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Updated: 17 hours 53 min ago

States Act To Safeguard Young Cancer Patients’ Chances To Have Children

October 17, 2018

When Katherine Frega was diagnosed with Hodgkin lymphoma eight years ago at age 17, she was so sick that all she could focus on was starting chemotherapy to treat her aggressive blood cancer. It was her dad who thought to ask the oncologist, “How is this treatment going to affect her ability to have children?”

The oncologist discussed the risks but stressed that Frega needed to start treatment right away.

The question of fertility is often overlooked when young cancer patients are battling a life-threatening illness. And since health insurance doesn’t typically cover fertility preservation care, patients and their families may be deterred by the cost.

But a growing number of states now require plans to cover such services when medically necessary treatment jeopardizes fertility.

In 2012, Katherine Frega had a bone marrow transplant to battle her aggressive blood cancer. Doctors told her the procedure would likely cause permanent infertility, so she had her eggs retrieved and frozen. But her insurance company wouldn’t pay for the services.(Courtesy of Katherine Frega)

Treatment for cancer and other serious conditions involves toxic chemotherapy drugs, radiation and surgery that can cause infertility in women and men.

The cost to freeze patients’ healthy eggs, sperm or embryos for future use can be a major barrier, said Dr. Eden Cardozo, a reproductive endocrinologist and director of the fertility preservation program at the Women & Infants Fertility Center in Providence, R.I. Cardozo was instrumental in getting Rhode Island’s law passed last year.

“[Patients] have to move quickly,” she said. “They don’t have time to raise funds from family and friends. They don’t have time to petition their insurance company.”

Reproductive health advocates argue that fertility preservation should be viewed as a core component of cancer care in younger people, not as an optional infertility offering. Some compare this type of coverage to the federal Women’s Health and Cancer Rights Act, which requires plans that cover a patient’s mastectomy to also provide for breast reconstruction.

New laws in Delaware, Illinois and Maryland require plans to include this benefit. The Delaware law applies to plans issued or renewed after June of this year; the requirement in the other two states starts in 2019. Connecticut and Rhode Island passed similar laws last year. New Jersey lawmakers are considering a bill, and advocates in New York plan to make another attempt after both legislative chambers passed fertility preservation bills in the last session but failed to reconcile them.

The state measures don’t apply to companies that are self-funded, meaning they pay their employee claims directly rather than buying state-regulated insurance policies for that purpose. They also don’t apply to government-funded programs such as Medicaid or the military’s Tricare program.

Although freezing sperm and embryos has been common medical practice for decades, egg freezing was considered experimental by professional groups until 2012. As the technology has improved, the need for insurance coverage has grown, said Joyce Reinecke, executive director of the Alliance for Fertility Preservation, an advocacy group for cancer patients.

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When Frega’s cancer didn’t respond to chemotherapy, her doctors recommended a bone marrow transplant in January 2012. Even if her eggs hadn’t been damaged by the chemotherapy, the transplant would likely cause permanent infertility, she was told. So Frega took hormones to stimulate her ovaries to produce more eggs, among other things, and seven were retrieved during an outpatient procedure days before her transplant.

Frega’s parents paid $10,000 for the medications and egg retrieval, a significant amount but less than what many pay. They were aided by Livestrong Fertility, a nonprofit group that provides access to discounted fertility preservation services for cancer patients who meet income guidelines.

Frega has good insurance through her mother’s employer plan. “They covered everything else, except for this,” she said. “They considered it not medically necessary.”

Cancer-free following two bone marrow transplants, Frega, now 25, is a third-year medical student at the Upstate Medical University in Syracuse, N.Y. She plans to specialize in oncology.

Between 20 and 70 percent of cancer patients experience some degree of fertility impairment, according to Cardozo in Rhode Island. Though they make up the largest at-risk group, the complication isn’t unique to cancer patients. People with other conditions such as lupus and rheumatoid arthritis who are treated with chemotherapy drugs may be affected, as may patients with conditions such as endometriosis who require surgery.

Despite the much-ballyhooed examples of tech companies like Facebook, Apple and Google that offer egg freezing as an employee perk, cryopreservation, as it’s called, isn’t a typical employee benefit.

Only 6 percent of large companies with 500 or more workers offer egg freezing for employees or their spouses, according to the 2017 annual employer survey by benefits consultant Mercer. About a quarter cover in vitro fertilization. Forty-four percent of large employers don’t offer any infertility services, the survey found.

Men face the same infertility risk when they need cancer treatment.

When Blake Hornbrook, an Army medic at Fort Campbell, Ky., had surgery to remove a cancerous testicle in the fall of 2015, he and his wife, Kelsey, were stationed in Germany. Hornbrook, then 26, looked into fertility preservation while overseas, but the annual storage fee of 1,000 euros (about $1,150) deterred the couple.

Hornbrook required a second surgery several months later to see if the cancer had spread to his lymph nodes. The couple returned to the United States and drove directly from the airport to a sperm bank in Fairfax, Va. It cost roughly $400 for the initial appointment to provide a sperm specimen and store it, Hornbrook said.

Tricare covered Hornbrook’s cancer treatment, but it didn’t pay for fertility preservation or for IVF, which he estimated cost the couple $6,500 in clinic fees. Tricare provided discounts on some of the fertility drugs.

Their daughter, Harper, was born seven months ago, and Hornbrook’s cancer remains in remission.

For young cancer patients, the cost of storing the eggs or sperm that have been preserved can add up. Even if a state has a fertility preservation law, it typically doesn’t cover those costs, Reinecke said.

The Hornbrooks pay $480 annually to store his sperm and $375 to store their remaining embryos. Frega pays $1,000 annually to store her eggs.

Frega hopes to be able to conceive naturally and knowing she has frozen eggs available is “relieving, but also anxiety-producing,” she said. If she can’t get pregnant later on, she may have to pay $10,000 or more for IVF as well. “That’s what lies ahead,” she said.

Sixteen states require insurers to offer or cover infertility services to some extent, according to infertility advocacy organization Resolve. Requirements vary: Insurers may have to cover diagnosis or testing for infertility, for example, but not treatments like in vitro fertilization or fertility medications, said Barbara Collura, president and CEO of Resolve.

Typically, state infertility coverage laws require couples to try to get pregnant for a year or two before they’re eligible for insurance coverage of IVF or other treatments.

That requirement makes little sense for patients trying to preserve their fertility before undergoing medically necessary cancer or other treatment.

“These people aren’t infertile,” said Collura. “They need to undergo some sort of intervention that is going to impair their future fertility, and what we say is that if it’s medically necessary, they should have a right to have it covered.”

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

Fact Check: Who’s Right On Protections For Preexisting Conditions? It’s Complicated

October 11, 2018

Ensuring that people with preexisting health conditions can get and keep health insurance is the most popular part of the Affordable Care Act. It has also become a flashpoint in this fall’s campaigns across the country.

And not only is the ACA, which mostly protects people who buy their own coverage, at risk. Also potentially in the crosshairs are preexisting conditions protections that predate the federal health law.

Democrats charge that Republicans’ opposition to the ACA puts those protections in peril, both by their (unsuccessful) votes in Congress in 2017 to “repeal and replace” the law, and via a federal lawsuit underway in Texas.

“800,000 West Virginians with preexisting conditions in jeopardy of losing their health care,” claimed Sen. Joe Manchin (D-W.Va.).

Republicans disagree. “Preexisting conditions are safe,” President Donald Trump declared at a rally in West Virginia for Manchin’s GOP opponent, Patrick Morrisey. Morrisey, West Virginia’s attorney general, is one of a group of state officials suing to overturn the ACA.

Who is right? Like everything else in health care, it’s complicated.

What is clear, however, is that voters want protections. Even majorities of Republicans told pollsters this summer that it is “very important” that guarantees of coverage for preexisting conditions remain law.

Here are some key details that can help put the current political arguments in perspective.

Preexisting conditions are common.

Preexisting conditions are previous or ongoing medical issues that predate health insurance enrollment. The problem is that the term is a grab bag whose limits have never been defined. It certainly applies to serious ongoing conditions such as cancer, heart disease and asthma. But insurers also have used it to apply to conditions like pregnancy or far more trivial medical issues such as acne or a distant history of depression.

The Kaiser Family Foundation estimated in 2016 that more than a quarter of adults younger than 65 — about 52 million people — have a preexisting health condition that likely would have prevented them from purchasing individual health insurance under the pre-ACA rules. (Kaiser Health News is an editorially independent program of the foundation.)

Protections vary by what kind of insurance you have.

But what protections people with preexisting conditions have depends on how they get their coverage. For that reason, it’s not right to say everyone with health problems is potentially at risk, as Democrats frequently suggest.

For example, Medicare, the federal health program for seniors, and Medicaid, the federal-state health plan for low-income people, do not discriminate in either coverage or price on the basis of preexisting conditions. The two programs together cover roughly 130 million Americans — nearly a third of the population.

The majority of Americans get their coverage through work. In 1996, Congress protected people with preexisting conditions in employer-based coverage with the passage of the Health Insurance Portability and Accountability Act, known as HIPAA.

HIPAA was intended to eliminate “job lock,” or the inability of a person with a preexisting condition (or a family member with a preexisting condition) to change jobs because coverage at the new job would likely come with a waiting period during which the condition would not be covered.

HIPAA banned those waiting periods for people who had maintained “continuous” coverage, meaning a break of no more than 63 days, and the law limited waiting periods to one year for those who were previously uninsured. In addition, it prohibited insurers from denying coverage to or raising premiums for workers based on their own or a family member’s health status or medical history.

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HIPAA was less successful in protecting people without job-based insurance. It sought to guarantee that people with preexisting conditions leaving the group market could buy individual coverage if they had remained continuously covered. But the law did not put limits on what individual insurers could charge for those policies. In many cases, insurers charged so much for these “HIPAA conversion” policies that almost no one could afford them.

The Affordable Care Act, passed in 2010, built on those 1996 protections, and specifically sought to help people buying their own coverage. It barred all health insurers from excluding people due to preexisting conditions, from charging them higher premiums and from imposing waiting periods for coverage of that condition.

While the protections were mostly aimed at the individual insurance market, where only a small portion of Americans get coverage, the ACA also made some changes to the employer market for people with preexisting conditions, by banning annual and lifetime coverage limits.

Will protections on preexisting conditions become collateral damage?

In 2017, the GOP-controlled House and Senate voted on several versions of a bill that would have dramatically overhauled the ACA, including its protections on preexisting conditions. Under the last bill that narrowly failed in the Senate, states would have been given authority to allow insurers to waive some of those protections, including the one requiring the same premiums be charged regardless of health status.

In February, 18 GOP attorneys general and two GOP governors filed suit in federal court in Texas. They charge that because Congress in its 2017 tax bill eliminated the ACA’s penalty for not having insurance, the entire federal health law is unconstitutional. Their argument is that the Supreme Court upheld the ACA in 2012 based only on Congress’ taxing power, and that without the tax, the rest of the law should fall.

The Trump administration, technically the defendant in that case, said in June that it disagreed that the entire law should fall. But it is arguing that the parts of the law addressing preexisting conditions are so tightly connected to the tax penalty that they should be struck down.

Clearly, if the lawsuit prevails in either its original form or the form preferred by the Trump administration, preexisting protections are not “safe,” as the president claimed.

Even more complicated, the protections written into HIPAA were rewritten and incorporated into the ACA, so if the ACA in whole or part were to be struck down, HIPAA’s preexisting conditions protections might go away, too.

Republicans in Congress have introduced a series of proposals they say would replicate the existing protections. But critics contend none of them covers as many situations as the ACA does. For example, a bill unveiled by several Republican senators in August would require insurers to offer coverage to people with preexisting health conditions, but not require coverage of the conditions themselves.

That hasn’t stopped Republicans from claiming that they support protections for preexisting conditions.

“Make no mistake about it: Patients with preexisting conditions should be covered,” said Wisconsin GOP Senate candidate Leah Vukmir, who is running to unseat Democratic Sen. Tammy Baldwin. Health care has been a major issue in that race, as well as many others. Yet Vukmir was recently hailed by Vice President Mike Pence as someone who will vote to “fully repeal and replace Obamacare.”

Meanwhile, Democrats who are chastising their Republican opponents over the issue are sometimes going a bit over the top, too.

