Tagged Medicare

Must-Reads Of The Week From Brianna Labuskes

We’re barreling toward November, folks. (How is it mid-October already?) As you might expect, election stories made up the bulk of the health care news this week. Other great gems and intriguing developments surfaced, though, so let’s get right to it.

Republicans on the campaign trail have been hammered by attack ads over their stance on the health law, with “preexisting conditions protections” — insurance safeguards for patients diagnosed with chronic illness — becoming a catch-all phrase for the most popular parts of the Affordable Care Act. Even the law’s most vocal opponents have been reading tea leaves and softening their stances. That’s why statements from GOP leadership this week that Congress could revisit their “repeal” fight post-midterms may have landed with a thunk.

The New York Times: Republican Candidates Soften Tone on Health Care As Their Leaders Dig In

The Washington Post: Trump Says ‘All Republicans’ Back Protections for Preexisting Conditions, Despite Repeated Attempts to Repeal Obamacare

Democrats are pulling out a tried-and-true talking point that seemed perfectly timed for them as news of the federal deficit reignited Republican talk about cutting entitlement programs. Dems (who have been playing defense over Medicare) seized the opportunity to accuse Republicans of putting the beloved program on the chopping block.

The Associated Press: Dems Shift Line of Attack, Warning of GOP Threat to Medicare

As the parties duke it out on the trail, voters seem to agree on one thing: Our health care system is broken and someone needs to fix it. “It’s crippling people. It’s crippling me,” one voter says in Politico’s deep read that takes us to a Pennsylvania county where the “margins of electoral victories traditionally are as slim as the spectrum of political opinion is vast.”

Politico Magazine: The Great American Health Care Panic

On the state level, a Missouri Democrat opposed to abortion struggles to find her place in the party. And Georgia becomes a preview of the growing political clout of home health aides.

The New York Times: Is It Possible to Be an Anti-Abortion Democrat? One Woman Tried to Find Out

Politico: Home Health Aides Test Political Clout in Georgia Governor’s Race


The Trump administration this week proposed a requirement that pharma add drug prices to TV ads — triggering skepticism. One problem is that ad prices wouldn’t reflect what most people end up paying for a drug at the pharmacy counter.

Politico: Trump Set to Force Drugmakers to Post Prices in Ads

What I found surprising, considering how common those ads are, is that just a few dozen drugmakers run any at all — nearly half are put out by five companies. Those manufacturers would bear the brunt of the new rules.

Stat: Five Drug Makers Will Be Hit Hardest By Trump’s New Proposal on Drug Ads

Trying to think outside the box to rein in high drug prices, several states are considering treating pharma as they would a public utility — with rate-setting bodies to review, approve or adjust medication prices.

Stat: A Growing Number of States Consider Legislation to Treat Pharma As a Utility

And keep an eye on this battle: Minnesota became the first state to sue drugmakers over the price of insulin, but I don’t think it will be the last. The “life-or-death” drug has gotten a lot of attention recently, synthesizing the human toll of high costs into a digestible talking point.

Stat: Minnesota Becomes First State to Sue Major Insulin Makers Over Price-Gouging


Another 4,100 Arkansas beneficiaries were dropped from the state’s Medicaid rolls, and 4,800 more are at risk next month (on top of the original 4,353 people dropped last month) — all because of the state’s new work requirements. For critics of the restrictions, their worst fears are realized, while state and national officials focus on what they call positive outcomes. It’s unclear why so many workers are failing to report their hours, but experts suggest limited internet access and lack of knowledge about the requirements as possibilities.

Modern Healthcare: 4,100 More Arkansans Lose Medicaid Over Work Requirements


Anthem was slammed this week with a $16 million settlement over its massive data breach. (Remember the biggest known health care hack in U.S. history?) That penalty is nearly three times the previous record paid over such a case.

The Associated Press: Insurer Anthem Will Pay Record $16M for Massive Data Breach


I’m not sure whether it’s because I saturate myself in health care stories, but I detect a serious reckoning in the field of medical research. The latest call for retractions involves a prominent cardiologist.

The New York Times: Harvard Calls for Retraction of Dozens of Studies by Noted Cardiologist


In the miscellaneous must-read file:

• A mysterious polio-like illness that causes sudden paralysis is hitting children in states across the country. The wave of cases is similar to one officials saw in 2014 and 2016, but experts are baffled.

Los Angeles Times: What Is AFM? Everything You Need to Know About the Polio-Like Virus Suddenly Affecting Children Across the U.S.

• I have to admit, this is the headline that most piqued my interest this week. Gene editing is such a hot field, but in the racially charged landscape of the country, scientists are worried their research into genes and genetic diversity will be twisted by hate groups to support their views.

The New York Times: Why White Supremacists Are Chugging Milk (And Why Geneticists Are Alarmed)

• Why hasn’t #WhyIStayed caught on fire like #MeToo? Stigma, for one. But also the #MeToo movement has shown how powerful multiple accusations can be, amplified to the point they can’t be ignored. In a domestic violence situation, it’s often only one survivor speaking out.

The New York Times: Domestic Violence Awareness Hasn’t Caught Up With #MeToo. Here’s Why.

• Viruses don’t always have to be a scary thing. This therapy uses bacteriophages — literally, eaters of bacteria — that inject themselves into germs and cause them to explode. (As this delightful image from the Stat article describes: The viruses can “pop bacteria the way middle schoolers pop zits.”)

Stat: How The Navy Brought a Once-Derided Scientist Out of Retirement — and Into the Virus-Selling Business

• “Pregnant? Don’t want to be? Call Jane.” That’s how a clandestine underground abortion network advertised during the years leading up to Roe v. Wade, according to this retro report from the NYT.

The New York Times: Code Name Jane: The Women Behind a Covert Abortion Network


It turns out, it is now scientifically supported that daylight helps kill germs indoors. So make sure to let the sun in this weekend! And have a good one.

Must-Reads Of The Week From Brianna Labuskes

We’re barreling toward November, folks. (How is it mid-October already?) As you might expect, election stories made up the bulk of the health care news this week. Other great gems and intriguing developments surfaced, though, so let’s get right to it.

Republicans on the campaign trail have been hammered by attack ads over their stance on the health law, with “preexisting conditions protections” — insurance safeguards for patients diagnosed with chronic illness — becoming a catch-all phrase for the most popular parts of the Affordable Care Act. Even the law’s most vocal opponents have been reading tea leaves and softening their stances. That’s why statements from GOP leadership this week that Congress could revisit their “repeal” fight post-midterms may have landed with a thunk.

The New York Times: Republican Candidates Soften Tone on Health Care As Their Leaders Dig In

The Washington Post: Trump Says ‘All Republicans’ Back Protections for Preexisting Conditions, Despite Repeated Attempts to Repeal Obamacare

Democrats are pulling out a tried-and-true talking point that seemed perfectly timed for them as news of the federal deficit reignited Republican talk about cutting entitlement programs. Dems (who have been playing defense over Medicare) seized the opportunity to accuse Republicans of putting the beloved program on the chopping block.

The Associated Press: Dems Shift Line of Attack, Warning of GOP Threat to Medicare

As the parties duke it out on the trail, voters seem to agree on one thing: Our health care system is broken and someone needs to fix it. “It’s crippling people. It’s crippling me,” one voter says in Politico’s deep read that takes us to a Pennsylvania county where the “margins of electoral victories traditionally are as slim as the spectrum of political opinion is vast.”

Politico Magazine: The Great American Health Care Panic

On the state level, a Missouri Democrat opposed to abortion struggles to find her place in the party. And Georgia becomes a preview of the growing political clout of home health aides.

The New York Times: Is It Possible to Be an Anti-Abortion Democrat? One Woman Tried to Find Out

Politico: Home Health Aides Test Political Clout in Georgia Governor’s Race


The Trump administration this week proposed a requirement that pharma add drug prices to TV ads — triggering skepticism. One problem is that ad prices wouldn’t reflect what most people end up paying for a drug at the pharmacy counter.

