Tagged Insurers

Must-Reads Of The Week From Brianna Labuskes

On this Friday the 13th, we’re wrapping up another week dominated by the upcoming battle over the next Supreme Court justice and the administration’s scramble to reunite separated families — not to mention new efforts to chip away at the health law.

Don’t feel overwhelmed. Here are some of the best stories on all that news and more.

The battle brewing over Supreme Court nominee Brett Kavanaugh highlights the political complexities of the upcoming midterms. In the Senate, where the battleground favors conservatives, the vote is an albatross around vulnerable red-state Democrats’ necks. But in the lower chamber, the fights are being waged in swing suburban districts around the country, giving Democrats the chance to appeal to independents and moderate Republicans.

The New York Times: Who Might the Court Fight Help in the Midterms? Democrats. and Republicans.

However, Democrats — in what even they say is a classic problem with the party — can’t seem to focus their message. Yes, they’re talking health care (threats to not only abortion but the health law itself). But they’re also focusing on presidential power and unions and LGBTQ rights and … the list goes on.

Politico: Dems Pitch Mixed Messages in Supreme Court Fight

(On that note, my favorite quote of the week comes from Politico’s coverage of Senate Minority Leader Chuck Schumer trying to get his people in line: “I’ll be 71 years old in August, you’re going to whip me? Kiss my you know what,” said Sen. Joe Manchin (D-W.Va.) when asked if Schumer can influence his vote.)

States are also scrambling to make sure they don’t have any centuries-old laws on the books banning abortions … just in case.

The Associated Press: States Brace for Abortion Fights After Kavanaugh Nomination

Even though the government missed the court-ordered deadline, officials have announced that all “eligible” children under age 5 have been reunited with their families. That still leaves 46 “ineligible” kids, plus thousands of older ones still in custody.

The New York Times: U.S. Says It Has Reunited Half of All Migrants Under 5, With Rest ‘Ineligible’

And somehow Health and Human Services Secretary Alex Azar has become the public face (and punching bag) of this crisis.

Politico: How the New Face of the Migrant Crisis Got Stuck With the Job

The health law absorbed a one-two blow this week. Not only did the administration slash funding for navigators (counselors who help people sign up for coverage), but it also froze a program that provides billions of dollars to insurers to help stabilize the marketplace. The reaction to both was fairly tempered, though. (Which might be a sign that upheaval and uncertainty has become the new norm.)

Politico: Latest Obamacare Shake-Up Could Fuel Rate Hikes

Modern Healthcare: CMS Risk-Adjustment Payment Freeze to Hit High-Cost Insurers Hardest

Pfizer’s agreement to roll back its price hikes earned the company flashy headlines. Looking more closely, the move doesn’t really translate to savings for consumers.

Stat: What Pfizer, Trump, and Consumers Got Out of a Surprising Deal

Be sure to check out this deep dive on the CEO who, while having a knack for turning a profit, is described as tone-deaf to the current outrage on drug prices.

Stat: How Pfizer’s CEO Kept on Raising Prices — Until Trump’s Tweet

If all that wasn’t enough news for you, here’s my miscellaneous file for the week: A startling report finds that drug distributors shipped the equivalent of about 260 opioid pills for every person in Missouri in a six-year period; despite New York’s abundance of world-class hospitals and surgeons, thousands of patients needing transplants are languishing on lists because New Yorkers donate organs at a lower rate than anywhere else in the country; and the administration tried to water down a global resolution on breastfeeding, resorting to trade threats and backing off only when Russia stepped in to introduce the measure.

The Washington Post: Companies Shipped 1.6 Billion Opioids to Missouri From 2012 to 2017, Report Says

The New York Times: New York Has World-Class Hospitals. Why Is It So Bad for People in Need of Transplants?

The New York Times: U.S. Opposition to Breast-Feeding Resolution Stuns World Health Officials

And just when we were getting over the romaine lettuce outbreak, we have not one but two more food-related illnesses popping up.

Have a great weekend!

Podcast: KHN’s ‘What The Health?’ ACA Under Fire. Again.

