Seeking to Grow Market Share?

Get a FREE assessment of your CDH products —
a $3,000 value.

New Members Named to Serve on Health Information Technology Advisory Committee Established in 21st Century Cures Act

HHS Gov News - November 17, 2017

Today, U.S. Department of Health and Human Services (HHS) Acting Secretary Eric D. Hargan named three members to the Health Information Technology Advisory Committee (HITAC).

The committee, created by the 21st Century Cures Act, is charged with making recommendations to the National Coordinator for Health Information Technology relating to the implementation of national and local health information technology (health IT) infrastructure. These recommendations include, “policies,…standards, implementation specifications, and certification criteria” that advance the electronic access, exchange, and use of health information.

The HITAC provides the opportunity for stakeholders and the public to provide direct input to HHS about the implementation and use of health IT. The committee is supported by HHS’ Office of the National Coordinator for Health Information Technology (ONC).

Acting Secretary Hargan has appointed the following individuals to the HITAC:

  • Leslie Lenert, M.D., Chief Research Information Officer, Medical University of South Carolina, Charleston, SC (Public Health Appointment)
  • Clem J. McDonald, M.D., Director, Lister Hill National Center for Biomedical Communications, Bethesda, MD (HHS Representative Appointment)
  • Robert Wah, M.D., Global Chief Medical Officer, DXC Technology, McLean, VA (At-large Appointment)

The HHS-appointed members join 15 Government Accountability Office-appointed members who will serve for one-, two-, or three-year terms:

  • Michael Adcock, Executive Director of the Center for Telehealth at the University of Mississippi Medical Center
  • Christina Caraballo, Director of Healthcare Transformation at Get Real Health
  • Tina Esposito, Vice President of Information and Technology Innovation at Advocate Health Care
  • Brad Gescheider, Senior Director of Provider and Payer Solutions at PatientsLikeMe
  • John Kansky, President and Chief Executive Officer of the Indiana Health Information Exchange
  • Kensaku Kawamoto, Associate Chief Medical Information Officer, University of Utah Health, and Assistant Professor, University of Utah Department of Biomedical Informatics
  • Denni McColm, Chief Information Officer at Citizens Memorial Healthcare
  • Brett Oliver, Chief Medical Information Officer for Baptist Health
  • Terrence O’Malley, Massachusetts General Hospital and Spaulding Nursing and Therapy Center North End
  • Carolyn Petersen, patient advocate and Senior Editor for Mayo Clinic’s health information website
  • Raj Ratwani, Acting Center Director and Scientific Director of the National Center for Human Factors in Healthcare within MedStar Health, and Assistant Professor at the Georgetown University School of Medicine
  • Sasha TerMaat, Director at Epic
  • Sheryl Turney, Senior Director of All-Payer Claims Database Analytics and Data Policy and Administration at Anthem Blue Cross Blue Shield
  • Andrew Truscott, Managing Director for Health and Public Service at Accenture
  • Denise Webb, Chief Information Officer of Marshfield Clinic Health System and Chief Executive Officer of Marshfield Clinic Information Services, Inc

In addition, six of eight appointments have been made by Congressional leaders:

  • Cynthia Fisher, Founder and Managing Director, WaterRev, LLC
  • Dr. Anil Jin, Vice President and Chief Health Informatics Officer, IBM Watson Health
  • Dr. Steven Lane, Clinical Informatics Director for Privacy, Health Information Security & Interoperability, Sutter Health
  • Arien Malec, Vice President for the Data Platform Solution Line, RelayHealth
  • Steven Ready, System Vice President and Chief Information Officer, Norton Healthcare
  • Dr. Patrick Soon-Shiong, Chairman and CEO, NantWorks

Learn more about the Health Information Technology Advisory Committee on

Readout of Acting HHS Secretary Hargan's Visit to Missouri to Discuss Tax Reform

HHS Gov News - November 17, 2017

Yesterday, Acting Health and Human Services Secretary Eric Hargan traveled to O’Fallon, Missouri where he was hosted by the Phoenix Textile Corporation to discuss the need for tax reform in the United States.

Acting Secretary Hargan toured and met with leadership of the Phoenix Textile Corporation which distributes textile products—such as scrubs, laboratory coats, uniforms, linens, and other items—to hospital and nursing homes across the nation. They have been in business since 1983 starting with a handful of employees and today have grown to have over 100 employees. As Acting Secretary Hargan noted in his speech, “This is a really special place — the epitome of the great American tradition of family-owned small businesses: 34 years in business, growing to 110 employees, woman-owned, passed down from one generation to the next. Businesses like this are the backbone of the American economy.”

Acting Secretary Hargan and the Trump Administration understand that businesses like Phoenix Textile Corporation across all sectors, including the healthcare industry, contribute to a healthier American economy and workforce. With this in mind, Acting Secretary Hargan concluded his visit with formal remarks on President Trump’s vision for reforming our nation’s broken tax code.

As Acting Secretary Hargan noted in his speech, “…strong small businesses don’t just create jobs and economic opportunity. They also provide a strong foundation for local communities and a good living for hardworking employees to support their families. In turn, healthy communities and strong families mean healthier Americans, which is why I’m here today. President Trump’s commitment to building a strong American economy, and to all the benefits that come with a strong economy, extends across his Administration.”

To learn more about President Trump’s vision for tax reform, please visit and to read Acting Secretary Hargan’s full remarks as prepared for delivery, please visit

Health Giant Sutter Destroys Evidence In Crucial Antitrust Case Over High Prices

Kaiser Health News:Marketplace - November 17, 2017

Sutter Health intentionally destroyed 192 boxes of documents that employers and labor unions were seeking in a lawsuit that accuses the giant Northern California health system of abusing its market power and charging inflated prices, according to a state judge.

In a ruling this week, San Francisco County Superior Court Judge Curtis E.A. Karnow said Sutter destroyed documents “knowing that the evidence was relevant to antitrust issues. … There is no good explanation for the specific and unusual destruction here.”

Karnow cited an internal email by a Sutter employee who said she was “running and hiding” after ordering the records destroyed in 2015. “The most generous interpretation to Sutter is that it was grossly reckless,” the judge wrote in his 12-page ruling.

Use Our Content

This Kaiser Health News story can be republished for free (details).

More Stories To Republish

Sutter, which has 24 hospitals and nearly $12 billion in annual revenue, said the destruction was a regrettable mistake.

Employers and policymakers across the country are closely watching this legal fight amid growing concern about the financial implications of industry consolidation. Large health systems are gaining market clout and the ability to raise prices by acquiring more hospitals, outpatient surgery centers and physician offices.

“It’s stunning what Sutter did to cover up incriminating documents in this case,” said Richard Grossman, the lead plaintiffs’ lawyer representing a class of more than 1,500 employer-funded health plans.

In April 2014, a grocery workers’ health plan sued Sutter and alleged it was violating antitrust and unfair competition laws. The plaintiffs began requesting documents related to contracting practices, such as “gag clauses” that prevent patients from seeing negotiated rates and choosing a cheaper provider and “all-or-nothing” terms that require every facility in a health system to be included in insurance networks.

Sutter disputes the broader allegations in the lawsuit over its market conduct and said its charges are in line with its competitors’.

The judge said that in 2015 Melissa Brendt, Sutter’s chief contracting officer in the managed-care department, and an assistant general counsel, Daniela Almeida, authorized Brendt’s executive assistant to destroy 10 years’ worth of managed-care documents going back to 1995. The company earlier had scheduled the documents to be destroyed in 2035 — 20 years later.

The executive assistant, Sina Santagata, testified in a deposition she wasn’t aware of any other time in her 17 years at Sutter when the managed-care department destroyed records held in storage.

In his Nov. 13 ruling against Sutter, the judge singled out an email by Santagata as “particularly noteworthy.”

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

The executive assistant emailed Brendt, the chief contracting officer, on July 30, 2015, after sending the order to destroy the records. She wrote, “I’ve pushed the button … if someone is in need of a box between 3/15/95 & 11/23/05 … I’m running and hiding. … ‘Fingers crossed’ that I haven’t authorized something the FTC will hunt me down for.”

The Federal Trade Commission (FTC) enforces antitrust laws in health care to prevent hospitals, drugmakers and other industry players from engaging in anti-competitive behavior that could harm consumers.

Santagata testified that she was being “sarcastic” in her email, and Sutter told the judge that the FTC reference was just a “joke.”

Karnow saw no humor in it. “There are infinite topics for jokes, and the choice of this one is strong evidence” in the plaintiffs’ favor, he wrote in his order Monday.

As part of his sanctions against Sutter, the judge ordered the health system to examine email backup tapes covering 2002 through 2005 to search for documents on some of the same topics as the destroyed records. Also, Karnow said he will consider a plaintiffs’ motion for issuing jury instructions that are adverse to Sutter in light of the document destruction. The trial is scheduled for June 2019.

“The record shows that Sutter’s conduct was more than just an inadvertent error,” Karnow wrote.

Sutter spokeswoman Karen Garner said the incident was a “mistake made as part of a routine destruction of old paper records” and the Sacramento-based health system disclosed the error as soon as it was discovered.

“We regret that as part of a routine archiving process we failed to preserve some boxes of decades-old hard-copy documents,” Garner said.

The United Food and Commercial Workers and its Employers Benefit Trust initially filed the case against Sutter in 2014. The joint employer-union health plan represents more than 60,000 employees, dependents and retirees. The court certified the case as a class action in August, allowing hundreds of other employers and self-funded health plans to potentially benefit from the litigation.

In addition to its 24 hospitals, Sutter’s nonprofit health system has 35 surgery centers and more than 5,000 physicians in its network. It reported $11.9 billion in revenue last year and income of $554 million.

Grossman, the plaintiffs’ counsel, said he welcomed the judge’s ruling. But he said much of the evidence is irreplaceable, particularly handwritten notes from negotiating sessions and meetings involving key Sutter executives.

He said those records covered a critical period in the early 2000s when there was a “sea change in Sutter’s contracting strategy” and it implemented provisions that insulated the health system from price competition.

“This was groundbreaking in the industry,” Grossman said. “Until we address the anti-competitive behavior of entities like Sutter, we will not solve the problem of high costs in health care.”

The plaintiffs are seeking to recover hundreds of millions of dollars from Sutter from what it claims are illegally inflated prices. The lawsuit alleges that an overnight hospital stay at Sutter hospitals in San Francisco or Sacramento costs at least 38 percent more than a comparable stay in the more competitive Los Angeles market.

A study published last year found that hospital prices at Sutter and Dignity Health, the two biggest hospital chains in California, were 25 percent higher than at other hospitals around the state. Researchers at the University of Southern California said the giant health systems used their market power to drive up prices — making the average patient admission at both chains nearly $4,000 more expensive.

“Sutter is a pretty extreme case of market power, but health care consolidation has become a really important issue across the country,” said Kathy Hempstead, a health care researcher at the Robert Wood Johnson Foundation. “It’s been on the back burner somewhat because of the debate over the Affordable Care Act, but there is bipartisan interest in tackling this.”