Politico: Trump Set to Force Drugmakers to Post Prices in Ads

What I found surprising, considering how common those ads are, is that just a few dozen drugmakers run any at all — nearly half are put out by five companies. Those manufacturers would bear the brunt of the new rules.

Stat: Five Drug Makers Will Be Hit Hardest By Trump’s New Proposal on Drug Ads

Trying to think outside the box to rein in high drug prices, several states are considering treating pharma as they would a public utility — with rate-setting bodies to review, approve or adjust medication prices.

Stat: A Growing Number of States Consider Legislation to Treat Pharma As a Utility

And keep an eye on this battle: Minnesota became the first state to sue drugmakers over the price of insulin, but I don’t think it will be the last. The “life-or-death” drug has gotten a lot of attention recently, synthesizing the human toll of high costs into a digestible talking point.

Stat: Minnesota Becomes First State to Sue Major Insulin Makers Over Price-Gouging


Another 4,100 Arkansas beneficiaries were dropped from the state’s Medicaid rolls, and 4,800 more are at risk next month (on top of the original 4,353 people dropped last month) — all because of the state’s new work requirements. For critics of the restrictions, their worst fears are realized, while state and national officials focus on what they call positive outcomes. It’s unclear why so many workers are failing to report their hours, but experts suggest limited internet access and lack of knowledge about the requirements as possibilities.

Modern Healthcare: 4,100 More Arkansans Lose Medicaid Over Work Requirements


Anthem was slammed this week with a $16 million settlement over its massive data breach. (Remember the biggest known health care hack in U.S. history?) That penalty is nearly three times the previous record paid over such a case.

The Associated Press: Insurer Anthem Will Pay Record $16M for Massive Data Breach


I’m not sure whether it’s because I saturate myself in health care stories, but I detect a serious reckoning in the field of medical research. The latest call for retractions involves a prominent cardiologist.

The New York Times: Harvard Calls for Retraction of Dozens of Studies by Noted Cardiologist


In the miscellaneous must-read file:

• A mysterious polio-like illness that causes sudden paralysis is hitting children in states across the country. The wave of cases is similar to one officials saw in 2014 and 2016, but experts are baffled.

Los Angeles Times: What Is AFM? Everything You Need to Know About the Polio-Like Virus Suddenly Affecting Children Across the U.S.

• I have to admit, this is the headline that most piqued my interest this week. Gene editing is such a hot field, but in the racially charged landscape of the country, scientists are worried their research into genes and genetic diversity will be twisted by hate groups to support their views.

The New York Times: Why White Supremacists Are Chugging Milk (And Why Geneticists Are Alarmed)

• Why hasn’t #WhyIStayed caught on fire like #MeToo? Stigma, for one. But also the #MeToo movement has shown how powerful multiple accusations can be, amplified to the point they can’t be ignored. In a domestic violence situation, it’s often only one survivor speaking out.

The New York Times: Domestic Violence Awareness Hasn’t Caught Up With #MeToo. Here’s Why.

• Viruses don’t always have to be a scary thing. This therapy uses bacteriophages — literally, eaters of bacteria — that inject themselves into germs and cause them to explode. (As this delightful image from the Stat article describes: The viruses can “pop bacteria the way middle schoolers pop zits.”)

Stat: How The Navy Brought a Once-Derided Scientist Out of Retirement — and Into the Virus-Selling Business

• “Pregnant? Don’t want to be? Call Jane.” That’s how a clandestine underground abortion network advertised during the years leading up to Roe v. Wade, according to this retro report from the NYT.

The New York Times: Code Name Jane: The Women Behind a Covert Abortion Network


It turns out, it is now scientifically supported that daylight helps kill germs indoors. So make sure to let the sun in this weekend! And have a good one.

Podcast: KHN’s ‘What The Health?’ Republicans’ Preexisting Political Problem

Ensuring that people with preexisting health conditions can get and keep health insurance has become one of the leading issues around the country ahead of this fall’s midterm elections. And it has put Republicans in something of a bind — many either voted to repeal these coverage protections as part of the 2017 effort in Congress or have signed onto a lawsuit that would invalidate them.

Meanwhile, the Trump administration, eager to show progress regarding high prescription drug costs — another issue important to voters — has issued a regulation that would require prices to be posted as part of television drug advertisements.

Also this week: an interview with California Attorney General Xavier Becerra, a former member of Congress who is using his current post to pursue a long list of health initiatives.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Stephanie Armour of The Wall Street Journal and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • Democrats have made health care — especially the protections for people with preexisting conditions — their central strategy in midterm campaigns. It’s an issue that the GOP did not want to be campaigning on.
  • Republicans say that despite their moves to destroy the federal health law, they would work to preserve coverage options for people with preexisting conditions. But they don’t lay out what those options would be and earlier efforts have major loopholes, Democrats point out.
  • The announcement by federal health officials this week that they want drug prices added to advertisements about the products is expected to have marginal effects because pricing is so complicated. If the federal government requires drugmakers to post their prices on ads, the manufacturers are widely expected to sue based on First Amendment issues.
  • Open enrollment for Medicare began this week and runs until Dec. 7. Medicare Advantage, the private-plan option for enrollees, is becoming increasingly popular and now covers more than a third of Medicare beneficiaries.
  • But while Medicare Advantage offers many benefits the traditional program does not — frequently including dental and foot care — a recent report from the inspector general at the Department of Health and Human Services finds that some of these plans may be wrongly denying care to Medicare patients. At the same time, Medicare beneficiaries who choose to use Medicare Advantage plans may be in for a shock if they later decide to switch back to the traditional form of Medicare. They may not be eligible at that point to buy a Medigap plan to help cover their cost sharing.

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

Julie Rovner: The New York Times’ “Is Medicare for All the Answer to Sky-High Administrative Costs?” by Austin Frakt

Stephanie Armour: The Associated Press’ “Study: Without Medicaid Expansion, Poor Forgo Medical Care,” by Ricardo Alonso-Zaldivar

Rebecca Adams: The New Yorker’s “Rural Georgians Want Medicaid, But They’re Divided on Stacey Abrams, the Candidate Who Wants to Expand It,” by Charles Bethea

Joanne Kenen: Seven Days Vermont’s “Obituary: Madelyn Linsenmeir, 1988-2018.”

To hear all our podcasts, click here.

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

Podcast: KHN’s ‘What The Health?’ Republicans’ Preexisting Political Problem

Ensuring that people with preexisting health conditions can get and keep health insurance has become one of the leading issues around the country ahead of this fall’s midterm elections. And it has put Republicans in something of a bind — many either voted to repeal these coverage protections as part of the 2017 effort in Congress or have signed onto a lawsuit that would invalidate them.

Meanwhile, the Trump administration, eager to show progress regarding high prescription drug costs — another issue important to voters — has issued a regulation that would require prices to be posted as part of television drug advertisements.

Also this week: an interview with California Attorney General Xavier Becerra, a former member of Congress who is using his current post to pursue a long list of health initiatives.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Stephanie Armour of The Wall Street Journal and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • Congress passed a package of bills addressing the nation’s opioid epidemic on a rare note of bipartisanship. Many of the measures are designed to help prevent opioid addiction but are short on treatment options.
  • Democrats have made health care — especially the protections for people with preexisting conditions — their central strategy in midterm campaigns. It’s an issue that the GOP did not want to be campaigning on.
  • Republicans say that despite their moves to destroy the federal health law, they would work to preserve coverage options for people with preexisting conditions. But they don’t lay out what those options would be and earlier efforts have major loopholes, Democrats point out.
  • The announcement by federal health officials this week that they want drug prices added to advertisements about the products is expected to have marginal effects because pricing is so complicated. If the federal government requires drugmakers to post their prices on ads, the manufacturers are widely expected to sue based on First Amendment issues.
  • Open enrollment for Medicare began this week and runs until Dec. 7. Medicare Advantage, the private-plan option for enrollees, is becoming increasingly popular and now covers more than a third of Medicare beneficiaries.
  • But while Medicare Advantage offers many benefits the traditional program does not — frequently including dental and foot care — a recent report from the inspector general at the Department of Health and Human Services finds that some of these plans may be wrongly denying care to Medicare patients. At the same time, Medicare beneficiaries who choose to use Medicare Advantage plans may be in for a shock if they later decide to switch back to the traditional form of Medicare. They may not be eligible at that point to buy a Medigap plan to help cover their cost sharing.