Democrats in the Senate are gearing up to fight President Donald Trump’s nominee to the Supreme Court, U.S. Circuit Judge Brett Kavanaugh. They argue he is not only a potential threat to abortion rights, but also to the Affordable Care Act.

Meanwhile, the Trump administration continues its efforts to undermine the workings of the Affordable Care Act. This week, officials announced a freeze on payments to insurers who enroll large numbers of sicker patients, and another cut to the budget for “navigators” who help people understand their insurance options and enroll for coverage.

This week’s panelists for KHN’s “What the Health?” are:

Julie Rovner of Kaiser Health News

Margot Sanger-Katz of The New York Times

Anna Edney of Bloomberg News

Julie Appleby of Kaiser Health News

Among the takeaways from this week’s podcast:

  • One reason Democrats are rallying around the health issue rather than the abortion issue is that there is more unity in their caucus over health than abortion. Also, the two key Republican senators who support abortion rights — Sen. Susan Collins (R-Maine) and Sen. Lisa Murkowski (R-Alaska) — also voted against GOP efforts to repeal the Affordable Care Act last year.
  • The Trump administration’s action on risk-adjustment payments sent yet another signal to insurers that the federal government does not necessarily have their backs and is willing to change the rules along the way.
  • The Trump administration says it wants to cut to payments for navigators because they are not cost-effective. But the navigator money does not come from taxpayers or government sources. It is paid from insurance industry user fees. These funds also go to support ACA advertising — which has also been cut. However, the user fees have not been reduced. In theory, reducing these fees could provide savings that could be passed on to consumers.
  • After being called out on Twitter by Trump, drugmaker Pfizer this week announced it would delay some already-announced price increases on about 100 of its drugs. It is worth noting that the president used his bully pulpit and gained some success. The six-month delay will mean that consumers will not experience an increase in cost at the pharmacy for at least that time period. But it still raises questions.
  • The Trump administration worked to block a World Health Organization resolution to promote breastfeeding. But while this seemed a clear case of promoting the interests of infant formula companies over public health experts, there was pushback from some women who say they are unable to breastfeed and feel stigma when they opt for formula instead. On the other hand, formula can be dangerous in developing countries without easy access to clean water.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too:

Julie Rovner: Politico Agenda’s “The One Big Winner of the Obamacare Wars,” by Joanne Kenen

Julie Appleby: The New York Times’ “Doctor, Your Patient Is Waiting. It’s a Red Panda,” by Karen Weintraub.

Anna Edney: Politico’s “CMS Quit Test of Pricey Cancer Treatment Amid Concerns Over Industry Role,” by Sarah Karlin-Smith and David Pittman

Margot Sanger-Katz: HuffPost’s “Trump Administration May Be Preparing A New Obamacare Sabotage Effort,” by Jonathan Cohn

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Podcast: KHN’s ‘What The Health?’ ACA Under Fire. Again.

Democrats in the Senate are gearing up to fight President Donald Trump’s nominee to the Supreme Court, U.S. Circuit Judge Brett Kavanaugh. They argue he is not only a potential threat to abortion rights, but also to the Affordable Care Act.

Meanwhile, the Trump administration continues its efforts to undermine the workings of the Affordable Care Act. This week, officials announced a freeze on payments to insurers who enroll large numbers of sicker patients, and another cut to the budget for “navigators” who help people understand their insurance options and enroll for coverage.

This week’s panelists for KHN’s “What the Health?” are:

Julie Rovner of Kaiser Health News

Margot Sanger-Katz of The New York Times

Anna Edney of Bloomberg News

Julie Appleby of Kaiser Health News

Among the takeaways from this week’s podcast:

  • One reason Democrats are rallying around the health issue rather than the abortion issue is that there is more unity in their caucus over health than abortion. Also, the two key Republican senators who support abortion rights — Sen. Susan Collins (R-Maine) and Sen. Lisa Murkowski (R-Alaska) — also voted against GOP efforts to repeal the Affordable Care Act last year.
  • The Trump administration’s action on risk-adjustment payments sent yet another signal to insurers that the federal government does not necessarily have their backs and is willing to change the rules along the way.
  • The Trump administration says it wants to cut to payments for navigators because they are not cost-effective. But the navigator money does not come from taxpayers or government sources. It is paid from insurance industry user fees. These funds also go to support ACA advertising — which has also been cut. However, the user fees have not been reduced. In theory, reducing these fees could provide savings that could be passed on to consumers.
  • After being called out on Twitter by Trump, drugmaker Pfizer this week announced it would delay some already-announced price increases on about 100 of its drugs. It is worth noting that the president used his bully pulpit and gained some success. The six-month delay will mean that consumers will not experience an increase in cost at the pharmacy for at least that time period. But it still raises questions.
  • The Trump administration worked to block a World Health Organization resolution to promote breastfeeding. But while this seemed a clear case of promoting the interests of infant formula companies over public health experts, there was pushback from some women who say they are unable to breastfeed and feel stigma when they opt for formula instead. On the other hand, formula can be dangerous in developing countries without easy access to clean water.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too:

Julie Rovner: Politico Agenda’s “The One Big Winner of the Obamacare Wars,” by Joanne Kenen

Julie Appleby: The New York Times’ “Doctor, Your Patient Is Waiting. It’s a Red Panda,” by Karen Weintraub.

Anna Edney: Politico’s “CMS Quit Test of Pricey Cancer Treatment Amid Concerns Over Industry Role,” by Sarah Karlin-Smith and David Pittman

Margot Sanger-Katz: HuffPost’s “Trump Administration May Be Preparing A New Obamacare Sabotage Effort,” by Jonathan Cohn

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Insurers Fall Short In Catching And Reporting Medicaid Fraud, Inspectors Find

Despite receiving billions of dollars in taxpayer money, Medicaid insurers are lax in ferreting out fraud and neglect to tell states about unscrupulous medical providers, according to a federal report released Thursday.

The U.S. Health and Human Services’ inspector general’s office said a third of the health plans it examined had referred fewer than 10 cases each of suspected fraud or abuse to state Medicaid officials in 2015 for further investigation. Two insurers in the program, which serves low-income Americans, didn’t identify a single case all year, the report found.

Some health plans terminated providers from their networks for fraud but didn’t inform the state. The inspectors said that could allow those doctors or providers to defraud other Medicaid insurers or other government programs in the same state.

In addition, some insurance companies failed to recover millions of dollars in overpayments made to doctors, home health agencies or other providers. The inspector general said insurers stood to benefit financially from this because higher costs can justify increased Medicaid rates in the future. (The report didn’t name specific insurers or states.)

Medicaid plans “are required by law to find fraud and abuse and to share information with states,” said Meridith Seife, a deputy regional inspector general in New York and a co-author of the report. “We are concerned anytime we see evidence that managed-care organizations are not doing that in a rigorous way. There’s a lot of taxpayer dollars at stake.”

In general, Medicaid has struggled for years with poor oversight and billions lost to improper payments, drawing regular scrutiny from federal auditors but little improvement. Authorities have found clinics overprescribing opioids to Medicaid patients and doctors running pill mills. Hospitals and other providers have falsified Medicaid claims, paid illegal kickbacks for patient referrals and billed for unnecessary services.

Health insurers serve about 55 million Medicaid patients across 38 states, and play an increasingly vital role in running the giant public insurance program. States generally split the cost of Medicaid with the federal government.

One in 5 Americans is on Medicaid and enrollment is poised to rise even further as more states consider expansion under the Affordable Care Act. About 75 percent of Medicaid patients are part of a privatized system in which managed-care companies are paid fixed fees per patient to coordinate their care. Big, publicly traded companies such as UnitedHealth, Anthem and Centene dominate the business. In some states like California, evidence shows the funding often flows to the plans with little oversight, sometimes regardless of their performance.

These companies tout their expertise at spotting suspicious billing patterns and chasing down criminals using sophisticated data mining, but the inspector general found that their fraud-fighting results don’t always match the rhetoric.

