Tag: Medicare

KFF Health News’ ‘What the Health?’: Democrats See Opportunity in GOP Threats to Repeal Health Law 

The Host

With other GOP presidential candidates following Donald Trump’s lead in calling for an end to the Affordable Care Act, Democrats are jumping on an issue they think will favor them in the 2024 elections. The Biden administration almost immediately rolled out a controversial proposal that could dramatically decrease the price of drugs developed with federally funded research dollars. The drug industry and the business community at large are vehemently opposed to the proposal, but it is likely to be popular with voters.

Meanwhile, the Supreme Court hears arguments in a case to decide whether the Sackler family should be able to shield billions of dollars taken from its bankrupt drug company, Purdue Pharma, from further lawsuits regarding the company’s highly addictive drug OxyContin.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico, and Rachana Pradhan of KFF Health News.

Among the takeaways from this week’s episode:

  • The ACA may end up back on the proverbial chopping block if Trump is reelected. But as many in both parties know, it is unlikely to be a winning political strategy for Republicans. ACA enrollment numbers are high, as is the law’s popularity, and years after a failed effort during Trump’s presidency, Republicans still have not unified around a proposal to replace it.
  • Democrats are eager to capitalize on the revival of “repeal and replace.” This week, the Biden administration announced plans to exercise so-called “march-in rights,” which it argues allow the government to seize certain patent-protected drugs whose prices have gotten too high and open them to price competition. The plan, once largely embraced by progressives, could give President Joe Biden another opportunity to claim his administration has proven more effective than Trump’s heading into the 2024 election.
  • The Senate voted to approve more than 400 military promotions this week, effectively ending the 10-month blockade by Republican Sen. Tommy Tuberville of Alabama over a Pentagon policy that helps service members travel to obtain abortions. At the state level, the Texas courts are considering cases over its exceptions to the state’s abortion ban, while in Ohio, a woman who miscarried after being sent home from the hospital is facing criminal charges.
  • Meanwhile, the Supreme Court soon could rule on whether EMTALA, or the Emergency Medical Treatment and Labor Act, requires doctors to perform abortions in emergencies. And justices are also considering whether to allow a settlement deal to move forward that does not hold the Sacker family accountable for the harm caused by opioids.
  • “This Week in Medical Misinformation” highlights a lawsuit filed by Texas Attorney General Ken Paxton accusing Pfizer of failing to end the covid-19 pandemic with its vaccine.

Also this week, Rovner interviews Dan Weissmann, host of KFF Health News’ sister podcast, “An Arm and a Leg,” about his investigation into hospitals suing their patients for unpaid medical bills.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Wisconsin State Journal’s “Dane, Milwaukee Counties Stop Making Unwed Fathers Pay for Medicaid Birth Costs,” by David Wahlberg.  

Anna Edney: Bloomberg News’ “Tallying the Best Stats on US Gun Violence Is Trauma of Its Own,” by Madison Muller.  

Alice Miranda Ollstein: Stat’s “New Abortion Restrictions Pose a Serious Threat to Fetal Surgery,” by Francois I. Luks, Tippi Mackenzie, and Thomas F. Tracy Jr. 

Rachana Pradhan: KFF Health News’ “Patients Expected Profemur Artificial Hips to Last. Then They Snapped in Half,” by Brett Kelman and Anna Werner, CBS News.

Also mentioned in this week’s episode:

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on SpotifyApple PodcastsPocket Casts, or wherever you listen to podcasts.

Dodging the Medicare Enrollment Deadline Can Be Costly

Angela M. Du Bois, a retired software tester in Durham, North Carolina, wasn’t looking to replace her UnitedHealthcare Medicare Advantage plan. She wasn’t concerned as the Dec. 7 deadline approached for choosing another of the privately run health insurance alternatives to original Medicare.

But then something caught her attention: When she went to her doctor last month, she learned that the doctor and the hospital where she works will not accept her insurance next year.

Faced with either finding a new doctor or finding a new plan, Du Bois said the decision was easy. “I’m sticking with her because she knows everything about me,” she said of her doctor, whom she’s been seeing for more than a decade.

Du Bois isn’t the only one tuning out when commercials about the open enrollment deadline flood the airwaves each year — even though there could be good reasons to shop around. But sifting through the offerings has become such an ordeal that few people want to repeat it. Avoidance is so rampant that only 10% of beneficiaries switched Medicare Advantage plans in 2019.

Once open enrollment ends, there are limited options for a do-over. People in Medicare Advantage plans can go to another Advantage plan or back to the original, government-run Medicare from January through March. And the Centers for Medicare & Medicaid Services has expanded the criteria for granting a “special enrollment period” to make changes in drug or Advantage plans anytime.

But most seniors will generally allow their existing policy to renew automatically, like it or not.

Keeping her doctor was not Du Bois’ only reason for switching plans, though. With help from Senior PharmAssist, a Durham nonprofit that advises seniors about Medicare, she found a Humana Medicare Advantage plan that would not only be accepted by her providers but also cover her medications — saving her more than $14,000 a year, said Gina Upchurch, the group’s executive director.

Senior PharmAssist is one of the federally funded State Health Insurance Assistance Programs, known as SHIPs, available across the country to provide unbiased assistance during the open enrollment season and year-round to help beneficiaries appeal coverage denials and iron out other problems.

“Many people are simply overwhelmed by the calls, ads, the sheer number of choices, and this ‘choice overload’ contributes to decision-making paralysis,” said Upchurch. Seniors in Durham have as many as 74 Advantage plans and 20 drug-only plans to choose from, she said.

Upchurch said the big insurance companies like the way the system works now, with few customers inclined to explore other plans. “They call it ‘stickiness,’” she said. “If we had fewer and clear choices — an apple, orange, grape, or banana — most people would review options.”

In Washington state, one woman switched from a plan she had had for more than a decade to one that will cover all her drugs and next year will save an estimated $7,240, according to Tim Smolen, director of the state’s SHIP, Statewide Health Insurance Benefits Advisors.

In Northern California, another woman changed drug plans for the first time since 2012, and her current premium of $86 will plummet to 40 cents a month next year, an annual savings of about $1,000, said Pam Smith, a local director for California’s SHIP, called the Health Insurance Counseling & Advocacy Program.

And in Ohio, a woman sought help after learning that her monthly copayment for the blood thinner Eliquis would rise from $102 to $2,173 next year. A counselor with Ohio’s SHIP found another plan that will cover all her medications for the year and cost her just $1,760. If she stuck with her current plan, she would be paying an additional $24,852 for all her drugs next year, said Chris Reeg, who directs that state’s program.

In some cases, CMS tries to persuade beneficiaries to switch. Since 2012, it has sent letters every year to thousands of beneficiaries in poorly performing Advantage and drug plans, encouraging them to consider other options. These are plans that have received less than three out of five stars for three years from CMS.

“You may want to compare your plan to other plans available in your area and decide if it’s still right for you,” the letter says.