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

Julie Rovner: The New York Times’ “Is Medicare for All the Answer to Sky-High Administrative Costs?” by Austin Frakt

Stephanie Armour: The Associated Press’ “Study: Without Medicaid Expansion, Poor Forgo Medical Care,” by Ricardo Alonso-Zaldivar

Rebecca Adams: The New Yorker’s “Rural Georgians Want Medicaid, But They’re Divided on Stacey Abrams, the Candidate Who Wants to Expand It,” by Charles Bethea

Joanne Kenen: Seven Days Vermont’s “Obituary: Madelyn Linsenmeir, 1988-2018.”

To hear all our podcasts, click here.

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

GOP’s Talk About Medicare Cuts Provides Democrats With Tried-And-True Talking Point Weeks Before Midterms

The widening budget deficit announced in recent days has sparked conversation among Republicans of cutting budgets and look for trims to entitlement programs. The Democrats are seizing on the tone shift, and using the potential changes to Medicare, Medicaid and other safety net programs as talking points on the campaign trail.

Company That Wants To Sell Medicare Advantage Plans Raises Additional $300M In Venture Capital Funding

The company, Devoted Health, was founded last year by Todd Park, a former chief technology officer for the Obama administration, and Ed Park, a former Athenahealth executive. In other health industry news: the ripple effects of Anthem’s privacy breach settlement; UnitedHealth earnings projections; and Catholic Health Initiatives’ merger with Dignity Health

Medicare For All? CMS Chief Warns Program Has Enough Problems Already

The Trump administration’s top Medicare official Tuesday slammed the federal health program as riddled with problems that hinder care to beneficiaries, increase costs for taxpayers and escalate fraud and abuse.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), said those troubles underscore why she opposes calls by many Democrats for dramatically widening eligibility for Medicare, now serving 60 million seniors and people with disabilities, to tens of millions other people.

“We only have to look at some of Medicare’s major problems to know it’s a bad idea,” Verma told health insurance executives at a meeting in Washington.

CMS lacks the authority from Congress to operate the program effectively, Verma said, which means it often pays higher-than-necessary rates to doctors and hospitals and can’t take steps used by private insurers to control costs.

“We face tremendous barriers to supporting and bringing innovation to Medicare, and it literally takes an act of Congress to add new types of benefits for the Medicare population,” she added.

Since Medicare was approved in 1965, Congress has held power over eligibility and benefits — largely to control spending. That has meant efforts to expand services can get weighed down by partisan politics and swayed by lobbying groups, which significantly delay changes. One example: Congress didn’t add a pharmaceutical benefit to Medicare until 2003 — decades after drugs became a mainstay in most treatments.

Advocates for seniors have called for adding vision and dental benefits for many years, but the proposals have gotten little traction because of cost concerns.

Another problem, according to Verma, is that her agency reviews less than 0.2 percent of the more than 1 billion claims that Medicare receives from providers. “That is ridiculously low,” she said.

Verma also lamented the traditional Medicare program’s limited ability to require doctors and hospitals to get prior authorization from the federal government before performing certain procedures. That process — which has been routine for decades in the private sector — can lead to higher improper payments to doctors and more fraud and abuse, she said.

Jonathan Oberlander, a professor in the department of health policy and management at the University of North Carolina-Chapel Hill, agreed with Verma that “Medicare is not always nimble, particularly in adjusting benefits,” and officials have long complained that Congress micromanages the program. Still, he added, “with a program as large and important to Americans as Medicare, it is perfectly appropriate for Congress to weigh in on the addition of new benefits, especially since taxpayers will bear the costs of those changes.”

Verma for months has spoken out against the “Medicare-for-all” proposals pushed by Sen. Bernie Sanders (I-Vt.) and a growing chorus of Democrats. But her 35-minute address to the meeting of the trade group America’s Health Insurance Plans marked the first time she listed the litany of problems with Medicare, which she has run since March 2017.

Proponents of “Medicare-for-all” are reacting to problems caused by the Affordable Care Act, she said, and should know expanding Medicare will worsen the program’s existing challenges of controlling costs and improving care.

“But their solution is literally to do more of what’s not working,” she added. “It’s like the man who has a pounding headache, who then takes a hammer to his head to make it go away.”

Verma’s comments, however, overlooked the key leadership role that Medicare plays in the health sector, which is often emulated by private insurers, Oberlander said.

“In payment reform, Medicare has a record of being a leader and innovator,” he said. “For all of their supposed advantages, private insurers pay much higher prices than Medicare does for medical services. Verma ignores the fact that Medicare’s price regulation has produced substantial savings.”

Although Verma heavily criticized the traditional Medicare program, which covers two-thirds of enrollees, she boasted about how she and the Trump administration were running Medicare Advantage, the fast-growing alternative program that is operated by private insurers such as UnitedHealthcare and Humana.

More than 20 million Medicare beneficiaries are enrolled in these plans, which often cost members less than traditional Medicare and have additional benefits. But they generally require members to use only the plan’s network of providers.

“Medicare Advantage represents value for our beneficiaries and taxpayers,” Verma said.

She touted a 2019 CMS initiative that will for the first time allow the Advantage plans to offer supplemental health benefits that go beyond traditional dental and health services. These include adult day care, in home support services and meals.

It is “one of the most significant changes made to the Medicare program” and “will have a major impact” on improving health for plan members, she said.

But the private plans have taken a cautious approach to adding those benefits.

About 270 Medicare Advantage plans — or fewer than 10 percent of the total — agreed to offer these services next year.

At the AHIP conference on Monday, health insurance executives said they were still trying to figure out which of their members would most likely benefit from the new offerings.

“We are operating in a vacuum of good evidence,” said William Shrank, chief medical officer of UPMC Health Plan in Pittsburgh. Nonetheless, Shrank said the opportunity to offer new benefits going beyond just health care could help beneficiaries stay out of the hospital and lead healthier lives.

Verma did not mention a report last month by the Department of Health and Human Services’ inspector general that found many Advantage plans were improperly denying claims from patients and doctors.

Administration critics were quick to note that omission.

“Her intemperate attack on traditional Medicare — on which two-thirds of all beneficiaries rely and which millions value so highly” — is “striking,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. As is “her utter failure to acknowledge the serious challenges in making Medicare Advantage operate fairly, which her own inspector general underscored.”

Medicare For All? CMS Chief Warns Program Has Enough Problems Already

The Trump administration’s top Medicare official Tuesday slammed the federal health program as riddled with problems that hinder care to beneficiaries, increase costs for taxpayers and escalate fraud and abuse.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), said those troubles underscore why she opposes calls by many Democrats for dramatically widening eligibility for Medicare, now serving 60 million seniors and people with disabilities, to tens of millions other people.

“We only have to look at some of Medicare’s major problems to know it’s a bad idea,” Verma told health insurance executives at a meeting in Washington.

CMS lacks the authority from Congress to operate the program effectively, Verma said, which means it often pays higher-than-necessary rates to doctors and hospitals and can’t take steps used by private insurers to control costs.

“We face tremendous barriers to supporting and bringing innovation to Medicare, and it literally takes an act of Congress to add new types of benefits for the Medicare population,” she added.

Since Medicare was approved in 1965, Congress has held power over eligibility and benefits — largely to control spending. That has meant efforts to expand services can get weighed down by partisan politics and swayed by lobbying groups, which significantly delay changes. One example: Congress didn’t add a pharmaceutical benefit to Medicare until 2003 — decades after drugs became a mainstay in most treatments.