Podcast: ‘What The Health?’ Tax Bill Or Health Bill?

Kaiser Health News:HealthReform - November 17, 2017


Republican efforts to alter the health law, left for dead in September, came roaring back to life this week as the Senate Finance Committee added a repeal of the “individual mandate” fines for not maintaining health insurance to their tax bill.

In this episode of “What the Health?” Julie Rovner of Kaiser Health News, Sarah Kliff of, Joanne Kenen of Politico and Alice Ollstein of Talking Points Memo discuss the other health implications of the tax bill, as well as the current state of the Affordable Care Act.

Among the takeaways from this week’s podcast:

  • The tax bill debate proves that Republicans’ zeal to repeal the Affordable Care Act is never dead. The new congressional efforts to kill the penalties for the health law’s individual mandate could seriously wound the ACA since the mandate helps drive healthy people to buy insurance.
  • One of the most overlooked consequences of the tax debate is that it could trigger a substantial cut in federal spending on Medicare.
  • A $25,000 MRI? That’s what one family paid to go out of their plan’s network to get the hospital they wanted for the procedure for their 3-year-old. Such choices are again drawing complaints about narrow networks of doctors and hospitals available in some health plans.
  • Although they don’t likely say it in front of cameras, many Democrats are relieved at President Donald Trump’s choice to head the Department of Health and Human Services, former HHS official Alex Azar.
  • Federal officials have given 10 states and four territories extra money to keep their Children’s Health Insurance Programs running but it’s not clear what couch they found the money hidden in.
  • And in remembrance of Uwe Reinhardt, a reminder that he always stressed that a health care debate was about more than money — it was about real people. Email Sign-Up

    Subscribe to KHN’s free Morning Briefing.

    Sign Up Please confirm your email address below: Sign Up

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

Julie Rovner:’s “This Tennessee insurer doesn’t play by Obamacare’s rules — and the GOP sees it as the future,” by Erin Mershon.

Also: Georgetown University Health Policy Institute’s “What’s Going on in Tennessee? One Possible Reason for Its Affordable Care Act Challenges,” by Kevin Lucia and Sabrina Corlette.

Sarah Kliff: Bloomberg Businessweek’s “How to Make a Fortune on Obamacare,” by Bryan Gruley, Zachary Tracer, and Hannah Recht.

Joanne Kenen: Politico Magazine’s “How Bourbon and Big Data Are Cleaning Up Louisville,” by Arthur Allen.

Alice Ollstein: Talking Points Memo’s “Trump’s Abrupt Policy Shift Fuels Misleading Obamacare Renewal Info,” by Alice Ollstein.

To hear all our podcasts, click here.

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

Despite ACA Cost Protections, Most Adolescents Skip Regular Checkups

Kaiser Health News:HealthReform - November 17, 2017

As children move through adolescence, some face health hurdles like obesity, sexually transmitted infections, depression and drug abuse. Regular checkups could help families address such problems, and the Affordable Care Act paved the way by requiring insurers to fully cover well-child visits, at no charge to patients.

But, both before and after the ACA was established, fewer than half of kids ages 10 to 17 were getting routine annual physical exams, according to a recent study.

“Most adolescents are pretty healthy, but a lot of them are headed for trouble with obesity” and mental illness and substance use, said Sally Adams, a research specialist on adolescents and young adults at the University of California-San Francisco, the study’s lead author. “These are things that can be caught early and treated, or at least managed.”

For the study, published online this month in JAMA Pediatrics, researchers analyzed data from the federal Medical Expenditure Panel Survey, which tracks health insurance coverage and health care use and spending. Researchers used data from 25,695 people who were caregivers of adolescents ages 10-17. About half were surveyed from 2007 to 2009 and the rest from 2012 to 2014.

Before the health law passed in 2010, caregivers reported that 41 percent of children had a well-child visit in the previous year. After the ACA’s preventive services protections became effective, typically in 2011, the rate climbed to 48 percent, a “moderate” increase, Adams said. The increase was greatest for minority and low-income groups.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Still, more than half of children in the survey didn’t go to the doctor for routine care over the course of a year, even though many families gained insurance and wouldn’t have owed anything for the visits.

That’s cause for concern, Adams said. A primary care provider can screen youngsters for risky behaviors and treat them if necessary. A checkup is also an opportunity to educate patients on health.

“The behaviors they pick up as adolescents have a strong influence on their adult health across their life course,” she said. For example, she noted, “if you can keep them from starting to smoke, then they probably won’t smoke.”

Young children typically have regular pediatrician visits for recommended vaccines, hearing and vision tests as well as school checkups. But those needs may change as children get older, and state requirements that kids get physicals before entering school vary. Some may require a checkup every year, others only at intervals.

Use Our Content

This Kaiser Health News story can be republished for free (details).

More Stories To Republish

“Healthcare professionals have told us that rates of well-child visits tend to be lower after the early childhood years,” Adams said.

The ACA required that most health plans cover preventive services recommended by four medical and scientific expert groups without charging consumers anything out-of-pocket. For children, many of these services are spelled out in the Bright Futures project guidelines, sponsored by the American Academy of Pediatrics and supported by the federal government, and by the U.S. Preventive Services Task Force, an independent group of medical experts that evaluates the evidence for clinical care.

About a fifth of adolescents ages 12 to 19 are obese, and between 13 and 20 percent of children have a mental disorder in any given year, according to the Centers for Disease Control and Prevention.

Some research has shown that parents may believe that adolescents do not need to go to the doctor unless they’re sick and that they can’t afford to pay for checkups, Adams said.

“What we would like is for families to understand that this is a right families have and that these are valuable services that can help their children,” she said.

Please visit to send comments or ideas for future topics for the Insuring Your Health column.

About A Third Of Americans Unaware Of Obamacare Open Enrollment

Kaiser Health News:HealthReform - November 17, 2017

While the Affordable Care Act’s fifth open enrollment season is off to a surprisingly good start, many uninsured people said they weren’t even aware of it, according to a survey released Friday.

Use Our Content

This Kaiser Health News story can be republished for free (details).

More Stories To Republish

Nearly a third of people overall — including a third of people without health insurance — said they had not heard anything about the sign-up period for individuals who buy health plans on their own, according to the survey by the Kaiser Family Foundation (KFF). (Kaiser Health News is an editorially independent program of the foundation.)

Open enrollment started Nov. 1 and runs through Dec. 15 in most states. Advocates fear enrollment will decline this year because President Donald Trump has been repeatedly saying the health law is “dead,” and his administration severely cut funding for publicity and in-person assistance.

Nonetheless, nearly 1.5 million people have enrolled on the federal health insurance exchange, which handles coverage in 39 states, federal officials reported Wednesday.

One factor that could be pushing more people to sign up earlier this year is the open enrollment season was cut in half from three months to 45 days for the states relying on the federal exchange. Some state exchanges allow enrollment into January.

Several state health insurance exchanges have also said early sign ups are running higher than last year. The Colorado insurance exchange on Thursday said it has enrolled more than 22,000 people in the first two weeks — a 33 percent jump from last year’s first weeks.

In the previous open-enrollment season, 12.2 million people nationwide selected individual market plans through the marketplaces. The number dropped off during the year because not everyone paid and some found coverage elsewhere.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Forty-five percent of all respondents to the KFF survey and 52 percent who said they were uninsured said they have heard less about open enrollment this year compared to previous years.

Insurers are trying to pick up some of the challenges of publicizing enrollment, and some of those ads are getting noticed.

The percentage of survey respondents who said they saw ads attempting to sell health insurance increased from 34 percent to 41 percent between the October and November KFF tracking polls. The share who say they saw ads that provided information about how to get health insurance under the ACA increased from 20 percent to 32 percent.

The poll found that nearly 8 in 10 Americans were aware the Affordable Care Act was still in effect.

The survey of 1,201 adults, which was conducted Nov. 8-13, has a margin of error +/-3 percent.

Medicaid Expansion Takes A Bite Out Of Medical Debt

Kaiser Health News:HealthReform - November 17, 2017

As the Trump administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger.

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News. It can be republished for free. (details)

On Nov. 7, Maine voters approved a ballot measure to expand Medicaid under the Affordable Care Act. Advocates are looking to follow suit with ballot measures in Utah, Missouri and Idaho in 2018.

Virginia may also have another go at expansion after the Legislature thwarted Gov. Terry McAuliffe’s attempt to expand Medicaid. Virginia voters elected Democrat Ralph Northam to succeed McAuliffe as governor in January, and Democrats made inroads in the state Legislature, too.

An exit poll of Virginia voters on Election Day found that 39 percent of them ranked health care as their No. 1 issue. More than three-quarters of the Virginians in this group voted for Democrats.

study from the Urban Institute may shed light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid.

In some cases, struggles with medical debt can be all-consuming.

Geneva Wilson is in her mid-40s and lives outside of Lowry City, Mo. She has a long history of health problems, including a blood disorder, depression and a painful misalignment of the hip joint called hip dysplasia.

She’s managed to find some peace living in a small cabin in the woods. She keeps chickens, raises rabbits and has a garden. Her long-term goal is to live off her land by selling what she raises at farmers markets.

Her health has made it hard to keep a job and obtain the insurance that typically comes with it. And Missouri’s stringent Medicaid requirements — which exclude nondisabled adults without children — have kept her from getting public assistance.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Since graduating from college more than 20 years ago, Wilson has mostly had to pay out-of-pocket for medical care, and that’s left her with a seemingly endless pile of medical debt.

“As soon as I get it down a little bit, something happens, and I have to start all over again,” Wilson said.

Right now her medical debt stands at about $3,000, which she pays down by $50 a month. She desperately needs a hip replacement, but she canceled the surgery because, even with a deeply discounted rate from a nearby hospital, she couldn’t afford it.

“Approximately $11,000 is what would come out of my pocket to pay for the hip. That’s my entire pretax wage from last year,” Wilson said. “So it’s kind of on hold, but I don’t know if I can survive the year without going ahead and trying to get it done.”

For many people like Wilson, medical debt can be nearly as problematic as an illness. In 2015, 30.6 percent of Missouri adults ages 18 to 64 had past-due medical debt, the seventh-highest rate in the country. Kansas, at 27 percent, had the 15th-highest rate. In Maine, which voted to expand Medicaid this week, it was 27.7 percent.

Researchers Aaron Sojourner and Ezra Golberstein of the University of Minnesota studied financial data from 2012 to 2015 for people who would be eligible for Medicaid where it was expanded.

They found that in states that didn’t expand, the percentage of low-income, nonelderly adults with unpaid medical bills dropped from 47 to 40 percent within three years.

“The economy improved and maybe other components of the ACA contributed to a 7-percentage-point reduction,” Sojourner says. “Where they did expand Medicaid, it fell by almost twice as much.”