An example is Manchin’s claim about the threat to coverage for 800,000 people in West Virginia. West Virginia’s population is only 1.8 million and more than a million of those people are on Medicare or Medicaid. That would mean every other person in the state has a preexisting condition. A recent study found West Virginia has a relatively high level of preexisting conditions among adults, but it is still less than 40 percent.

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

October 10, 2018

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

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

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

The bills — one for Medicare and Medicare Advantage beneficiaries and another for commercial employer-based and individual policies— were passed by Congress in nearly unanimous votes last month.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model

October 09, 2018

Calvin Brown doesn’t have a primary care doctor — and the peripatetic 23-year-old doesn’t want one.

Since his graduation last year from the University of San Diego, Brown has held a series of jobs that have taken him to several California cities. “As a young person in a nomadic state,” Brown said, he prefers finding a walk-in clinic on the rare occasions when he’s sick.

“The whole ‘going to the doctor’ phenomenon is something that’s fading away from our generation,” said Brown, who now lives in Daly City outside San Francisco. “It means getting in a car [and] going to a waiting room.” In his view, urgent care, which costs him about $40 per visit, is more convenient — “like speed dating. Services are rendered in a quick manner.”

Brown’s views appear to be shared by many millennials, the 83 million Americans born between 1981 and 1996 who constitute the nation’s biggest generation. Their preferences — for convenience, fast service, connectivity and price transparency — are upending the time-honored model of office-based primary care.

Many young adults are turning to a fast-growing constellation of alternatives: retail clinics carved out of drugstores or big-box retail outlets, free-standing urgent care centers that tout evening and weekend hours, and online telemedicine sites that offer virtual visits without having to leave home. Unlike doctors’ offices, where charges are often opaque and disclosed only after services are rendered, many clinics and telemedicine sites post their prices.

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A national poll of 1,200 randomly selected adults conducted in July by the Kaiser Family Foundation for this story found that 26 percent said they did not have a primary care provider. There was a pronounced difference among age groups: 45 percent of 18- to 29-year-olds had no primary care provider, compared with 28 percent of those 30 to 49, 18 percent of those 50 to 64 and 12 percent age 65 and older. (Kaiser Health News is an editorially independent program of the foundation.)

A 2017 survey by the Employee Benefit Research Institute, a Washington think tank, and Greenwald and Associates yielded similar results: 33 percent of millennials did not have a regular doctor, compared with 15 percent of those age 50 to 64.

“There is a generational shift,” said Dr. Ateev Mehrotra, an internist and associate professor in the Department of Health Care Policy at Harvard Medical School. “These trends are more evident among millennials, but not unique to them. I think people’s expectations have changed. Convenience [is prized] in almost every aspect of our lives,” from shopping to online banking.

So is speed. Younger patients, Mehrotra noted, are unwilling to wait a few days to see a doctor for an acute problem, a situation that used to be routine. “Now,” Mehrotra said, “people say, ‘That’s crazy, why would I wait that long?'”

Until recently, the after-hours alternative to a doctor’s office for treatment of a strep throat or other acute problem was a hospital emergency room, which usually meant a long wait and a big bill.

Luring Millennials

For decades, primary care physicians have been the doctors with whom patients had the closest relationship, a bond that can last years. An internist, family physician, geriatrician or general practitioner traditionally served as a trusted adviser who coordinated care, ordered tests, helped sort out treatment options and made referrals to specialists.

But some experts warn that moving away from a one-on-one relationship may be driving up costs and worsening the problem of fragmented or unnecessary care, including the misuse of antibiotics.

A recent report in JAMA Internal Medicine found that nearly half of patients who sought treatment at an urgent care clinic for a cold, the flu or a similar respiratory ailment left with an unnecessary and potentially harmful prescription for antibiotics, compared with 17 percent of those seen in a doctor’s office. Antibiotics are useless against viruses and may expose patients to severe side effects with just a single dose.

“I’ve seen many people who go to five different places to be treated for a UTI [urinary tract infection] who don’t have a UTI,” said Dr. Janis Orlowski, a nephrologist who is chief health care officer at the Association of American Medical Colleges, or AAMC. “That’s where I see the problem of not having some kind of continuous care.”

“We all need care that is coordinated and longitudinal,” said Dr. Michael Munger, president of the American Academy of Family Physicians, who practices in Overland Park, Kan. “Regardless of how healthy you are, you need someone who knows you.” The best time to find that person, Munger and others say, is before a health crisis, not during one.

And that may mean waiting weeks. A 2017 survey by physician search firm Merritt Hawkins found that the average wait time for a new-patient appointment with a primary care doctor in 15 large metropolitan areas is 24 days, up from 18.5 days in 2014.

While wait times for new patients may reflect a shortage of primary care physicians — in the view of the AAMC — or a maldistribution of doctors, as other experts argue, there is no dispute that primary care alternatives have exploded. There are now more than 2,700 retail clinics in the United States, most in the South and Midwest, according to Rand Corp. researchers.

Connecting With Care

To attract and retain patients, especially young adults, primary care practices are embracing new ways of doing business.

Many are hiring additional physicians and nurse practitioners to see patients more quickly. They have rolled out patient portals and other digital tools that enable people to communicate with their doctors and make appointments via their smartphones. Some are exploring the use of video visits.

Mott Blair, a family physician in Wallace, N.C., a rural community 35 miles north of Wilmington, said he and his partners have made changes to accommodate millennials, who make up a third of their practice.

“We do far more messaging and interaction through electronic interface,” he said. “I think millennials expect that kind of connectivity.” Blair said his practice has also added same-day appointments.

Although walk-in clinics may be fine as an option for some illnesses, few are equipped to provide holistic care, offer knowledgeable referrals to specialists or help patients decide whether they really need, say, knee surgery, he noted. Primary care doctors “treat the whole patient. We’re tracking things like: Did you get your mammogram? Flu shot? Pap smear? Eye exam?”

Dr. Nitin Damle, an internist and past president of the American College of Physicians, said that young people develop diabetes, hypertension and other problems “that require more than one visit.”

“We know who the best and most appropriate specialists in the area are,” said Damle, an associate clinical professor of medicine at Brown University in Providence, R.I. “We know who to go to for asthma, allergies, inflammatory bowel disease.”

Marquenttha Purvis, 38, said her primary care doctor was instrumental in helping arrange treatment for her stage 2 breast cancer last year. “It was important because I wouldn’t have been able to get the care I needed” without him, said Purvis, who lives in Richmond, Va.

Sometimes the fragmented care that can result from not having a doctor has serious consequences.

Orlowski cites the case of a relative, a 40-year-old corporate executive with excellent medical insurance. The man had always been healthy and didn’t think he needed a primary care physician.

“Between treating himself and then going to outpatient clinics,” he spent nearly a year battling a sore throat that turned out to be advanced throat cancer, she said.

For patients without symptoms or a chronic condition such as asthma or high blood pressure, a yearly visit to a primary care doctor may not be necessary. Experts no longer recommend the once-sacrosanct annual physical for people of all ages.

“Not all access has to be with you sitting on an exam table,” Munger said. “And I may not need to see you more than every three years. But I should be that first point of contact.”

Convenience Is Paramount

Caitlin Jozefcyk, 30, a high school history teacher in Sparta, N.J., uses urgent care when she’s sick. She dumped her primary care doctor seven years ago because “getting an appointment was so difficult” and he routinely ran 45 minutes behind schedule. During her recent pregnancy, she saw her obstetrician.

Jozefcyk knows she’s not building a relationship with a physician — she sees different doctors at the center — but “really likes the convenience” and extended hours.

Digital access is also important to her. “I can make appointments directly through an app, and prescriptions are sent directly to the pharmacy,” she said.

After years of going to an urgent care center or, when necessary, an emergency room, Jessica Luoma, a 29-year-old stay-at-home mother in San Francisco, recently decided to find a primary care doctor.

“I’m very healthy, very active,” said Luoma, who has been treated for a kidney infection and a miscarriage.

Luoma said her husband pushed her to find a doctor after the insurance offered by his new employer kicked in.

“He’s a little more ‘safety first’ than me,” she said. “I figured, ‘Why not?’ — just in case.”

Immigrants’ Health Premiums Far Exceed What Plans Pay For Their Care

October 01, 2018

President Donald Trump has repeatedly condemned U.S. immigration policy, arguing that many immigrants pose a threat to the nation and drain U.S. resources. But a study released Monday about health insurance challenges the president’s portrayal.

The study in the journal Health Affairs found that immigrants covered by private health insurance and their employers contributed nearly $25 billion more in premiums in 2014 than was spent on their care. Those in the country without legal status contributed nearly $8 billion toward the surplus.

In contrast, U.S.-born enrollees spent nearly $25 billion more than they paid for in premiums.

These findings surface as the Trump administration’s immigration policies — including a plan to tie migrants’ efforts to get permission for permanent residency to their use of federal benefit programs — have come under scrutiny.

Earlier studies also found that immigrants contribute more to Medicare than they receive in benefits, but the authors of this study say it is the first to look at the effect in private insurance plans.

Leah Zallman, assistant professor of medicine at Harvard Medical School and lead author of the study, said her findings allude to the potentially negative consequences that tighter immigration policies could have on the health care industry.

“I think in today’s era … there’s so much concern about immigrants and immigration really sort of draining our resources in the U.S.,” Zallman said. “This really points to the critical role that immigrants have in actually subsidizing and maintaining our current systems.”

Researchers calculated the financial contributions and expenses of enrollees and their employers using two surveys created by the federal government. Plans sold on the federal health law’s insurance exchanges were not included because they “differ from other private insurance in important ways and are unavailable to undocumented people,” the study authors noted.

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Anyone born outside of the United States was categorized as an immigrant. However, the surveys did not ask non-citizens with private coverage about their legal status. Researchers used national data on undocumented immigrants to estimate how many people in the study group illegally resided in the country.

In 2014, immigrants and their employers contributed $88.7 billion in private insurance premiums, but spent only $64 billion for care, according to the study’s findings. Of that group, undocumented immigrants alone paid more than $17 billion to private insurers but used only $9.4 billion.

Native-born consumers paid $616 billion in premiums and received nearly $641 billion in insurers’ payments for care. They also consistently outspent immigrants across all age groups. Among enrollees 65 and older, the U.S.-born made a net contribution of nearly $10,000 more toward their care than those born overseas, according to the study.

The researchers reported that, on average, individual immigrants paid $1,123 more for premiums in 2014 than they received in insurance-covered care. U.S. natives instead cost insurers $163 on average.

Leighton Ku, director of the Center for Health Policy Research at George Washington University who was not involved in the study, said several factors contribute to immigrants’ low health care expenses. The group tends to be healthier and younger when they arrive in the United States. Cultural and language differences also hinder them from accessing care.

The study noted that immigrants’ health care expenditures increased the longer they remained in the country. But it added that since their premiums also increased at the same time, they continued to make a net contribution to their private health plans.

The findings come about a week after the Department of Homeland Security proposed redefining how it would determine “public charge,” a term used to describe a person likely to become dependent on the government for assistance. The proposal would make it harder for immigrants to live and work permanently in the U.S. if they receive certain types of federal assistance, such as Medicaid, food stamps and housing subsidies.

Trump has vowed to be tough on immigration standards. During his campaign, he berated U.S. health expenditures on immigrants, arguing that the U.S. spent $11 billion for care to people who were in the country without authorization, the study’s authors note.

But they point out that earlier research shows that immigrants have low rates of health care use and spending, compared with native residents. Their payments to private plans and Medicare in essence prop up care for patients who are U.S.-born, the authors say.

A study Zallman published earlier showed unauthorized immigrants contributed $35.1 billion more to Medicare from 2000 to 2011 than they used in services.

Benedic Ippolito, an economist at the American Enterprise Institute, cautioned using the study’s findings to draw conclusions on a large scale about immigrants and their role in health insurance. An estimated 20 percent of immigrants — including nearly half of the undocumented population — are uninsured, according to the study. Ippolito said the cost of their uncompensated care affects whether immigrants’ financial contributions actually lead to surpluses for health care overall.

“I would be careful about how much I extrapolate these results to a) other parts of the health insurance market and b) even further to what this means for immigration policy,” Ippolito said. “This paper alone does not tell us everything we need to know.”