Advocates for seniors have called for adding vision and dental benefits for many years, but the proposals have gotten little traction because of cost concerns.

Another problem, according to Verma, is that her agency reviews less than 0.2 percent of the more than 1 billion claims that Medicare receives from providers. “That is ridiculously low,” she said.

Verma also lamented the traditional Medicare program’s limited ability to require doctors and hospitals to get prior authorization from the federal government before performing certain procedures. That process — which has been routine for decades in the private sector — can lead to higher improper payments to doctors and more fraud and abuse, she said.

Jonathan Oberlander, a professor in the department of health policy and management at the University of North Carolina-Chapel Hill, agreed with Verma that “Medicare is not always nimble, particularly in adjusting benefits,” and officials have long complained that Congress micromanages the program. Still, he added, “with a program as large and important to Americans as Medicare, it is perfectly appropriate for Congress to weigh in on the addition of new benefits, especially since taxpayers will bear the costs of those changes.”

Verma for months has spoken out against the “Medicare-for-all” proposals pushed by Sen. Bernie Sanders (I-Vt.) and a growing chorus of Democrats. But her 35-minute address to the meeting of the trade group America’s Health Insurance Plans marked the first time she listed the litany of problems with Medicare, which she has run since March 2017.

Proponents of “Medicare-for-all” are reacting to problems caused by the Affordable Care Act, she said, and should know expanding Medicare will worsen the program’s existing challenges of controlling costs and improving care.

“But their solution is literally to do more of what’s not working,” she added. “It’s like the man who has a pounding headache, who then takes a hammer to his head to make it go away.”

Verma’s comments, however, overlooked the key leadership role that Medicare plays in the health sector, which is often emulated by private insurers, Oberlander said.

“In payment reform, Medicare has a record of being a leader and innovator,” he said. “For all of their supposed advantages, private insurers pay much higher prices than Medicare does for medical services. Verma ignores the fact that Medicare’s price regulation has produced substantial savings.”

Although Verma heavily criticized the traditional Medicare program, which covers two-thirds of enrollees, she boasted about how she and the Trump administration were running Medicare Advantage, the fast-growing alternative program that is operated by private insurers such as UnitedHealthcare and Humana.

More than 20 million Medicare beneficiaries are enrolled in these plans, which often cost members less than traditional Medicare and have additional benefits. But they generally require members to use only the plan’s network of providers.

“Medicare Advantage represents value for our beneficiaries and taxpayers,” Verma said.

She touted a 2019 CMS initiative that will for the first time allow the Advantage plans to offer supplemental health benefits that go beyond traditional dental and health services. These include adult day care, in home support services and meals.

It is “one of the most significant changes made to the Medicare program” and “will have a major impact” on improving health for plan members, she said.

But the private plans have taken a cautious approach to adding those benefits.

About 270 Medicare Advantage plans — or fewer than 10 percent of the total — agreed to offer these services next year.

At the AHIP conference on Monday, health insurance executives said they were still trying to figure out which of their members would most likely benefit from the new offerings.

“We are operating in a vacuum of good evidence,” said William Shrank, chief medical officer of UPMC Health Plan in Pittsburgh. Nonetheless, Shrank said the opportunity to offer new benefits going beyond just health care could help beneficiaries stay out of the hospital and lead healthier lives.

Verma did not mention a report last month by the Department of Health and Human Services’ inspector general that found many Advantage plans were improperly denying claims from patients and doctors.

Administration critics were quick to note that omission.

“Her intemperate attack on traditional Medicare — on which two-thirds of all beneficiaries rely and which millions value so highly” — is “striking,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. As is “her utter failure to acknowledge the serious challenges in making Medicare Advantage operate fairly, which her own inspector general underscored.”

Medicare Advantage Riding High As New Insurers Flock To Sell To Seniors

EMBARGOED UNTIL 5 AM., MONDAY, OCT. 15

Health care experts widely expected the Affordable Care Act to hobble Medicare Advantage, the government-funded private health plans that millions of seniors have chosen as an alternative to original Medicare.

To pay for expanding coverage to the uninsured, the 2010 law cut billions of dollars in federal payments to the plans. Government budget analysts predicted that would lead to a sharp drop in enrollment as insurers reduced benefits, exited states or left the business altogether.

But the dire projections proved wrong.

Since 2010, enrollment in Medicare Advantage has doubled to more than 20 million enrollees, growing from a quarter of Medicare beneficiaries to more than a third.

“The Affordable Care Act did not kill Medicare Advantage, and the program looks poised to continue to grow quite rapidly,” said Bill Frack, managing director with L.E.K. Consulting, which advises health companies.

And as beneficiaries get set to shop for plans during open enrollment — which runs from Monday through Dec. 7 — they will find a greater choice of insurers.

Fourteen new companies have begun selling Medicare Advantage plans for 2019, several more than a typical year, according to a report out Monday from the Kaiser Family Foundation. (KHN is an editorially independent part of the foundation.)

Overall, Medicare beneficiaries can choose from about 3,700 plans for 2019, or 600 more than this year, according to the federal government’s Centers for Medicare & Medicaid Services.

CMS expects Medicare Advantage enrollment to jump to nearly 23 million people in 2019, a 12 percent increase. Enrollees shopping for new plans this fall will likely find lower or no premiums and improved benefits, CMS officials say.

With about 10,000 baby boomers aging into Medicare range each day, the general view of the insurance industry, said Robert Berenson, a Medicare expert with the nonpartisan Urban Institute, “is that their future is Medicare and it’s crazy not to pursue Medicare enrollees more actively.”

Bright Health, Clover Health and Devoted Health, all for-profit companies, began offering Medicare Advantage plans for 2018 or will do so for 2019.

Mutual of Omaha, a company owned by its policyholders, is also moving into Medicare Advantage for the first time in two decades, providing plans in San Antonio and Cincinnati.

Some nonprofit hospitals are offering Medicare plans for the first time too, such as the BayCare Health system in the Tampa, Fla., area.

While Medicare beneficiaries in most counties have a choice of several plans, enrollment for years had been consolidated into several for-profit companies, primarily UnitedHealthcare, Humana and Aetna, which have accumulated just under half the national enrollment.

These insurance giants are also expanding into new markets for next year. Humana in 2019 will offer its Medicare HMO in 97 new counties in 14 states. UnitedHealthcare is moving into 130 new counties in 13 states, including for the first time Minnesota, its headquarters for the past four decades.

Extra Benefits

Seniors have long been attracted to Advantage plans because they often include benefits not available with government-run Medicare, such as vision and dental coverage. Many private plans save seniors money because their premiums, deductibles and other patient cost sharing are lower than what beneficiaries pay with original Medicare. But there is a trade-off: The private plans usually require seniors to use a restricted network of doctors and hospitals.

The federal government pays the plans to provide coverage for beneficiaries. When drafting the ACA, Democratic lawmakers targeted the Medicare Advantage plans because studies had shown that enrollees in the private plans cost the government 14 percent more than people in the original program.

Medicare plans weathered the billions in funding cuts in part by qualifying for new federal bonus payments available to those that score a “4” or better on a five-notch scale of quality and customer satisfaction.

Health plans also gained extra revenue by identifying illnesses and health risks of members that would entitle the companies to federal “risk-adjustment” payments. That has provided hundreds of billions in extra dollars to Medicare plans, though congressional analysts and federal investigators have raised concerns about insurers exaggerating how sick their members are.

A study last year found that those risk adjustments could add more than $200 billion to the cost of Medicare Advantage plans in the next decade, despite no change in enrollees’ health.

For-profit Medicare Advantage insurers made a 5 percent profit margin in 2016 — twice the average of Medicare plans overall, according to the Medicare Payment Advisory Commission, which reports to Congress. That’s slightly better than the health insurance industry’s overall 4 percent margin reported by Standard & Poor’s.

Those profit margins could expand. The Trump administration boosted payments to Medicare Advantage plans by 3.4 percent for 2019, 0.45 percentage points higher than the 2018 increase.