CMS allows low-scoring plans to continue to operate. In an unusual move, officials recently found that one plan had such a terrible track record that they will terminate its contract with government health programs next December.

CMS also contacts people about changing plans during open enrollment if they get a subsidy — called “extra help” — that pays for their drug plan’s monthly premium and some out-of-pocket expenses. Because some premiums will be more expensive next year, CMS is warning beneficiaries that they could be in for a surprise: a monthly bill to cover cost increases the subsidy doesn’t cover.

But many beneficiaries receive no such nudge from the government to find out if there is a better, less expensive plan that meets their needs and includes their health care providers or drugs.

That leaves many people with Medicare drug or Advantage plans on their own to decipher any changes to their plans while there is still time to enroll in another. Insurers are required to alert members with an “annual notice of change,” a booklet often more than two dozen pages long. Unless they plow through it, they may discover in January that their premiums have increased, the provider network has changed, or some drugs are no longer covered. If a drug plan isn’t offered the next year and the beneficiary doesn’t pick a new one, the insurer will select a plan of its choosing, without considering costs or needed drug coverage.

“Every year, our call volume skyrockets in January when folks get invoices for that new premium,” said Reeg, the Ohio program director. At that point, Medicare Advantage members have until March 30 to switch to another plan or enroll in government-run Medicare. There’s no similar grace period for people with stand-alone drug plans. “They are locked into that plan for the calendar year.”

One cost-saving option is the government’s Medicare Savings Program, which helps low-income beneficiaries pay their monthly premium for Medicare Part B, which covers doctor visits and other outpatient services. The Biden administration’s changes in eligibility for subsidies announced in September will extend financial assistance to an estimated 860,000 people — if they apply. In the past, only about half of those eligible applied.

Fixing a mistake after the open enrollment period ends Dec. 7 is easy for some people. Individuals who receive “extra help” to pay for drug plan premiums and those who have a subsidy to pay for Medicare’s Part B can change drug plans every three months.

At any time, beneficiaries can switch to a Medicare Advantage plan that earns the top five-star rating from CMS, if one is available. “We’ve been able to use those five-star plans as a safety net,” said Reeg, the Ohio SHIP director.

Other beneficiaries may be able to get a “special enrollment period” to switch plans after the open enrollment ends if they meet certain conditions. Local SHIP offices can help people make any of these changes when possible.

Reeg spends a lot of time trying to ensure that unwelcome surprises — like a drug that isn’t covered — don’t happen in the first place. “What we want to do is proactively educate Medicare patients so they know that they can go to the doctors and hospitals they want to go to in the upcoming year,” she said.

Desperate Families Search for Affordable Home Care

It’s a good day when Frank Lee, a retired chef, can slip out to the hardware store, fairly confident that his wife, Robin, is in the hands of reliable help. He spends nearly every hour of every day anxiously overseeing her care at their home on the Isle of Palms, a barrier island near Charleston, South Carolina.

Robin Lee, 67, has had dementia for about a decade, but the couple was able to take overseas trips and enjoy their marriage of some 40 years until three years ago, when she grew more agitated, prone to sudden outbursts, and could no longer explain what she needed or wanted. He struggled to care for her largely on his own.

“As Mom’s condition got more difficult to navigate, he was just handling it,” said Jesse Lee, the youngest of the couple’s three adult children. “It was getting harder and harder. Something had to change, or they would both perish.”

Frank Lee’s search for trustworthy home health aides — an experience that millions of American families face — has often been exhausting and infuriating, but he has persisted. He didn’t entirely trust the care his wife would get in an assisted living facility. Last August, when a respite program paid for her brief stay in one so Frank, 69, could take a trip to the mountains, she fell and fractured her sacrum, the bone that connects the spine to the pelvis.

There is precious little assistance from the government for families who need a home health aide, unless they are poor. The people working in these jobs are often woefully underpaid and unprepared to help a frail, older person with dementia bathe and use the bathroom, or to defuse an angry outburst.

Usually, it is family that steps into the breach — grown children who cobble together a fragile chain of visitors to help an ailing father; a middle-aged daughter who returns to her childhood bedroom; a son-in-law working from home who keeps a watchful eye on a confused parent; a wife who can barely manage herself looking after a faltering husband.

A photo of a caretaker helping an elderly woman walk outside.
Nearly a year ago, Robin Lee was coaxed to walk in her yard by family friend and home caregiver Amanda Falkner. Since then, Lee’s condition has deteriorated.(Desiree Rios/The New York Times)
A photo of a man rubbing his wife's shoulders.
Lee with her husband, Frank, at home. He manages the schedules of three home care employees who have assisted his wife since her dementia diagnosis 10 years ago.(Desiree Rios/The New York Times)
A photo of a caregiver helping an elderly woman with a blanket in bed.
Lee with Ronnie Smalls, an independent dementia specialist and caregiver.(Desiree Rios/The New York Times)

Frank Lee finally found two aides on his own, with no help from an agency. Using the proceeds from the sale of his stake in a group of restaurants, including the popular Charleston bistro Slightly North of Broad, he pays them the going rate of about $30 an hour. Between his wife’s care and medical expenses, he estimates he’s spending between $80,000 and $100,000 a year.

“Who the hell can afford this?” he asked. “There’s no relief for families unless they have great wealth or see their wealth sucked away.” He worries that he will run out of money and be forced to sell their home of more than three decades. “Funds aren’t unlimited,” he said.

Credited with emphasizing local ingredients and mentoring young chefs in Charleston, Lee retired in 2016, a few years after his wife’s diagnosis.

In an interview at the time, he said, “My wife has given up her life to help me in my career, and now I need to pay attention to her.”

In 2020, he contacted a half-dozen home care agencies. Some couldn’t fill the position. Others sent aides who were quickly overwhelmed by his wife’s behavior. Doctors told the family they believed she has frontotemporal dementia, which appeared to affect her language and how she behaved.

One woman seemed promising, only to quit after a week or two. “We never saw her again,” Lee said. He tried a friend of the family for a time, but she left when her grandmother developed liver cancer.

“It was the whole year of going through different caregivers,” said son Jesse.

Finally, Frank found two women to help. One of them, Ronnie Smalls, has more than a dozen years of experience and is trained in dementia care. She has developed a rapport with Robin, who seems reassured by a quick touch. “We have a really good bond,” Smalls said. “I know her language, her expression.”

A photo of a caregiver holding an elderly woman's hand.
Smalls holds the hand of her primary patient, Robin Lee, as she sits inside her bedroom. (Desiree Rios/The New York Times)
A photo of an elderly man holding up a lanyard with an emergency button on it.
Daniel “Dan” Missroon, 86, shows the emergency button he uses to summon a caregiver when in need. (Desiree Rios/The New York Times)

One day at the Lees’ cozy one-story house, decorated with furniture made by Robin, and with a yard overflowing with greenery, Smalls fed her lunch at the kitchen table with her husband and daughter. Robin seemed to enjoy the company, murmuring in response to the conversation.