Those states saw an average drop of 13 percentage points, from 43 to 30 percent.

In Kansas, the rate of medical debt for nonelderly adults fell by 4 percentage points to 27 percent. In Missouri, the rate dropped 4 points to 31 percent, according to the Urban Institute. In Maine, it dropped only 1.4 percentage points from 2012 to 2015.

Medicaid, as opposed to private insurance, is the key, said the Urban Institute’s Kyle Caswell, because it requires little out-of-pocket costs.

Even if Medicaid patients need lots of care, they aren’t on the hook for big out-of-pocket costs in the same way someone with private insurance might be.

“We would certainly expect their risk to out-of-pocket expenses to be much lower, and ultimately the risk of unpaid bills to ultimately be also lower,” Caswell said.

But Medicaid’s debt-reducing advantages over private insurance could disappear under the leadership of the Trump administration.

Shortly after Seema Verma was confirmed as the administrator for the Centers for Medicare & Medicaid Services, she and Tom Price, then head of the Department of Health and Human Services, sent a letter to the governors outlining their plans for Medicaid.

The letter encouraged states to consider measures that would make their Medicaid programs operate more like commercial health insurance, including introducing premiums and copayments for emergency room visits.

Verma said that by giving recipients more “skin in the game,” they will take more responsibility for the cost of care and save the program money.

Republican proposals in Congress to repeal and replace the Affordable Care Act would have eliminated or limited Medicaid expansion. And that would have affected the last few years’ downward trend in medical debt.

“Anything that reduces access to Medicaid most likely would have the reverse effect of what we’re seeing in our paper,” Caswell said. “Reduced access to Medicaid would likely increase exposure to medical out-of-pocket spending and ultimately unpaid medical bills.”

As Geneva Wilson tends to her chickens, she said, she tries not to think too much about her medical debt or how she’ll pay for that hip replacement.

“It’s going to the point where, if I were to go shopping at Walmart, I would have to get one of the carts you drive because I can’t manage,” she said.

Wilson has already sold her jewelry, some furniture and a wood stove to pay down her debts. Now there’s not much left to sell except her cabin and her land.

“Probably the homestead and garden that I want, that I’ve been wanting and trying to work for, I don’t think they are a viable dream either,” Wilson said. “It’s hard losing your dreams.”

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.

For Millions of Insured Americans, State Health Laws Don’t Apply

Kaiser Health News:Insurance - November 16, 2017

Let’s say you have health insurance through your employer and live in one of 21 states with laws protecting consumers against surprise medical bills from out-of-network providers.

Ask Emily

Senior Correspondent Emily Bazar’s answers consumers’ questions about California’s changing medical landscape.

Send questions for Emily to

More Columns
Should one of those unwanted bills land in your mailbox, you can turn to your state law and regulators for help, right?

Not necessarily.

If you’re among the millions of Americans with a category of job-based health coverage known as self-funded insurance, most state health care laws do not apply to you.

Plus, if you have an issue with your coverage, you must go through a different appeals process than other state residents with private insurance. You must seek help from a federal regulator that may — or may not — be responsive.

“We have unequal consumer protections for a big chunk of our population,” says Tam Ma, legal and policy director for the advocacy group Health Access California.
For Millions of Insured Americans, State Health Laws Don’t Apply
Nationally, 61 percent of covered workers were in self-funded plans last year, according to the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

In California, about 5.7 million people were enrolled in such plans. Last year, the Golden State’s two health insurance regulators received more than 1,000 requests for help from consumers in self-funded plans. The departments have no authority over those plans and had to refer many of the enrollees to the U.S. Department of Labor, which regulates them.

Businesses that opt for self-funded plans — also called self-insured plans — generally pay the medical bills of their employees directly.

Under a fully insured plan, on the other hand, the employer — or an individual or family — buys coverage from a state-regulated insurance company, which assumes the financial risk. In California, fully insured plans are overseen by the state Department of Managed Health Care or the state Department of Insurance.

Large companies are more likely to self-insure. Among companies with 5,000 or more employees, 94 percent of covered workers were in self-funded plans last year, KFF data show.

More businesses — including smaller ones — are self-insuring because they can save money, says Dean Hoffman, an employee benefits consultant based in Wisconsin who specializes in self-insured plans.

One way they save is by avoiding the cost of complying with state-mandated benefits. For example, Hoffman says, for every premium dollar spent on fully insured plans in Wisconsin, about 11 cents goes toward state-mandated requirements.

“Every time you add a benefit, there’s a price associated with that,” he says.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

It might not be obvious that you’re covered by a self-funded plan. Most businesses contract with health insurance companies to administer them, pay claims and provide access to their provider networks. That means your insurance card will likely have a Cigna, Blue Shield or other familiar logo on it even if your plan is self-funded.

If you’re not sure whether your plan is self-insured, ask your human resources department.

“To the consumer, it feels no different,” says Karen Pollitz, a senior fellow at KFF. “If you work for a big company, it’s a pretty good bet you’re in a self-funded plan.”

If you are, you may feel the difference in coverage, consumer protection and grievance procedures, however. “The only consumer protections available to those folks are just what federal law provides,” Ma says.

Consider state laws relating to surprise medical bills. Among the states that have adopted various protections against such bills, Connecticut, Illinois, New York, Florida, Maryland and California have the strongest and most comprehensive measures.

But even if you live in one of these states, “you still might get hit by large medical bills” if you’re in a self-funded plan, Pollitz says.

Some self-insured businesses, however, voluntarily provide many of the same protections as state law, says Lauren Vela, a senior director at the Pacific Business Group on Health, which represents about 75 companies that self-insure nationwide.

In the case of surprise bills — from out-of-network doctors such as anesthesiologists, for instance — “a lot of employers, not all of them, would have it written into their plan that it would not be considered out-of-network,” Vela says. “No employer wants to have employees get these kinds of surprise bills.”

To handle complaints about coverage, most states have laws allowing consumers in private health plans to appeal to an independent, external reviewer chosen by the state if your plan denies a claim and you disagree, Ma says.

In self-insured plans, you are entitled to external review — but your employer chooses, hires and pays the reviewer, Pollitz says. “It’s not independent in the way that state programs are.”

Plus, your regulator, the U.S. Department of Labor, may be slow to get involved in the grievance process, Ma says.

The department “doesn’t really have the resources or the ability to protect consumers in a timely way,” she says. “It may take them a very long time to get to your case, if they do at all, compared to state-regulated plans.”

So, if you’re in a self-funded plan and disagree with a coverage decision, look at your explanation of benefits, which will describe how to appeal. You can also ask your human resources department for guidance, or your union, if one represents you.

Most experts agree that your first step will likely be to contact the customer service line on your insurance card and request a review.

If your concern isn’t resolved that way, reach out to the Employee Benefits Security Administration (EBSA) through the Department of Labor at 866-444-3272 or

EBSA “has experts who can help on this,” says Michael Trupo, a spokesman for the department, though he did not answer follow-up questions for more details.

If you don’t get your questions answered, many states have Consumer Assistance Programs that help you navigate insurance problems, including those with self-funded plans. The Department of Managed Care administers California’s program, which can be reached at 888-804-3536.

“They’ll help you file your appeal and make inquiries on your behalf,” Pollitz says. “They can be your advocate.”

How Older Patients Can Dodge Pitfalls Entrenched In Health Care System

Kaiser Health News:Marketplace - November 16, 2017
Navigating Aging

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.

To contact Judith Graham with a question or comment, click here.

Join the Navigating Aging Facebook Group.

See All Columns

Being old and sick in America frequently means a doctor won’t ask you about troublesome concerns you deal with day to day — difficulty walking, dizziness, a leaky bladder, sleep disturbances memory lapses, and more.

It means that if you’re hospitalized, you have a good chance of being treated by a physician you’ve never met and undergoing questionable tests and treatments that might end up compromising your health.

It means that if you subsequently seek rehabilitation at a skilled nursing facility, you’ll encounter another medical team that doesn’t know you or understand your at-home circumstances. Typically, a doctor won’t see you very often. In her new book, “Old & Sick in America: The Journey Through the Health Care System,” Dr. Muriel Gillick, a professor of population medicine at Harvard Medical School and director of the Program in Aging at Harvard Pilgrim Health Care Institute, delves deeply into these concerns and why they’re widespread.

Her answer: a complex set of forces is responsible.  Some examples:

  • Medical training doesn’t make geriatric expertise a priority.
  • Care at bottom-line-oriented hospitals is driven by the availability of sophisticated technology.
  • Drug companies and medical device manufacturers want to see their products adopted widely and offer incentives to ensure this happens.
  • Medicare, the government’s influential health program for seniors, pays more for procedures than for the intensive counseling that older adults and caregivers need.

In an interview, Gillick offered thoughts about how older adults and their caregivers can navigate this treacherous terrain. Her remarks have been edited for clarity and length:

Q: What perils do older adults encounter as they travel through the health care system?

The journey usually begins in the doctor’s office, so let’s start there. In general, physicians tend to focus on different organ systems. The heart. The lungs. The kidneys. They don’t focus so much on conditions that cross various organ systems, so-called geriatric syndromes. Things like falling, becoming confused or dealing with incontinence.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Q: What can people do about that?

Older people are often unwilling to bring these issues to the attention of their doctors. But if a family member is accompanying the patient, they should speak up.

In some practices, a nurse practitioner may be more attuned to these issues than the physician. So, it’s a good idea to learn who in the medical office you go to is good at what.

Another approach is to request a geriatric assessment or consultation that will bring these issues to the forefront.

Q: How do geriatric assessments work?

A geriatric assessment does two major things. It looks at the whole person. And it focuses on that person’s functioning — on what they can do. Can they dress themselves, walk, get to the bathroom? Can they cook meals? Take a bus downtown? Balance their checkbook?

An outpatient geriatric assessment is typically 1½ to two hours and conducted by an interdisciplinary team. A social worker or a mental health professional will ask about the person’s family situation. Are they living alone? Do they have support? A nurse practitioner will look at physical function. And a physician will go over medical concerns and examine the cognitive performance of the individual. Then, the team pulls all these pieces together to look at what’s going on with that person.

When someone starts being frail — having consistent difficulty doing things — an assessment of this kind is often a good idea.

More Columns See All Columns

Q: The next step you talk about in your book is the hospital.

One of the big perils in the hospital is technology, which is also its great virtue.  Technology can improve quality of life and be life-extending. But, sometimes, it creates endless complications.

An example are imaging tests such as CT scans. Physicians hardly think of this as an invasive test. But often one has to administer a dye to see what’s going on.  That dye can cause kidney failure in someone with impaired kidney function — something that’s common in older adults.

Sometimes there’s no real need for scans. An example would be an older person who becomes acutely confused in the hospital, which happens a lot. The appropriate response is to look at what’s causing the confusion and take away the offending agent. Often, that’s a medication that was started in the hospital. Or, it’s an infection. But the routine knee-jerk reaction is to do a CT scan to rule out the possibility of a stroke or bleeding in the brain.