Betsy Seals, chief consulting officer for Gorman Health Group, a Washington company that advises Medicare Advantage plans, said many health plans hesitated to enter that market or expand after President Donald Trump was elected because they weren’t sure the new administration would support the program. But such concerns were erased with the announcement on 2019 reimbursement rates.

“The administration’s support of the Medicare Advantage program is clear,” Seals said. “We have seen the downstream impact of this support with new entrants to the market — a trend we expect to see continue.”

Getting Consumers To Switch

Since the 1960s, Mutual of Omaha has sold Medicare Supplement policies — coverage to help beneficiaries in government-run Medicare pay the portion of costs that program doesn’t pick up. But the company only briefly entered the Medicare Advantage business once — in its home state of Nebraska in the 1990s.

“In the past 10 or 20 years it never seemed quite the right time,” said Amber Rinehart, a senior vice president for the insurer. “The main hindrance was around the political environment and funding for Medicare Advantage.”

Yet after watching Medicare Advantage enrollment soar and government funding increase, the insurer has decided now is the time to act. “We have seen a lot more stability of funding and the political tailwinds are there,” she said.

One challenge for the new insurers will be attracting members from existing companies since beneficiaries tend to stick with the same insurer for many years.

Vivek Garipalli, CEO of Clover Health, said his San Francisco-based company hopes to gain members by offering low-cost plans with a large choice of hospitals and doctors and allowing members to see specialists in its network without prior approval from their primary care doctor. The company is also focused on appealing to blacks and Hispanics who have been less likely to join Medicare Advantage.

“We see a lot of opportunity in markets where there are underserved populations,” Garipalli said.

Clover has received funding from Alphabet Inc., the parent company of Google. Clover sold Medicare plans in New Jersey last year and is expanding for 2019 into El Paso, Texas; Nashville, Tenn.; and Savannah, Ga.

Newton, Mass.-based Devoted Health is moving into Medicare Advantage with plans in South Florida and Central Florida. Minneapolis-based BrightHealth is expanding into several new markets including Phoenix, Nashville, Cincinnati and New York City.

BayCare, based in Clearwater, Fla., is offering a Medicare plan for the first time in 2019.

“We think there is enough market share to be had and we are not afraid to compete,” said Jim Beermann, vice president of insurance strategy for BayCare.

Hospitals are attracted to the Medicare business because it gives them access to more of premium dollars directed to health costs, said Frack of L.E.K. Consulting. “You control more of your destiny,” he added.

Must Reads Of The Week From Brianna Labuskes

Just in case our ever-decreasing anonymity in this tech-driven world hasn’t scared you enough, new studies find that within a few years 90 percent — 90 percent! — of Americans of European descent will be identifiable from their DNA. If you fall into that group, it doesn’t even matter whether you’ve given a DNA sample to one of the popular gene-testing sites (like 23andMe). Enough of your distant relatives have, so there’s a good chance you’re in the system.

Take your mind off that by checking out what you may have missed in health care this week.

The biggie, of course, was President Donald Trump’s opinion piece in USA Today about “Medicare-for-all.” (And the rebuttal from Vermont Sen. Bernie Sanders.)

Fact checkers came out in droves to comb through Trump’s arguments and found that nearly every paragraph contained a misleading statement or falsehood.

The Washington Post: Fact-Checking President Trump’s USA Today Op-Ed on ‘Medicare-for-All’

More than shedding any kind of light on the complicated topic, the back-and-forth highlights how much of a role health care is playing in the upcoming midterm elections. Each side has doubled down on its respective talking points (read: preexisting conditions and Medicare-for-all — I warned you you’d get tired of me saying that). In fact, health care is featured so heavily in ads that it trumps the topics of jobs or taxes.

The Wall Street Journal: Health Care Crowds Out Jobs, Taxes in Midterm Ads

(Side note: If you do want some light shed on Medicare-for-all and single-payer systems, check out these great pieces from KHN’s own Shefali Luthra.)

Speaking of midterms, the Democrats’ attempt to block the administration’s expansion of short-term plans (very predictably) failed, with only Maine Republican Sen. Susan Collins joining the Democrats. It was never about winning, though. What it did was force Republicans to go on record with a vote that is potentially politically dangerous in the current landscape.

Politico: Senate Democrats Fail to Block Trump’s Short-Term Health Plans

In stark contrast to the sharply partisan discourse, Trump signed two bipartisan health care measures into law this week. The bills banned “gag clauses” on pharmacists, which had prohibited them from offering consumers cheaper options. The legislation won’t directly affect drug prices, but it might mean people will pay less at the register.

The New York Times: Trump Signs New Laws Aimed at Drug Costs and Battles Democrats on Medicare


For the first time, premiums for the most popular level of insurance sold in the health law marketplaces have gone down. The numbers are the latest sign that the marketplace is stabilizing. (Centene’s expansion into new states is another from this week.) CMS Administrator Seema Verma touted the success, saying the news counters any accusations of sabotage. Health experts, however, said those price tags would have been even lower if not for the administration’s actions over the past year.

The Washington Post: Premiums for Popular ACA Health Insurance Dip for the First Time


The Justice Department approved CVS’ $69 billion merger with Aetna, and although the deal still needs approval from state regulators, the green light is a major hurdle cleared. The merger would reshape the health landscape and mark the end of an era for free-standing pharmacy benefit managers. The potential consolidation is just one of many in recent years in a fast-evolving industry — a trend critics worry will lessen competition and drive up prices for consumers.

The New York Times: CVS Health and Aetna $69 Billion Merger Is Approved With Conditions


Hospitals scrambled to ensure patient safety as Hurricane Michael battered Florida and Georgia this week. “It was like hell,” said one doctor who rode out the storm at Bay Medical Center in Panama City, Fla. The hurricane brought with it memories of last year’s power outages that came with Hurricane Irma and were linked to the deaths of several nursing home residents.

The New York Times: Hospitals Pummeled by Hurricane Michael Scramble to Evacuate Patients


Now that the Brett Kavanaugh battle is over and he’s taken a seat on the Supreme Court, Planned Parenthood has gone into planning mode in case anything happens to Roe v. Wade. A key component of the organization’s plan is to shore up networks in states where abortion would likely remain legal (with longer hours for clinics, for example). On the other side, abortion-rights opponents are getting primed for a new high court that’s likely friendlier to them by strategizing what cases would be best to move forward with.

NPR: With Kavanaugh Confirmed, Both Sides of Abortion Debate Gear Up for Battle

How do you fight measures to expand abortion rights in progressive states? Make it about money. A battle in Oregon illustrates a strategy that — although unlikely to be successful — gives opponents of the bills at least a hope of winning.

Politico: Oregon’s Unlikely Abortion Fight Hinges on Taxes


Holes in the court system have allowed state judges to grant full custody of migrant children to American families — without notifying their parents. Federal officials say it should never happen, but oversight of the problem is scattershot and challenging because states handle adoption proceedings differently.

The Associated Press: Deported Parents May Lose Kids to Adoption

Democrats have been vocal about what they don’t like when it comes to immigration policy. But they have a problem: a lack of cohesion within the party about the correct way forward.

The New York Times: The Democrats Have an Immigration Problem


In the miscellaneous, must-read file:

• A gripping piece takes you into the bowels of a Philadelphia neighborhood dubbed the “Walmart of heroin.” “Drug tourists” come from all over to buy the cheap, pure heroin flowing through the veins of the streets, and some never make it out. (Warning: Make sure you have some time before you start, it will suck you in completely.)

The New York Times: Trapped by the ‘Walmart of Heroin’

• Why were nursing home residents getting extremely pricey therapy in the last weeks of their lives? Bloomberg takes a closer look at these cash-strapped facilities and the questionable decisions made about patients’ rehab.

Bloomberg: Nursing Homes Are Pushing the Dying Into Pricey Rehab

• In good news from the segment of people who were too old to take advantage of the HPV vaccine, the Food and Drug Administration just approved its use for those up to age 45.