At other times, she seemed oblivious to the people around her. She can no longer walk on her own. Two people are often needed to help her get up from a chair or go to the bathroom, transitions she often finds upsetting. A day without an aide — out because of illness or a family emergency — frays the tenuous links that hold the couple’s life together.

Lee said his wife barely resembles the woman he married, the one who loved hiking, skiing, and gardening, and who started a neighborhood preschool while raising their three children. A voracious reader, she is now largely silent, staring into space.

The prognosis is bleak, with doctors offering little to hang onto. “What’s the end game look like?” Lee asks, wondering if it would be better if his wife had the right to die rather than slowly disappear before his eyes. “As she disintegrates, I disintegrate,” he said. She recently qualified for hospice care, which will involve weekly visits from a nurse and a certified nursing assistant paid under Medicare.

Charleston is flush with retirees attracted by its low taxes and a warm climate, and it boasts of ways to care for them with large for-profit home health chains and a scattering of small agencies. But many families in Charleston and across the nation can’t find the help they need. And when they do, it’s often spotty and far more expensive than they can afford.

Most Americans want to remain in their own homes, living independently, for as long as possible. They want to avoid nursing homes, which they see as providing poor care, polls have found. And the ranks of older people who need such help will grow. By 2030, 1 in 5 Americans will be at least 65 as millions in the baby boomer generation retire.

In dozens of interviews, families described a desperate and sometimes fruitless search for aides to help loved ones with simple tasks on a predictable schedule at an hourly rate they can afford.

Roughly 8 million people 65 and older had dementia or needed help with two or more activities of basic daily life, like getting out of bed, according to an analysis of a federally funded survey of older Americans by KFF Health News and The New York Times. Only a million received paid help outside of a nursing home, and nearly 3 million had no help at all.

Most families can’t afford what agencies charge — about $27 an hour, according to Genworth, a long-term care insurance company. So, many take their chances on untrained caregivers found through word-of-mouth, Craigslist, or other resources.

A Scarcity of Workers

A portrait of a home health aide standing outside.
Dawn Geisler has made $10 an hour working as a home health aide in the Charleston area for the past four years, without getting a single raise.(Desiree Rios/The New York Times)

One of the main obstacles to finding paid help is the chronic shortage of workers. Some 3.7 million people had jobs as aides in home health or personal care in 2022, with half of them earning less than $30,000 year, or $14.51 an hour, according to the Bureau of Labor Statistics. The number of people needed is expected to increase by more than 20% over the next decade. But the working conditions are hard, the pay is usually bad, and the hours are inconsistent.

About 3 million people are working in private homes, according to a 2023 analysis by PHI, a nonprofit that studies and acts as an advocate for the workforce, although official estimates may not count many workers paid off the books or hired outside of an agency by a family. Eighty-five percent of home care workers are women, two-thirds are people of color, and roughly a third are immigrants. The pay is often so low that more than half qualify for public assistance like food stamps or Medicaid.

Dawn Geisler, 53, has made only $10 an hour working as a home health aide in the Charleston area for the past four years, without ever getting a raise. She declined to name the agency that employs her because she doesn’t want to lose her job.

Geisler discovered she liked the work after caring for her mother. Unlike an office job, “every day is just a little bit different,” she said. She now juggles two clients. She might accompany one to the doctor and keep the other one company. “I’m taking care of them like they were my own family,” she said.

The agency provides no guarantee of work and doesn’t always tell her what to expect when she walks through the door, except to say someone has Alzheimer’s or is in a wheelchair. Her supervisors often fail to let her know if her client goes to the hospital, so families know to call her cellphone. She has waited weeks for a new assignment without getting paid a penny. She herself has no health insurance and sometimes relies on food banks to put meals on the table.

“I’m not making enough to pay all the bills I have,” said Geisler, who joined an advocacy group called the Fight for $15, which is pushing to raise the minimum wage in South Carolina and across the country. When her car broke down, she couldn’t afford to get it fixed. Instead, she walked to work or borrowed her fiancé’s bicycle.

A photo of a caretaker helping an elderly man wash his hands at a kitchen sink.
Laurie Gregory, a patient care aide at Interim HealthCare, with Daniel Missroon in his home in Summerville, South Carolina.(Desiree Rios/The New York Times)
A photo of a caretaker dancing with an elderly woman indoors.
Ronnie Smalls helps Robin Lee dance at home. “We have a really good bond,” Smalls says. “I know her language, her expression.”(Desiree Rios/The New York Times)
A photo of a caretaker sitting on a sofa, talking to an elderly man.
April Abel, a home health nurse from Roper St. Francis, sits with patient Ron Ceur Jr., in his home in North Charleston, South Carolina. “I feel so bad for them because they don’t have the support system they need,” she says.(Desiree Rios/The New York Times)

Most home health agencies nationwide are for-profit and are often criticized for ignoring the needs of workers in favor of the bottom line.

“The business models are based on cheap labor,” said Robyn Stone, senior vice president of research for LeadingAge, which represents nonprofit agencies. The industry has historically tolerated high turnover but now can’t attract enough workers in a strong, competitive job market. “I think there has been a rude awakening for a lot of these companies,” she said.

Many agencies have also refused to pay overtime or travel costs between jobs, and many have been accused of wage theft in lawsuits filed by home care workers or have been sanctioned by state and federal agencies.

Medicaid, the federal-state program that provides health care for the poor, is supposed to provide home aides but faces shortages of workers at the rates it pays workers. At least 20 states pay less than $20 an hour for a personal care aide, according to a recent state survey by KFF. Aides are often paid less under Medicaid than if they care for someone paying privately.

With low pay and few benefits, many people would rather work the checkout line in a supermarket or at a fast-food chain than take on the emotionally demanding job of caring for an older person, said Ashlee Pittmann, the chief executive of Interim HealthCare of Charleston, a home health agency. She said that she recently raised wages by $2 an hour and had had more success keeping employees, but that she still worried that “we may not be able to compete with some larger companies.”

The Biden administration failed to obtain an additional $400 billion from Congress for home- and community-based services to shift emphasis away from institutional care. President Joe Biden signed an executive order this year to encourage some reforms, and federal officials have proposed requiring home health agencies to spend 80 cents of every government dollar on paying workers under Medicaid. But so far, little has changed.

Falling Through the ‘Doughnut Hole

A photo of a caretaker taking an elderly woman's blood pressure at home.
April Abel takes Joanne Ganaway’s blood pressure at Ganaway’s North Charleston, South Carolina, home.(Desiree Rios/The New York Times)

Long-term care coverage for most Americans is a yawning gap in government programs. And the chasm is widening as more Americans age into their 70s, 80s, and 90s.

The government’s main program for people 65 and older is Medicare, but it pays for a home aide only when a medical condition, like recovery from a stroke, has made a person eligible for a nurse or therapist to come to the home. And the aide is usually short-term. Medicare doesn’t cover long-term care.