For the most part, doctors want to do whatever it takes to diagnose a problem.  For younger patients, this may make sense. But for frail older patients with multiple medical conditions, a cascade of complications can result.

Q: What do you advise older patients and their families do?

When a test is proposed, ask the doctor “how important is it to pursue this diagnosis” and “how will the results change what you do?”

It’s also reasonable to say something along the lines of “every time I’ve had a test, it seems like I get into some kind of trouble. So, I really want to know, with this test or this treatment, what kind of trouble could I get into?”

Q: In your book, you talk about how a doctor-patient relationship can be sidelined when someone goes to the hospital. Instead, hospitalists provide care. How should people respond?

It’s really important to give that doctor a sense of the patient and who they are.  Say, your 88-year-old mother is in the hospital, and she’s become profoundly confused. The doctor doesn’t know what she was like a week or a month ago. He may assume she has dementia unless he hears otherwise. He won’t understand it might be delirium.

You or a caregiver want to come across as someone who can make it easier for the doctor to do his or her job — versus someone who’s a nuisance. You want to build trust, not annoyance.

Use Our Content

This Kaiser Health News story can be republished for free (details).

More Stories To Republish

Q: What about skilled nursing facilities?

These are settings that people go to after the hospital, to get rehabilitation.  Typically, the contact with doctors is minimal after an initial evaluation, though there’s a spectrum as to how much medical care there is.

A subset of older adults go to rehab just to get physical therapy after they’ve had a joint replacement or a hip fracture. They are really pretty stable, medically. If they get good physical therapy and nursing care, it’s probably OK that the doctor isn’t around much.

But there are also older patients who come to skilled nursing facilities, or SNFs, after having had one complication after another in the hospital. These patients can be very fragile, with many medical problems. They’re at risk of getting some new problem in the SNF — perhaps an infection — or an exacerbation of one of the problems they already have that hasn’t resolved.

Q: What do you recommend?

When you arrive at an SNF, it’s a new cast of characters. A physician whom you’ll see fleetingly. Nurses. Physical therapists. Aides. If you’re a caregiver, make sure you have face-to-face time with these staffers.

SNFs are required within the first week or so to have a care planning meeting with the team. They’re supposed to invite patients and their representatives to the meeting. This is a good place to say something along the lines of “My mother has been through a lot, and now that we’ve met you and seen what you can do, we’d like you to do your best to treat her here and not send her back to the hospital.”

You have to have trust to make that happen. The family has to trust the medical team. And the team has to trust that the family isn’t going to get upset and sue them. A meeting of this kind has the potential to allow everyone to figure out what’s important and what the plan will be going forward.

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 to submit your requests or tips.

California Fines Anthem $5 Million For Failing to Address Consumer Grievances

Kaiser Health News:Insurance - November 15, 2017

California’s managed-care regulator announced Wednesday it has fined insurance giant Anthem Blue Cross $5 million for repeatedly failing to resolve consumer grievances in a timely manner.

The state Department of Managed Health Care criticized Anthem, the nation’s second-largest health insurer, for systemic violations and a long history of flouting the law in regard to consumer complaints.

“Anthem Blue Cross’ failures to comply with the law surrounding grievance and appeals rights are long-standing, ongoing and unacceptable,” said Shelley Rouillard, director of the Department of Managed Health Care. “Anthem knows this is a huge problem, but they haven’t addressed it.”

Before this latest action, California had already fined Anthem more than $6 million collectively for grievance-system violations since 2002.

The state said it identified 245 grievance-system violations during this latest investigation of consumer complaints at Anthem from 2013 to 2016.

Rouillard cited one example in which Anthem denied a submitted claim for an extensive surgical procedure, even though it had issued prior approval for the operation. Twenty-two calls contesting the denial — placed by the patient, the patient’s spouse, the couple’s insurance broker and the medical provider — failed to resolve the complaint. It was not until the patient sought help from the managed-care agency, more than six months after the treatment, that Anthem paid the claim.

Anthem Inc. could not be immediately reached for comment. The company, based in Indianapolis, sells Blue Cross policies in California and 13 other states.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

California is known for having tough consumer protection laws on health coverage and for assisting policyholders when they exhaust their appeals with insurers. In other actions, the state has fined insurers for overstating the extent of their doctor networks and for denying patients timely access to mental health treatment.

Jamie Court, president of Consumer Watchdog, an advocacy group in Santa Monica, Calif., said the regulatory response to these problems varies greatly by state.  He singled out New York, Washington and Kansas as some of the states with good track records of holding health insurers accountable.

“The real problem is when states don’t act there is not a great avenue for the consumer. It’s very hard to bring legal action,” Court said. “Anthem definitely needed a wake-up call. But this will also send a message to other insurers.”

Nationally, consumers continue to express their displeasure with health insurers over a wide range of issues, including denials for treatment, billing disputes and the lack of in-network doctors.

Verified complaints related to health insurance and accident coverage rose 12 percent in 2016 compared to the previous year, totaling 53,680, according to data compiled by the National Association of Insurance Commissioners. The data only includes incidents in which state regulators confirmed there was a violation or error by the insurer involved.

Court and other advocates welcomed the significant fine in California and said this is just the latest example of Anthem’s failure to uphold basic consumer protections.

Overall, state officials said that calls to Anthem’s customer service department often led to repeated transfers and that the company failed to follow up with enrollees.

After previous fines, Anthem has pledged to provide more training to employees and to better track grievances and appeals in order to reduce delays.

“If you look at the history of Anthem and the penalties assessed over the years, they are definitely an outlier compared to other health plans,” Rouillard said.

“All the plans have some issues with grievances, but nothing to the degree we are seeing with Anthem.”

The managed-care department said a health plan’s grievance program is critical, so that consumers know they have the right to pursue an independent medical review or file a complaint with regulators if they are dissatisfied with the insurer’s decision. The grievance system can also help insurers identify systemic problems and improve customer service, state officials said.

The state’s independent medical review program allows consumers to have their case heard by doctors who are not tied to their health plan. The cases often arise when an insurer denies a patient’s request for treatment or a prescription drug.

In 2016, insurance company denials were overturned in nearly 70 percent of medical review cases and patients received the requested treatment, according to state officials.

California Firm Running Physician Practices Is Closing Down as Scrutiny Ramps Up

Kaiser Health News:Marketplace - November 15, 2017

SynerMed, a company that manages physician practices serving hundreds of thousands of Medicaid and Medicare patients across California, is planning to shut down amid scrutiny from state regulators and health insurers.

The company’s chief executive, James Mason, notified employees in an internal email Nov. 6, obtained by Kaiser Health News, that audits by health plans found “several system and control failures within medical management and other departments.”

As a result, Mason wrote, the company “will begin the legal and operational steps to shut down all operations.” He said he was working on the transition of SynerMed’s clients to another management firm within the next 180 days.

Separately, the California Department of Managed Health Care confirmed it is investigating the company.

“There is an open investigation of SynerMed, but the details are confidential right now,” said spokesman Rodger Butler. His agency monitors the financial solvency and claims-payment practices of many physician groups that contract with health plans.

The company’s sudden decision to shut down has sparked alarm among some doctors and medical groups that have relied on the company to handle their finances and business operations.

For years, SynerMed has served as a key middleman between health plans and independent physician practices, handling insurance contracting, paying claims and performing other administrative tasks so doctors can focus on treating patients. That role has expanded as millions more Californians are enrolled in Medicaid managed-care plans under the Affordable Care Act.

SynerMed has billed itself as “one of the largest Medicaid/Medicare management service organizations in the nation.” Last year, the company boasted that it had enrollment of 1 million patients in California, aided by an influx of enrollees who got coverage under the federal health law.

Mason, the CEO, didn’t respond to requests for comment. The company referred calls to its general counsel, but she couldn’t be reached.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

In his email to employees, Mason said he had “discovered certain internal control issues within the medical management department.”

“Well,” he wrote, “as a result of the manner in which those issues were disclosed to the health plans and regulatory agencies, we have been subject to unannounced audits by almost all of our health plan partners.”

The CEO said two medical groups, AlphaCare and EHS (Employee Health Systems) Medical Group, have already terminated their contracts with SynerMed.

“I am heartbroken and saddened by these events after we have worked so hard to build our reputation as a company that operates with integrity,” Mason wrote in his email to employees.

Part of SynerMed’s growth had come from managing care for low-income seniors and people with disabilities who are eligible for both Medicare and Medicaid, called Medi-Cal in California. The state has been at the forefront nationally in trying to shift those “dual-eligible” patients into managed-care plans, which are paid a fixed rate per patient to coordinate a range of medical care.

A spokesman for the Medi-Cal program said the agency had no information to share on SynerMed.

SynerMed is a subsidiary of PAMC, Ltd., which also owns Pacific Alliance Medical Center in Los Angeles’ Chinatown. The hospital agreed to pay $42 million in June to settle federal allegations of improper kickbacks to referring physicians.

The U.S. Justice Department said Pacific Alliance Medical Center agreed to the settlement to resolve a whistleblower lawsuit alleging that the hospital submitted false claims to Medi-Cal and Medicare. In a news release at the time, federal officials said the hospital and its owners did not admit liability in settling the case.

The hospital is closing later this month. Officials there attributed the closure to the fact that the lease on the property is ending and it wasn’t financially feasible to retrofit facilities to meet the state’s seismic requirements.

In a statement to Kaiser Health News, PAMC said “there is no connection between the closure of [the hospital] and any matters involving SynerMed. SynerMed is a wholly owned subsidiary that provides completely different services.”

Trump Administration Plan to Add Medicaid Work Requirement Stirs Fears

Kaiser Health News:HealthReform - November 15, 2017

The Trump administration’s recent endorsement of work requirements in Medicaid and increased state flexibility is part of broader strategy to shrink the fast-growing program for the poor and advance conservative ideas that Republicans failed to get through Congress.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, laid out her vision for the state-federal program in two appearances last week, saying her new course give states wide latitude over eligibility and benefits.

In a speech Nov. 7 to state Medicaid directors, Verma said the program needs to give people “hope that they can achieve a better future for themselves and their families, hope that they can one day break the chains of generational poverty and no longer need public assistance.”

She has noted other government assistance programs such as food stamps, have similar requirements.

But her outline scares advocates who see the changes as a way for states to kick millions of adults off the program and undermine its mission of providing health coverage to the poor. They note most nondisabled adults on Medicaid already work. Many who don’t are either too sick, go to school or care for relatives.

“Medicaid coverage is not something that should be earned,” said Robert Doherty, senior vice president at the American College of Physicians. “Medicaid is not a welfare program. It is a health care entitlement program, and anyone who meets the requirements should be able to have coverage.”