Ku echoed the uncertainty. He said he is not certain how the Trump administration’s latest actions will affect immigrants enrolled in private insurance. Having a private plan may suggest they are employed with a certain income stability. However, if enough immigrants leave the insurance market, he added, it may have the unintended consequence of making health plans more expensive for everyone else.

“That does have the following implication that to the extent that we do things to suppress immigrants or make it harder for them to purchase insurance then in that case we may do harm to the citizens,” he said.

‘Contraception Deserts’ Likely To Widen Under New Trump Administration Policy

September 28, 2018

LAWRENCEVILLE, Ga. — When Nikia Jackson needed to be screened for a sexually transmitted disease, she wanted a clinic that was reputable, quick and inexpensive.

After searching online, Jackson, 23, ended up at the Obria Medical Clinics’ sparkling new facility in an office park in suburban Atlanta. She was unaware that the clinic does not offer condoms or other kinds of birth control beyond so-called natural family planning methods.

Religious conservatives say these types of clinics are the future of women’s sexual health care in the United States.

“A woman needs choice, but you can’t have a choice if the only clinic that a woman can go to is Planned Parenthood,” said Kathleen Bravo, chief executive of the Obria Group and a devout Catholic.

Young women, she said, “don’t want to live every day having to take a carcinogen,” referring to hormonal contraception.

For decades, contraception drew widespread bipartisan support, but since the passage of the Affordable Care Act in 2010, religious conservatives trained their ire on the law’s contraception mandates, and the politics of abortion and birth control converged.

Bravo is positioning her company to become a nationwide alternative to Planned Parenthood and aims for it to qualify for millions of dollars in federal family planning funds next year. With 38 clinics and 22 more slated to open, Obria offers tests for pregnancy, STIs, HIV and cervical cancer and prenatal care.

But patients seeking to prevent pregnancy can receive only fertility planning methods that require women to track their periods and refrain from sex when most fertile. When followed exactly, the method is 76 percent effective, according to the Centers for Disease Control and Prevention.

That vision has found favor with the Trump administration, which has proposed sweeping changes to a $280 million federal program called Title X, the only source of federal funds for birth control for low-income women who lack health insurance.

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For more than four decades, thousands of women’s health clinics, including Planned Parenthood affiliates, that received these federal funds have been required to offer a full range of medically effective contraception, including condoms, birth control pills, intrauterine devices and implants. (The clinics cannot use federal funds to pay for abortion, and many Title X clinics do not offer the procedure.)

But with Title X now under the direction of Dr. Diane Foley, the former chief executive of Life Network, a Christian organization that operates anti-abortion pregnancy centers, the Trump administration is widely expected to adopt rules in the coming months that promote and direct federal dollars to clinics like Obria that do not offer condoms, hormonal contraception, intrauterine devices or abortion.

Called the “Protect Life Rule,” the new restrictions are aimed at narrowing women’s access to clinics that discuss or refer patients to abortion providers. The Trump administration has worked quickly to shape women’s reproductive health care, rolling back an Obama-era rule that required employers to cover contraception in their health insurance plans and nominating to the Supreme Court Judge Brett Kavanaugh, who referred to common forms of contraception as “abortion-inducing drugs” during his confirmation hearing.

With Vice President Mike Pence, an evangelical Christian, as a powerful ally and anti-abortion and abstinence advocates, including Foley, appointed by the Trump administration overseeing key federal health programs, religious conservatives are seizing this moment to shape women’s sexual health care.

In 2011, anti-abortion state lawmakers sought to shutter Planned Parenthood clinics and slashed state funding for family planning by 66 percent. As a result, more than 80 family planning clinics closed, and women across Texas suddenly found their birth control needs caught up amid the fight against abortion.

The impact was swift and widespread: Researchers found the number of women on the most effective forms of birth control ― IUDs, implants and injections ― plunged by a third, and births by poor women on Medicaid increased 27 percent from 2011 to 2014.

In the aftermath, family planning clinics in Texas became almost entirely dependent on Title X federal funds. Now many administrators here and around the country are bracing for the Trump administration’s new rules.

Kathryn Hearn, community services director at Access Esperanza in McAllen, Texas, said clinics that offer the full range of FDA-approved birth control could be replaced by those like Obria.

“Today a woman can come into a Title X clinic, any clinic in the United States, in Texas, and be offered a wide range of contraceptive methods,” she said. “With these proposed rules, she could only be offered abstinence. Well, she says, I’m married. Or I’m in a relationship. That does not work for me. I need real contraceptive care.”

Ofelia Alonso, a 22-year-old community organizer, said that because of deceptive tactics and lack of comprehensive sex education, young women in Texas already find it difficult to discern between medical clinics and crisis pregnancy centers, offices where women are counseled against abortion.

“It’s like abstinence only, and then, crisis pregnancy centers, anti-abortion propaganda, defunding our family clinics. So what is left for us?” Alonso said. “We’re going to have these weird centers where you can’t get anything?”

But women seeking contraception have to go somewhere, and one alternative, she said, is to cross the nearby border into Mexico to buy birth control over the counter.

“It shouldn’t have to be that way,” she said. “We shouldn’t have to travel to another country to get what we need.”

Some uninsured patients in Texas do find alternative ways to get birth control.

Claire Hammons runs an historic hotel in Llano, a small city an hour and half west of Austin with no full-service women’s health clinic.

The vast geography combined with widespread clinic closures means that some 10 million Texans live at least half an hour from a clinic, a common standard used to determine health care shortages. It’s a phenomenon some call “contraception deserts.”

Hammons lives in one of these contraception deserts and when she could no longer afford health insurance, she turned to the internet for help. Now, she gets her birth control delivered every three months to her mailbox from a San Francisco-based company called Nurx. She pays about $15 a month and can message Dr. Jessica Rubino, a Nurx physician in Austin. Rubino can review her patients’ medical histories and renew their prescriptions without additional cost.

Rubino said she sees what happens to women who live in contraception deserts.

“I’m also an abortion provider, and I do that outside of Nurx at another facility,” she said. “I had one [patient] last week who drove five hours to see me. And the entire reason that she came to see me for the abortion is because she didn’t have any access to contraception.”

That lack of access worries Kami Geoffray, CEO of the Women’s Health and Family Planning Association of Texas, the nonprofit group that has coordinated the state’s application for Title X funds.

If the Trump administration’s overhaul of Title X succeeds, Geoffray said, it will undermine the goal of the program that the federal government has operated since the 1970s.

“We know that every dollar we spend on Title X saves $7 across other government programs, including Medicaid,” said Geoffray. “We avert Medicaid births very frequently by [getting contraception for] clients and preventing unplanned pregnancies.”

But back in suburban Atlanta at the Obria Medical Clinic, Bravo has declared it’s time for companies like hers to put a bigger mark on reproductive health care. The company is launching a $240 million capital campaign to open more clinics.

“Obria is a comprehensive primary care clinic for women that is an alternative model to Planned Parenthood,” said Bravo. “We put huge amounts of money into marketing our clinics, like all medical clinics do, to make sure that women know that we’re here in their city.”

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

Taken For A Ride: After ATV Crash, Doctor Gets $56,603 Bill For Air Ambulance Trip

September 26, 2018

It was the first — and only — time Dr. Naveed Khan, a 35-year-old radiologist, ever rode in an all-terrain vehicle.

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Khan took the wheel from his friend and drove circles in the sand, on a trail along the Red River in Texas.

“As soon as I turned to the side where my body weight was, this two-seater vehicle … just tilted toward the side and toppled,” Khan recalled. It landed on his left arm.

“I had about a 6-inch-wide exposed flesh gap that I could see below, on my forearm,” he said. “And I could see muscle. I could see the fat. I could see the skin. The blood was pooling around it.”

Khan, feeling lightheaded, tied his jacket around his arm like a tourniquet. He and his friend managed to right the ATV, drive back toward the street and call 911.

When an ambulance delivered him to the emergency room at United Regional Health Care System in Wichita Falls, Khan was surprised to hear a doctor murmur that it was the worst arm injury he’d ever seen.

Khan needed immediate helicopter transport to a trauma center for surgery in Fort Worth, if there was any hope of saving the arm.

Groggy from painkillers, Khan managed to ask the doctors how much the flight would cost and whether it would be covered by his insurer. “I think they told my friend, ‘He needs to stop asking questions. He needs to get on that helicopter. He doesn’t realize how serious this injury is,'” Khan recalled.

Flown 108 miles to John Peter Smith Hospital in Fort Worth, the closest Level I trauma center, Khan was whisked into surgery to clean out the wound, repair his shattered bones and get blood flowing to the tissue.

He had a total of eight operations to try to save his left forearm before he finally gave up. After weeks in the hospital, he asked the doctors to amputate, so he could get on with his life.

And then the bill came.

Patient: Naveed Khan, 35, a radiologist and married father of three small children in Southlake, Texas.

Total bill: $56,603 for an air ambulance flight. Blue Cross Blue Shield of Texas, Khan’s insurer, paid $11,972, after initially refusing altogether; the medevac company billed Khan for the remaining $44,631.

Service provider: Air Evac Lifeteam, an air ambulance company that operates 130 bases in 15 states. It’s owned by Air Medical Group Holdings, a holding company that owns four other air ambulance companies and one ground ambulance company. Air Medical, in turn, is owned by the giant private equity firm Kohlberg Kravis Roberts, or KKR.

Medical service: Khan was flown from the United Regional Health Care System in Wichita Falls, Texas, to the John Peter Smith Hospital in Fort Worth.

What gives: Khan got his first call from Air Evac Lifeteam just three days after the accident, while he was still lying in the hospital. A company representative told him the helicopter ride would likely cost more than $50,000 and asked him how he planned to pay.

For Khan, rapid transportation to the trauma center was absolutely essential since the blood supply to his arm had been cut off, said Dr. Raj Gandhi, the medical director for trauma services at JPS Hospital.

“If there’s no blood going that means there’s no oxygen,” he said. “It there’s no oxygen, that means those cells are going to die.” Minutes are precious and the helicopter can get from Wichita Falls to Fort Worth in an hour or less, half the time it takes by ground ambulance, he said.

But complaints about sky-high bills to patients for air ambulance services are common. Since launching the “Bill of the Month” series in February, NPR and Kaiser Health News have received more than a dozen bills from critically ill patients like Khan who were charged tens of thousands of dollars for an air ambulance ride even after insurers’ payments.

Khan cooks lunch for his wife, Ayesha, and children, Nazneen, 7, Yasmeen, 4, and Rehan, 1, in their home in Southlake, Texas.(Shelby Knowles for NPR)

Air ambulance companies defend their charges.

Rick Sherlock, president of the Association of Air Medical Services, a trade group, said air ambulances require a more highly trained crew than a ground ambulance, because only the sickest or most seriously injured patients need air transport.

AAMS commissioned a study to determine the actual cost of a medevac ride. The report found it takes about $2.9 million a year to run a single helicopter base. Each base handles about 300 transports a year, and the rides cost about $11,000 each, according to the report.

A spokeswoman for Air Evac Lifeteam said the company bills people so much because it is trying to make up for what she said are meager payments from Medicare and Medicaid.

“Our real cost per flight is the $10,200 plus the unreimbursed cost on each flight for Medicare, Medicaid and patients without any coverage,” wrote Shelly Schneider, the company spokeswoman.

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The Centers for Medicare & Medicaid Services said it pays an average of $4,624 per ride, plus $31.67 a mile — which works out to an average Medicare reimbursement of $6,556 for helicopter ambulance rides for seniors. Medicaid in most states pays less.

The industry has been advocating hard to get Medicare to boost its reimbursements, Sherlock said. Legislation pending in both the House and Senate would do so, but there hasn’t been much movement on those bills.

Others say the industry’s cost estimates are inflated by profit-driven expansion of a lucrative industry. Ground ambulances often carry critically ill patients, too.

Too many air ambulances sit idle much of the time, said Dr. Ira Blumen, a professor of emergency medicine at the University of Chicago and medical director of the university’s Aeromedical Network.

Blumen said the industry — which is dominated by a few companies owned by private equity firms — expanded dramatically the last time Medicare boosted its payments, in 2002. And now there are too many helicopters — 908 as of last year — fighting for patients and profits at the same time.

“The number of helicopters is outrageous for the continental United States,” he said. In the 1990s, most helicopters ran more than 500 flights per year on average. At that rate, the cost per flight today would be less than $6,000.