Medicaid, which does pay for long-term care at home, is limited to serving the poor or those who can demonstrate they have hardly any assets. But, again, the worker shortage is so pervasive that waiting lists for aides are years long, leaving many people without any option except a nursing home.

So millions of Americans keep trying to hang in and stay home as long as they can. They’re not poor enough to qualify for Medicaid, but they can’t afford to hire someone privately.

Many fall through what April Abel, a former home health nurse from Roper St. Francis Healthcare in Charleston, described as “the doughnut hole.”

“I feel so bad for them because they don’t have the support system they need,” she said.

She tried fruitlessly for months to find help for Joanne Ganaway, 79 and in poor health, from charities or state programs while she visited her at home. Ganaway had trouble seeing because of a tear in her retina and was often confused about her medications, but the small pension she had earned after working nearly 20 years as a state employee made her ineligible for Medicaid-sponsored home care.

Three photos shown in a row: an elderly woman with a walker standing outside; the same woman getting medicine from a pill organizer; the same woman taking her pills.
The small pension Joanne Ganaway had earned after working nearly 20 years as a state employee made her ineligible for Medicaid-sponsored home care. “It has been difficult for me, to be honest,” Ganaway says.(Desiree Rios/The New York Times)

So Ganaway, who rarely leaves her house, relies on friends or family to get to the doctor or the store. She spends most of her day in a chair in the living room. “It has been difficult for me, to be honest,” she said.

Turning to Respite Services

A photo of people sitting in chairs while using pool noodles to bounce a balloon in the air.
Residents of Respite Care Charleston, a nonprofit, play a game at Martin Luther Lutheran Church.(Desiree Rios/The New York Times)

With no hope of steady help, there is little left to offer overstretched wives, husbands, sons, and daughters other than a brief respite. The Biden administration has embraced the idea of respite services under Medicare, including a pilot program for the families of dementia patients that will begin in 2024.

One nonprofit, Respite Care Charleston, provides weekday drop-off sessions for people with dementia for almost four hours a day.

Lee’s wife went for a couple of years, and he still makes use of the center’s support groups, where caregivers talk about the strain of watching over a loved one’s decline.

On any given morning, nearly a dozen people with dementia gather around a table. Two staff members and a few volunteers work with the group as they play word games, banter, bat balls around, or send a small plastic jumping frog across the table.

Their visits cost $50 a session, including lunch, and the organization’s brief hours keep it under the minimum state requirements for licensing.

“We’re not going to turn someone away,” Sara Perry, the group’s executive director, said. “We have some folks who pay nothing.”

The service is a godsend, families say. Parkinson’s disease and a stroke have left Dottie Fulmer’s boyfriend, Martyn Howse, mentally and physically incapacitated, but he enjoys the sessions.

“Respite Care Charleston has been a real key to his keeping going,” she said, “to both of us, quite frankly, continuing to survive.”

A photo of an elderly woman walking down a hallway indoors.
Robin Lee paces throughout her home on the Isle of Palms, South Carolina. Frank Lee says his wife barely resembles the woman he married, the one who loved hiking, skiing and gardening, who started a neighborhood preschool while raising their three children.(Desiree Rios/The New York Times)

Desperate Families Search for Affordable Home Care

Facing a severe shortage of aides and high costs, people trying to keep aging loved ones at home often cobble together a patchwork of family and friends to help.

KFF Health News’ ‘What the Health?’: Trump Puts Obamacare Repeal Back on Agenda

The Host

Former president and current 2024 Republican front-runner Donald Trump is aiming to put a repeal of the Affordable Care Act back on the political agenda, much to the delight of Democrats, who point to the health law’s growing popularity.

Meanwhile, in Texas, the all-Republican state Supreme Court this week took up a lawsuit filed by more than two dozen women who said their lives were endangered when they experienced pregnancy complications due to the vague wording of the state’s near-total abortion ban.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Johns Hopkins University and Politico Magazine, Victoria Knight of Axios, and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s episode:

  • The FDA recently approved another promising weight loss drug, offering another option to meet the huge demand for such drugs that promise notable health benefits. But Medicare and private insurers remain wary of paying the tab for these very expensive drugs.
  • Speaking of expensive drugs, the courts are weighing in on the use of so-called copay accumulators offered by drug companies and others to reduce the cost of pricey pharmaceuticals for patients. The latest ruling called the federal government’s rules on the subject inconsistent and tied the use of copay accumulators to the availability of cheaper, generic alternatives.
  • Congress will revisit government spending in January, but that isn’t soon enough to address the end-of-the-year policy changes for some health programs, such as pending cuts to Medicare payments for doctors.
  • “This Week in Medical Misinformation” highlights a guide by the staff of Stat to help lay people decipher whether clinical study results truly represent a “breakthrough” or not.

Also this week, Rovner interviews KFF Health News’ Rachana Pradhan, who reported and wrote the latest “Bill of the Month” feature, about a woman who visited a hospital lab for basic prenatal tests and ended up owing almost $2,400. If you have an outrageous or baffling medical bill you’d like to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: KFF Health News’ “Medicaid ‘Unwinding’ Makes Other Public Assistance Harder to Get,” by Katheryn Houghton, Rachana Pradhan, and Samantha Liss.

Joanne Kenen: KFF Health News’ “She Once Advised the President on Aging Issues. Now, She’s Battling Serious Disability and Depression,” by Judith Graham.  

Victoria Knight: Business Insider’s “Washington’s Secret Weapon Is a Beloved Gen Z Energy Drink With More Caffeine Than God,” by Lauren Vespoli.

Sarah Karlin-Smith: ProPublica’s “Insurance Executives Refused to Pay for the Cancer Treatment That Could Have Saved Him. This Is How They Did It,” by Maya Miller and Robin Fields.

Also mentioned in this week’s episode:

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on SpotifyApple PodcastsPocket Casts, or wherever you listen to podcasts.

Adultos mayores, detectives contra avisos engañosos de Medicare Advantage

Después de una ofensiva sin precedentes contra las publicidades engañosas de las aseguradoras que venden planes privados de Medicare Advantage y de medicamentos, la administración Biden espera utilizar un arma especial para asegurarse que las empresas sigan las nuevas reglas: esa arma eres tú.

Funcionarios de los Centros de Servicios de Medicare y Medicaid (CMS) le han pedido a las personas mayores y a otros miembros de la comunidad que sean detectives contra el fraude, denunciando tácticas de venta engañosas al 800-MEDICARE, la línea de información las 24 horas de la agencia.

Entre los productos sospechosos se encuentran las tarjetas postales diseñadas para que parezcan del gobierno y los anuncios de televisión con famosos que prometen prestaciones y tarifas bajas que sólo están disponibles para algunas personas en ciertos condados.

Las nuevas normas, vigentes desde el 30 de septiembre, describen lo que las aseguradoras pueden decir en anuncios y otros materiales promocionales, y durante el proceso de inscripción.