Verma’s plan to greenlight work requirements is only just the beginning of dramatic changes, these advocates said. They expect that she would allow more states to charge monthly premiums, as Indiana has proposed; approve drug testing of enrollees, as Wisconsin has requested; and putting a time limit on coverage, as Arizona has asked.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Katherine Howitt, associate director of policy at the Community Catalyst, a consumer health advocacy group that backs the federal health law and  expansion of Medicaid, said Verma has thrown open the door to allowing states to add more restrictions on coverage.

“This new approach is not really about promoting work or improving care or improving state flexibility,” she added. “At the end of the day, it is making it harder for low-income people to access health coverage.”

Nearly 75 million people are covered by Medicaid, including 16 million added since 31 states and the District of Columbia expanded their programs under the Affordable Care Act.

Verma said her goal for Medicaid is to move people out of the program by getting them into jobs that offer coverage or provide enough income so they buy it on their own.

“Her comments show she doesn’t understand the reality that many low-wage jobs don’t offer benefits,” Howitt said.

Several states, including Arkansas, Kentucky and Maine, have asked CMS to allow them to require Medicaid recipients to work or do volunteer work as a condition of enrollment. The Obama administration turned down such proposals.

Even some right-leaning pundits say work requirements could backfire because taking away health coverage could make individuals sicker and less likely to hold down jobs.

“This could run counter to the goal of Republicans to help put people to work,” said Jason Fichtner, a health policy expert at the conservative Mercatus Center at George Mason University in Fairfax, Va.

But Josh Archambault, senior fellow for the conservative Foundation for Government Accountability, said he was encouraged by Verma’s approach.

“I think the intent of the program depends on different populations it serves,” he said. “For someone in a nursing home, it’s a health program. But for people in the Medicaid expansion, it is more like a welfare program where able-bodied people are expected to move back into the workforce.”

Congress, with the blessing of President Donald Trump, tried earlier this year to make substantial changes to Medicaid as part of the bills to replace the ACA. Those efforts stalled.

The changes included offering states more flexibility, but federal funding would not be as generous. The nonpartisan Congressional Budget Office said millions fewer people would eventually be covered.

Verma, a former health consultant who helped Indiana expand Medicaid in 2015 under Obamacare, said the law should never have allowed so-called able-bodied adults into the program. That’s because Medicaid already had too many problems, including not enough doctors and wait lists for some people seeking coverage, she said.

Before the ACA, Medicaid mainly covered children, disabled people and pregnant women.

More Medicaid Stories

The health law broadened Medicaid to all low-income people, opening up the program to cover nondisabled adults without children with incomes up to 138 percent of the federal poverty level (about $16,600 for an individual).

“We put people on the Medicaid program — able-bodied individuals — in a program that is essentially designed for people that are going to be on the program for the rest of their lives,” Verma said Nov. 9 at an event sponsored by The Wall Street Journal.

Two-thirds of people on Medicaid are disenrolled within three years, according to a U.S. Census Bureau report.

Verma’s pointed criticism of Medicaid, the Affordable Care Act’s expansion and even state officials who helped implement that effort drew rebukes from state Medicaid directors.

Critics said her remarks were misguided and showed she doesn’t understand the program she runs.

Doherty said that by law Medicaid allows states to conduct experiments in how they run the program, but not by making it harder for people to get covered.

Nothing stops states, he added, from offering job training and other programs to help people on Medicaid get back to work. “But we can’t deny them access to health care just because they happen to be poor,” he said.

Robin Rudowitz, a Kaiser Family Foundation policy analyst, said Verma appears willing to let states experiment as never before.

“Some proposals [like work requirements] could create barriers to coverage for eligible beneficiaries and result in losses of coverage for Medicaid enrollees,” she said. (Kaiser Health News is an editorially independent program of the foundation.)

Some health experts said they see many contradictions in Verma’s approach. They said she wants Medicaid to focus only on the most needy — but she has been unwilling to criticize Congress for failing to reauthorize the Children’s Health Insurance Program (CHIP) that covers 9 million children. Federal CHIP funding ran out Sept. 30.

Verma also questioned why some states spend significantly more per enrollee than other states on Medicaid. But the reason, these experts note, is because states have flexibility to vary their benefits, eligibility rules and payments to providers.

As Medicaid has grown to cover more than 1 in 5 Americans, it has become more popular among beneficiaries, health care providers and even among some Republican governors who agreed to expand it. Howitt said the Trump plan would take Medicaid back to the 1980s when it was often linked to cash assistance welfare and carried a stigma.

Joan Alker, director of the Georgetown University Center for Children and Families, said backing work-requirement proposals helps the Trump administration further its ideological message that Medicaid is a welfare program and not a health program.

Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities, which supports the ACA, said Verma’s vision is simple: to undo the health law’s coverage gains.

“In 2010, Congress decided to expand Medicaid as the vehicle for low-wage workers to have coverage as part of health reform,” she said. “That is still the law and she [Verma] doesn’t get to disagree with that, she has to follow the law not sabotage it.”

Some States Roll Back ‘Retroactive Medicaid,’ A Buffer For The Poor — And For Hospitals

Kaiser Health News:Insurance - November 14, 2017

If you’re poor, uninsured and fall seriously ill, in most states if you qualify for Medicaid — but weren’t enrolled at the time — the program will pay your medical bills going back three months. It protects hospitals, too, from having to absorb the costs of caring for these patients.

But a growing number of states are rescinding this benefit known as “retroactive eligibility.” On Nov. 1, Iowa joined three states that have eliminated retroactive coverage for some groups of Medicaid patients since the Affordable Care Act passed. Each state had to secure approval by the federal government.

Retroactive eligibility has been a feature of Medicaid for decades, reflecting the program’s emphasis on providing a safety net for poor, disabled and other vulnerable people. In contrast to private insurance, determining Medicaid eligibility can be complex and the application process daunting, advocates say. A patient’s medical condition also may keep families from applying promptly for coverage.

Insuring Your Health

KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.

To contact Michelle with a question or comment, click here.

This KHN story can be republished for free (details).

All four states — Arkansas, Indiana and New Hampshire, in addition to Iowa — have expanded Medicaid under the health law, which allowed states to include adults with incomes up to 138 percent of the federal poverty level, or about $16,000 for one person. So, in theory, most adults are required to have insurance under the ACA. In practice, each state still has a significant number of uninsured, ranging from 5 to 8 percent of the population.

The retroactive coverage “can compensate for the sorts of errors and lapses that can so easily occur on the part of both the applicant and the government bureaucracy” that delay applications, said Gordon Bonnyman, staff attorney at the Tennessee Justice Center, a public interest law firm that represents low-income and uninsured residents.

State and federal officials say eliminating the retroactive coverage helps encourage people to sign up for and maintain coverage when they’re healthy rather than waiting until they’re sick to enroll. It also fits into federal officials’ efforts to make Medicaid, the federal-state program that provides health care for low-income adults and children, more like private insurance.

But consumer advocates and health care providers say the shift will saddle patients with hefty medical bills and leave hospitals to absorb more uncompensated care when patients can’t pay. Some worry this could be the start of a trend.

In Iowa, the change applies to just about anyone coming into Medicaid — except for pregnant women and children under age 1. The change will affect up to 40,000 residents annually and save the program more than $36 million a year.

“We’re making it a lot more likely that Medicaid-eligible members are going to incur significant medical debt,” said Mary Nelle Trefz, health policy associate at the Child & Family Policy Center in Des Moines, whose organization opposed the change.

When someone has a traumatic health event, the initial focus is to get them stabilized, not figure out how to pay for it, said MaryBeth Musumeci, associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Patients may neglect to apply immediately for Medicaid, leaving them financially responsible for days or months of care they received before they got in their application, even though they may have been eligible for Medicaid all along.

That’s not the only issue, advocates say. Unlike the commercial insurance market where re-enrollment through someone’s employer is routine, Medicaid requires that beneficiaries’ eligibility be reassesed every year.

“People fall through the cracks,” said Andrea Callow, associate director of Medicaid initiatives at Families USA, a consumer advocacy group.

In addition, complications can arise for people who might need Medicaid coverage for long-term care services. “The criteria are complicated. For a layperson to find those criteria and figure out if they’re eligible” is challenging and they may need extra time, said Musumeci. Once patients have secured coverage, they may already have accrued hefty expenses.

Maybe so, but some people argue that a 90-day retroactive eligibility guarantee is counterproductive.

“We’re trying to get people to behave more responsibly, not less responsibly,” said Gail Wilensky, an economist who oversaw the Medicaid and Medicare programs in the early 1990s under President George H.W. Bush. “That is not the signal you’re sending” with three months of retroactive eligibility. A 30-day time frame is more reasonable, Wilensky said.

In contrast to Iowa, the waivers in Arkansas, Indiana and New Hamsphire generally apply only to adults who gained coverage under the law’s Medicaid expansion. (Indiana’s waiver also applies to other groups.)

Kentucky has a request pending that, like Iowa, would eliminate retroactive Medicaid eligibility except for pregnant women and children under 1, according to KFF.

Under federal law, officials can waive some Medicaid coverage rules to give states flexibility to experiment with different approaches to providing services. And retroactive eligibility waivers in Medicaid are hardly new. A few states like Tennessee have had them in place for years. Tennessee officials eliminated retroactive eligibility for all Medicaid beneficiaries in 1994 when the state significantly expanded coverage under TennCare, as Medicaid is known there. At the time, the state even allowed uninsured people to buy into the program who wouldn’t otherwise qualify based on income, said Bonnyman.

“There was no reason for anybody to be uninsured except undocumented immigrants,” said Bonnyman. “It didn’t seem to have the potential for harm.”

But state officials revamped that program after serious financial problems. Eligibility for TennCare has become more restrictive again.

Other states that waived retroactive coverage for at least some Medicaid groups include Delaware, Maryland, Massachusetts and Utah, according to the Kaiser Family Foundation.

Bonnyman said his group frequently works with Medicaid beneficiaries who have medical bills they can’t afford that accumulated during the months before they applied for Medicaid.

“If you’re a moderate- to low-income working family, one or two days in the hospital is enough to ruin you financially,” he said.

Please visit to send comments or ideas for future topics for the Insuring Your Health column.

Taking A Page From Pharma’s Playbook To Fight The Opioid Crisis

Kaiser Health News:Marketplace - November 14, 2017

Dr. Mary Meengs remembers the days, a couple of decades ago, when pharmaceutical salespeople would drop into her family practice in Chicago, eager to catch a moment between patients so they could pitch her a new drug.

Now living in Humboldt County, Calif., Meengs is taking a page from the pharmaceutical industry’s playbook with an opposite goal in mind: to reduce the use of prescription painkillers.

Meengs, medical director at the Humboldt Independent Practice Association, is one of 10 California doctors and pharmacists funded by Obama-era federal grants to persuade medical colleagues in Northern California to help curb opioid addiction by altering their prescribing habits.

This story also ran on KQED’s California Report. It can be republished for free (details).