Andy Schneider, a former federal health official and now a research professor at Georgetown University’s Center for Children and Families, said the lack of reporting to states is “a big problem.”

“If states don’t know a provider has ripped off the managed-care organization, how can they protect other state programs or insurers from that behavior?” he said.

Last year, new Obama-era rules went into effect that seek to strengthen fraud-detection efforts in Medicaid managed care. For now, the Trump administration has endorsed those changes.

Last month, the administration said they would monitor state compliance and conduct more audits. 

“With historic growth in Medicaid comes an urgent federal responsibility to ensure sound fiscal stewardship and oversight of the program,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a statement last month.

In a May 17 response to the inspector general, Verma cited the Obama administration’s managed-care rules and she agreed with nearly all of the recommendations the inspector general made to help remedy the problems.

In the report, the inspector general’s office examined data from the health plan with the largest Medicaid spending in each of the 38 states with managed care. Inspectors also conducted interviews with officials and insurance companies in five states. Among the findings:

  • The 38 plans received $62.2 billion in federal and state money in 2015. That represents about a quarter of the $236 billion Medicaid plans received that year. That figure has grown to nearly $300 billion last year, or about half of Medicaid spending overall.
  • The health insurers identified $57.8 million in overpayments related to fraud or abuse during 2015. Health plans only recovered $12.5 million, or 22 percent, of those overpayments. (Four of the health plans found no such overpayments all year.)
  • Insurers performed better on erroneous billing and other overpayments not related to fraud. Health plans collected 68 percent of the $831.4 million they identified in 2015.

Insurance industry officials say they couldn’t comment specifically on the audit until they had more time to review the findings. They agreed that the number of cases identified and shared with states appeared relatively small in comparison to the Medicaid spending involved.

Jeff Myers, chief executive of Medicaid Health Plans of America, an industry trade group, said state contracts vary widely and may not require health plans to report every questionable provider or billing discrepancy.

“Those numbers do seem low,” Myers said of the fraud instances cited in the report. “If the Trump administration and states decide they need to get more data and do more rigorous analysis, plans will provide it.”

Myers pushed back on the inspectors’ suggestion that insurers are purposely ignoring wasteful spending in order to boost their own revenue and profits from states.

“States look very seriously at ways to reduce Medicaid spending because every dollar spent on Medicaid is a dollar not spent somewhere else,” Myers said.

Some health-policy experts said the federal report reflects the insurance industry’s resistance to what it perceives as meddling in its private business even though plans are participating in a public program. “This kind of behavior, like not reporting bad actors, is totally consistent with their broader philosophy of ‘It’s my money and let me run my business,’” said Schneider, the former federal official.

Christopher Koller, former Rhode Island health insurance commissioner, said states bear the responsibility to address these problems in their contracts with health plans.

“This is one more example of how state oversight can often be insufficient,” said Koller, president of the Milbank Memorial Fund, a foundation focused on health policy. “States who think they can outsource all of the work to the private-sector ‘experts’ are not serving their citizens well.”

In 2015, the 38 health plans examined by inspectors collectively took 2,668 corrective actions, such as payment suspensions, against providers suspected of fraud or abuse, according to the report.

Eighteen health plans canceled contracts for a total of 179 providers “for cause” in 2015. Three of those insurers said they didn’t typically notify the state of provider terminations.

Now the new Medicaid regulations require insurers to notify states about providers’ terminations and other changes in their status, according to the report.


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Must-Reads Of The Week From Brianna Labuskes

It’s been a week since a tweet went viral about an injured woman begging fellow train passengers not to call an ambulance for fear of the expense — and the story is still resonating. It was a snapshot of our reality, a shocking but relatable moment, where we all wondered: When is a $3,000 ride to the hospital worth it?

Here are some other stories — and yes, much longer than 140 or so characters — that will make you think as well.

Democrats are walking a tightrope as they strategize for the upcoming Supreme Court nominee battle. They have a base that’s raring for a knock-down, drag-out brawl on one side, and vulnerable red-state candidates that need protection on the other. Help might come from an unlikely source: the health law.