Las campañas publicitarias de las aseguradoras se lanzan cada otoño, cuando los adultos mayores pueden comprar pólizas que comienzan el 1 de enero. Las personas con cobertura tradicional de Medicare pueden añadir o cambiar un plan de medicamentos recetados o inscribirse en un plan Medicare Advantage, que combina cobertura médica y de fármacos.

Aunque los planes privados Advantage ofrecen prestaciones adicionales no disponibles en el Medicare tradicional, algunos servicios requieren autorización previa y los beneficiarios están limitados a una red de proveedores de salud que puede cambiar en cualquier momento.

Los beneficiarios de Medicare tradicional pueden acudir a cualquier proveedor. La temporada de inscripción abierta termina el 7 de diciembre.

Los planes Medicare Advantage que cruzan alguna línea no son la única razón para estar atentos a los fraudes comerciales. La información precisa del plan puede ayudar a evitar trampas en la inscripción.

Aunque, en general, las aseguradoras y los profesionales que abogan por las personas mayores han acogido con satisfacción las nuevas normas de veracidad en la publicidad, que se cumplan es el gran reto.

Esperar que los beneficiarios controlen los argumentos de venta de las aseguradoras es pedir demasiado, afirmó Semanthie Brooks, trabajadora social y defensora de los adultos mayores en el noreste de Ohio. Lleva casi dos décadas ayudando a beneficiarios de Medicare a analizar sus opciones. “No creo que los afiliados deban hacer de policías”, dijo.

Elegir un plan de Medicare Advantage puede ser abrumador. En Ohio, por ejemplo, hay 224 y 21 planes de medicamentos para elegir que entrarán en vigencia el año que viene. La elegibilidad y las prestaciones varían según los condados.

“Los CMS deberían estudiar cómo educar a las personas para que cuando oigan hablar de las servicios en televisión, entiendan que se trata de un anuncio promocional y no necesariamente de una prestación que podrían utilizar”, señaló Brooks. “Si no se dan cuenta de que estos anuncios pueden ser fraudulentos, entonces no sabrán que deben denunciarlos”.

La agencia confía en los beneficiarios para ayudar a mejorar los servicios, declaró por escrito a KFF Health News Meena Seshamani, directora de Medicare en los CMS. “Las voces de las personas a las que servimos hacen que nuestros programas sean más fuertes”, dijo.

Las quejas de los beneficiarios motivaron la intervención del gobierno. “Es por eso que, después de escuchar a nuestra comunidad, tomamos nuevas medidas para proteger a las personas con Medicare del marketing confuso y potencialmente engañoso”, agregó.

Aunque alrededor de 31 millones de los 65 millones de personas con Medicare están inscritas en Medicare Advantage, esta gran cantidad de personas podría no ser suficiente para controlar el tsunami de publicidad en la televisión, la radio, Internet y el papel que llega a los buzones.

El año pasado hubo más de 9,500 anuncios diarios durante el período de comercialización de planes de nueve semanas, según un análisis de KFF. Más del 94% de los anuncios televisivos estaban patrocinados por aseguradoras, brokers y empresas de marketing, frente a sólo un 3% del gobierno federal que promocionaba el programa tradicional de Medicare.

Según los investigadores, durante una hora del noticiero de Cleveland en diciembre, los telespectadores vieron nueve anuncios de Advantage.

Por primera vez, los CMS pidieron este año a las compañías de seguros y de marketing que les presentaran sus anuncios televisivos de Medicare Advantage, para asegurarse de que cumplían las nuevas normas.

Entre el 1 de mayo y el 30 de septiembre, los funcionarios revisaron 1,700 anuncios, y rechazaron más de 300 por considerarlos engañosos, según informes de la prensa. También se rechazaron otros 192 anuncios, de un total de 250, de empresas de marketing. La agencia no reveló si se analizaron otros medios.

Las nuevas restricciones se aplican también a los vendedores, ya sea en un anuncio, en material escrito o en una conversación cara a cara.

Según una norma nueva e importante, el vendedor debe explicar en qué se diferencia el nuevo plan del actual seguro médico de una persona antes de que se pueda realizar cualquier cambio.

Esa información podría haber ayudado a una mujer de Indiana que perdió la cobertura de sus medicamentos recetados, que le cuestan más de $2,000 al mes, indicó Shawn Swindell, supervisor de voluntarios del Programa Estatal de Asistencia sobre Seguros de Salud para 12 condados del centro-este del estado.

Un representante inscribió a la mujer en un plan de Medicare Advantage sin decirle que no incluía cobertura de medicamentos porque el plan está dirigido a veteranos que pueden obtener esa cobertura a través del Departamento de Asuntos de Veteranos en lugar de Medicare. La mujer no es veterana, añadió Swindell.

En Nueva York, el Centro de Derechos de Medicare recibió una queja de un hombre que solo quería inscribirse para obtener una tarjeta de débito prepagada para comprar productos farmacéuticos no recetados, contó Emily Whicheloe, directora de educación de la organización. No sabía que el vendedor lo inscribiría en un nuevo plan de Medicare Advantage que ofrecía la tarjeta. Whicheloe reparó el error pidiendo a los CMS que permitieran al hombre volver a su plan Advantage anterior.

Las tarjetas de débito forman parte de la vertiginosa gama de ventajas adicionales no médicas que ofrecen los planes Medicare Advantage, junto con el transporte a las citas médicas, las comidas a domicilio y el dinero para servicios públicos, comestibles e incluso artículos para mascotas. El año pasado, los planes ofrecieron un promedio de 23 prestaciones adicionales, según los CMS. Sin embargo, algunas aseguradoras han comunicado a la agencia que sólo un pequeño porcentaje de pacientes las utiliza, aunque el uso real no se reporta.

Este mes, los CMS propusieron normas adicionales sobre Advantage para 2025, incluida una que obligaría a las aseguradoras a informar a sus afiliados sobre los servicios disponibles que aún no hayan utilizado. Los recordatorios “garantizarán que la gran inversión federal de dinero de los contribuyentes en estos beneficios llegue realmente a los beneficiarios y no se utilice principalmente como una estratagema de marketing”, según señalan las autoridades en una hoja informativa.

Por lo general, los afiliados a Medicare Advantage permanecen vinculados a sus planes durante todo el año, salvo raras excepciones, como el traslado fuera del área de servicio o la quiebra del plan.

Pero hace dos años, los CMS agregaron una vía de escape: las personas pueden abandonar un plan al que se han afiliado basándose en información engañosa o inexacta, o si descubren que las prestaciones prometidas no existen o no pueden ver a sus proveedores. Esta excepción también se aplica cuando representantes del plan, sin escrúpulos, ocultan información e inscriben a personas en una póliza Advantage sin su consentimiento.

