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Updated: 21 hours 45 min ago

Seniors Steamed Over Cuts To SilverSneakers Fitness Program

December 06, 2018
Navigating Aging

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

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John Garland Graves was taken aback when he walked into his McKinleyville, Calif., gym in October and learned that his SilverSneakers membership was being canceled.

Since 2014, Graves, 69, has enjoyed free access to the gym through SilverSneakers, the nation’s best-known fitness program for seniors. He was disturbed by the news, as are many other people who have recently learned they’re losing this benefit.

A controversial business decision by UnitedHealthcare, the nation’s largest health insurance carrier, is causing the disruption. As of Jan. 1, the company is dropping SilverSneakers — an optional benefit — for 1.2 million customers with Medicare Advantage plans in 11 states (California, Connecticut, Illinois, Indiana, Iowa, Kansas, Missouri, Nebraska, Nevada, North Carolina and Utah) as well as 1.3 million customers with Medicare supplemental (Medigap) insurance in nine states (Arizona, California, Connecticut, Illinois, Indiana, North Carolina, Ohio, Utah and Wisconsin).

Graves, who works out four to five days a week and has a UnitedHealthcare Medigap policy, decided to seek coverage elsewhere after the company raised his policy’s rates and eliminated SilverSneakers in California. He has signed up for a new policy with Blue Shield of California.

Starting next year, UnitedHealthcare will offer members a package of fitness and wellness benefits instead of paying to use SilverSneakers — a move that will give the company more control over its benefits and may save it money.

Seniors with UnitedHealthcare Medicare supplemental policies will get 50 percent off memberships at thousands of gyms across the country, telephone access to wellness coaches and access to various online communities and health-related resources. Those with Medicare Advantage policies can join Renew Active, UnitedHealthcare’s fitness program, with a network of more than 7,000 sites, at no cost, and qualify for an evaluation from a personal trainer and an online brain-training program, among other services.

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Steve Warner, who leads UnitedHealthcare’s Medicare Advantage product team, explained the company’s move by noting that over 90 percent of policyholders who are eligible for SilverSneakers “never step foot in a gym” or use this benefit.

UnitedHealthcare wants to reach “a broader portion of our membership” with a “wider variety of fitness resources,” he said, noting that the company’s shift away from SilverSneakers began last year and has accelerated this year. (Altogether, more than 5 million customers have been affected. But the company is making market-by-market decisions, and nearly 675,000 UnitedHealthcare Medigap policyholders and 1.9 million UnitedHealthcare Medicare Advantage plan members will retain access to SilverSneakers in 2019.)

“I think it’s a smart move,” said Connie Holt, an independent broker with Goldsum Insurance Solutions of Pleasant Hill, Calif.

But many of the company’s customers aren’t happy that SilverSneakers, which offers group classes tailored to seniors in addition to gym access at 15,000 sites, is disappearing. And confusion about alternatives is widespread.

It’s one of the “top topics” that seniors have been raising over the past few months when they call Ohio’s Senior Health Insurance Information Program, said Chris Reeg, the OSHIIP program director.
This story also ran on NPR. This story can be republished for free (details).
Michael Chanak Jr., 69, of Wadsworth, Ohio, had problems getting through to UnitedHealthcare’s customer relations department several times when he called with questions — a common complaint. “The way this is being implemented is a train wreck,” said Chanak, who has a UnitedHealthcare Medicare supplemental policy and spends an hour every day exercising at his gym.

People are “extremely upset,” wrote Margaret Lee of Arroyo Grande, Calif., in an email. “That’s about the only topic of conversation at my water exercise class!”

AARP has also become a target of anger because it endorses UnitedHealthcare’s Medigap and Medicare Advantage insurance policies — an arrangement that yields substantial royalties for the organization.

In an email, Mark Bagley, a spokesman for the organization, said, “UHC [UnitedHealthcare], not AARP, operates these plans and determines the benefits.”

“I will be dropping my AARP membership when it is time to renew,” wrote Shelley Holbrook, 67, of Yorba Linda, Calif., a UnitedHealthcare Medigap policyholder, in an email exchange about the loss of SilverSneakers. “I am a Parkinson’s patient who has been prescribed this type of exercise program,” she explained. “This program is under the guidance of certified instructors that make sure the exercise routines are performed correctly. … An ordinary gym membership provides no instruction on how to use the equipment safely for seniors.”