"The biggest challenge for me was to see how I would be a father again," said Dr. Naveed Khan, who was injured while driving an all-terrain vehicle. (Shelby Knowles for NPR)

"With two able-bodied parents at home, it was easier," he said. (Shelby Knowles for NPR)

A BCBS of Texas spokesman said the insurer does have a contracted rate with an in-network air ambulance company, but it is not Air Evac Lifeteam. After initially refusing to pay anything for an out-of-network claim, it agreed to the $11,972 payment.

But in some sense, the reason ambulance companies charge so much is simply because they can: Air ambulances are largely regulated not as health care but as part of the aviation industry. Federal laws prevent states from limiting aviation rates, routes and services.

So many people have been hit with shockingly high air ambulance bills that members of Congress on both sides of the aisle are trying to do something about it. Legislation to reauthorize funding for the Federal Aviation Administration that is moving through Congress now would set up a council of industry experts to address balance billing and other issues, and set up a complaint line for consumers.

Resolution: Khan has allowed Air Evac Lifeteam to negotiate with BCBS of Texas over the remaining $44,000 air ambulance bill. The company has asked him to appeal to the state’s Department of Insurance, and though he first balked at the suggestion, he’s now considering doing so. Khan says he doesn’t understand why the helicopter flight, an integral part of the emergency medical care he received, is treated differently than his surgeries, nursing care and physical therapy.

“I thought that this was another piece of that puzzle,” he said. “It turns out that this was glaringly different.”

He is waiting for resolution as he gets accustomed to life with his disability. Holding his baby son, he asked in frustration: “How do I hold him while he’s crying and at the same time heat up his bottle?”

“It’s unfair,” Khan says. “It’s random, it’s arbitrary. It’s whatever price they want to set. And to put that onto a person who’s already been through what I’ve been through, I hate to say it, but it’s cruel.”(Shelby Knowles for NPR)

Khan, who has had to fight with his insurance company to get coverage for a prosthetic arm, is frustrated to learn that the air ambulance company expects him to pay far more than the actual cost of his flight.

“It’s unfair,” he said. “It’s random, it’s arbitrary. It’s whatever price they want to set. And to put that onto a person who’s already been through what I’ve been through, I hate to say it, but it’s cruel.”

Related Stories

The Takeaway: Most people with health problems serious enough to require a helicopter flight are in no position to ask if the medevac company is in-network or whether there’s a choice. But if you or a family member has time to ask, it could pay off.

Steps you should take if you’re faced with a huge bill for a medevac ride:

  • First, let your insurer’s process play out. Blue Cross Blue Shield of Texas first denied Khan’s claim altogether. But he looked closely at his policy and saw that the threat of loss of limb was explicitly covered. He appealed, and that’s when the insurer paid $11,972.
  • Second, negotiate! The air ambulance company might be willing to negotiate a settlement for a fraction of the bill to avoid turning to debt collectors, who would pay them pennies on the dollar.

Both Sherlock of the Association of Air Medical Services and Schneider of Air Evac Lifeteam said companies will try to determine what a patient can afford. So people with high incomes may find it hard to obtain a substantial reduction for their bill. Still, if patients know the true cost of the service they received, they may be better equipped to negotiate a discount.

Many air ambulance companies offer membership plans that can cost less than $100 a year, and guarantee that the company will accept whatever payment an insurance company makes without billing the patient for the rest. But buyer, beware: When someone needs an air ambulance, they are often not in a position to choose which company will respond to the call.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Readers And Tweeters Slice And Dice Precision Medicine, Step Therapy

September 26, 2018

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Precision Medicine: The Full Picture

Thank you for publishing Liz Szabo’s piece, “Much Touted For Cancer, ‘Precision Medicine’ Often Misses The Target” (Sept. 13). In calculating the pluses and minuses of precision medicine, please add attention to “side effects,” which can be more like full-frontal assaults. In my sweetheart’s four years of living with a terminal diagnosis, she had two experiences with precision medicine. The first probably extended her life, even though it brought a disabling side effect. The second sent her to the hospital with a pulmonary embolism and pneumonitis — it probably shortened her life. At best, 2 in 25 patients live five years with the diagnosis of metastatic lung cancer, instead of the estimated 1 in 25 about 10 years ago. Yes, it’s progress, but at great physical and emotional cost.

— Jack Hailey, Fair Oaks, Calif.

But cancer survivor @MarkstageIV exhorts others never to discount the hope that comes with treatment.

When DX. w/stageIV Metastatic Melanoma. 1st doc said "you're done" no cure no treatment , you have 6 months /2 years max. I went home that day to prepare to die. Thankfully I was referred to another Dr. This was 11 years ago! 9 plus NED. People need hope! Hope keeps us going.

— Mark Williams (@MarkstageIV) September 13, 2018

— Mark Williams, Portland, Ore.

By suggesting that positive characterizations of precision medicine’s potential “mislead the public,” Liz Szabo may undermine patients’ confidence in treatment approaches that save lives and inhibit future investment upon which improvement in cancer care depends.

While she is correct to note that precision medicine is not yet “addressing the needs of the majority of cancer patients,” she overlooks the considerable progress in the last two decades, when, beginning with Herceptin (trastuzumab) in 1998, targeted therapies began to redefine possible cancer treatment beyond surgery, chemotherapy and radiation.

Precision treatments targeting the “Philadelphia” genetic mutation in patients with chronic myeloid leukemia, for example, have more than doubled the overall five-year survival rate for patients with this disease over the past decade.

In total, the Food and Drug Administration has approved more than 40 precision medicines for the treatment of many types of cancer. On the labels of these drugs, the agency requires drugmakers to include information about their use in molecularly defined subsets of the patient population. This information underpins precision cancer care that is helping many — albeit not all — patients live longer and healthier lives.

— Edward Abrahams, president of Personalized Medicine Coalition, Washington, D.C.

Let’s not forget the unpleasant alternatives to “precision medicine,” says a California doctor:

How about the women who are spared of unnecessary chemo and its short & long term side effects? This article generalizes ‘precision medicine’ to targeted txs but completely overlooks tests like oncotypedx. Sometimes our own biases blind us to leveraging what good can be done.

— Ayse Tezcan

‘Physicians Of The Mouth’? Dentists Absorb The Medical Billing Drill

September 24, 2018

DUBLIN, Calif. — On a recent Friday morning, more than 30 dentists and dental staffers gathered in a conference room to learn an arcane new skill: how to bill medical insurers.

Pacing back and forth, the Florida dentist leading the two-day course advised the participants to stop thinking of themselves as tooth technicians and reposition themselves as “physicians of the mouth.”

“There is a medical part of our practice and a dental part,” said the presenter, Chris Farrugia, as audience members tapped on their keyboards or scribbled notes. “You have teeth, [and] you got the ‘other stuff.’ It’s the other stuff that medical insurance pays for.”

Faruggia’s seminar is a sign of a growing trend in dental offices, as providers seek greater reimbursement for expensive services and patients balk at big bills. Around the internet, firms have popped up claiming expertise in medical billing for dentists and offering courses and consulting services.

The reason is simple: Medical insurance is generally much more generous in its coverage than dental insurance.

Unlike medical coverage, dental insurance is mostly geared to the healthy — something many people don’t realize until they experience serious oral problems and get socked with unexpected costs. Standard dental insurance covers cleanings, fillings and other routine care. But major work like a crown or a bridge is often covered only at 50 percent and implants generally aren’t covered at all. And dental insurance is usually capped at $1,000 or $1,500 per year.

As a result, people who require extensive reconstructive work often pay many thousands of dollars, or sometimes tens of thousands, in out-of-pocket expenses. Many other people, even with dental coverage, go without care because they cannot afford the large balances or co-pays for crowns, root canals and other major procedures.

Because of these differences in reimbursement, Farrugia told his seminar attendees, dentists should first consider what medical insurance might cover and then bill the dental plan for the rest.

For example, he said, dentists should seek medical coverage for the full head, neck and mouth exams they perform when they see a new patient, since the goal is to assess more than just the teeth. Medical insurers should also cover oral problems attributable to an underlying medical condition, such as diabetes or dry mouth, a common side effect of many medications, Farrugia said.

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Besides sparing patients the pain of big bills, the strategy can also boost income for dentists, said Farrugia, who estimated that revenues for his practice rose almost 10 percent the first year he fully implemented medical billing. Patients, too, can learn to file claims for medical reimbursement if their dentists won’t, he said.

On its website, the California Dental Association explains that health insurance should cover costs that are “medically necessary” and lists more than a dozen categories of procedures that could qualify. Among them: treatment related to inflammation and infection, dental repair due to injury, certain periodontal surgery procedures and appliances for sleep apnea.

Kristine Grow, a spokeswoman for America’s Health Insurance Plans, the industry trade association, did not dispute that some dental procedures could be covered by medical insurance. However, she cautioned that medical insurers were always on the lookout for abuse.

“Claims that are billed inappropriately or submitted fraudulently hurt everyone because they raise costs,” Grow said. “It’s important to note that procedures not related to an emergency event or trauma may not be medically necessary, and therefore would not be covered by medical insurance,” she added.

Asked about the potential for abuse, Farrugia said: “There are unethical providers in all health care services, and dentistry is not immune to that. You will always have some that try to game the system.”

Farrugia adopted medical billing several years ago after paying more than $100,000 for a CT scanner that produces 3-D images of the bone in the mouth and jaws.

“It occurred to me that this was a medical device,” he said of the CT scanner. “I’m a licensed health care provider, I’m providing this within the scope of my license. They can’t discriminate against me.”

Once he investigated the matter, Farrugia discovered that medical insurance could be asked to cover not just CT scans but a wide range of services regularly performed by dentists. He buried himself in the arcana of coding, ultimately writing three workbooks for dentists about medical billing.

At first it was trial-and-error, and Farrugia learned that claims often get rejected if they do not cite a medically legitimate reason for the procedure as well as the appropriate code.

These days, Farrugia bills medical plans $744 for a CT scan (medical code: CPT 70486), receiving an average reimbursement of about $500. Medical plans generally require pre-authorization for non-emergency CT scans, he said, so his office staff had to learn how to explain why the scan was medically required — such as to assess bone quality.

The same procedure can be billed to a dental plan (dental code: D0367), but the average reimbursement is $125 — if the plan covers CT scans at all.

Others are following his example. Iowa dentist Richard Downs attended one of Farrugia’s medical billing seminars last year in Chicago. “I’d never heard these things before,” he said.

He said he recently sought and received prior authorization from a medical insurer for $60,000 to cover multiple implants and other costs for a woman whose dental woes stemmed from severe atrophy of the jaw and other medical problems.

During a break in the seminar, San Ramon, Calif., dentist Rashpal Deol said Farrugia’s approach made sense. “We look at the soft tissues in the mouth, the muscles, the bone, the TM [temporomandibular] joint, and the head and neck area,” he said. “You always check the lymph nodes, we do oral cancer screening, so that is a comprehensive medical exam.”

Other seminar attendees also were enthusiastic, if a bit daunted. “People go to school to learn medical coding,” said Kelly Bradshaw, a staff member at a Santa Rosa, Calif., dental practice. “To try to bridge that gap in order to help our patients is intimidating. You have to be open-minded to look at things in different ways.”

Margaret Busch, an office manager for an Arizona dentist, said she planned to start medical billing as soon as she returned from the seminar.

“I’ve been making a list of people that we can go back and probably get money for,” she said, mentioning patients who have had CT scans and those with dental problems related to medical conditions like diabetes.

“I think they’ll be excited,” she said.

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

Blood, Sweat And Workplace Wellness: Where To Draw The Line On Incentives

September 24, 2018

Workplace wellness programs that offer employees a financial carrot for undergoing health screenings, sticking to exercise regimens or improving their cholesterol levels have long been controversial.

Next year, they may become even more contentious. Two recent court rulings have cast uncertainty over what is the appropriate limit for financial incentives that employers can offer workers to participate in programs that require clinical testing or disclosure of personal health data. The dollar amount is subject to debate because it raises questions about when the incentives become so high that employees feel they don’t have a choice about participating.

As a result, workers may find programs offer smaller incentives, consultants say. Also, programs might give employees options for qualifying for those incentives — a choice, for instance, between undergoing a medical exam or completing online health education modules.