Otra nueva norma, que debería evitar que las inscripciones salgan mal, prohíbe a los planes promocionar prestaciones que no están disponibles en el lugar donde vive el potencial afiliado. Las promesas vacías se han convertido en una fuente creciente de quejas de los clientes del Programa de Información sobre Seguros de Salud para Mayores de Louisiana, según Vicki Dufrene, su directora estatal. “Iban a tener todas estas opciones y estos extras, y cuando llega el momento, no tienen ni opciones ni extras, pero el vendedor siguió adelante y les inscribió en el plan”.

Así que esperamos ver más cláusulas de exención de responsabilidad en anuncios y correos como esta carta no solicitada que un plan Aetna Medicare Advantage envió a una mujer de Nueva York: “Las características y la disponibilidad del plan pueden variar según el área de servicio”, dice una advertencia incluida en letra chica. “El formulario y/o la red de farmacias pueden cambiar en cualquier momento”, continúa, refiriéndose a la lista de medicamentos cubiertos. “Recibirá un aviso cuando sea necesario”.

Sin embargo, las normas siguen permitiendo a las aseguradoras presumir de sus calificaciones de los CMS —cinco estrellas es la máxima—, aunque estas no reflejen el rendimiento del plan mencionado en un anuncio o mostrado en el sitio web del gobierno para encontrar planes de Medicare.

“No hay forma de que los consumidores sepan con qué exactitud la calificación por estrellas refleja el diseño específico del plan, la red de proveedores concreta o cualquier otro aspecto específico de una póliza en su condado”, afirmó Laura Skopec, investigadora del Urban Institute y coautora de un estudio reciente sobre el sistema de calificación.

Y como los datos de las calificaciones pueden tener más de un año de antigüedad y los planes cambian cada año, las publicadas este año no se aplican a los planes de 2024 que ni siquiera han empezado, a pesar de las afirmaciones en sentido contrario.

Cómo detectar argumentos de venta engañosos de Medicare Advantage y planes de medicamentos (y qué hacer al respecto)

Los Centros de Servicios de Medicare y Medicaid tienen nuevas reglas que toman medidas enérgicas contra la publicidad y promoción engañosas o inexactas de Medicare Advantage y los planes de medicamentos. Hay que tener cuidado con los avisos que:

  • Los beneficios sugeridos están disponibles para todos los que se registren cuando solo algunas personas califican.
  • Menciona los beneficios que no están disponibles en el área de servicio donde se anuncian.
  • Utiliza superlativos como “la mayoría” o “mejor”, a menos que estos datos estén respaldados por datos del año actual o anterior.
  • Reclama ahorros poco realistas, como $9,600 en ahorros en medicamentos, que se aplican sólo en circunstancias excepcionales.
  • Habla de cobertura sin nombrar el plan.
  • Muestra el nombre oficial de Medicare, la tarjeta de membresía o el logotipo sin la aprobación de los CMS.
  • Contacta al miembro de un plan Advantage o de medicamentos sobre otros productos sin autorización.
  • Finge ser del programa Medicare administrado por el gobierno, que no realiza llamadas de ventas no solicitadas a los beneficiarios.

Si crees que una empresa está violando las nuevas reglas, comuníquese con CMS al 800-MEDICARE, su línea directa de información las 24 horas. Si cree que eligió un plan basándose en información inexacta y desea cambiar de plan, comuníquese con CMS o con su Programa estatal de asistencia sobre seguros médicos: http://www.shiphelp.org o al 877-839-2675. Para obtener más información sobre cómo protegerse de las infracciones de marketing, visite http://www.shiphelp.org/about-medicare/blog/protecting-yourself-marketing-violations.

Uncle Sam Wants You … to Help Stop Insurers’ Bogus Medicare Advantage Sales Tactics

After an unprecedented crackdown on misleading advertising claims by insurers selling private Medicare Advantage and drug plans, the Biden administration hopes to unleash a special weapon to make sure companies follow the new rules: you.

Officials at the Centers for Medicare & Medicaid Services are encouraging seniors and other members of the public to become fraud detectives by reporting misleading or deceptive sales tactics to 800-MEDICARE, the agency’s 24-hour information hotline. Suspects include postcards designed to look like they’re from the government and TV ads with celebrities promising benefits and low fees that are available only to some people in certain counties.

The new rules, which took effect Sept. 30, close some loopholes in existing requirements by describing what insurers can say in ads and other promotional materials as well as during the enrollment process.

Insurance companies’ advertising campaigns kick into high gear every fall, when seniors can buy policies that take effect Jan. 1. People with traditional government Medicare coverage can add or change a prescription drug plan or join a Medicare Advantage plan that combines drug and medical coverage. Although private Advantage plans offer extra benefits not available under the Medicare program, some services require prior authorization and beneficiaries are confined to a network of health care providers that can change anytime. Beneficiaries in traditional Medicare can see any provider. The open enrollment season ends Dec. 7.

Catching Medicare Advantage plans that step out of line isn’t the only reason to keep an eye out for marketing scams. Accurate plan information can help avoid enrollment traps in the first place.

Although insurers and advocates for older adults have generally welcomed the new truth-in-advertising rules, compliance is the big challenge. Expecting beneficiaries to monitor insurance company sales pitches is asking a lot, said Semanthie Brooks, a social worker and advocate for older adults in northeast Ohio. She’s been helping people with Medicare sort through their options for nearly two decades. “I don’t think Medicare beneficiaries should be the police,” she said.

Choosing a Medicare Advantage plan can be daunting. In Ohio, for example, there are 224 Advantage and 21 drug plans to choose from that take effect next year. Eligibility and benefits vary among counties across the state.

“CMS ought to be looking at how they can educate people, so that when they hear about benefits on television, they understand that this is a promotional advertisement and not necessarily a benefit that they can use,” Brooks said. “If you don’t realize that these ads may be fraudulent, then you won’t know to report them.”

The agency relies on beneficiaries to help improve services, Meena Seshamani, CMS’ Medicare director, told KFF Health News in a written statement. “The voices of the people we serve make our programs stronger,” she said. Beneficiary complaints prompted the government’s action. “That’s why, after hearing from our community, we took new critical steps to protect people with Medicare from confusing and potentially misleading marketing.”

Although about 31 million of the 65 million people with Medicare are enrolled in Medicare Advantage, even that may not be enough people to monitor the tsunami of advertising on TV, radio, the internet, and paper delivered to actual mailboxes. Last year more than 9,500 ads aired daily during the nine-week marketing period that started two weeks before enrollment opened, according to an analysis by KFF. More than 94% of the TV commercials were sponsored by health insurers, brokers, and marketing companies, compared with only 3% from the federal government touting the original Medicare program.

During just one hourlong Cleveland news program in December, researchers found, viewers were treated to nine Advantage ads.

For the first time, CMS asked insurance and marketing companies this year to submit their Medicare Advantage television ads, to make sure they complied with the expanded rules. Officials reviewed 1,700 commercials from May 1 through Sept. 30 and nixed more than 300 deemed misleading, according to news reports. An additional 192 ads out of 250 from marketing companies were also rejected. The agency would not disclose the total number of TV commercials reviewed and rejected this year or whether ads from other media were scrutinized.