The Associated Press: Dems Want to Focus High Court Fight on Abortion, Health Care

As lawmakers gird for the fight even before a nominee is picked, President Donald Trump mulls over his short list. But we can expect a choice as early as Monday.

The Washington Post: Trump Narrows List for Supreme Court Pick, With Focus on Kavanaugh and Kethledge

“Death spiral” and “doomsday” predictions were thick on the ground last year when it came to the health law marketplaces, but the exchanges are proving to be surprisingly resilient to any attempts to kill them.

The New York Times: Obamacare Is Proving Hard to Kill

The Washington Post: More Americans Pay for ACA Health Plans, Despite Trump Administration Moves to Undercut Law

True to his word, Kentucky Gov. Matt Bevin announced the state is cutting benefits for Medicaid recipients as “an unfortunate consequence” of a judge’s ruling on Kentucky’s work requirements waiver. But, it might be a little more complicated than that: Some say the announcement is actually misleading and people will continue receiving limited coverage.

Modern Healthcare: Questions Arise Over Kentucky’s Medicaid Cuts Following Work Requirement Rejection

Is the convenience of getting prescription pills at your door worth handing over a ton of your personal health care information to Amazon? The company is in a league of its own when it comes to analyzing consumers’ shopping behaviors and preferences — and critics wonder what will happen when it is handed sensitive health care data.

The Wall Street Journal: Amazon’s PillPack Deal Gives It Access to Sensitive Health Data

In the miscellaneous file this week: the heartbreaking story of the unclaimed AIDS victims buried during the height of the crisis on a small island in New York; revelations about a persistent weakness in the nation’s food-safety system — with a lot of fingers pointing at the Food and Drug Administration; in an experiment right out of pulp fiction, scientists have shown that zapping the front part of someone’s brain can actually curb aggressive tendencies; and people are rushing to get their genes checked for dangerous mutations — but are failing to read the small print where it says those results could be completely and totally wrong.

The New York Times: Dead of AIDS and Forgotten in Potter’s Field

Politico: Victims Blame FDA for Food-Recall Failures

Stat: Can Zapping Brains Reduce Violence? Controversial Study Sees Potential

The New York Times: The Online Gene Test Finds a Dangerous Mutation. It May Well Be Wrong.

In news that cheered many a journalist in this newsroom (though not me, because I don’t drink coffee), a new study finds that you should indulge in that cup of joe in the morning: You might live longer for it.

Must-Reads Of The Week From Brianna Labuskes

It’s been a week since a tweet went viral about an injured woman begging fellow train passengers not to call an ambulance for fear of the expense — and the story is still resonating. It was a snapshot of our reality, a shocking but relatable moment, where we all wondered: When is a $3,000 ride to the hospital worth it?

Here are some other stories — and yes, much longer than 140 or so characters — that will make you think as well.

Democrats are walking a tightrope as they strategize for the upcoming Supreme Court nominee battle. They have a base that’s raring for a knock-down, drag-out brawl on one side, and vulnerable red-state candidates that need protection on the other. Help might come from an unlikely source: the health law.

The Associated Press: Dems Want to Focus High Court Fight on Abortion, Health Care

As lawmakers gird for the fight even before a nominee is picked, President Donald Trump mulls over his short list. But we can expect a choice as early as Monday.

The Washington Post: Trump Narrows List for Supreme Court Pick, With Focus on Kavanaugh and Kethledge

“Death spiral” and “doomsday” predictions were thick on the ground last year when it came to the health law marketplaces, but the exchanges are proving to be surprisingly resilient to any attempts to kill them.

The New York Times: Obamacare Is Proving Hard to Kill

The Washington Post: More Americans Pay for ACA Health Plans, Despite Trump Administration Moves to Undercut Law

True to his word, Kentucky Gov. Matt Bevin announced the state is cutting benefits for Medicaid recipients as “an unfortunate consequence” of a judge’s ruling on Kentucky’s work requirements waiver. But, it might be a little more complicated than that: Some say the announcement is actually misleading and people will continue receiving limited coverage.