The Associated Press: FDA Expands Use of Cervical Cancer Vaccine up to Age 45


As an office of ardent dog lovers, we were distressed to hear the news that therapy dogs in hospitals are little germ machines, leaving behind happiness but also superbugs.

Have a great (hopefully superbug-free) weekend!

Will Maine Voters Decide To Make Aging In Place Affordable?

As Election Day draws near, a ballot initiative in Maine to provide universal home care is shining a spotlight on the inadequacies of the nation’s long-term care system.

The essential problem: Although most older adults want to live at home when their health starts to decline or they become frail, programs that help them do so are narrow in scope, fragmented and poorly funded.

Medicare’s home care benefits are limited to seniors and adults with disabilities who are homebound and need skilled services intermittently. State Medicaid programs vary widely but are generally restricted to people at the lower end of the income ladder. Long-term care insurance is expensive and covers only a small slice of the older population.

That leaves millions of middle-class families struggling to figure out what to do when an older relative develops a serious chronic illness, such as heart failure, or suffers an acute medical crisis, such as a stroke.

“We’re about to have the largest older population we’ve ever had, which is going to need exponentially more care than has ever been needed before. And we’re not prepared,” said Ai-jen Poo, co-director of Caring Across Generations, an organization working to expand long-term care services across the U.S.

Maine, with nearly 20 percent of its residents age 65 and older, is exploring a radical response to this dilemma that’s being closely watched by other states.

Its ballot initiative, known as Question 1, proposes that home care services be available to all residents, at no cost, regardless of income. If enacted, it would become the first such program in the nation.

Adults would be eligible for the program when they need help with at least one “activity of daily living”: walking, bathing, dressing, eating, toileting, personal hygiene, and getting in or out of bed. Services covered would include care from aides and companions; speech, physical and occupational therapy; counseling; home repairs; transportation; respite care; devices for people with disabilities; and even, occasionally, small rent subsidies.

Stipends would be granted to family caregivers. Seventy-seven percent of program funds would be directed to home care aides, in a move to strengthen this workforce.

More than 21,000 people could qualify for home care services under the new program, in addition to about 5,600 people who already receive services through Maine Medicaid and other state programs, according to the most definitive analysis to date, published last month by researchers at the University of Southern Maine’s Muskie School of Public Service.

Funding for the new program would come from a new 3.8 percent tax on wages and non-wage income that isn’t taxed by Social Security: a threshold of $128,400 per person in 2018. Between $180 million and $310 million would be raised annually, according to various estimates. The program would be fully implemented by January 2022.

The political battle over Question 1 is fierce, although no one questions the need for affordable home care for seniors and people with disabilities. In AARP’s most recent “Long-Term Services and Supports State Scorecard,” Maine ranked last in the nation on affordability of home care.

Among thousands of people affected are Rick Alexander of Blue Hill, Maine. 70, a retired school librarian, and his wife, Debbie, 64, who has multiple sclerosis.

“Since Debbie has a progressive form of MS, her needs are going to increase,” said Alexander, his wife’s sole, unpaid caregiver and a supporter of Question 1. “We brought in some paid help years back, but we couldn’t do that for very long: It’s too expensive.”

Alexander wants to keep Debbie at home as long as possible, but he worries about the physical demands and emotional consequences. “I have chronic clinical depression and periodically I go down into the dumps, a long way,” he admitted. “When that happens, it’s hard for me to motivate myself to do anything.”

Also, it’s generally accepted in Maine that something needs to be done about a severe shortage of home care aides — a problem surfacing nationwide. Each week, 6,000 hours of home care services that have been authorized aren’t delivered by Maine agencies because of staff shortages, which are particularly acute in rural areas, according to the Maine Council on Aging.

Despite these areas of consensus, however, disagreements surrounding Question 1 are intense and most Maine health care and business associations oppose it, along with all four candidates for governor.

Taxes are a key point of contention. Question 1 supporters argue that a relatively small number of high-income individuals would pay extra taxes. The Maine Center for Economic Policy estimates that only 3.4 percent of people earning income in Maine would be affected, according to a September report.

Citing ambiguous language in the initiative, opponents argue that families earning more than $128,400 would also be subject to the tax hike, significantly expanding its impact. A pressing concern is that higher taxes would discourage doctors, nurses and other professionals from moving to or remaining in Maine.

“We have a workforce crisis already, and this increase — which would make our income tax rate among the highest in the country — would be a disaster,” said Jeffrey Austin, vice president of government affairs at the Maine Hospital Association.

The program is too expansive and expensive to be sustained long term, other opponents say. “We have limited public resources in Maine and those should be dedicated to the people most in need, fiscally and physically,” said Newell Augur, a lobbyist for the Home Care & Hospice Alliance of Maine and chair of the “NO on Question One/Stop the Scam” campaign.

In a statement, AARP Maine, which has not taken a stand on Question 1, expressed reservations. “Using a payroll tax to pay for HCBS [home and community-based services] is an untested policy at the local level,” it noted.

Also controversial is the board that would be established to operate the home care program. The initiative calls for nine members (three from home care agencies, three direct care workers and three service recipients) elected by constituent organizations to oversee the program.

“The board wouldn’t be accountable to the governor or the legislature, and Maine taxpayers would have no say over how their money is being spent,” said Jacob Posik, a policy analyst at the conservative-leaning Maine Heritage Policy Center.

Supporters note that an advisory committee would include state officials from multiple agencies. The board’s structure is meant to be “responsive to the people providing and receiving the care,” said Mike Tipping, communications director for the Maine People’s Alliance, a grass-roots organization that’s spearheading Question 1 and that helped pass a 2017 ballot initiative expanding Medicaid in Maine, currently tied up in the courts.

For all these policy disputes, it’s clear that Question 1 has considerable emotional resonance. “I’ve never had people cry signing a petition and tell me how much something like this would have changed their lives,” said Kevin Simowitz, political director for Caring Across Generations.

One of the people who’s spoken out publicly is the Rev. Myrick Cross, 75, of St. Patrick’s Episcopal Church in Brewer.

Cross works part time at the church so he can pay for aides that care for his 38-year-old daughter with Down syndrome and his 95-year-old mother, who has suffered from kidney disease, falls, wounds that didn’t heal and pneumonia in the past several years. “I will do whatever I need to keep them home,” he said.

Originally, Cross looked to home care agencies for assistance, but with rates of $23 to $25 per hour “that was more than I could afford,” he said. Today, three local residents provide more than 50 hours of care a week for $12 to $15 an hour.

“I’m blessed that I’m able to work and to hire all these people to keep us going,” Cross said. “But several members of my congregation are older and don’t have the family resources that we have. This would make the quality of their lives better.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

Doctors Give Medicare’s Proposal To Pay For Telemedicine Poor Prognosis

The Trump administration wants Medicare for the first time to embrace telemedicine across the country by paying doctors $14 for a five-minute “check-in” phone call with their patients.

But many physicians say the proposed reimbursement will cover a service they already do for free. And the Medicare reimbursement — intended to motivate doctors to communicate with patients outside the office — could have a chilling effect on patients because they would be required to pay a 20 percent cost-sharing charge.

Medicare said the call would be used to help patients determine whether they need to come in for an appointment. But doctors and consultants said the virtual sessions could cover a broad array of services, including monitoring patients starting a new medicine or those trying to manage chronic illnesses, such as diabetes. The Medicare Payment Advisory Commission, which provides guidance to Congress, panned the proposal last month, saying it could lead to excess spending without benefiting patients.

“Direct-to-consumer telehealth services … appear to expand access, but at a potentially significant cost and without evidence of improved quality,” the commission’s chairman, Dr. Francis Crosson, said in a letter to the Centers for Medicare & Medicaid Services (CMS). “Due to their greater convenience, these services are at risk of misuse by patients or provider.”

Congress has shied away from expanding the use of telemedicine in Medicare — even as it has become commonplace among private insurers — because of concerns about higher spending. Budget hawks worry that rather than replace comparatively expensive in-person visits, extra telemedicine billings would add to them.