The new restrictions also apply to salespeople, whether their pitch is in an ad, written material, or a one-on-one conversation.

Under one important new rule, the salesperson must explain how the new plan is different from a person’s current health insurance before any changes can be made.

That information could have helped an Indiana woman who lost coverage for her prescription drugs, which cost more than $2,000 a month, said Shawn Swindell, the State Health Insurance Assistance Program supervisor of volunteers for 12 counties in east-central Indiana. A plan representative enrolled the woman in a Medicare Advantage plan without telling her it didn’t include drug coverage because the plan is geared toward veterans who can get drug coverage through the Department of Veterans Affairs instead of Medicare. The woman is not a veteran, Swindell said.

In New York, the Medicare Rights Center received a complaint from a man who had wanted to sign up just for a prepaid debit card to purchase nonprescription pharmacy items, said the group’s director of education, Emily Whicheloe. He didn’t know the salesperson would enroll him in a new Medicare Advantage plan that offered the card. Whicheloe undid the mistake by asking CMS to allow the man to return to his previous Advantage plan.

Debit cards are among a dizzying array of extra nonmedical perks offered by Medicare Advantage plans, along with transportation to medical appointments, home-delivered meals, and money for utilities, groceries, and even pet supplies. Last year, plans offered an average of 23 extra benefits, according to CMS. But some insurers have told the agency only a small percentage of patients use them, although actual usage is not reportable.

This month, CMS proposed additional Advantage rules for 2025, including one that would require insurers to tell their members about available services they haven’t used yet. Reminders will “ensure the large federal investment of taxpayer dollars in these benefits is actually making its way to beneficiaries and are not primarily used as a marketing ploy,” officials said in a fact sheet.

Medicare Advantage members are usually locked into their plans for the year, with rare exceptions, including if they move out of the service area or the plan goes out of business. But two years ago, CMS added an escape hatch: People can leave a plan they joined based on misleading or inaccurate information, or if they discovered promised benefits didn’t exist or they couldn’t see their providers. This exception also applies when unscrupulous plan representatives withhold information and enroll people in an Advantage policy without their consent.

Another new rule that should prevent enrollments from going awry prohibits plans from touting benefits that are not available where the prospective member lives. Empty promises have become an increasing source of complaints from clients of Louisiana’s Senior Health Insurance Information Program, said its state director, Vicki Dufrene. “They were going to get all these bells and whistles, and when it comes down to it, they don’t get all the bells and whistles, but the salesperson went ahead and enrolled them in the plan.”

So expect to see more disclaimers in advertisements and mailings like this unsolicited letter an Aetna Medicare Advantage plan sent to a New York City woman: “Plan features and availability may vary by service area,” reads one warning packed into a half-page of fine print. “The formulary and/or pharmacy network may change at any time,” it continues, referring to the list of covered drugs. “You will receive notice when necessary.”

However, the rules still allow insurers to boast about their ratings from CMS — five stars is the top grade — even though the ratings do not reflect the performance of the specific plan mentioned in an ad or displayed on the government’s Medicare plan finder website. “There is no way for consumers to know how accurately the star rating reflects the specific plan design, specific provider network, or any other specifics of a particular plan in their county,” said Laura Skopec, a senior researcher at the Urban Institute who recently co-authored a study on the rating system.

And because ratings data can be more than a year old and plans change annually, ratings published this year don’t apply to 2024 plans that haven’t even begun yet — despite claims to the contrary.

How to spot misleading Medicare Advantage and drug plan sales pitches (and what to do about it)

The Centers for Medicare & Medicaid Services has new rules cracking down on misleading or inaccurate advertising and promotion of Medicare Advantage and drug plans. Watch out for pitches that:

  • Suggest benefits are available to all who sign up when only some individuals qualify.
  • Mention benefits that are not available in the service area where they are advertised (unless unavoidable because the media outlet covers multiple service areas).
  • Use superlatives like “most” or “best” unless claims are backed up by data from the current or prior year.
  • Claim unrealistic savings, such as $9,600 in drug savings, which apply only in rare circumstances.
  • Market coverage without naming the plan.
  • Display the official Medicare name, membership card, or logo without CMS approval.
  • Contact you if you’re an Advantage or drug plan member and you told that plan not to notify you about other health insurance products.
  • Pretend to be from the government-run Medicare program, which does not make unsolicited sales calls to beneficiaries.

If you think a company is violating the new rules, contact CMS at 800-MEDICARE, its 24-hour information hotline. If you believe you chose a plan based on inaccurate information and want to change plans, contact CMS or your State Health Insurance Assistance Program: www.shiphelp.org or 877-839-2675. For more information about protecting yourself from marketing violations, go to www.shiphelp.org/about-medicare/blog/protecting-yourself-marketing-violations.

Medicare Advantage Increasingly Popular With Seniors — But Not Hospitals and Doctors

A hospital system in Georgia. Two medical groups in San Diego. Another in Louisville, Kentucky, and nearly one-third of Nebraska hospitals. Across the country, health care providers are refusing to accept some Medicare Advantage plans — even as the coverage offered by commercial insurers increasingly displaces the traditional government program for seniors and people with disabilities.

As of this year, commercial insurers have enticed just over half of all Medicare beneficiaries — or nearly 31 million people — to sign up for their plans instead of traditional Medicare. The plans typically include drug coverage as well as extras like vision and dental benefits, many at low or even zero additional monthly premiums compared with traditional Medicare.

But even as enrollment soars, so too has friction between insurers and the doctors and hospitals they pay to care for beneficiaries. Increasingly, according to experts who watch insurance markets, hospital and medical groups are bristling at payment rates Medicare Advantage plans impose and at what they say are onerous requirements for preapproval to deliver care and too many after-the-fact denials of claims.

The insurers say they’re just trying to control costs and avoid inappropriate care. The disputes are drawing more attention now, during the annual open enrollment period for Medicare, which runs until Dec. 7.

Stuck in the middle are patients. People whose preferred doctors or hospitals refuse their coverage may have to switch Medicare Advantage plans or revert to the traditional program, although it can be difficult or even impossible when switching back to obtain what is called a “Medigap” policy, which covers some of the traditional plan’s cost-sharing requirements.

For example, more than 30,000 San Diego-area residents are looking for new doctors after two large medical groups affiliated with Scripps Health said they would no longer contract with Medicare Advantage insurers.

“The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents the for-profit hospital sector.

The insurance industry’s lobbying arm, AHIP, said in a February letter to the Centers for Medicare & Medicaid Services that prior approvals and other similar reviews protect patients by reducing “inappropriate care by catching unsafe or low-value care, or care not consistent with the latest clinical evidence.”

AHIP spokesperson David Allen said in an email that Medicare Advantage plans are growing in enrollment because people like them, citing surveys conducted by an AHIP-backed coalition.

The vast majority, he wrote, said they were satisfied with their plans and the access to care they provide.