“A health coach is not what I need,” Holbrook continued. “I have used the health coaches before, and have found them to be totally worthless.”

For policyholders like Holbrook, the situation is complicated by another factor: Federal laws don’t ensure that seniors can switch Medicare supplemental insurance plans without undergoing new medical evaluations after an initial “guarantee issue” period. (This period occurs six months following a person’s enrollment in Medicare. Changes are allowed under a few specific circumstances and by laws in a few states.)

If seniors can meet medical standards, they’ll find SilverSneakers available from other insurance operators. In 2019, Tivity Health is offering the program through more than 65 health plans covering more than 15 million older adults and introducing a new digital platform that emphasizes its social benefits: SilverSneakers Connect.

“There are people we’ve learned who are alone but don’t want to go to the gym,” and the new platform can help them connect with each other as well as activities in their communities, said Donato Tramuto, Tivity Health’s CEO. Recent research suggests that SilverSneakers may help reduce isolation and loneliness in seniors who go to classes and form new relationships, he noted.

Whether UnitedHealthcare’s health plans will be less appealing because of the shift away from SilverSneakers is yet to be determined. Several years ago, Humana, another giant insurer, also began reducing the number of plans that offered SilverSneakers, but it faced a backlash from members and sales representatives. “The membership perceives [SilverSneakers] as a valuable benefit despite the fact that not everyone uses it,” said George Renaudin, Humana’s senior vice president of Medicare.

Humana subsequently reversed course and is now making SilverSneakers broadly available to about 3.5 million Medicare Advantage and Medigap policyholders.

Ray Liss, who retired seven years ago, just changed over from UnitedHealthcare to a Humana Medicare supplemental policy with his wife. The loss of SilverSneakers precipitated the switch, which has an unexpected benefit: The couple will save almost $60 a month next year on their new policy.

In an email, Liss, who declined to say where he lives, was philosophical about the value of exploring his options, writing, “I was pretty mad at the time, but it worked out for the best.”

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

KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

Readers And Tweeters Demand Action On Gun Violence, Mental Health Care Options

December 03, 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.

Behind The Bloodshed

In 2018 alone, there have been more than 300 mass shootings in the United States (“Gun Control Vs. Mental Health Care: Debate After Mass Shootings Obscures Murky Reality,” Nov. 19). That’s almost equivalent to the number of days in the year. When so many shootings occur in such a short period of time, it’s clear there’s at least one common reason behind them. But many people assume there’s only one reason and are divided over what that reason is. Some people say the underlying problem is gun control. Others say the underlying problem is mental health. Statistics prove that mental health is definitely one of the problems. In that case, why are the people, including the people in power, who blame mental health as the issue so hesitant to make reforms to the health care system and the way mental health is handled? They could at least attempt to fix the problem. Gun violence is becoming a prevalent issue in American society, one that simply can’t keep being ignored. We need to stop debating and start doing something to protect the lives of innocent civilians. How many more deaths will it take before people in power take action?

— Srija Ponna, San Jose, Calif.

An Untenable Solution On Mental Health Care?

So the family becomes the untrained caregiver (“With Hospitalization Losing Favor, Judges Order Outpatient Mental Health Treatment,” Nov. 13). From experience, it’s impossible to find good, timely assistance for a person with bipolar disorder. The patient can just disappear for days, wreak havoc in the community, hurt themselves or others. By the time the patient has reached the point of mandatory outpatient treatment, a lot of damage has probably already occurred and both the patient and family are desperate. How can they be certain a person with bipolar disorder is properly taking medicine? Such patients often shun their medicine, especially when experiencing mania. This is an unrealistic option for treatment of some mental health disorders. I think it places the patient, family and community in danger of further damage.

— Glenn McGahee, Fort Lauderdale, Fla.

More research couldn’t hurt, tweeted Daphne Chakurian of California:

Interesting concept. This needs research to evaluate cost to benefit for patients vs. some other model of care that is desperately needed.

— Daphne Chakurian (@DaphneChakurian) November 14, 2018

— Daphne Chakurian, Roseville, Calif.