About 4 in 10 employers participating in an informal survey by benefits firm Mercer said “they really were not sure what they would do,” said Steven Noeldner, its senior consultant in total health management specialty practice. “Some are modifying … others are taking a wait-and-see-attitude.”

Eighty-five percent of large employers offering health insurance included a wellness program designed to help people stop smoking, lose weight or take other healthful actions, according to a 2017 survey by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.) Just over half of those included some type of medical screening. Rewards or incentives to participate vary. The most common are gift cards, fitness trackers or other merchandise, or discounts on what workers pay toward their health insurance coverage.

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The Cleveland Clinic’s version is more extensive than most, said Dr. Bruce Rogen, chief medical officer for the effort. He described it as a “population health program,” with differing goals for workers who have chronic diseases like diabetes versus those who don’t.

Full participation, which may mean losing weight, keeping blood sugar levels in check or hitting a gym at least 10 times a month, can save workers 30 percent in insurance premiums. That could be as much as $1,443 a year.

“Part of what makes the plan work is the fact we can offer that benefit discount,” Rogen said.

That 30 percent amount is the ceiling set in a 2016 Equal Employment Opportunity Commission (EEOC) rule for what an employer can offer.

But it’s also the point that leads critics to question when incentives become significant enough that employees no longer feel that participation is voluntary.

“You and I can look at the same incentive and you will find it’s truly voluntary and I would say, given my financial circumstances, I feel I’m being compelled,” said Tom Luetkemeyer, an attorney specializing in employment law at Hinshaw & Culbertson in Chicago.

Shortly after the EEOC’s guidance was issued, the AARP challenged it in court, arguing that workers who did not want to provide medical information could feel coerced to do so because not participating would cost them substantial sums, ranging from hundreds to thousands of dollars.

Wellness In The Workplace

More Wellness Stories

In his first ruling, D.C. Circuit Court Judge John Bates noted that the EEOC had failed to provide justification for how it settled on that percentage. He also pointed out that 30 percent of a worker’s health insurance costs could be “the equivalent of several months’ worth of food for the average family, two months of child care in most states, and roughly two months’ rent.”

Bates ultimately ordered the 30 percent limit vacated as of Jan. 1, 2019, after the EEOC said it would not produce that justification or a new number until 2021.

Employers now putting together next year’s health benefit programs don’t have specific rules to follow.

The advice they are receiving from benefit consultants ranges widely, from “drop all incentives and penalties” to “stay the course.”

Few expect employers will outright stop offering wellness programs because they hope the programs will hold down health costs by getting workers to take steps to improve their well-being. Critics, however, point out that studies show little evidence that workplace wellness programs achieve these goals.

The ruling does not affect some wellness program efforts, such as offering financial incentives for going to the gym or walking a certain number of steps per day. Substantial financial incentives to get people to quit tobacco are also not covered by the ruling, so long as there is no medical test required to check for nicotine use.

But “you can’t fine them for not getting their weight down, because then you have to measure their weight and that becomes clinical,” said Al Lewis, a frequent critic of workplace wellness programs who runs a company that offers an alternative.

Some employers say they will stick with their existing programs — even if they hit the 30 percent level — because the EEOC is unlikely to challenge those that stick with the rescinded percentage until new rules come out.

The Cleveland Clinic’s Rogen, who credits the wellness program for holding medical costs almost flat for the past five years, said clinic officials plan to leave it at that level next year, despite the uncertainty.

Not all benefit consultants would agree with that choice.

“The way we interpret the ruling is that financial incentives that relate to physical exams, including questions about health history, would not be allowed starting Jan. 1,” said Noeldner, of Mercer.

Others suggest that is taking the judge’s ruling too far. After all, the Affordable Care Act provides a precedent for the 30 percent threshold — and the EEOC may well come back with a rule that reaffirms that amount. The ACA included a provision that raised the limit on health-contingent wellness incentives to that amount.

“People may be overreacting to this by saying with these rules null and void, we are out in the Wild West,” said Todd Hlasney, senior vice president and director of health risk solutions at Lockton Companies, a benefits consultancy. “We are advising clients to be more conservative … but don’t panic and say [you] can’t do anything because of EEOC.”

Senators Unveil Legislation To Protect Patients Against Surprise Medical Bills

September 19, 2018

With frustration growing among Americans who are being charged exorbitant prices for medical treatment, a bipartisan group of senators Tuesday unveiled a plan to protect patients from surprise bills and high charges from hospitals or doctors who are not in their insurance networks.

The draft legislation, which sponsors said is designed to prevent medical bankruptcies, targets three key consumer concerns:

  • Treatment for an emergency by a doctor who is not part of the patient’s insurance network at a hospital that is also outside that network. The patients would be required to pay out-of-pocket the amount required by their insurance plan. The hospital or doctor could not bill the patient for the remainder of the bill, a practice known as “balance billing.” The hospital and doctor could seek additional payments from the patient’s insurer under state regulations or through a formula established in the legislation.
  • Treatment by an out-of-network doctor or other provider at a hospital that is in the patient’s insurance network. Patients would pay only what is required by their plans. Again, the doctors could seek more payments from the plans based on formulas set up by state rules or through the federal formula.
  • Mandated notification to emergency patients, once they are stabilized, that they could run up excess charges if they are in an out-of-network hospital. The patients would be required to sign a statement acknowledging that they had been told their insurance might not cover their expenses, and they could seek treatment elsewhere. Don't Miss A Story

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“Our proposal protects patients in those emergency situations where current law does not, so that they don’t receive a surprise bill that is basically uncapped by anything but a sense of shame,” Sen. Bill Cassidy (R-La.) said in his announcement about the legislation.

Kevin Lucia, a senior research professor at Georgetown University’s Center on Health Insurance Reforms who had not yet read the draft legislation, said the measure was aimed at a big problem.

“Balance billing is ripe for a federal solution,” he said. States regulate only some health plans and that “leaves open a vast number of people that aren’t covered by those laws.”

Federal law regulates health plans offered by many larger companies and unions that are “self-funded.” Sixty-one percent of privately insured employees get their insurance this way. Those plans pay claims out of their own funds, rather than buying an insurance policy. Federal law does not prohibit balance billing in these plans.

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Cassidy’s office said, however, that this legislation would plug that gap.

In addition to Cassidy, the legislation is being offered by Sens. Michael Bennet (D-Colo.), Chuck Grassley (R-Iowa), Tom Carper (D-Del.), Todd Young (R-Ind.) and Claire McCaskill (D-Mo.).

Cassidy’s announcement cited two recent articles from Kaiser Health News and NPR’s “Bill of the Month” series, including a $17,850 urine test and a $109,000 bill after a heart attack.

In a statement to Kaiser Health News, Bennet said, “In Colorado, we hear from patients facing unexpected bills with astronomical costs even when they’ve received a service from an in-network provider. That’s why Senator Cassidy and I are leading a bipartisan group of senators to address this all-too-common byproduct of limited price transparency.”

Emergency rooms and out-of-network hospitals aren’t the only sources of balance bills, Lucia said. He mentioned that both ground and air ambulances can leave patients responsible for surprisingly high costs as well.

Lucia said he was encouraged that both Democrats and Republicans signed on to the draft legislation.

“Any effort at the federal level is encouraging because this has been a challenging issue at the state level to make progress on,” Lucia said.

KHN reporter Carmen Heredia Rodriguez contributed to this article.

Much Touted For Cancer, ‘Precision Medicine’ Often Misses The Target

September 13, 2018

Facing incurable breast cancer at age 55, MaryAnne DiCanto put her faith in “precision medicine” — in which doctors try to match patients with drugs that target the genetic mutations in their tumors. She underwent repeated biopsies to identify therapies that might help.

“She believed in it wholeheartedly,” said her husband, Scott Primiano of Amityville, N.Y., a flood-insurance broker. “You live on hope for so long, it’s hard to let go.”

Around this point in the average news story, readers would learn how DiCanto — mother to a blended family of five — took a chance on an experimental drug that no one expected to work.

She would be the scrappy protagonist whose determination to “keep fighting” enabled her to beat the odds — allowing us to celebrate the triumph of modern science and worry a bit less about our own mortality.

But there’s a serious problem with talking about precision medicine for cancer this way.

It misleads the public.

In spite of DiCanto’s high hopes, none of it helped. DiCanto died last year at age 59.

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Doctors and hospitals love to talk about the patients they’ve saved with precision medicine, and reporters love to write about them. But the people who die — patients like DiCanto, who succumb to advanced cancer despite the advanced testing — still vastly outnumber the rare successes.

“There are very few instances in which we can look at a genomic test and pick a drug off the shelf and say, ‘That will work,’” said Dr. Nikhil Wagle, a cancer specialist at Boston’s Dana-Farber Cancer Institute who helped develop precision-medicine tests. “That’s our goal in the long run, but in 2018 we’re not there yet.”

Reflecting on his family’s experience with “precision” treatment, Primiano said, “You think it’s going to be more precise, like a laser versus a shotgun. But it’s still a shotgun.”

There has been real progress, of course.

MaryAnne DiCanto(Courtesy of Scott Primiano)

Testing for genetic mutations has become the standard of care in lung cancer, melanoma and a handful of other tumor types. But the number of people with advanced cancer eligible for these approaches is just 9 percent to 15 percent, experts estimate. These targeted therapies help about half of patients who try them, said Dr. Vinay Prasad, an associate professor at Oregon Health and Science University.

Targeted therapies tend to be less successful in patients like DiCanto, who have exhausted all standard treatments. In a large study published last year in Cancer Discovery, precision medicine failed to help 93 percent of the 1,000 patients who signed up for the study.

At the most recent meeting of the American Society of Clinical Oncology — the largest cancer meeting in the world — researchers presented four precision-medicine studies. Two were total failures. The other two weren’t much better, failing to shrink tumors 92 percent and 95 percent of the time.

The studies received almost no news coverage.

Some experts, including Dr. David Hyman of New York’s Memorial Sloan Kettering Cancer Center, say that such testing should be available to everyone with advanced cancer, because no one can predict which individual might have a rare mutation that can be targeted with a new or experimental drug. When patients respond to these drugs, they tend to do very well, and some survive much longer than expected.

But Hyman acknowledged that many people who pursue precision medicine will be disappointed, because testing won’t lead to a new treatment. Precision medicine “is not addressing the needs of the majority of cancer patients,” he said.

Many of the doctors I interview as a health care reporter are uncomfortable talking about patients who don’t survive.

While acknowledging that not all patients are helped by tumor sequencing, they quickly pivot to talking about people they’ve saved. They rush past the disappointing present and fast-forward to a future in which every patient gets the treatment she or he needs. If you don’t listen carefully, you could easily be led to believe those future cures are already here.

There are very few instances in which we can look at a genomic test and pick a drug off the shelf and say, ‘That will work.’

Dr. Nikhil Wagle, cancer specialist at Boston’s Dana-Farber Cancer Institute

Hospitals promote their precision-medicine programs by showcasing the stories of long-term survivors. Companies such as Foundation Medicine, Caris Life Sciences and Guardant Health — which sell the tests that look for cancer mutations — highlight only the best-case scenarios on their websites. In drug company marketing, patients are cheerleaders for the latest treatment fad.

Against this backdrop of hope and desperation, how are patients supposed to make informed decisions?

DiCanto gave precision medicine everything she had, including biopsies from her lungs and liver, where her cancer had spread. Over 2½ years, her doctor sent seven blood and tissue samples to specialized labs for “next-generation sequencing,” which can quickly scan hundreds of genes. The tests aim to locate a cancer’s Achilles’ heel — a genetic vulnerability that can be targeted with a drug.

MaryAnne DiCanto preps for a biopsy. Doctors took samples of cancer cells from her lung, liver and blood.(Courtesy of Scott Primiano)

DiCanto’s first genomic test matched her to a newly approved drug she would have tried anyway, Primiano said. When it stopped working, she had another biopsy.

That time, tests matched her to a different drug approved for breast cancer. But it proved so toxic that it “nearly killed her,” Primiano said.

Additional tests matched DiCanto to drugs available only in clinical trials. Eligibility criteria for clinical trials are notoriously strict, however, and often exclude people who’ve been heavily treated with other medications. DiCanto wasn’t eligible for any of them. Even when patients are eligible for trials, many turn them down. They’re just too frail and sick to travel to the metropolitan areas where most trials are run.