The disputes so far don’t appear to center on any particular insurer, region, or medical provider, although both UnitedHealthcare and Humana Inc. — the two largest Medicare Advantage insurers — are among those that have had contracts canceled.

Baptist Health in Louisville, Kentucky, said in a statement that all nine of its hospitals, along with its clinics and physician groups, would cut ties with Advantage plans offered by UnitedHealthcare and Wellcare Health Plans Inc. beginning in January unless they reach an agreement.

“Many Medicare Advantage plans routinely deny or delay approval or payment for medical care recommended by a patient’s physician,” Baptist Health said in its statement.

The system’s medical group, with nearly 1,500 physicians and other providers, left Humana’s network in September.

In a similar move, Brunswick, Georgia-based Southeast Georgia Health System, which includes two hospitals, two nursing homes, and a physician network, warned this fall that it would end its contract with Centene Corp.’s Wellcare Medicare Advantage plans in December, citing what it said was years of “inappropriate payment of claims and unreasonable denials.”

In some cases, health systems’ threats to abandon Advantage plans — as well as insurers’ threats not to include providers in their networks — are negotiating tactics, intended as leverage to win concessions on payment rates or other issues. And some have been resolved. Ohio’s Adena Regional Medical Center, for example, said in September it would drop Medicare Advantage plans offered by Elevance Health, formerly known as Anthem Inc., but reinstated them following additional negotiations.

Still, some hospital and policy experts say the conflicts may be the beginning of a trend.

“This seems different,” said David Lipschutz, associate director and senior policy attorney at the Center for Medicare Advocacy, who said hospitals and doctors are becoming “much more vocal” about their frustration with some cost-control efforts by Medicare Advantage insurers.

“There have been serious problems with payment suspensions and reviews that annoy the providers. I would not be surprised if we start to see more of this pushback” as the Medicare market becomes more concentrated among a handful of insurers, said Don Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement and a former CMS administrator.

While availability varies from county to county, Medicare beneficiaries can choose on average among 43 plans, according to KFF. UnitedHealthcare and Humana account for about half of the nationwide enrollment in Advantage plans.

Studies show that Medicare Advantage costs taxpayers more per beneficiary than the traditional program. But the plans enjoy the backing of many lawmakers, especially Republicans, because of their popularity.

The Health and Human Services Department’s inspector general reported last year that some Advantage plans have denied coverage for care that should have been provided under Medicare’s rules.

The report examined prior authorization requests — a requirement to seek insurers’ OK before certain treatments, procedures, or hospital stays — and claims denials, where insurers refuse to pay for all or part of care that’s already been performed.

Lawmakers have recently demanded additional information from Advantage insurers about the factors they use to make such determinations.

CMS proposed a rule this month to cap commissions for brokers who sell Medicare Advantage plans and require more detail on how the plans’ prior approval programs affect certain low-income enrollees and people with disabilities.

Lipschutz said the HHS inspector general’s study may have encouraged hospitals and doctors to be more outspoken.

The inspector general’s office found that 13% of the denied requests for treatment it reviewed and 18% of denied claims were for care that should have been covered. Responding in part to that report, the Biden administration issued a rule set to take effect in January that requires Medicare Advantage plans to provide “the same medically necessary care” as the traditional program. Every Advantage insurer must also annually review its own policies to make sure they match those in the traditional program.

The American Hospital Association, while lauding the administration’s action, questioned whether it would be enough. In a letter sent last month to CMS, the hospital lobbying group said its members “have heard from some [insurers] that they either do not plan to make any changes to their protocols” or “have made changes to their denial letter terminology or procedures in a way that appears to circumvent the intent of the new rules.” The letter urged “rigorous oversight” by CMS.

Allen, the AHIP spokesperson, did not respond to a request to comment on the AHA letter.

Hospitals and Doctors Are Fed up With Medicare Advantage

Medicare Advantage plans are pretty popular with both lawmakers and ordinary Americans — they now enroll about 31 million people, representing just over half of everyone in Medicare, by KFF’s count.

But among doctors and hospitals, it’s a different story.

Across the country, provider grumbling about claim denials and onerous preapproval requirements by Advantage plans is crescendoing. Some hospitals and physician practices are so fed up they’re refusing to accept the plans — even big ones like those offered by United Healthcare and Humana.

“The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents the for-profit hospital sector.

Last week, the industry’s largest lobbying group, the American Hospital Association, fired off a letter to the Centers for Medicare and Medicaid Services warning that some insurers seem intent on circumventing new rules put in place by the Biden administration aimed at reining in some prior authorization and claim denials.

It isn’t like we’ve never seen disputes between insurers and providers before, especially in negotiations with employer-sponsored plans.

But the focus now on Medicare Advantage “seems different,” said David Lipschutz, associate director and senior policy attorney for the Center for Medicare Advocacy, who says hospitals and doctors are becoming “much more vocal” about their frustrations with some of the insurers’ cost-control efforts.

Baptist Health in Louisville, for example, has threatened that all of its nine hospitals, along with its clinics and physician groups, will cut ties with Advantage plans offered by UnitedHealthcare and WellCare Health Plans Inc. beginning in January unless they can come to terms.

The plans “routinely deny or delay approval or payment for medical care recommended by your physician,” the system wrote in a message to patients posted on its website.

The system’s medical group, with nearly 1,500 physicians and other providers, left Humana’s network in September.

And in San Diego, more than 30,000 people are looking for new doctors after two large medical groups affiliated with Scripps Health said they would no longer contract with any Medicare Advantage insurers. Revenue “is not sufficient to cover the cost of patient care we provide,” they said in a statement.

Lipschutz thinks providers are feeling emboldened following a study by the Health and Human Services Department’s inspector general published last year that found some Advantage plans have denied coverage for care that should have been provided under Medicare’s rules.

The Biden administration’s new rules, set to take effect in January, are in part a response to the OIG report. Enrollment for Medicare Advantage plans, supplemental plans for traditional Medicare coverage and stand-alone Medicare drug plans is open until Dec. 7.

While the insurance industry likes to boast that a huge majority of Congress supports the plans, there’s increasing scrutiny at the Capitol, too.

Prior approval is a big point of friction. Virtually all Medicare Advantage enrollees are in plans that require the insurer to sign off in advance for at least some care, according to KFF. Insurers say that process ensures treatments are coordinated and appropriate.

In 2021, more than 35 million requests for prior approval were submitted for Medicare Advantage enrollees, according to KFF, and over 2 million of them were denied. For the small minority of patients who appeal (11 percent), a whopping 82 percent won a full or partial overturning of the insurers’ decision.

To be sure, commercial plans covering people with job-based insurance or those who buy their own through the Affordable Care Act also engage in prior approval, and there’s lots of complaints about them, too.

The difference with Medicare, though, is that beneficiaries can choose the traditional, government-run program, where prior approval and claim denials are much more limited. Doctors and hospitals have plenty of gripes about how much traditional Medicare pays them, but from their point of view, they spend less time fighting over medical decisions.

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