aid on the problem. And it’s not even a band-aid for everyone.
Varney: In Washington this year, lawmakers have grilled executives from the three main producers — Eli Lilly, Novo Nordisk and Sanofi — and investigated price-fixing. But, so far, no bills have passed.
In May, Colorado became the first state to cap monthly insulin copayments at $100. And, in Minnesota, people like Nicole Smith-Holt have pushed for legislation to provide free or low-cost emergency insulin.
Her son Alec, a Type 1 diabetic, died because he couldn’t afford the drug. We met Smith-Holt on the second anniversary of Alec’s death. Her family has made a memorial in their backyard. When Alec turned 26, he was no longer allowed on his mother’s insurance plan, and the restaurant he worked at didn’t offer any.
Nicole Smith-Holt: The lowest plan that we found was $450 a month with a $7,600 deductible. That’s really not affordable.
Varney: Instead, he decided to pay for his insulin over the counter at list price. But the pharmacist told him a month’s supply would be $1,300. With only $1,000 in his bank account, he left empty-handed.
When did you first get word that something had gone terribly wrong?
Smith-Holt: Five days later, I received a phone call from actually my mother, who received a phone call from his girlfriend. He wasn’t answering his door and he wasn’t answering his phone. She could hear the phone ringing in the apartment.
And she just happened — you know, checked one of his windows that happened to be unlocked, and she was able to climb in through his bedroom window, and she found him on his floor, cold and unresponsive.
Varney: Alec’s official cause of death was diabetic ketoacidosis, or DKA, when, without insulin, acid dangerously builds up in the bloodstream. DKA can occur when diabetics ration their insulin. A study found 1 in 4 do so because of cost.
Smith-Holt: I went through a stage where I felt extremely guilty, like I could’ve prevented it somehow, or I should have seen something, or I should’ve known something. It wasn’t long before, you know, my sadness turned into anger.
Varney: In the wake of Alec’s death, Smith-Holt began sharing her story.
Did you think at that point this — Alec’s story — had just been unique, that this had just happened to you?
Smith-Holt: Oh, yes, yes. I thought we were, like, the only ones. And I was reluctant to share the story at first, because I was, like, why would people want to hear, you know, our sad story about Alec passing away?
And now I know why. Every single Type 1 diabetic in the world can picture themselves in Alec’s situation.
Varney: Until prices come down in the U.S., people with Type 1 diabetes and activists like Smith-Holt are making these trips to Canada to stock up on insulin and call attention to the dramatic price difference.
Unlike in the U.S., the Canadian government and many other countries negotiate insulin prices with manufacturers. So they traveled through Wisconsin, Illinois, Indiana and Michigan, adding riders and cars to the caravan. Their reasons for joining were all personal.
Deb Souther: When I was 10 years old, I remember going to the pharmacy, and we bought a vial of insulin for $3. Now I’m paying $380.
Kristen Hoatson: I’m going for my son. He’s 11 years old. He’s had Type 1 diabetes for three years.
Varney: The trip is both practical and symbolic.
Nystrom: I don’t think anybody on this bus would have chosen to go on an 817-mile ride today, but we’re being forced to do this because we’re in a crisis in America.
Varney: In statements to the “NewsHour” and in public testimony, Eli Lilly, Novo Nordisk and Sanofi blame high-deductible insurance plans and payments to pharmacy middlemen for the out-of-pocket costs borne by patients.
For example, Sanofi said: “We believe lowering list prices alone will not necessarily result in lower out-of-pocket costs for most patients at the pharmacy. This is why we have not dropped the list price of our insulins.”
The companies all say they offer coupons and discounts to help defray the price of insulin. The patients we talked to said it was difficult to qualify for these assistance programs.
Some 16 hours later, the bus crosses the border to Canada, arriving well after midnight in London, Ontario.
Nystrom: We made it.
Varney: The next morning, the logistical problems continue for Nystrom. Multiple pharmacies have turned the group away, not wanting the media attention.
Nystrom: The insulin’s here. Let’s go and get it!
Varney: The group finally loads onto the bus and heads off to a local Walmart. At a pharmacy inside, one by one, they fill their prescriptions, some filming on their cellphones.
Nystrom: I can buy nine vials of this for significantly less than one vial.
Varney: The group spent about $2,000 for insulin. The same haul would cost almost $24,000 in the U.S.
To mark the end of the trip, they head to a spot revered by diabetes activists. It was here in London, Ontario, at this house that Dr. Frederick Banting first had the idea that led to the discovery of insulin. That was nearly 100 years ago.
Dr. Banting sold the patent for $1 to the University of Toronto. Pharmaceutical companies started manufacturing the drug that remained cheap well into the 20th century.
And, in Canada, insulin has stayed inexpensive. Nicole Smith-Holt says if she only knew she could have come here for Alec, she would have walked, crawled, done anything to save her son. And in a quiet, painful moment at the Banting house, she left some of Alec’s ashes.
For the “PBS NewsHour” and Kaiser Health News, I’m Sarah Varney in London, Ontario.
Opinion writers focus on these health care topics and others.
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