Lofty Praise

Excellent piece about air quality (“Smoke-Filled Snapshot: California Wildfire Generates Dangerous Air Quality For Millions,” Nov. 21). Once auto emissions plummeted, I never thought about any planetary forces except earthquakes. This raises awareness exactly as everything you do should. ;-) Thanks.

Lucy Johns MPH, San Francisco

Casting A Wide Net On Fish Oil Study

NPR and ABC covered these studies, and included positive results at the end of the articles. KHN didn’t even mention benefits (“Fish Oil And Vitamin D Pills No Guard Against Cancer Or Serious Heart Trouble,” Nov. 10). UPI reported an “overwhelming benefit of fish oil supplements for black participants, who had a 77 percent reduction in their risk of heart attack.” I think this shows a lack of thorough reporting on KHN’s part.

— Joy Thomas, Foster City, Calif.

Mixed messages about the study were prevalent online, one tweeter noted:

Everything is conflicting these days. Earlier today I heard the opposite

— Matt Jade (@matthewhochstra) November 12, 2018

— Matt Jade, New York City

Echoing an expert in the KHN story, that’s what happens when researchers slice data into smaller segments, with fewer patients in each group. The results can prove unreliable when zeroing in on specific outcomes such as heart attacks among blacks.

Have A Whole Look At Medical Records, Holes And All

Not likely to be revealed in a medical record: any complication from treatment that results in harm or death to a patient and is not owned up to by the physician/surgeon or hospital (“In Days Of Data Galore, Patients Have Trouble Getting Own Medical Records,” Oct. 25). Thus, a medical record can be used as documentary evidence of not reporting an adverse medical or surgical event that should have been reported to the Centers for Medicare & Medicaid or other patient safety organizations. In my opinion, that is the primary reason for providers’ reluctance to furnish medical records related to a harmed/killed patient.

— Lars Aanning, Yankton, S.D.

Quality not quantity is what matters when collecting health data, one tweeter observed:

Large part of the failure of EHRs to improve care is “data galore”. Too much clinically irrelevant data for reimbursement not care. Ten pages of documentation from ER visit often contain little or no clinically important data. Need good data not galore.

— Edward T Chory (@DrEdMDBFD) October 25, 2018

— Dr. Edward Chory, Lancaster, Pa.

It’s not as if solutions don’t exist; the challenge is executing them, reader Michael Millenson suggested on Twitter.

"In Days Of Data Galore, Patients Have Trouble Getting Own Medical Records." All true, but CMS proposals to make it easier drew little support, except those of us @S4PM. industry opposed. https://t.co/vxF7yMIeII @khnews @judith_graham

— Michael Millenson (@MLMillenson) October 26, 2018

— Michael Millenson, Chicago

Monster Bills Only Scratch The Surface

This is the tip of the iceberg (Bill of the Month’s “That’s A Lot Of Scratch: The $48,329 Allergy Test,” Oct. 29). Medicine has become a medical-Industrial complex ever as powerful as the military-industrial complex that President Dwight Eisenhower warned us about. Hospitals all over the country use this same “scam” to maximize their profits. Recent schemes by private individuals involve the billing for medical laboratory studies done by private labs, but billed through rural hospitals such that a drug screen urine test costs $2,500. Other hospitals bill insurance companies up to $10,000 for an outpatient sleep study, for which Medicare allows $180.

Two hospitals here in San Antonio bill $8,000-$10,000 for inpatient sleep studies for which Medicare allows $950. A local, private cardiac catheterization laboratory bills $99,999 as a facility fee for a cardiac pacemaker change that literally takes 30-45 minutes — and they manage to collect $75,000.

Most private emergency room facilities bill out-of-network for thousands of dollars for routine visits. Medicare patients who go to these facilities are billed outside of Medicare and held responsible for all charges. Almost all ER facilities “upcode” to a higher level of care to maximize profit. Emergency rooms historically have been operated at a loss. They are now among the most profitable centers for hospitals.

This is a national scandal and costs the insurance companies and American patients hundreds of millions of dollars a year. No one does this to Medicare, because they might go to jail. But outside of Medicare, it is a civil matter.

— Dr. Michael Wooley, San Antonio

Exorbitant bills could be avoided altogether if prices for medical treatment were standardized and publicized, David Vuk argued on Twitter.