Although DiCanto benefited from standard cancer treatments, none of the targeted therapies recommended through genetic testing extended her life, Primiano said.

“She didn’t give up,” Primiano said. “Her body gave up. Her body just couldn’t take it anymore.”

Primiano said patients should remember that precision medicine is in its infancy. Although scientists have identified tens of thousands of genetic “variations” — changes from normal DNA that could play a role in cancer — doctors have only a few dozen drugs with which to target them. In the majority of cases, genetic mutations are of “unknown significance”; they’re essentially useless, because scientists don’t know if they affect how patients respond to drugs.

Even when drugs are a good match for a specific mutation, they don’t always work. A targeted therapy that works in melanoma, for example, doesn’t help people with colorectal cancer — even when patients have the exact same mutation, said Wagle, a member of the medical advisory board for Living Beyond Breast Cancer, a patient advocacy group in which DiCanto was active.

MaryAnne DiCanto and her husband, Scott Primiano, spoke with Democratic presidential candidate Hillary Clinton about health care costs during the 2016 campaign. Primiano says Clinton stayed in contact with DiCanto throughout her treatment and called on the day she died to thank her.(Courtesy of Scott Primiano)

Paying for tests and treatment poses its own hurdles. Insurers often tell patients that next-generation sequencing is unproven. Even when insurers agree to cover the testing, they won’t necessarily cover nonstandard or experimental treatments that sequencing companies recommend.

Primiano, a insurance broker, said his family was able to handle the costs: $500,000 out-of-pocket on his wife’s cancer care over 13 years. But managing his wife’s cancer “was a full-time job — doing the research, finding the clinical trials, dealing with the insurance companies, managing the money.”

He worries about people with fewer resources, especially patients tempted to drain their savings account to pay for a treatment with little to no chance of working.

The very words “precision medicine” suggest a high rate of success, Primiano said. While its successes should be celebrated, its failures must be acknowledged and tallied, reminding us how much is left to learn. When patients and their families have so much on the line, they deserve to understand what they’re paying for.

“Let’s not pretend this is something it isn’t,” Primiano said. “I’m not saying we shouldn’t try it. I just don’t want people to have false hope.”

KHN’s coverage of these topics is supported by John A. Hartford Foundation and Gordon and Betty Moore Foundation

Insulin’s High Cost Leads To Deadly Rationing

September 07, 2018

Diabetic ketoacidosis is a terrible way to die. It’s what happens when you don’t have enough insulin. Your blood sugar gets so high that your blood becomes highly acidic, your cells dehydrate, and your body stops functioning.

Nicole Smith-Holt lost her son to diabetic ketoacidosis, three days before his payday, because he couldn’t afford his insulin.

“It shouldn’t have happened,” Smith-Holt said, looking down at her son’s death certificate on her dining room table in Richfield, Minn. “That cause of death of diabetic ketoacidosis should have never happened.”

The price of insulin in the U.S. has more than doubled since 2012 alone. That’s put the lifesaving hormone out of reach for some people with diabetes, like Smith-Holt’s son Alec Raeshawn Smith. It has left others scrambling for solutions to afford the one thing they need to live. I’m one of those scrambling.

Not Enough Time

Most people’s bodies create insulin, which regulates the amount of sugar in the blood. The roughly 1.25 million of us in the U.S. with Type 1 diabetes have to buy insulin at a pharmacy because our pancreases stopped producing it.

My first vial of insulin cost $24.56 in 2011, after insurance. Seven years later, I pay more than $80. That’s nothing compared with what Alec was up against when he turned 26 and aged off his mother’s insurance plan.

Smith-Holt said she and Alec started reviewing his options in February 2017, three months before his birthday on May 20. Alec’s pharmacist told him his diabetes supplies would cost $1,300 a month without insurance — most of that for insulin. His options with insurance weren’t much better.

Alec’s yearly salary as a restaurant manager was about $35,000. Too high to qualify for Medicaid, and, Smith-Holt said, too high to qualify for significant subsidies in Minnesota’s Affordable Care Act insurance marketplace. The plan they found had a $450 premium each month and an annual deductible of $7,600.

“At first he didn’t realize what a deductible was,” Smith-Holt said. She said Alec figured he could pick up a part-time job to help cover the $450 per month.

Then Smith-Holt explained to her son what a deductible was.

“You have to pay the $7,600 out-of-pocket before your insurance is even going to kick in,” she recalled telling him. Alec decided going uninsured would be more manageable. Although there might have been cheaper alternatives for his insulin supply that Alec could have worked out with his doctor, he never made it that far.

He died less than one month after going off of his mother’s insurance. His family thinks he was rationing his insulin — using less than he needed — to try to make it last until he could afford to buy more. He died alone in his apartment three days before payday. The insulin pen he used to give himself shots was empty.

“It’s just not even enough time to really test whether [going without insurance] was working or not,” Smith-Holt said.

The price of insulin in the U.S. has more than doubled since 2012. That’s put the lifesaving hormone out of reach for some people like Smith-Holt’s son Alec, and left others with Type 1 diabetes scrambling to find ways to afford the medicine they must take each day to survive.(Bram Sable-Smith for NPR)

A Miracle Discovery

Insulin is an unlikely symbol of America’s problem with rising prescription costs.

Before the early 1920s, Type 1 diabetes was a death sentence for patients. Then researchers at the University of Toronto — notably Dr. Frederick Banting, Charles Best and J.J.R. Macleod — discovered a method of extracting and purifying insulin that could be used to treat the condition. Banting and Macleod were awarded a Nobel Prize for the discovery in 1923.

For patients, it was nothing short of a miracle. The patent for the discovery was sold to the University of Toronto for only $1 so that lifesaving insulin would be available to everyone who needed it.

Today, however, the list price for a single vial of insulin is more than $250. Most patients use two to four vials per month (I personally use two). Without insurance or other forms of medical assistance, those prices can get out of hand quickly, as they did for Alec.

Depending on whom you ask, you’ll get a different response for why insulin prices have risen so high. Some blame middlemen — such as pharmacy benefit managers, like Express Scripts and CVS Health — for negotiating lower prices with pharmaceutical companies without passing savings on to customers. Others say patents on incremental changes to insulin have kept cheaper generic versions out of the market.

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For Nicole Smith-Holt, as well as a growing number of online activists who tweet under the hashtag #insulin4all, much of the blame should fall on the three main manufacturers of insulin today: Sanofi of France, Novo Nordisk of Denmark and Eli Lilly in the U.S.

The three companies are being sued in U.S. federal court by diabetic patients in Massachusetts who allege the prices are rising at the expense of patients’ health.

Eli Lilly and Company did not make anyone available for an interview for this story. But a company spokesman noted in an email that high-deductible health insurance plans — like the one Alec found — are exposing more patients to higher prices. In August, Eli Lilly opened a help line that patients can call for assistance in finding discounted or even free insulin.

A Dangerous Solution

Rationing insulin, as Nicole Smith-Holt’s son Alec did, is a dangerous solution. Still, 1 in 4 people with diabetes admit to having done it. I’ve done it. Actually, there’s a lot of Alec’s story that feels familiar to me.

We were both born and raised in the Midwest, just two states apart. We were both diagnosed at age 23 — pretty old to develop a condition that used to be called “juvenile diabetes.” I even used to use the same sort of insulin pens that Alec was using when he died. They’re more expensive, but they make management a lot easier.

“My story is not so different from what I hear from other families,” Smith-Holt recently told a panel of Senate Democrats in Washington, D.C., in a hearing on the high price of prescription drugs.

“Young adults are dropping out of college,” she told the lawmakers. “They’re getting married just to have insurance, or not getting married to the love of their lives because they’ll lose their state-funded insurance.”

I can relate to that too. My fiancée moved to a different state recently and soon I’ll be joining her. I’ll be freelancing, and won’t have health benefits, though she will, via her job. We got married — one year before our actual wedding — so I can get insured, too.

This story is part of a partnership that includes Side Effects Public Media, NPR and Kaiser Health News. A version of this story appears in The Workaround podcast.

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

A Texas Lawsuit Being Heard This Week Could Mean Life Or Death For The ACA

September 04, 2018

Wednesday is looking like yet another pivotal day in the life-or-death saga that has marked the history of the Affordable Care Act.

In a Texas courtroom, a group of Republican attorneys general, led by Texas’ Ken Paxton, are set to face off against a group of Democratic attorneys general, led by California’s Xavier Becerra, in a lawsuit aimed at striking down the federal health law. The Republicans say that when Congress eliminated the penalty for not having health insurance as part of last year’s tax bill, lawmakers rendered the entire health law unconstitutional. The Democrats argue that’s not the case.

But first, the sides will argue before U.S. District Judge Reed O’Connor in Fort Worth, Texas, whether the health law should be put on hold while the case is litigated. The GOP plaintiffs are seeking a “preliminary injunction” on the law.

Ending the health law, even temporarily, “would wreak havoc in our health care system,” said Becerra in a call with reporters last week. “And we don’t believe Americans are ready to see that their children are no longer able to see a doctor or that they cannot get treated for a preexisting health condition.”

Here are five questions and answers to help understand the case, Texas v. U.S.

1. What is this suit about?

In February, 18 GOP attorneys general and two GOP governors filed the suit in federal district court in the Northern District of Texas. They argue that because the Supreme Court upheld the ACA in 2012 by saying its requirement to carry insurance was a legitimate use of Congress’ taxing power, eliminating the tax penalty for failure to have health insurance makes the entire law unconstitutional.

“Texans have known all along that Obamacare is unlawful and a divided Supreme Court’s approval rested solely on the flimsy support of Congress’ authority to tax,” Paxton said in a statement when the suit was filed. “Congress has now kicked that flimsy support from beneath the law.”

The lawsuit asks the judge to prohibit the federal government “from implementing, regulating, enforcing, or otherwise acting under the authority of the ACA.”

2. Why are Democratic attorneys general defending the law?

The defendant in the case is technically the Trump administration. But in June, the administration announced it would not fully defend the law in court.

The Justice Department, in its filing in the case, did not agree with the plaintiffs that eliminating the tax penalty should require that the entire law be struck down. But it did say that without the tax, the provisions of the law requiring insurance companies to sell to people with preexisting conditions and not charge them more should fall, beginning Jan. 1, 2019. That is when the tax penalty goes away.

The Republican attorneys general say they still believe the entire law should be invalidated, but if that does not happen, they would accept the elimination of the preexisting condition protections.

The Democratic attorneys general applied to “intervene” in the case to defend the law in its entirety. They say they needed to step forward to protect the health and well-being of their residents. The judge granted them that status on May 16.

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3. What would happen if the judge grants a preliminary injunction?

The GOP plaintiffs say the law needs to be stopped immediately, “both because individuals will make insurance decisions during fall open-enrollment periods and because the States cannot turn their employee insurance plans and Medicaid operations on a dime,” according to their brief.

But setting aside the ACA while the case proceeds “would throw the entire [health] system into chaos,” Becerra said. That’s because the ACA made major changes not just to the insurance market for individuals, but also to Medicare, Medicaid and the employer insurance market.

Even in 2012, when the Supreme Court was considering the constitutionality of the law before much of it had taken effect, some analysts from both parties predicted that finding the law unconstitutional could have serious repercussions for the Medicare program and the rest of the health care system.

In practice, however, even if Judge O’Connor were to rule in favor of the Republicans’ request to stop the law’s enforcement immediately, the decision could be quickly appealed up the line, including, if necessary, before the Supreme Court.

4. Is this case purely Republicans versus Democrats?

The case is largely partisan — with Republicans who oppose the health law arguing for its cancellation and Democrats who support it fighting to keep it in place.

But a friend-of-the-court brief filed by five law professors who disagree on the merits of the ACA said that, regardless, both the GOP states and the Justice Department are wrong to conclude that eliminating the tax penalty should result in the entire law being thrown out.

In this case, “Congress itself has essentially eliminated the provision in question and left the rest of a statute standing,” so courts do not need to guess whether lawmakers intended for the rest of the law to remain, they wrote.

5. What is Congress doing about this?

Technically, Congress is watching the case just as everyone else is. But Republicans in particular, while they mostly oppose the health law, are aware that the provisions protecting people with preexisting conditions are by far the most popular part of the ACA. And Democrats are already using the issue to hammer opponents in the upcoming midterm elections.