Lack of coverage — except in rare circumstances — means fewer than 1 percent of the 50 million Medicare beneficiaries use telemedicine services each year.

Federal law forbids Medicare from paying for telemedicine services that replace in-person office visits, except in certain rural areas. That’s why CMS called the new benefit a check-in using “virtual” or “communications technology,” said Jacob Harper, who specializes in health issues at the law firm Morgan, Lewis & Bockius.

In addition to the check-in call, CMS has proposed starting to pay physicians to review photos that patients text or email to them to evaluate skin and eye problems, as well as and other conditions. It also has proposed paying physicians an unspecified fee for consulting electronically or by phone with other doctors.

“Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly,” said CMS Administrator Seema Verma when announcing the proposal.

CMS said it hopes to enact the changes in 2019. Officials will announce their final rule after evaluating public comments on the plan.

Verma and other CMS officials say they believe the change would end up saving Medicare money by reducing unnecessary office visits and catching health problems early, before they become more costly to treat.

But in its detailed proposal, CMS acknowledges the telehealth service will increase Medicare costs. CMS said the telehealth will result in “fewer than 1 million visits in the first year but will eventually result in more than 19 million visits per year, ultimately increasing payments under the [Medicare physician pay schedule] by about 0.2 percent,” or eventually about $180 million per year. Because the change must be budget-neutral, CMS is paying for this by decreasing some other Medicare physician payments.

CMS doesn’t expect rapid adoption of the telehealth service, partly because doctors can get paid from $35 to $150 for an in-person visit. “Because of the low payment rate relative to that for an office visit, we are assuming that usage of these services will be relatively low,” CMS said in its proposal.

The virtual check-in can be conducted by physicians or nurse practitioners or physician assistants working with a doctor.

Only patients who have established relationships with a doctor would be eligible for the service. Doctors also would not be allowed to bill for the check-in service if it stems directly from an in-person visit or is followed by an appointment with the doctor, according to the CMS proposal.

Dr. Michael Munger, a family physician in Overland Park, Kan., and president of the American Academy of Family Physicians, said many doctors routinely check on patients by phone. Still, he applauded the effort to increase physician pay.

“Anytime you can tie payment to what many of us are already doing is good,” he said.

Mercy, a large hospital system in St. Louis, has been offering telehealth services even without reimbursement because it helps patients access care and lowers costs in the long run, said Dr. J. Gavin Helton, president of clinical integration at Mercy Virtual.

“We are already on this path, and this will help to continue to grow our programs and make them financially sustainable,” he said.

Still, Helton said the “check-in” fee from Medicare won’t be enough to motivate providers to start telehealth services.

He said the new reimbursement signals that Medicare wants to pay for services to keep patients well rather than just treat them while they are sick.

Other physicians were more skeptical, particularly while Medicare has also proposed reducing some fees for in-person office visits.

In a letter to CMS, Dr. Amy Messier, a family medicine doctor in Wilmington, N.C., raised concerns about the effect this could have on patients’ expenses.

“I worry about implementation of this from the patient perspective now that we are charging patients for this previously free service and they have to pay their portion of the charge,” she said.

“Patients will be less likely to engage their physician outside of the office visit and more likely to seek care face-to-face at more expense, when perhaps that visit could have been avoided with a phone call which they will no longer make because it comes with a charge,” she said.

Dr. Todd Czartoski, chief executive of telehealth at Providence St. Joseph Health in Renton, Wash., predicts most doctors won’t use the proposed telehealth service.

“It’s still easier for a doctor to go room to room with patients lined up,” he said. “It’s a step in the right direction, but I don’t think it will open the floodgates for virtual care.”


KHN’s coverage of these topics is supported by
John A. Hartford Foundation
and
The SCAN Foundation

No More Secrets: Congress Bans Pharmacist ‘Gag Orders’ On Drug Prices

For years, most pharmacists couldn’t give customers even a clue about an easy way to save money on prescription drugs. But the restraints are coming off.

When the cash price for a prescription is less than what you would pay using your insurance plan, pharmacists will no longer have to keep that a secret.

President Donald Trump was expected to sign two bills Wednesday that ban “gag order” clauses in contracts between pharmacies and insurance companies or pharmacy benefit managers — those firms that negotiate prices for employers and insurers with drugstores and drugmakers. Such provisions prohibit pharmacists from telling customers when they can save money by paying the pharmacy’s lower cash price instead of the price negotiated by their insurance plan.

The bills — one for Medicare and Medicare Advantage beneficiaries and another for commercial employer-based and individual policies— were passed by Congress in nearly unanimous votes last month. A spokesman for Sen. Susan Collins (R-Maine) said her office had been told the president would sign the bills Wednesday. The White House declined to comment.

“Americans deserve to know the lowest drug price at their pharmacy, but ‘gag clauses’ prevent your pharmacist from telling you!” Trump wrote on Twitter three weeks ago, shortly before the Senate voted on the bills. “I support legislation that will remove gag clauses.” The change was one of the proposals included in Trump’s blueprint to cut prescription drug prices issued in May.

Ronna Hauser, vice president of payment policy and regulatory affairs at the National Community Pharmacists Association, said many members of her group “say a pharmacy benefit manager will call them with a warning if they are telling patients it’s less expensive” without insurance. She said pharmacists could be fined for violating their contracts and even dropped from insurance networks.

According to research published in JAMA in March, people with Medicare Part D drug insurance overpaid for prescriptions by $135 million in 2013. Copayments in those plans were higher than the cash price for nearly 1 in 4 drugs purchased in 2013. For 12 of the 20 most commonly prescribed drugs, patients overpaid by more than 33 percent.

Yet some critics say eliminating gag orders doesn’t address the causes of high drug prices. “As a country, we’re spending about $450 billion on prescription drugs annually,” said Steven Knievel, who works on drug price issues for Public Citizen, a consumer advocacy group. The modest savings gained by paying the cash price “is far short of what needs to happen to actually deliver the relief people need.”

After the president signs the legislation affecting commercial insurance contracts, gag order provisions will immediately be prohibited, said a spokesman for Collins, who co-authored the bill. The bill affecting Medicare beneficiaries wouldn’t take effect until Jan. 1, 2020.

But there’s a catch: Under the new legislation, pharmacists will not be required to tell patients about the lower cost option. If they don’t, it’s up to the customer to ask.

The Pharmaceutical Care Management Association, a trade group representing pharmacy benefit managers, said gag orders are increasingly rare. The association supported the legislation. Some insurers have also said their contracts don’t include these provisions. Yet two members of Congress have encountered them at the pharmacy counter.

At a hearing on the gag order ban, Collins said she watched a couple leave a Bangor, Maine, pharmacy without their prescription because they couldn’t afford the $111 copayment and the pharmacist did not advise them about saving money by paying directly for the medicine. When she asked him how often that happens, he said every day.

“Banning gag clauses will make it easier for more Americans to afford their prescription drugs because pharmacists will be able to proactively notify consumers if a less expensive option may be available,” she said last week.

When Rep. Debbie Dingell (D-Mich.) went to a Michigan pharmacy to pick up a prescription recently, she was told it would cost $1,300. “After you peeled me off the ceiling, I called the doctor and screamed and talked to the pharmacist,” she recalled during a hearing last month. “I’m much more aggressive than many in asking questions,” she admitted, and ended up saving $1,260 after she learned she could get an equivalent drug for $40.

While the legislation removes gag orders, it doesn’t address how patients who pay the cash price outside their insurance plan can apply that expense toward meeting their policy’s deductible.

But for Medicare beneficiaries there is a little-known rule — not found in the “Medicare & You” handbook or on its website —that helps people with Medicare Part D or Medicare Advantage coverage. If they pay the lower cash price for a covered drug at a pharmacy that participates in their insurance plan and then submit the proper documentation to their plan, insurers must count it toward patients’ out-of-pocket expenses.

The total of those expenses are important because that amount affects the drug coverage gap commonly called the “doughnut hole.” (This year, the gap begins after the plan and beneficiary spend $3,750 and ends once the beneficiary has spent a total of $5,000.)