STOP STOP STOP letting insurance companies be the middle man!! Standard prices for just about everything can and should be posted nationwide. Doctors should not have to charge insurance companies $400 to accept $150!

— David Vuk (@doesnotcompute0) October 29, 2018

— David Vuk, Eastsound, Wash.

And some aspects of the convoluted health care system may simply be above a patient’s pay grade.

Why is a dermatologist or allergist in a hospital outpatient clinic? Stanford is absolutely 100% aware that this is not patient-friendly. Patients should not be expected to understand provider-based regulations for an encounter like this one.

— Ben Carver (@bencarverclt) October 29, 2018

— Ben Carver, Charlotte, N.C.

Watch: Why Infusion Drugs Come With Sticker Shock

November 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 an Ohio mom who faced an outrageous bill for a new medicine for multiple sclerosis is part of an ongoing crowdsourced investigation by KHN and NPR.

Chronically Ill, Traumatically Billed: The $123,000 Medicine For MS

November 28, 2018

Shereese Hickson’s multiple sclerosis was flaring again. Spasms in her legs and other symptoms were getting worse.

She could still walk and take care of her son six years after doctors diagnosed the disease, which attacks the central nervous system. Earlier symptoms such as slurred speech and vision problems had resolved with treatment, but others lingered: she was tired and sometimes still fell.

This summer, a doctor switched her to Ocrevus, a drug approved in 2017 that delayed progression of the disease in clinical trials better than an older medicine did.

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Do you have an exorbitant or baffling medical bill? Join the KHN and NPR’s Bill-of-the-Month Club and tell us about your experience. We’ll feature a new one each month.

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Genentech, a South San Francisco-based subsidiary of Swiss pharma giant Roche, makes Ocrevus. It is one of several drugs for multiple sclerosis delivered intravenously in a hospital or clinic. Such medicines have become increasingly expensive as a group, priced in many cases at well over $80,000 a year. Hospitals delivering the drugs often take a cut by upcharging the drug or adding hefty fees for the infusion clinic.

Hickson received her first two Ocrevus infusions as an outpatient two weeks apart in July and August. And then the bill came.

Patient: Shereese Hickson, 39, single mother who worked as a health aide and trained as a medical coder, living in Girard, Ohio. Because her MS has left her too disabled to work, she is now on Medicare; she also has Medicaid for backup.

Total Bill: $123,019 for two Ocrevus infusions taken as an outpatient. CareSource, Hickson’s Medicare managed-care plan, paid a discounted $28,960. Hickson got a bill for about $3,620, the balance calculated as her share by the hospital after the insurance reimbursement.

Medical Service: Two Ocrevus infusions, each requiring several hours at the hospital.

Service Provider: Cleveland Clinic, a nonprofit, academic medical center in Ohio.

What Gives: Hickson researched Ocrevus online after her doctor prescribed the new medicine. “I’ve seen people’s testimonies about how great it is,” on YouTube, she said. “But I don’t think they really go into what it’s like receiving the bill.”

That was particularly shocking because, covered by government insurance for her disability, she’d never received a bill for MS medicine before.

“I have a 9-year-old son and my income is $770 a month,” said Hickson. “How am I supposed to support him and then you guys are asking me for $3,000?”

More From Our Bill Of The Month Series

Even in a world of soaring drug prices, multiple sclerosis medicines stand out. Over two decades ending in 2013, costs for MS medicines rose at annual rates five to seven times higher than those for prescription drugs generally, found a study by researchers at Oregon Health & Science University.

“There was no competition on price that was occurring,” said Daniel Hartung, the OHSU and Oregon State University professor who led the study. “It appeared to be the opposite. As newer drugs were brought to market, it promoted increased escalation in drug prices.”

With Ocrevus, Genentech did come up with a price that was slightly less than for rival drugs, but only after MS medicines were already extremely expensive. The drug launched last year at an annual list price of $65,000, about 25 percent lower than that of other MS drugs, Hartung said. MS drugs cost about $10,000 per year in the 1990s and about $30,000 a decade ago.

“We set the price of Ocrevus to reduce price as a barrier to treatment,” said Genentech spokeswoman Amanda Fallon.

It was also probably a response to bad publicity about expensive MS drugs, Hartung said. “Now companies are very aware at least of the optics of releasing drugs at higher and higher prices,” he said.