She committed this past summer to a two-year project consisting of occasional visits to medical providers in California’s most rural areas, where opioid deaths and prescribing rates are high.

“I view it as peer education,” Meengs said. “They don’t have to attend a lecture half an hour away. I’m doing it at [their] convenience.”

This one-on-one, personalized medical education is called “academic detailing” — lifted from the term “pharmaceutical detailing” used by industry salespeople.

Detailing is “like fighting fire with fire,” said Dr. Jerry Avorn, a Harvard Medical School professor who helped develop the concept 38 years ago. “There is some poetic justice in the fact that these programs are using the same kind of marketing approach to disseminate helpful evidence-based information as some [drug] companies were using … to disseminate less helpful and occasionally distorted information.”

Recent lawsuits have alleged that drug companies pushed painkillers too aggressively, laying the groundwork for widespread opioid addiction.

Avorn noted that detailing has also been used to persuade doctors to cut back on unnecessary antibiotics and to discourage the use of expensive Alzheimer’s disease medications that have side effects.

Kaiser Permanente, a large medical system that operates in California, as well as seven other states and Washington, D.C., has used the approach to change the opioid-prescribing methods of its doctors since at least 2013. (Kaiser Health News is not affiliated with Kaiser Permanente.)

In California, detailing is just one of the ways in which state health officials are attempting to curtail opioid addiction. The state is also expanding access to medication-assisted addiction treatment under a different, $90 million grant through the federal 21st Century Cures Act.

The total budget for the detailing project in California is less than $2 million. The state’s Department of Public Health oversees it, but the money comes from the federal Centers for Disease Control and Prevention through a program called “Prevention for States,” which provides funding for 29 states to help combat prescription drug overdoses.

The California doctors and pharmacists who conduct the detailing conversations are focusing on their peers in the three counties hardest hit by opioid addiction: Lake, Shasta and Humboldt.

They arrive armed with binders full of facts and figures from the CDC to help inform their fellow providers about easing patients off prescription painkillers, treating addiction with medication and writing more prescriptions for naloxone, a drug that reverses the toxic effects of an overdose.

“Academic detailing is a sales pitch, an evidence-based … sales pitch,” said Dr. Phillip Coffin, director of substance-use research at San Francisco’s Department of Public Health — the agency hired by the state to train the detailers.

In an earlier effort, Coffin said, his department conducted detailing sessions with 40 San Francisco doctors, who have since increased their prescriptions of naloxone elevenfold.

“One-on-one time with the providers, even if it was just three or four minutes, was hugely beneficial,” Coffin said. He noted that the discussions usually focused on specific patients, which is “way more helpful” than talking generally about prescription practices.

Meengs and her fellow detailers hope to make a dent in the magnitude of addiction in sparsely populated Humboldt County, where the opioid death rate was the second-highest in California last year — almost five times the statewide average. Thirty-three people died of opioid overdoses in Humboldt last year.

One recent afternoon, Meengs paid a visit during the lunch hour to Fortuna Family Medical Group in Fortuna, a town of about 12,000 people in Humboldt County.

“Anybody here ever known somebody, a patient, who passed away from an overdose?” Meengs asked the group — a physician, two nurses and a physician assistant — who gathered around her in the waiting room, which they had temporarily closed to patients.

“I think we all do,” replied the physician, Dr. Ruben Brinckhaus.

Brinckhaus said about half the patients at the practice have a prescription for an opioid, anti-anxiety drug or other controlled substance. Some of them had been introduced to the drugs years ago by other prescribers.

Dr. Ruben Brinckhaus says his small family practice in Fortuna, Calif., has been trying to wean patients off opiates. (Pauline Bartolone/California Healthline)

Meengs’ main goal was to discuss ways in which the Fortuna group could wean its patients off opioids. But she was not there to scold or lecture them. She asked the providers what their challenges were, so she could help them overcome them.

Meengs will keep making office calls until August 2019 in the hope that changes in the prescribing behavior of doctors will eventually help tame the addiction crisis.

“It’s a big ship to turn around,” said Meengs. “It takes time.”

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

Vaccine Shortage Complicates Efforts To Quell Hepatitis A Outbreaks

Kaiser Health News:Marketplace - November 14, 2017

San Diego County, battling a deadly outbreak of hepatitis A, is postponing an outreach campaign to provide the second of two inoculations against the contagious liver disease until a national shortage of the vaccine is resolved, the county’s chief public health officer said.

“Our goal is to get that vaccine in as many arms as possible for that first dose,” said Dr. Wilma Wooten, who is leading the fight against an epidemic that has ravaged unsanitary homeless encampments in San Diego County for the past year, sickening 544 people and killing 20 of them as of Nov. 6.

Nurses and other county medical workers are fanning out across the most at-risk areas to offer onsite inoculations, and if they run into people who are due for the second shot, they will still give it to them, said Wooten, Public Health Director at the county’s Health and Human Services Agency.

Use Our ContentThis story can be republished for free (details).

The two hepatitis A vaccinations, considered the best way to control the spread of the virus, should be administered six months apart. The first shot is the most important, Wooten said, because it protects people 90 to 95 percent of the time against the virus that causes the disease. The second shot raises the protection level to “close to 100 percent,” she said.

So far, 90,735 people have received vaccinations in San Diego County — most of them the first of the two-shot series, according to the county’s health agency.

The San Diego outbreak, and a number of others in California and across the United States, have generated a spike in demand for hepatitis A vaccine and put a squeeze on supplies, according to the federal Centers for Disease Control and Prevention. Unexpectedly high demand worldwide has constrained availability outside the U.S. as well, the agency said.

Merck & Co. and GlaxoSmithKline, the two companies with approval from the Food and Drug Administration to sell the vaccine in the United States, said they have been hard-pressed to keep up with the demand and are working to boost their production.

The effects of hepatitis A can range from mild to fatal. In addition to the deaths in San Diego, an outbreak of the illness in Michigan has sickened 486 people and killed 19, as of last Friday, according to the Michigan Department of Health & Human Services.

Los Angeles and Santa Cruz counties are also fighting the illness, and infections linked to California’s outbreaks are spreading to homeless people in Utah and Arizona, and to men engaging in gay sex in Colorado, the CDC said. In New York City, health officials are confronting a smaller outbreak, mostly among gay or bisexual men.

The deadly nature of the epidemics in San Diego and Michigan worries public health officials the most, said Dr. Noele Nelson, a CDC specialist in hepatitis vaccine research and policy. “The number of deaths in the Michigan and San Diego outbreaks are quite high from what we’ve seen in the past,” she told members of the CDC’s Advisory Committee on Immunization Practices at a late-October meeting in Atlanta.

Hepatitis A is typically spread through the ingestion of fecal matter from an infected person — even in microscopic amounts. That can happen when people carrying the virus fail to wash their hands after defecating and then contaminate objects, food or water used by others. It can also spread through sexual contact.

On Oct. 13, California Gov. Jerry Brown declared a state of emergency in an effort to increase the state’s supply of adult hepatitis A vaccine. The declaration allowed the state “to immediately purchase additional vaccines directly from manufacturers and coordinate distribution to people at greatest risk in affected areas,” the California Department of Public Health said.

Before Brown’s emergency declaration, the department had distributed nearly 80,000 doses of the vaccine obtained through a federal vaccine program, but those supplies were insufficient, it said.

Merck and GlaxoSmithKline sell the hepatitis A vaccine in pre-filled syringes and less costly single-dose vials.

Pamela Eisele, a Merck spokeswoman, said the unexpectedly sharp rise in demand for the vaccine has limited availability of the company’s vaccine this year.

Single-dose vials of the company’s VAQTA brand vaccine have been on backorder since May and weren’t available until last week, Eisele said. The company expects prefilled syringes to be unavailable until the first quarter of next year, she added.

Likewise, GlaxoSmithKline has been struggling to fill orders for its Havrix brand of the vaccine.

“It’s unprecedented, and it’s very large what’s happening,” said Robin Gaitens, a spokeswoman for the company. GlaxoSmithKline only recently received a shipment of prefilled syringes and has a “limited supply of vials in stock,” she said.

“We will continue to work with CDC, the California Department of Public Health, which is coordinating vaccine orders and distribution on behalf of the counties, and our private customers in California to help address the needs in the state,” Gaitens added.

San Diego County’s Wooten said that despite the supply constraints nationwide, the county now has enough vaccine on hand to give the first injection, but not the second, to those most at risk of contracting the virus — namely, the county’s homeless people, illicit drug users and the professionals who provide care to them.

The biggest challenge posed by the San Diego outbreak is getting the vaccines to people in the transient homeless population, Wooten said. To help address that, the county has hired about 100 temporary nurses to supplement the public health nursing staff, nurse volunteers from local hospitals, paramedics and homeless outreach workers who are on the front lines of the vaccination effort.

The city of San Diego has also been taking actions to curb the spread of the infection. In addition to spraying the streets in infected areas with a bleach solution, it has so far installed 78 hand-washing stations and 16 portable toilets for the homeless.

The city has also opened a public campsite with tents, sinks and restrooms for up to 200 people in a municipal operations yard downtown, said Katie Keach, spokeswoman for the city.

Amy Gonyeau, chief operating officer of the Alpha Project, a homeless outreach organization that is operating the campsite for the city, said 181 people, including 40 children, are living there so far.

Whether those efforts are making a dent in the spread of the hepatitis A infection isn’t yet known.

“San Diego has reported fewer cases per week over the past two weeks than it reported previously,” the CDC’s Nelson said at last month’s advisory committee meeting in Atlanta. “But it’s too early to say this indicates a downward trend in the overall outbreak.”

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

Charlan sobre posponer la maternidad mientras toman vino en “fiestas de óvulos”

Kaiser Health News:Marketplace - November 13, 2017

Dos asistentes del Southern California Reproductive Center registran a los asistentes a una “reunión de óvulos” en la suite presidencial del Viceroy L’Ermitage en Beverly Hills, California. (Anna Gorman/KHN)

Dominika Martínez, de 35 años, quien decidió con su esposo congelar embriones después de casarse el año pasado, asistió a una “reunión de óvulos”. (Anna Gorman/KHN)

BEVERLY HILLS, California. – Tu abuela fue anfitriona de fiestas de Tupperware. Tu mamá asistió a las veladas de Mary Kay.

Use Nuestro Contenido

Este contenido puede usarse de manera gratuita (detalles).

Ahora, podrías estar bebiendo cócteles en una fiesta de congelamiento de huevos.
A juzgar por un reciente evento en un ostentoso hotel de Beverly Hills, la fertilidad femenina podría ser la próxima gran novedad en el campo del marketing directo.

Unas 20 mujeres, y algunos hombres, se reunieron recientemente en la suite presidencial del Virrey L’Ermitage en esta lujosa ciudad para conversar, beber vino y comer hors d’oeuvres mientras escuchaban sobre la posibilidad de congelar sus huevos para una futura concepción.