And beneficiaries don’t have to wait until the gag order ban takes effect in two years.

The Medicare rule also says that if a senior asks about a lower price for a prescription, the pharmacist can answer.

Rep. Buddy Carter (R-Ga.), a pharmacist who sponsored the Medicare gag order bill, said he wasn’t surprised by the bipartisan support for the legislation. “High prescription drug costs affect everyone,” he said.


KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Cash-Strapped Nursing Homes Reaping Financial Windfalls From Patients’ Possibly Unnecessary Pricey Therapy

Some residents are being treated with “ultrahigh intensity” rehab in their last week of life, which has experts looking at who is benefiting from that decision. Meanwhile, CMS aims to increase its enforcement actions of nursing home staff in cases of elder abuse. Nursing home and elder care news comes out of Kansas and Florida, as well.

Medicare Advantage Plans Shift Their Financial Risk To Doctors

STUART, Fla. — Dr. Christopher Rao jumped out of his office chair. He’d just learned an elderly patient at high risk of falling was resisting his advice to go to an inpatient rehabilitation facility following a hip fracture.

He strode into the exam room where Priscilla Finamore was crying about having to leave her home and husband, Freddy.

“Look, I would feel the same way if I was you and did not want to go to a nursing home, to a strange place,” Rao told her in September, holding her hand. “But the reality is, if you slip at home even a little, it could end up in a bad, bad way.”

After a few minutes of coaxing, Finamore, 89, relented and agreed to go into rehab.

Keeping patients healthy and out of the hospital is a goal for any physician. For Rao, a family doctor in this retiree-rich city 100 miles north of Miami, it’s also a wise financial strategy.

Rao works for WellMed, a physician-management company whose doctors treat more than 350,000 Medicare patients at primary care clinics in Florida and Texas. Instead of being reimbursed for each patient visit, WellMed gets a fixed monthly payment from private Medicare Advantage plans to cover virtually all of their members’ health needs, including drugs and physician, hospital, mental health and rehabilitation services.

If they can stay under budget, the physician companies profit. If not, they lose money.

Dr. Christopher Rao, a family doctor at WellMed in Stuart, Fla., comforts Priscilla Finamore about seeking inpatient rehabilitation care.(Phil Galewitz/KHN)

This model — known as “full-risk” or “global risk” — is increasingly used by Medicare plans such as Humana and UnitedHealthcare to shift their financial exposure from costly patients to WellMed and other physician-management companies. It gives the doctors’ groups more money upfront and control over patient care.

As a result, they go to extraordinary lengths to keep their members healthy and avoid expensive hospital stays.

WellMed, along with similar fast-growing companies such as Miami-based ChenMed, Boston-based Iora Health and Chicago-based Oak Street Health, say they provide patients significantly more time with their doctors, same-day or next-day appointments and health coaches. These doctors generally work on salary.

ChenMed doctors encourage their Medicare patients to visit their clinic every month — for no charge and with free door-to-door transportation — to stay on top of preventive care and better manage chronic conditions. If patients are not feeling well after-hours, ChenMed even will send a paramedic to their home.

“We can be much more creative in how we meet patient needs,” said Iora CEO Rushika Fernandopulle. “By taking risk, we never have to ask … ‘Do we get paid for this or not?’”

A Way To ‘Provide Less Care’

Some patient advocates, pointing to similar experiments that failed in the 1990s, fear “global risk” could lead doctors to skimp on care — particularly for expensive services such as CT tests and surgical procedures.

“At the end of the day, this is a way to keep costs down and provide less care,” said Judith Stein, executive director of the Center for Medicare Advocacy.

Dr. Brant Mittler, a Texas cardiologist and trial attorney who has followed the issue, said Medicare Advantage members should be suspicious.

“Patients don’t know that decisions made on their behalf are often financially based. There may be pressure on doctors to cut corners to save money and that may not be in the best interests of a patient’s health,” he said.

The insurers and physician groups disagree. They said limiting necessary care would only exacerbate a patient’s health problems and cost the doctors’ group more money.

Noting that Medicare members stay with Humana an average of eight years, Roy Beveridge, the insurer’s chief medical officer, said the plan would be unwise to skimp on care because that would eventually leave the company with sicker patients and longer hospitalizations.

“It makes even less sense for physicians at financial risk to skimp on care because patients are typically with their physicians much longer than they are with a health plan,” he said.

A study that examined care at ChenMed, published last month in the American Journal of Managed Care, found health costs were 28 percent lower among patients who had more than double the number of typical visits with their primary physician. The study was conducted by researchers at ChenMed and the University of Miami.

To offer more personal care, ChenMed doctors typically see only about a dozen patients per day — about half as many as is usual for a doctor who gets paid for each individual service.

Medicare beneficiaries, who can choose a private health plan during the open-enrollment period that runs from Oct. 15 to Dec. 7, generally have no idea if their health plan has ceded control of their care to these large doctors’ groups.

After choosing a Medicare Advantage plan, they generally sign up for a medical group that is part of their health plan’s network, often because doctors are close to where they live or because the doctors offer extra benefits such as free transportation to appointments.

Eloy Gonzalez, 71, of Miami, said that before switching to ChenMed a couple of years ago his doctors always seemed to be in a hurry when he saw them. He’s happy with his ChenMed physicians.

On a recent visit, he spent nearly 20 minutes with Dr. Juana Sofia Recabarren-Velarde talking about keeping his blood pressure and lung condition under control. She also showed him exercises to manage back and shoulder pain.

“If she thinks she needs to see me once a month to monitor my blood pressure and see if anything else is happening, it’s OK with me,” said Gonzalez, who pays nothing for the office visits or generic drugs under his Humana Medicare Advantage plan with ChenMed.

A Growth Spurt

Nearly one-third of the 57 million Medicare beneficiaries are covered by private Medicare Advantage plans — an alternative to government-run Medicare — and federal officials have estimated that the proportion will rise to 41 percent over the next decade. The government pays these plans to provide medical services to their members.

The “global risk” system has been used in South Florida and Southern California since the late 1990s and nearly half of Medicare Advantage members in those regions get care in the model. The use has spread further in the past two years as large physician companies have become more common, and about 10 percent of Medicare Advantage plan members across the nation are in them now, health consultants say.

In addition, new information technology allows these groups to better track their patients. With mixed results, Medicare Advantage insurers for years offered doctors bonuses to meet certain quality care standards, such as getting members vaccinated against the flu or controlling diabetes and other chronic diseases.

Under the “global risk” arrangements, the health plans give the physician companies the bulk of their Medicare funding when they take on the mantle of being financially responsible for all patient care.

For the doctors’ groups, the arrangement means they get paid a large amount of money upfront for patient care and don’t have to worry about billing or having to get insurers to always preapprove treatments.

Because the “global risk” arrangements are designed to reduce plans’ costs, they potentially allow the companies to lower premiums and attract more customers, said Mark Fendrick, director of the University of Michigan’s Center for Value-Based Insurance Design.

“I see this trend continuing to grow as clinicians will be accountable for the first time for the care they provide,” he said.

Historical Lessons

But Ana Gupte, a securities analyst with Leerink Partners in New York, noted providers can also lose money if not successful.

That’s what happened in the late 1990s when some physician-management companies such as FPA Medical Management and PhyMatrix took on financial risk from insurers only to later go bankrupt, interrupting care to thousands of patients.

Health insurers say they now trust only doctors’ groups that have shown they can handle the financial risk. They also retain varying levels of control. Insurers set benefits, handle member complaints and review which doctors are allowed in its network.

Martin Graf, a partner with consulting firm Oliver Wyman, said the old financial arrangements failed because provider groups did not manage the risks facing their patients.

“Now they know physician groups must be vigilant about their patients — whether they are in the office or not,” he said. “Everyone is aware of the failure of the past.”


KHN’s coverage of these topics is supported by
John A. Hartford Foundation
and
The SCAN Foundation