Patients starting Ocrevus get two initial infusions of 300 milligrams each and then 600 mg twice a year. Cleveland Clinic charged $117,089 for Hickson’s first two doses of Ocrevus — more than three times what hospitals typically pay for the drug, said John Hennessy, chief business development officer at WellRithms, a firm that analyzes medical bills for self-insured employers.

As is typical of government programs such as Medicare, the $28,960 reimbursement ultimately collected by the Cleveland Clinic was far less — but still substantial.

“We kind of got ourselves in a pickle here,” he said. “We’re more excited about the discount than we are about the actual price.”

Hickson’s nearly $3,620 bill represented the portion that Medicare patients often are expected to pay themselves.

Shereese Hickson, diagnosed with multiple sclerosis in 2012 and unable to work, supports herself and her son, Isaiah, on $770 a month.(Shane Wynn for KHN)

Last year, the Institute for Clinical and Economic Review, an independent nonprofit that evaluates medical treatments, completed a detailed study on MS medicines. It found that Ocrevus was one of three or four medicines that were most effective in reducing MS relapses and preventing MS from getting worse. But it also found that patient benefits from MS drugs “come at a high relative cost” to society.

At the same time, deciding which MS drug — there are about a dozen — would best suit patients is something of a shot in the dark: The science showing the comparative effectiveness of MS drugs is not as strong as it could be, researchers say.

“In general, there’s a real lack of head-to-head studies for many of these drugs,” said Hartung. The FDA has no required comparison standard for MS drugs, an agency spokeswoman said. Sometimes they’re rated against placebos. With everyone able to charge a high price, the companies have little incentive to see which works better and which worse.

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Resolution: After Hickson questioned the charges over the phone, the billing office told her to apply to the hospital for financial assistance. Hickson had to print a form, provide proof of her disabled status, mail it and wait.

Hospital officials told her in October she qualified for assistance based on her income through a state program funded by hospital contributions and federal money. Cleveland Clinic wiped out the $3,620 balance.

“I’m grateful that they approved me for that, but not everybody’s situation is like that,” she said. She was worried enough about being billed again for her next Ocrevus infusion that she considered switching back to her old medicine. But her doctor wants her to give it more time to gauge its effects.

The Takeaway: Always ask about charity care or financial assistance programs. Hospitals have different policies and wide discretion about how to apply them, but often do not even tell patients such programs exist.

Because health care costs are so high, you may be eligible even if you have a decent salary. Cleveland Clinic gives free care to everybody below a certain income, said spokeswoman Heather Phillips. But it wasn’t until Hickson called that the hospital agreed to erase the charge.

While there are multiple new drugs to treat serious chronic conditions, they have often not been tested against one another. Moreover, your doctor may have no idea about their relative prices. He or she should. For newer drugs, all options may well be very expensive.

Keep in mind that drugs which must be infused often come with facility fees and infusion charges, which can leave patients with hefty copayments for outpatient treatment. Ask about oral medicines or those you can self-inject at home.

NPR produced and edited the interview with Elisabeth Rosenthal for broadcast. Marlene Harris-Taylor, from member station Ideastream in Cleveland, provided audio reporting.

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR Bill-of-the-Month Club and tell us about your experience.

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

Trumpeted New Medicare Advantage Benefits Will Be Hard For Seniors To Find

November 09, 2018

For some older adults, private Medicare Advantage plans next year will offer a host of new benefits, such as transportation to medical appointments, home-delivered meals, wheelchair ramps, bathroom grab bars or air conditioners for asthma sufferers.

But the new benefits will not be widely available, and they won’t be easy to find.

Of the 3,700 plans across the country next year, only 273 in 21 states will offer at least one. About 7 percent of Advantage members — 1.5 million people — will have access, Medicare officials estimate.

That means even for the savviest shoppers it will be a challenge to figure out which plans offer the new benefits and who qualifies for them.

Medicare officials have touted the expansion as historic and an innovative way to keep seniors healthy and independent. Despite that enthusiasm, a full listing of the new services is not available on the web-based “Medicare Plan Finder,” the government tool used by beneficiaries, counselors and insurance agents to sort through dozens of plan options.