Algunas de las mujeres dijeron que no habían encontrado a la pareja perfecta y que querían mantener abiertas sus opciones de fertilidad. Otras dijeron que ahora estaban enfocadas en sus carreras y no querían comprometer sus posibilidades de tener una familia más tarde.

Todas estaban dispuestas a dejar de lado sus inhibiciones por una noche para aprender sobre un tema intensamente privado en un entorno inusual: un happy hour.
Frances Hagan, de 35 años, había escuchado sobre las “reuniones de óvulos” (egg social en inglés) de un amigo y estaba ansiosa por saber cómo funcionaba la congelación de huevos. Hagan, quien es abogada, dijo que es soltera y que todavía espera encontrar a alguien con quien pueda tener hijos en la forma tradicional. Pero agregó que no hace daño considerar congelar sus huevos como respaldo.

“Me gustaría esperar y ver qué pasa”, dijo Hagan. “Pero si espero demasiado, tal vez no suceda. Estoy tratando de ser proactiva”.

Probablemente no sea una coincidencia que el evento haya tenido lugar en un lugar como Beverly Hills, dado el gasto considerable que implica congelar óvulos para utilizarlos más tarde.

El congelamiento de óvulos cuesta entre $10,000 y $ 15,000 entre procedimiento y los medicamentos. Descongelar los óvulos, fertilizarlos y transferir un embrión al útero podría costar otros miles, más adelante. Algunos empleadores de Silicon Valley, incluidos Facebook y Apple, cubren el congelamiento de huevos para sus trabajadores, pero la mayoría de los empleadores y las aseguradoras no.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

En el pasado, se congelaban óvulos era principalmente en el caso de mujeres que corrían el riesgo de infertilidad debido a tratamientos contra el cáncer. Pero en los últimos años, más mujeres han optado por congelar sus óvulos por razones no médicas, como por ejemplo no estar listas para tener un bebé.

A medida que la práctica se generaliza, también lo hacen los eventos diseñados para dar a conocer y reclutar pacientes para las clínicas que realizan el procedimiento. En los últimos años, ciudades como Los Ángeles, Nueva York y San Francisco han sido las sedes de las fiestas de congelamiento de óvulos.

En el hotel Beverly Hills, los médicos del Centro Reproductivo del Sur de California, la clínica de fertilidad que patrocinó el evento, proyectaron diapositivas sobre una pared y explicaron la historia y la ciencia del congelamiento de óvulos. Les dijeron a los invitados que era una póliza de seguro para las mujeres que quieren hijos en el futuro.

“Es lo más inteligente que una mujer puede hacer si no está en una relación seria que la está llevando a tener hijos”, dijo Shahin Ghadir, especialista en fertilidad del centro.
Ghadir dijo que reunir mujeres en un ambiente informal hace que la idea sea menos intimidante y estigmatizante. “Les permite a las personas saber que no es un problema médico, es un problema social”, dijo.

Además, dijo Ghadir, “con un vaso de vino, todo suena mejor”.

El primer bebé creado a partir de un óvulo congelado nació hace unos 30 años, pero no fue sino hasta 2012 que la Sociedad Estadounidense de Medicina Reproductiva declaró que el congelamiento de óvulos ya no debería considerarse experimental. Eso abrió la puerta para que más mujeres congelaran sus óvulos, dijo Evelyn Mok-Lin, directora médica del Centro de Salud Reproductiva de UC-San Francisco.

UC-San Francisco comenzó a ofrecer congelamiento de óvulos “de manera electiva” poco después, y el número de mujeres que optaron por congelar sus huevos ha aumentado desde entonces, dijo Mok-Lin.

Más de 6,200 mujeres en Estados Unidos congelaron sus óvulos en 2015, frente a 475 en 2009, según la Society for Assisted Reproductive Technology. Y 155 nacimientos fueron el resultado de la fertilización de óvulos congelados en 2014, frente a 28 en 2009.

Congelar los óvulos les da a las mujeres control sobre su salud reproductiva y fertilidad, y los riesgos médicos son muy bajos, dijo Mok-Lin. Pero dado el alto costo, no todas pueden hacerlo, y no siempre funciona. “Es un lujo para muchas personas y sin ninguna garantía de que la inversión valdrá la pena”, dijo.

El proceso implica estimular la ovulación, extraer los óvulos y congelarlos.
Necka Taylor, una enfermera que asistió a la velada de Beverly Hills, dijo que su primer ciclo de fertilización in vitro no tuvo éxito, pero que espera volver a intentarlo. Taylor, de 32 años, dijo que tiene varios amigos que han tenido bebés y que ella también quiere tener hijos.

“Simplemente no sé cuándo va a suceder”, dijo. “Sabía que tenía que tomar medidas para tener un bebé saludable”.

Su amiga, Dominika Martínez, de 35 años, dijo que había considerado el congelamiento de óvulos en el pasado, pero que no fue hasta que se casó el año pasado que decidió con su esposo congelar embriones.

“Todavía no estoy donde quiero estar en mi carrera”, dijo Martínez, quien trabaja en marketing de redes sociales. “Siento que necesito un poco más de tiempo”.
Martínez dijo que cuando ella y su esposo estén listos, tratarán de concebir naturalmente. Pero si no funciona, dijo, “tenemos un plan de respaldo”.

Ghadir, del Centro Reproductivo del Sur de California, le dijo al grupo que tenía hijos y que no había anticipado el gasto, el tiempo y la energía de la crianza de los hijos. Los óvulos congelados pueden ayudar a las mujeres a tener hijos a su propio ritmo, dijo.
“Si estuviera haciendo esto en el momento equivocado de mi vida, hubiera sido un desastre”, dijo. “Hacer las cosas en el momento correcto, cuando sabes que estás listo… es una de las razones más importantes para congelar tus óvulos”.

La cobertura de KHN en California está financiada en parte por Blue Shield of California Foundation. La cobertura de los problemas de salud de las mujeres es apoyada en parte por The David and Lucile Packard Foundation.

Sip Wine And Chat About Postponing Motherhood — At An ‘Egg Social’

Kaiser Health News:Marketplace - November 13, 2017

Two Southern California Reproductive Center employees register attendees of an “egg social” at the presidential suite of the Viceroy L’Ermitage in Beverly Hills, Calif. (Anna Gorman/KHN)

Dominika Martinez, 35, who decided to freeze embryos with her husband after getting married last year, attends an “egg social.” (Anna Gorman/KHN)

This story also ran on USA Today. This story can be republished for free ( details ). BEVERLY HILLS, Calif. — Your grandma hosted Tupperware parties. Your mom attended Mary Kay soirees.

Now, you might be sipping cocktails at an egg-freezing fête.

Judging from a recent event at a swanky Beverly Hills hotel, female fertility could be the next big thing in direct marketing.

About 20 women — and a few men — gathered recently in the presidential suite of the Viceroy L’Ermitage in this famously upscale city to chat, drink wine and eat hors d’oeuvres while hearing about the possibility of freezing their eggs for future conception.

Some of the women said they hadn’t found the perfect partner and wanted to keep their fertility options open. Others said they were focused on their careers now and didn’t want to compromise their chances of having a family later.

All were willing to put aside their inhibitions for one evening to learn about an intensely private subject in an unusual setting: a cocktail party.

Frances Hagan, 35, had heard about the “egg social” from a friend and was eager to find out how egg freezing worked. Hagan, a lawyer, said she is single and still hopes to find someone with whom she can have children the old-fashioned way. But she said it doesn’t hurt to consider freezing her eggs as a backup.

“I’d like to wait and just see what happens,” Hagan said. “But if I wait too long, maybe it won’t happen. I’m trying to be proactive.”

It is probably no coincidence that the event was held in a place like Beverly Hills, given the considerable expense of freezing eggs — and of using them later.

Egg freezing costs between $10,000 and $15,000 for the procedure and the medications. Thawing the eggs and fertilizing and transferring an embryo could cost thousands more later on. A few Silicon Valley employers, including Facebook and Apple, cover egg freezing for their workers, but most employers and insurers do not.

In the past, egg freezing was primarily for women who risked infertility because of cancer treatments. But in recent years, more women have been choosing to freeze their eggs for non-medical reasons — such as not being ready to have a baby.

As the practice becomes more widespread, so do events designed to raise awareness of it and recruit patients for clinics that perform the procedure. In recent years, cities such as Los Angeles, New York and San Francisco have been the venues of egg-freezing parties.

At the Beverly Hills hotel, physicians from the Southern California Reproductive Center, the fertility clinic that sponsored the event, projected slides on a wall and explained the history and science of egg freezing. They told the guests that it was an insurance policy for women who want children in the future.

“It’s the smartest thing any woman can do if they are not in a serious relationship that is leading to children,” said Shahin Ghadir, a fertility specialist at the practice.

Ghadir said hosting women in a casual environment makes the idea less intimidating and stigmatizing. “It lets people know it’s not a medical issue — it’s a social issue,” he said.

Besides, Ghadir said, “with a glass of wine, everything sounds better.”

The first baby created from a frozen egg was born about 30 years ago, but it wasn’t until 2012 that the American Society for Reproductive Medicine declared that egg freezing should no longer be considered experimental. That opened the door for more women to freeze their eggs, said Evelyn Mok-Lin, medical director of the UC-San Francisco Center for Reproductive Health.

UC-San Francisco started offering “elective” egg freezing soon afterward, and the number of women opting to freeze their eggs has since risen sharply, Mok-Lin said.

More than 6,200 women in the U.S. froze their eggs in 2015, up from 475 in 2009, according to the Society for Assisted Reproductive Technology. And 155 births resulted from the fertilization of women’s frozen eggs in 2014, up from 28 in 2009.

Egg freezing gives women control over their reproductive health and fertility, and the medical risks are very low, said Mok-Lin. But given the high cost, not everyone can afford egg freezing, and it doesn’t always work. “It is a luxury for many people and without any guarantee in the end that the investment will pay off,” she said.

The process involves stimulating the ovaries, extracting the eggs and flash-freezing them.

Necka Taylor, a nurse who attended the Beverly Hills soiree, said her first cycle of in vitro fertilization was unsuccessful, but she’s hoping to try again. Taylor, 32, said she has several friends who have had babies, and she knows she wants children herself.

“I just don’t know when it’s going to happen,” she said. “I knew I needed to take steps to have a healthy baby.”

Her friend Dominika Martinez, 35, said she had considered egg freezing in the past but it wasn’t until she got married last year that she decided to freeze embryos with her husband.

“I am still not where I want to be in my career,” said Martinez, a social media marketer. “I feel like I need a little more time.”

Martinez said that when she and her husband are ready, they will try to conceive naturally. But if it doesn’t work, she said, “we have a backup plan.”

Ghadir, of the Southern California Reproductive Center, told the group that he had children and had not anticipated the expense, time and energy of parenting. Freezing eggs can help women have children on their own timeline, he said.