Modern Healthcare: Questions Arise Over Kentucky’s Medicaid Cuts Following Work Requirement Rejection

Is the convenience of getting prescription pills at your door worth handing over a ton of your personal health care information to Amazon? The company is in a league of its own when it comes to analyzing consumers’ shopping behaviors and preferences — and critics wonder what will happen when it is handed sensitive health care data.

The Wall Street Journal: Amazon’s PillPack Deal Gives It Access to Sensitive Health Data

In the miscellaneous file this week: the heartbreaking story of the unclaimed AIDS victims buried during the height of the crisis on a small island in New York; revelations about a persistent weakness in the nation’s food-safety system — with a lot of fingers pointing at the Food and Drug Administration; in an experiment right out of pulp fiction, scientists have shown that zapping the front part of someone’s brain can actually curb aggressive tendencies; and people are rushing to get their genes checked for dangerous mutations — but are failing to read the small print where it says those results could be completely and totally wrong.

The New York Times: Dead of AIDS and Forgotten in Potter’s Field

Politico: Victims Blame FDA for Food-Recall Failures

Stat: Can Zapping Brains Reduce Violence? Controversial Study Sees Potential

The New York Times: The Online Gene Test Finds a Dangerous Mutation. It May Well Be Wrong.

In news that cheered many a journalist in this newsroom (though not me, because I don’t drink coffee), a new study finds that you should indulge in that cup of joe in the morning: You might live longer for it.

Podcast: KHN’s ‘What The Health?’ Whither Work Requirements?

A federal District Court judge in Washington, D.C., has — for now — blocked Kentucky’s proposal to add a work requirement for much of its adult Medicaid population. The decision, while far from final, is likely to prompt lawsuits from advocates in other states where the Department of Health and Human Services has approved similar proposals.

Also this week, HHS released updated enrollment information about those purchasing health insurance in the individual market. Despite efforts by the Trump administration and Republicans in Congress to depress enrollment by cutting outreach and canceling federal payments to insurers, the number of people who actually paid their first month’s premium was up slightly in 2018, compared with 2017.

This week’s panelists for KHN’s “What the Health?” are: Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Anna Edney of Bloomberg News and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • While the overall number of people buying coverage in the health law’s exchanges rose, the number of people not getting help with their premiums fell for the third-straight year. While some consumers may have found other coverage (through Medicare or jobs), rising premiums have been a problem.
  • The court decision blocking Kentucky’s Medicaid work requirement does not necessarily preclude other states’ work requirements from going forward. But the decision is likely to spark lawsuits in those states that have already had their work programs approved by HHS.
  • The window for bipartisan action on health care costs on Capitol Hill has closed. The Justice Department’s decision to join the state attorneys general lawsuit on preexisting conditions was likely the last straw. Issues surrounding coverage of preexisting conditions will now likely dominate the political discussion leading up to the midterm elections this fall.
  • Two things worth noting from the month of June. First, the recent court decision on risk-corridor payments to insurers seems to be a significant blow to the industry. Also, the Trump administration announced a major reorganization of Cabinet-level agencies. Although this is a common step for an administration, and something that rarely moves beyond “pie-in-the-sky” discussions, this one seems to be encapsulating the debate about the safety-net and social welfare programs.

Read the latest on the Bill of the Month series:

“Father’s And Son’s Injuries Lead To The Mother Of All Therapy Bills,” By Stephanie O’Neill.

If you have a medical bill you’d like NPR and KHN to investigate, you can submit it here.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too:

Julie Rovner: Kaiser Health News’ “Unlocked And Loaded: Families Confront Dementia And Guns,” by JoNel Aleccia and Melissa Bailey

Stephanie Armour: NPR’s “Rising Cost of PrEP to Prevent HIV Infection Pushes It Out of Reach for Many,” by Shefali Luthra and Anna Gorman

Anna Edney: The New York Times’ “Emergency Rooms Run Out of Vital Drugs, and Patients Are Feeling It,” by Katie Thomas

Joanne Kenen: The Washington Post’s “College Students Are Forming Mental-Health Clubs — and They’re Making a Difference,” By Amy Ellis Nutt

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.