Even if people sign up for those plans, they won’t all be eligible for all the benefits. Advantage members will need a recommendation from a health care provider in the plan’s network. Then they may need to have a certain chronic health problem, a recent hospitalization or meet other eligibility requirements.

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Medicare counselors from California to Maine say key details are not included on the government’s website. In some cases, if insurers offer the new benefits, the plan finder “will indicate ‘yes’ or ‘no,'” said Georgia Gerdes a health care choices specialist at AgeOptions, the Area Agency on Aging in Oak Park, Ill., outside Chicago. That’s hardly enough, she said.

“There is a lot of information on the plan finder, but there is a lot of information missing that requires beneficiaries to do more research,” said Deb McFarland, Medicare services program supervisor at the Southern Maine Agency on Aging.

Nonetheless, officials say the added benefits will help Advantage members prevent costly hospitalizations. Federal approval of additional benefits is “one of the most significant changes made to the Medicare program,” Seema Verma, the head of the Centers for Medicare & Medicaid Services, told an insurers’ meeting last month. She said she expects plans to expand services in coming years.

Medicare Advantage plans, which are an alternative to traditional Medicare, serve 21 million beneficiaries and limit their out-of-pocket expenses. But they also restrict members to a network of doctors, hospitals and other medical providers. They often offer benefits not available in traditional Medicare, such as dental and vision care, hearing aids and gym memberships.

The federal government pays a set amount to the plans to help cover the cost of each member. The Trump administration gave insurers more money to spend on benefits next year — an average pay raise of 3.4 percent, seven times more than the rate of increase in 2018.

Enrollment is underway for Medicare Advantage plans, as well as for people in traditional Medicare who want to buy a policy for drug coverage. The deadline for choosing either type of plan is Dec. 7.

Among the new benefits that some Medicare Advantage plans said they will offer are:

  • Trips to the pharmacy or fitness center in addition to doctor’s appointments for plan members, depending on where they live or their health conditions.
  • A monthly or quarterly allowance for over-the-counter pharmacy products such as cold and allergy medications, eye drops, vitamins, supplements and compression stockings.
  • House calls by doctors or other health care providers, under certain conditions.
  • A home health care aide for a limited number of hours to help with dressing, eating and other daily activities, possibly including household chores and light housekeeping.

However, plans offering these and other services will likely have only some of the options and will have different eligibility criteria and other limitations. The same services likely won’t be available in every county the plan serves.

For example, next year an estimated 150,000 Humana Medicare Advantage members in Texas and South Florida — two of the 43 states Humana serves — who cannot be left alone at home will be able to get a free in-home personal care aide for up to 42 hours a year, so that their regular caregiver can get a break. And more than half of the members in Cigna-HealthSpring Advantage plans will have access to free transportation services in all but five of the 16 states and the District of Columbia where the company sells coverage.

To find these supplemental benefits, seniors can use the online plan finder. After they enter their ZIP code and get a list of plans available locally, they can click on a plan name. That will take them to another page that offers more details about coverage, including a tab for health and drug plan benefits. That page might say whether the new services are offered.

But often the website will simply indicate that specific benefits are available — and perhaps not name them — and advise consumers to contact the plan for more information. A Medicare spokesperson confirmed that there is currently not an indicator on the plan finder for plans offering these expanded health-related supplemental benefits.

In addition to extra benefits, other variables should be considered when choosing an Advantage plan, such as which health care providers and pharmacies participate in a plan’s network, which drugs are covered and the costs.

Where available, several insurers say the new services will be free with no increase in monthly premiums.

“We certainly believe that all of the ancillary benefits we provide will help keep our members healthy, which is good for them, and it’s good for us in the long run,” said Steve Warner, head of the Medicare Advantage product team at UnitedHealthcare, which insures about 5 million seniors or 1 in 4 Medicare Advantage members.

Insurers are betting that services will eventually pay for themselves.

Dawn Maroney, consumer president at Alignment Healthcare, which serves eight counties in Southern California, said it’s much cheaper to give an air conditioner to someone with congestive heart failure to keep that patient healthy than to pay for more expensive medical treatment.

But if the new benefits are such a good idea, they should be available to the majority of older adults in traditional Medicare, said David Lipschutz, a senior policy attorney at the Center for Medicare Advocacy.