Last month, 10 GOP senators introduced legislation they said would maintain the ACA’s preexisting condition protections in the event the lawsuit succeeds.

“This legislation is a common-sense solution that guarantees Americans with preexisting conditions will have health care coverage, regardless of how our judicial system rules on the future of Obamacare,” said Sen. Thom Tillis (R-N.C.), the bill’s lead sponsor, in a statement.

Critics, however, were quick to point out that the bill doesn’t actually offer the same protections that are embodied in the ACA. While the health law requires coverage for all conditions without extra premiums, the GOP bill would require that insurers sell to people with preexisting conditions, but not that those policies actually cover those conditions.

Watch: What Happened To That $109,000 Heart Attack

August 29, 2018

Kaiser Health News editor-in-chief Elisabeth Rosenthal discusses the latest Bill of the Month installment on “CBS This Morning” on Wednesday.  The story of a high school teacher who faced an outrageous hospital bill is part of an ongoing crowdsourced investigation by KHN and NPR.

Wisconsin Reinstates Coverage Of Transgender Treatment For State Workers

August 29, 2018

In a surprising reversal, a Wisconsin board has voted to again offer insurance coverage to transgender state employees seeking hormone therapy and gender confirmation surgery.

Members of the Group Insurance Board, which manages the insurance program for Wisconsin’s public workers and retirees, last week voted 5-4 to overturn its current policy barring treatments and procedures “related to gender reassignment or sexual transformation.”

The change will take effect Jan. 1, allowing insurance to defray the cost of care deemed medically necessary.

“This was an empowering moment, offering up hope things can get better,” Wren Logan, a trans woman and psychiatry resident at UW Health who fought the policy, wrote in an email to Kaiser Health News.

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The board’s decision comes less than a month after Kaiser Health News, in partnership with NPR, published a project as part of its Bill of the Month series about a 24-year-old trans woman, Wren Vetens, who fought to get her gender confirmation surgery covered after the Group Insurance Board’s initial decision left her without insurance coverage.

It has been two years since the board first opted to pay for such expenses. That decision came shortly after the Obama administration unveiled a rule in May 2016 prohibiting discrimination based on gender identity, and the board was advised that refusing to cover certain treatments for trans patients could run afoul of that rule. Members voted unanimously in July 2016 for the change.

State officials soon began pressuring the board to not cover these services, despite the Obama administration’s directive.  About the same time, Wisconsin’s justice department joined a lawsuit challenging the anti-discrimination rule.

The board voted to reinstate the restrictive policy should a handful of conditions be met — one of which was a court decision to halt the rule. By coincidence, that ruling came the following day. A month later, in February 2017, the restrictions took effect once more, again barring trans patients from obtaining coverage.

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In a recent memo to the board, a state health policy adviser noted the “legal landscape” had changed, broadening protections for the transgender community. Last month, a federal judge ordered Wisconsin to pay for gender confirmation surgery for two individuals on Medicaid, who sought coverage to treat their gender dysphoria.

Gender dysphoria is the diagnosis for those with “significant distress” due to the difference between their gender and sex, according to the American Psychiatric Association.

In another case, two transgender women employed by the University of Wisconsin and covered by the state insurance program have sued the Group Insurance Board and the university’s board of regents, among others, accusing them of discrimination based on their inability to get coverage for gender confirmation surgery. The case is scheduled to go to trial in October, before the same judge who ruled in favor of the patients on Medicaid.

Officials from the University of Wisconsin — as well as UnitedHealthcare, which is opening a Medicare Advantage program for Wisconsin’s public employees and retirees — have also raised concerns about the policy.

The decision comes amid speculation that the Trump administration will soon unveil a new rule formally overturning the Obama-era anti-discrimination rule.

A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack

August 27, 2018

Drew Calver took out his trash cans and then waved goodbye to his wife, Erin, as she left for the grocery store the morning that upended his picture-perfect life.

Minutes later, the popular high school history teacher and swim coach in Austin, Texas, collapsed in his bedroom from a heart attack. He pounded his fist on the bed frame, violent chest pains pinning him to the floor.

“I thought I was dying,” the 44-year-old father recalled. He called out to the only other person in the house, his oldest daughter, Eleanor, now 7. Using his voice, he texted his wife, who was at the store with their youngest, Emory, now 6. A neighbor rushed him to the nearby emergency room at St. David’s Medical Center on April 2, 2017.

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The ER doctors confirmed the trauma to Calver’s heart and admitted him to the hospital’s cardiac unit. The next day, doctors implanted stents in his clogged “widow-maker” artery.

The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before.

Despite the surprise, even from his hospital bed, Calver asked whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David’s is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.

The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, records show. Despite the difference of more than $100,000, with the hospital’s prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.

And then the bills came.

Patient: Drew Calver, 44, a high school history teacher and father of two in Austin, Texas.

Total Bill: $164,941 for a four-day hospital stay, including $42,944 for four stents and $10,920 for room charges. Calver’s insurer paid $55,840. The hospital billed Calver for the unpaid balance of $108,951.31.

Service Provider: St. David’s HealthCare, a large hospital system in central Texas. It’s run by HCA Healthcare, the nation’s largest for-profit hospital chain, and two nonprofit foundations.

Medical Treatment: Emergency room treatment followed by four days in the hospital, most of it spent in the cardiac unit. During surgery, four stents were implanted to clear a blockage in his left anterior descending artery, the source of so-called widow-maker heart attacks, because they are so frequently deadly.

What Gives: St. David’s Medical Center is billing Calver for the $109,000 balance — an amount nearly twice his annual pay as a teacher.

The hospital’s billing company sent a notice June 26, urging him to take advantage of this “FINAL opportunity to settle your balance.

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“They’re going to give me another heart attack stressing over this bill,” Calver said. “I can’t pay this bill on my teacher salary, and I don’t want this to go to a debt collector.”

In the wake of his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans, even as legislators have tried to protect them: surprise bills and balance billing.

Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor that does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out-of-network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.

The total bill for Drew Calver’s four-day hospital stay at St. David’s Medical Center in April 2017 was $164,941.(Callie Richmond for KHN)

His insurer paid $55,840, leaving Calver responsible for the unpaid balance of $108,951.31.(Callie Richmond for KHN)

Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.

But there’s a huge loophole: Those state-mandated protections don’t apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds.  Federal law governs those health plans — and it does not include such protections.

About 60 percent of people with employer health benefits are covered by self-insured plans, but many don’t even know it, since employers typically hire an insurer to administer the plan and employees carry a card bearing the name of Blue Cross Blue Shield or another major insurer.

Drew Calver sits with his wife, Erin, and daughters Eleanor (left) and Emory (middle) in their Austin, Texas, home where he had a heart attack on April 2, 2017.(Callie Richmond for KHN)

This case “illustrates the dangers that even insured people face,” said Carol Lucas, an attorney in Los Angeles with experience in health care payment disputes. “The unfairness is especially acute when there is an emergency and the patient, who might ordinarily be completely compliant, has no say about the facility he winds up in.”

In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.

“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said.

Patients experiencing an emergency are particularly at risk of landing at an out-of-network hospital. St. David’s said once ER patients are deemed stable, it tries to transfer them to an in-network facility. “However, this is not always possible because the patient’s health must come first,” the hospital said.

This case also raises questions about the validity of the hospital’s charges.

Industry analysts and consumer advocates say St. David’s has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider. “This is a well-known, problematic provider. We’ve seen multiple bills from them and they are always highly inflated,” said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide.

WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half what Aetna paid.

Healthcare Bluebook, which offers cost estimates for medical tests and treatments, arrived at a similar conclusion. It said a fair price for a hospitalization in Austin involving four heart stents would be about $36,800. St. David’s Medical Center charged four times that amount.

Quarum and other analysts who reviewed the bill said several charges stood out, especially on the four stents, which were billed at $42,944. Coronary stents are typically metal mesh tubes implanted in arteries to improve blood flow. Most are coated with drugs to assist in healing.

St. David’s charged $19,708 apiece for two Synergy stents made by device giant Boston Scientific. Two other stents used were far cheaper.

The $20,000 price tag represents a significant markup of what U.S. hospitals typically pay themselves for stents. The median price paid by hospitals for the Synergy stent was $1,153 over the past year, according to the nonprofit research firm ECRI Institute.

“St. David’s charge of over $19,000 for those stents is absolutely outrageous,” Quarum said.

St. David’s declined to comment on its markup for the stents or what it actually paid the manufacturer.

Resolution: For now, Calver still faces a bill for $108,951.31, with none of the parties involved in his treatment or coverage providing significant redress.

In fact, the hospital’s debt collector sent the Calvers a letter Aug. 3 demanding payment in full.

After a reporter made inquiries, St. David’s said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.

In a statement, St. David’s said “we work with all patients needing financial assistance to help determine their eligibility for this discount.”

Calver said that approach doesn’t address the balance billing or whether the charges were appropriate.

A spokeswoman for Aetna said “we are actively working to rectify the situation on behalf of the member.” But the health plan hasn’t shared any further details. The Austin school district declined to discuss this specific case.

Calver said the whole ordeal has been incredibly stressful for him and his wife.

“I am stuck in the middle of this convoluted, flawed system,” he said. “I’ve never owed a large amount like this or had credit card debt. What does it mean if this goes on my credit report?”

Drew Calver’s daughters visit him at the hospital in April 2017 after his heart attack and resulting emergency surgery.(Courtesy of the Calver family)

The Takeaway: Faced with a surprise bill or a balance-billing situation, don’t rush to pay any medical bills you receive. First, let the insurance process play out completely so you’re sure what the health plan is paying the hospital and doctors — and what you ultimately might be responsible for, in terms of coinsurance or copayments.

Ask for an itemized bill. Review the charges carefully and talk to your insurer, your employer and the hospital if the prices seem out of line. Arm yourself with estimates you can find online of the average prices charged in your area as you negotiate with all the players.

If the bills keep coming, talk to your employer’s benefits department or the state insurance department about your legal protections. The situation will vary depending on the type of health insurance you have and the state you live in. Tell any debt collection agencies that may contact you that you are contesting the bill.

With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.

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

Readers And Tweeters Revisit Surgery Centers, Think Twice About Single-Payer

August 24, 2018

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

A Duty To Report On Surgery Centers

Your article regarding unreported bad outcomes from outpatient surgery centers (“Lax Oversight Leaves Surgery Center Regulators And Patients In The Dark,” Aug. 9) had been a concern of mine for some time. I am a retired radiologist and have personally seen bad outcomes and wondered if they are a public safety issue and go unreported. Accredited hospitals must keep track of outcomes, but the outpatient surgery centers are variable. Good investigative journalism as yours provides a valuable service to the public and will save lives.

— James LaManna, Gillette, Wyo.

On Twitter, a spine surgeon pointed out what he sees as holes in the story. Dr. Paul Kraemer, a specialist at North Meridian Surgery Center in Carmel, Ind., argued that the story was based on the false assumption that hospitals have better trained staff than do surgery centers. Rather than set up the dichotomy of surgery center vs. hospital, he told KHN, the article should have differentiated between generalist and specialty centers — that is, those performing spine procedures occasionally vs. every day. At specialty centers, the nurses in the recovery room can spot a problem — especially an airway problem — and alert a surgeon or anesthetist to intervene, he said. They see what is normal and recognize early warning signs of trouble, whether the procedure is simple or complex.

1. No mention of millions who have had surgery safely to provide perspective.

2. No mention that same complication can happen in hospital (seen it)

3. No mention of conflicts inherent in hospital news promoting and funding story

4. No mention of steps taken to prevent tragedy

— Paul Kraemer MD (@PK_Spine) August 1, 2018

— Dr. Paul Kraemer, Carmel, Ind.

Dr. Ronald Hirsch of Illinois told KHN he has been trying for a year to get insight from the Centers for Medicare & Medicaid Services on its fast-track approval of increasingly complex procedures — while oversight lags.

And yet, @CMSGov allows @Humana to authorize "Inpatient Only" surgeries to be done at surgery centers on Medicare Advantage beneficiaries. Hip fracture repair? Open cholecystectomy? Carotid artery stenting? https://t.co/0BZ0JSDlwf

— Ronald Hirsch, MD (@signaturedoc) August 10, 2018

— Dr. Ronald Hirsch, Elgin, Ill.