“If I was doing this at the wrong time in my life, it would have been a disaster,” he said. “Doing things at the right time, when you know you are ready … is one of the most important reasons to freeze your eggs.”

KHN’s coverage in California is funded in part by Blue Shield of California Foundation. Coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

Brokers Are Reluctant Players In A Most Challenging ACA Open-Enrollment Season

Kaiser Health News:HealthReform - November 13, 2017

Lee Nathans, like insurance brokers in many states, expects to be crazy busy for the next several weeks, fielding calls from “people who are not going to be happy.”

Open enrollment for Affordable Care Act coverage started Nov. 1, and the approximately 10 million people who buy their own health insurance are only now getting a look at what’s being offered. It’s daunting.

“There will be a lot of people who will need to use a broker,” said Nathans, of Columbus, Ohio.

The enrollment period is also shorter than in previous years, ending Dec. 15.

In many places, there are fewer health insurance carriers offering coverage — and those that remain have sharply raised prices and changed their networks of doctors and hospitals.

More perplexing for people sifting through these options is the fact that this year there’s less on-the-ground assistance to help decode those complexities because of Trump administration funding cuts.

This KHN story also ran on NBC. It can be republished for free (details).

All that means brokers are coping with what may be the most challenging sign-up period since the ACA marketplaces, also known as exchanges, debuted in 2014.

When the ACA became law, some thought the days of brokers were numbered.

The ACA’s rules and online state and federal exchanges were supposed to make comparing plans and purchasing health insurance easier.

But for many consumers — particularly those who have never bought insurance before — having help is vital.

“Yes, health insurance is complicated,” said Lisa Hamler-Fugitt, executive director for the Ohio Association of Foodbanks, which provided such help for the past four years through federal grant-funded navigator programs in the state. Navigators are trained individuals or groups that guide consumers and small businesses through the process, for free.

“[Customers] didn’t turn to us just during open enrollment, but also when they had questions about how to use their plan, about deductibles and copayments.”

This year is different.

The Trump administration, criticizing the navigator effort nationwide, slashed funding. The Ohio program learned it would get a 71 percent cut and reluctantly closed its doors for this enrollment season.

There were also cuts to other states, which varied, but averaged 40 percent nationally. In Tennessee, for example, navigator funding was reduced by 16 percent, while in Indiana it fell 82 percent.

The Department of Health and Human Services appears to be turning to brokers to fill this gap. It announced in late October that the federal online marketplace,, has a new resource under its “Find Local Help” tab. Consumers can enter their contact information in the “Help On Demand” feature — and get a call back from a state licensed broker.

It isn’t known how many brokers signed up to participate, but agent John Dodd thinks it’s a good idea.

“This move of working more with brokers will help make up some of the difference [from losing the navigator program], although anytime you remove help, that’s not a positive step,” said Dodd, president-elect of the Ohio Association of Health Underwriters and owner of his own agency in Westerville.

But growing pressure on brokers — from smaller commissions to increased complexity of the health offerings — means they may be harder to find.

Last year, several big Blue Cross Blue Shield insurers cut or reduced their commissions, citing it as a cost-cutting move, following a similar action in 2015 by UnitedHealthcare. Some brokers then began charging a fee to help people enroll, while others stopped entirely.

When insurers pay commissions, the amounts are included in premiums and can be between 2 and 5 percent, depending on the carrier.

This year, “I’m still going to help my clients, but I’m not doing direct enrollments,” said Nathans. He will refer customers who need this assistance to a colleague.

There are reasons why the enrollment process is a heavy lift.

Licensed insurance broker John Jaggi of Forsyth, Ill., said he and his daughter, Anne Petri, also a broker, often spend the first 35 minutes of appointments just helping clients figure out the math to determine if they can get a premium subsidy. People who qualify earn less than 400 percent of the federal poverty level ($48,240 for an individual) and don’t have other coverage.

By that point, clients are exhausted and don’t even want to talk about the details of the plan, Jaggi said. And he’s paid “almost nothing” for his efforts.

Still, Jaggi and Petri plan to continue helping individuals with this year’s enrollment.

A Trump administration decision in October likely has created even more demand for these services. President Donald Trump said then that he was stopping federal “cost-sharing reduction” payments to insurers. These payments were used to offset the costs of coverage for certain low-income policyholders by reducing their deductibles and copayments.

Even without the federal assistance, insurers are still required to provide these cost reductions. To make up for them, insurers boosted premiums, particularly in middle-level “silver” plans. Because the cost of these plans is also the benchmark used to set the tax-credit subsidy many people receive to help pay their premiums, eligible consumers will likely receive more federal assistance this year and have more affordable options from which to choose.

In other words, people who receive the tax credits are not likely to feel a financial pinch. People who don’t, though, will likely take a hit.

“You have to feel bad for them,” said Petri. “How can they afford another $100 to $200 a month in premium?”

The individual market has always been volatile, but brokers say the situation is bad this year.

Dodd, the Westerville, Ohio-based broker, said he hopes Congress acts to stabilize the market. And soon.

Without that, “2019 could be Armageddon, off-the-charts bad,” he said.

Podcast: ‘What The Health?’ We Have Numbers!

Kaiser Health News:HealthReform - November 10, 2017

Democrats won some unexpectedly large victories in Tuesday’s off-off-year elections, putting health care squarely back on the political map. Meanwhile, enrollment was unexpectedly high in the insurance exchanges’ opening days, according to the Department of Health and Human Services.

In this episode of “What the Health?” Julie Rovner of Kaiser Health News, Sarah Kliff of, Joanne Kenen of Politico and Alice Ollstein of Talking Points Memo discuss the potential political impact of Tuesday’s voting, including the success in Maine of a referendum to expand the Medicaid program, as well as the latest news from Washington, D.C.

Among the takeaways from this week’s podcast:

— Voters in exit polls cited health care as a major voting issue — and in Virginia the vast majority of those who said health care was a top issue voted for the Democrat. But some Republicans continue to insist that voters are angry that they did not repeal the Affordable Care Act and are doubling down on efforts to make that happen before the congressional midterm elections in 2018.

— Tuesday’s results in the Maine Medicaid referendum might prompt voters in other states that have yet to expand the program to try the direct-ballot route. But Maine’s governor has said he will continue to try to block implementation, which could lead to lawsuits.

— Despite the Trump administration’s efforts to undermine the Affordable Care Act, open enrollment for 2018 has seen a spike in sign-ups in the first few days. Some suggest one reason is that many people who qualify for tax credits are getting an unexpected windfall this year because of the way states have addressed federal cuts in subsidies for low-income enrollees. People who earn just over the cutoff for federal help, however, are facing frequently unaffordable rates.

— Federal Medicaid chief Seema Verma this week suggested the Trump administration will be approving state requests to require Medicaid recipients to work or perform community service in exchange for their benefits. Work requirements would be a major change for the program, and one several states are seeking.

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

Julie Rovner: Kaiser Health News and Climate Central, “Breathing Fire: Health Is A Casualty Of Climate-Fueled Blazes,” by John Upton and Barbara Feder Ostrov.

Sarah Kliff: Kaiser Health News, “Liquid Gold: Pain Doctors Soak Up Profits By Screening Urine For Drugs,” by Fred Schulte and Elizabeth Lucas.

Joanne Kenen: The New Yorker, “Faces of an epidemic,” by Philip Montgomery and Margaret Talbot.

Alice Ollstein: Reuters, “Exclusive: FBI agents raid headquarters of major U.S. body broker,” by John Shiffman and Brian Grow.

To hear all our podcasts, click here.

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

Study Gives Mixed Reviews On Laws To Equalize Cancer Patients’ Out-Of-Pocket Costs

Kaiser Health News:States - November 10, 2017

Laws designed to equalize out-of-pocket costs faced by cancer patients undergoing chemotherapy — whether treated intravenously, with pills or liquid doses — are having mixed results, according to new research.

The study, published online this week by JAMA Oncology, found these so-called state “parity” laws have not uniformly reduced patients’ out-of-pocket spending.

The laws became popular in the past decade as pricey anti-cancer oral medications grew more common. They were intended to address the variation in what insurers expected patients to pay, depending on the form of chemo they received.

In many plans, oral anti-cancer drugs were placed in high cost-sharing tiers in patients’ prescription coverage. Drug infusions — which took place at a doctor’s office — were handled as an office visit and sometimes required minimal copayments.

The researchers analyzed health plan claims of 63,780 adult cancer patients younger than age 65. All lived in the 43 states and the District of Columbia that passed parity laws from 2008 to 2012.

Insuring Your Health

KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.

To contact Michelle with a question or comment, click here.

This KHN story can be republished for free (details).

They compared the use of oral anti-cancer medicines and out-of-pocket spending between patients in two types of health plans: state-regulated plans and “self-funded” employer health plans. The employer plans pay workers’ claims directly and therefore are not subject to state parity laws. Just under half of the patients involved in the study had coverage through a self-funded plan.

They came to various conclusions.

First, “these laws have not consistently reduced out-of-pocket spending for orally administered anticancer medications,” they wrote. More broadly, they noted, while these parity laws offered many patients “modestly improved financial protection,” the laws alone “may be insufficient to ensure that patients are protected from high out-of-pocket medication costs.”

And the researchers were surprised and concerned by these findings.

“When you think about who would have been the target of the law, parity is intended to help people afford the cost of their treatment,” said Stacie Dusetzina, an assistant professor of pharmacy and public health at the University of North Carolina-Chapel Hill, who was the study’s lead author. “The most expensive fills got more expensive after parity. That’s concerning.”

Among their specific findings:

  • The number of prescriptions requiring high out-of-pocket spending grew, despite parity laws. The proportion of prescriptions filled in plans subject to parity that cost more than $100 out-of-pocket per month increased from 8.4 to 11.1 percent, the study found. That figure declined slightly for prescriptions in plans that weren’t subject to parity, from 12 to 11.7 percent.
  • In plans subject to parity laws, the proportion of prescription fills for orally administered therapy without copayment increased from 15 to 53 percent, more than double the increase in plans not subject to parity. Those plans increased from 12 to 18 percent.
  • Parity laws did not increase six-month total spending for users of any anti-cancer therapy or for users of oral anti-cancer therapy alone.

The researchers suggested that continuing growth in high-deductible plans and high coinsurance charges may have contributed to the rise in the number of patients with high out-of-pocket costs for cancer treatment, even in states that have parity laws.

The study also found that out-of-pocket spending on infused drugs, which are typically older and less expensive than oral anti-cancer therapies, remained stable during the study period and was unaffected by parity laws.

A federal law that would extend parity to the seven states that don’t have it has been proposed in the past, most recently in March. Such a law could also benefit people in self-funded plans that aren’t subject to state laws, as well as Medicare beneficiaries.

“A federal law would potentially provide a lot of benefit, because we do feel parity has a net benefit for patients,” Dusetzina said.

Update: This story was updated at 5:40 p.m. ET. 

Please visit to send comments or ideas for future topics for the Insuring Your Health column.