Glenn Krauss of Vermont explained why he avoids surgery centers at all costs.

— Glenn Krauss, Burlington, Vt.

Filling A Gnawing Need On Campus

“Insuring Your Health” columnist Michelle Andrews did her homework on solutions for a rampant problem: food insecurity among college students (“For Many College Students, Hunger Can ‘Make It Hard To Focus In Class,” July 31). Readers such as J.K. Devine of Gainesville, Ga., joined a chorus of those commending universities for coming to the aid of hungry scholars.

Enjoyed reading your story about college students going hungry. The University of North Georgia is one of those universities that has started food pantries on 3 of its 5 campuses to help students, faculty and staff who need it.

— J.K. Devine (@JKDevine1) July 31, 2018

— J.K. Devine, Gainesville, Ga.

A Californian shared her firsthand experience with hunger as a college freshman.

I remember freshmen year going to bed hungry every night, wishing I was home so I could at least have cereal. I did have a dinning hall pass, but social anxiety and peak dinner times don’t mix.

— Korahline (@Krhddg) August 1, 2018

— Paola Viveros, Oxnard, Calif.

Doctors for America, a coalition of 18,000 physicians and medical students whose goal is to improve access to health care, also rallies to fight hunger, especially among medical students who are at risk of being saddled with tuition debt.

While the US is the wealthiest country, up to a half of all college students suffer from food insecurity. We must not allow future medical students to suffer from such a gap. All while the US is declining their contribution to student financial aid https://t.co/rHgWlrMpKm

— Doctors for America (@Drsforamerica) August 3, 2018

Zachary LeClaire of California has adopted the philosophy that he would rather go hungry than let his college bills add up. On Twitter, he mused: Are parents doing enough to tend to the financial needs of their “dependents”?

One of the main problems with this is many college students are under the age of 24 and are considered "dependent students" regardless of whether or not they're parents actually give them any money. Also I'd rather eat 1 meal a day than be in debt for the rest of my life

— The Useless Philosopher (@GenYDiogenes) July 31, 2018

— Zachary LeClaire, Huntington Beach, Calif.

Although nutrition needs are being addressed where she lives in Washington state, Erin Davis looked at the big picture.

https://t.co/nniqYTfIsN

Proud and thankful that my institution has a food bank for students. Food insecurity among community college students is a pervasive problem that also needs larger, systemic solutions.

— Erin Davis (@FreckleErin) August 1, 2018

— Erin Davis, Spokane, Wash.

Second Thoughts On Single-Payer

In almost 100 percent of the discussions on health coverage plans, it is assumed that providers will both exist and will work for whatever the plan will pay them (“Once Its Greatest Foes, Some Doctors Are Now Embracing Single-Payer,” Aug. 7). Most people, when they hear “single-payer,” expect that everything will be covered with minimal copay and deductible. They are wrong, but no one will admit it upfront.

The alleged coverage crisis — wherein medical insurance was conflated with service availability, resulting in Obamacare — was caused by the government. Both Medicaid and Medicare health benefits were originally designed to provide basic health services while paying providers little more than direct costs, allowing private pay and commercial insurance payments to cover overhead and profit. Medicaid and Medicare were not expected to be a significant percentage of any provider’s practice. Over time, the good-hearted liberals kept expanding the scope of benefits with marginal improvements in reimbursement calculations and certainly without consideration of “unintended consequences,” especially the predictable ones pertaining to demand and cost.

Experience shows that A) any national single-payer system will be run at least as well as the VA and the Indian Health Services and B) our Fearless Leaders will exempt themselves from the system.

— Ed Connelly, Shaftsbury, Vt.

On Twitter, Ryan Quattro of Michigan wondered how an overhaul in health care policy might play against the backdrop of precarious foreign, defense and other domestic policies.

We need to have a conversation on what single-payer means for US role in the world.

End of role in NATO and seriously reduced military means reduced influence in world. Then there is the issue of infrastructure. $2.5 trillion. America is a hot mess.

— Ryan Quattro (@forzaquattro77) August 2, 2018

— Ryan Quattro, Ann Arbor, Mich.

A reader in Iowa warned that the flip side of single-payer means doctors would earn far less than they traditionally do, and that American innovation would be sacrificed.

Wait until these new physicians have to pay back their student loans on single payer compensation…good luck…oh, say goodbye to innovation, too. #Shame
Once Its Greatest Foes, Doctors Are Embracing Single-Payer https://t.co/MSpDmvkv2k via @khnews

— Sean Yolish (@SeanYolish) August 8, 2018

— Sean Yolish, West Des Moines, Iowa

Power to the younger generation, was the message from an Idaho tweeter.

The youngin's are gonna change our country for the better. I believe that. Enough is enough.

— IndiraShanti (@IndiraShanti) August 2, 2018

— Tina Neidig, Boise, Idaho

Podcast: KHN’s ‘What The Health?’ Opioids, EpiPens And Health Funding

August 23, 2018
Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Joanne Kenen

Politico

@JoanneKenen

Read Joanne's Stories Alice Ollstein

Talking Points Memo

@AliceOllstein

Read Alice's Stories Margot Sanger-Katz

The New York Times

@sangerkatz

Read Margot's Stories

The Senate is still working, well into August – something it hasn’t done in years — and it’s debating the funding bill for the Department of Health and Human Services.

There is a back-to-school shortage of EpiPens, needed by people with severe allergies to treat potentially life-threatening reactions, and the Food and Drug Administration is weighing in. And “reinsurance” is back in the picture. The Trump administration has granted permission for New Jersey and Maryland to create such programs aimed at helping bring down premiums in the individual insurance market by helping pay for the most expensive enrollees.

And in weird science: An asthmatic otter sends a signal about the serious public health impact of this summer’s wildfires in the western U.S.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Alice Ollstein of Talking Points Memo and Margot Sanger-Katz of The New York Times.

This is your last chance to send questions for next week’s “ask us anything” episode. You can email us at Whatthehealth@kff.org

Among the takeaways from this week’s podcast:

• One provision of the HHS funding bill that is getting attention is the effort to require drugmakers to add their prices to any advertisements. President Donald Trump is pushing for this, and it could be popular politically. But since consumers pay different prices depending on a variety of factors, including their insurance and the source of drugs, it isn’t clear how impactful such a law would be.

• The announcement this week by federal authorities that an estimated 72,000 people had died of drug overdoses — 49,000 of them as a result of opioids — has spurred interest on Capitol Hill for legislation to help fight the opioid epidemic. Bills that had been expected to move after the election could now see a faster track to voting.

• Consumers are reporting a shortage in EpiPens, the prescription drug and self-injector that can prevent death from a lethal allergy. The FDA has agreed with the EpiPen maker to extend the expiration date to ease the shortage. The FDA also approved a generic version of the EpiPen, but that is unlikely to lower costs anytime soon. Generics often don’t have much impact on pricing until there are several generic options available.

• The announcement by New York University’s medical school that it will provide free tuition to all students sent a shock wave through the academic community. Although it appears to be a great strategy to attract students, it’s unclear whether it will encourage more new doctors to choose primary care rather than higher-paying specialties. Doctors do come out of school with high debt levels, but most studies show that they also have high salaries and pay off those debts within 10 years.

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

Julie Rovner: NPR’s “NYU’s Move To Make Medical School Free For All Gets Mixed Reviews,” by Julie Rovner

Joanne Kenen: Politico’s “Lax State Ethics Rules Leave Health Agencies Vulnerable to Conflicts,” by Brianna Ehley, Sarah Karlin-Smith, Rachana Pradhan and Jennifer Haberkorn

Alice Ollstein: The New York Times’ “Vitamin D, the Sunshine Supplement, Has Shadowy Money Behind It,” by Liz Szabo

Margot Sanger-Katz: The Wall Street Journal’s “What Does Knee Surgery Cost? Few Know, and That’s a Problem,” by Melanie Evans

To hear all our podcasts, click here.

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

Biorhythms And Birth Control: FDA Stirs Debate By Approving ‘Natural’ App

August 21, 2018

The Food and Drug Administration took a “big tent” approach earlier this month when it approved two new forms of birth control that prevent pregnancy in very different ways.

Women’s health advocates applauded the availability of a new vaginal ring that could be used for up to a year. But some questioned the approval of a mobile phone app that helps women avoid pregnancy by tracking their body temperature and menstrual cycle, a type of contraception called “fertility awareness.”

Critics pointed to reports that three dozen women in Sweden got pregnant despite monitoring their cycle with the app. They also fear that the FDA approval of the app may encourage patients to think that fertility awareness methods, which include a range of practices to track ovulation, and avoid unprotected sex during that time, are just as good at preventing pregnancy as some highly effective types of birth control, like the intrauterine device, or IUD. While “natural” methods can be successful, they generally require close daily attention.

There’s still room for improvement in contraceptive use by women and men. Nearly half of the 6.1 million pregnancies in the United States — 45 percent — in 2011 were unplanned, according to a study published in the New England Journal of Medicine. That figure is lower than the 51 percent rate in 2008, but is higher than the rate in many other industrialized countries.

The FDA has approved nearly two dozen contraceptive methods, including the pill, the patch, IUDs and hormonal implants and shots, among others. Insurance is required to cover all FDA-approved methods without charging women anything out-of-pocket.

The new vaginal ring, Annovera, releases hormones that prevent ovulation and must be removed after three weeks for seven days, then reinserted. It can be used for a year. The device will not be on the market until at least late 2019, and the price hasn’t been released by the manufacturer.

The Natural Cycles app instructs women to take their temperature at the same time every morning when they awake and record it in the app. They also track information about their menstrual cycle. When a slight temperature increase indicates they are ovulating, the app signals that women should avoid unprotected sex. It costs about $80 per year.

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Both of the new methods require more attention on the part of the user than say, an IUD, which once inserted can be ignored and is designed to prevent pregnancy for five to 10 years, depending on the brand.

Still, some women’s health experts worry that the FDA stamp of approval may be misinterpreted by some women.

“People will interpret this to mean that the FDA approves this and thinks it’s a good method,” said Dr. Christopher Zahn, vice president of practice activities for the American College of Obstetricians and Gynecologists.

“That’s why counseling is so important,” he said, noting that doctors should discuss all forms of birth control with women, and the conversation should include the efficacy of different methods.

But Dr. Gillian Dean, senior director of medical services at Planned Parenthood Federation of America, welcomes the approval of both new methods.

“More options are always better,” she said. “It isn’t one size fits all, and more options increases the likelihood that women will find a method that works for their needs.”

The right contraceptive depends on a woman’s goals, Dean said, including her reproductive plans, what her menstrual cycle is like, the number of partners she has and how important it is for her not to get pregnant. She said most women who visit Planned Parenthood clinics ask for and receive birth control pills, but an increasing number are asking for long-acting reversible methods of contraception, such as IUDs and hormonal implants.

The IUD and hormonal implants have a “failure rate” of less than 1 percent, making them among the most effective ways of preventing pregnancy (on par with permanent sterilization). Birth control pills, the patch and the vaginal ring have effectiveness rates of about 91 percent, according to the federal Centers for Disease Control and Prevention.

Fertility awareness methods, on the other hand, have a failure rate of about 24 percent, according to the CDC. But that figure is widely misunderstood, said Chelsea Polis, a senior research scientist at the Guttmacher Institute, a sexual and reproductive health research and advocacy organization.

Polis co-authored an analysis of studies of fertility awareness-based contraceptive methods that was published in August in the journal Obstetrics and Gynecology.

The 24 percent figure, she said, primarily reflects the expected failure rate for women who used the rhythm method, a calendar-based approach to calculating when ovulation occurs, rather than newer biometric methods that track body temperature, cervical mucous or urinary hormones. Some of those methods may be more effective, she said.

Based on a review of published studies, Polis and colleagues reported that the Natural Cycles app had a 9.8 percent unintended pregnancy rate. The FDA announcement, which includes the results of an additional study, noted a 6.5 percent rate.

Polis said her research indicates that about 3 percent of women who use contraception practice fertility awareness-based methods, either alone or with other types of birth control, and their numbers are growing.

“I think [the app approval] is largely a positive step forward,” Polis said. “I’m relieved that the FDA has a regulatory pathway to evaluate these uses and claims.”

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

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