For free help with Medicare Advantage and drug plan enrollment, contact the federally funded State Health Insurance Assistance Program (www.shiptacenter.org), the Medicare Rights Center, 800-333-4114 or its website, www.medicareinteractive.org. The Medicare Plan Finder website is available at https://www.medicare.gov/find-a-plan/questions/home.aspx or call 800-633-4227.

California Dreamin’? With Newsom’s Win, Single-Payer Unlikely To Follow Anytime Soon

November 07, 2018

Californians on Tuesday elected a governor who campaigned for a complete overhaul of how people get their health coverage — but they shouldn’t hold their breath.

Rather, as Gov.-elect Gavin Newsom and the Democratic-controlled legislature take steps to provide more people with health insurance, they’ll likely approach it piecemeal over several years.

Newsom himself is already tempering expectations about California’s move to a single-payer system, saying it will take more than the will of one person to realize.

“I’m not going to hesitate to be bold on this issue, and I also want to set expectations,” Newsom told reporters last week at a campaign stop in Sacramento. “It’s a multiyear process.”

The Democratic lieutenant governor easily routed Republican John Cox in the governor’s race Tuesday, with Newsom vowing to stand up to President Donald Trump and restore the “California Dream” by addressing affordable housing, health care and income inequality in the nation’s most populous state.

Newsom’s views are in stark contrast to Cox’s, who maintained that government should largely stay out of health care. The free-market businessman said single-payer would send health care costs soaring while diminishing quality, and warned that it “is a sure way to destroy the California economy.”

Like many Democrats, Newsom has described health care as a right and vowed to defend the Affordable Care Act as governor. He also criticized the legislature last year when it held up a single-payer bill that would have created one government-run public insurance program for all Californians.

He won the endorsement from the politically powerful California Nurses Association for vigorously advocating single-payer. Going slow on single-payer could test his relationship with the union, which launched a brutal attack against the Democratic state Assembly speaker when he shelved the measure last year.

It could also upset progressive Democrats and donors who are counting on action.

“This is the governor who has the best shot to get this done,” said Stephanie Roberson, the union’s director of government relations. “It takes political will and courage, and I’m going to cash in on what he said to my association.”

Now Newsom’s attitude is cautious — many say realistic — even in a state that aims to set national trends and relishes its role at the forefront of the resistance to the Trump administration.

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Last week, Newsom called single-payer the most “effective and efficient” strategy to achieve universal coverage, but he questioned whether it could be achieved at the state level, given the Trump administration’s opposition to the concept.

Trump’s top Medicare and Medicaid official, Seema Verma, last summer firmly rejected the idea that the federal government would grant the essential exemptions from federal rules to try single-payer, which she called “unaffordable” and “something that’s not going to work.” The exemptions, or waivers, are necessary because the state relies heavily on federal health care dollars that would be needed to pay single-payer costs.

Undaunted, the California Nurses Association said it intends to bring another single-payer bill before the legislature next year and has launched a national campaign to pass single-payer in other states and convince Congress of its merits.

But it’s unlikely that a single-payer bill will make it to Newsom’s desk next year, in part due to the price tag: A single-payer system could cost an estimated $400 billion annually. Lawmakers earlier this year directed a council to study the feasibility of a publicly funded health insurance plan, and its findings aren’t due until 2021 — giving the new governor and lawmakers time to punt on the issue.

Still, Democrats who head the key legislative health committees see Newsom as a partner who will be more engaged on health care than fellow Democrat Gov. Jerry Brown has been these past eight years.

“Health care has not been one of the issues that he’s been particularly focused on,” Assemblyman Jim Wood, chairman of the Assembly Health Committee, said of Brown. “I think we’ve missed some opportunities to really move forward on some policies that would be good for all Californians.”

Brown this year blocked measures that would have expanded health care coverage to some low-income unauthorized immigrants — not because he philosophically opposed the idea, lawmakers say, but because it would have required new state spending.

He also raised cost concerns about bills that would have provided state-funded tax credits and subsidies to people who buy coverage through Covered California, the state’s insurance exchange.

With a new governor, those proposals are back on the table. Newsom was, after all, the San Francisco mayor who signed off on the nation’s first universal health care program for city residents without insurance, including undocumented immigrants. And, as he has reminded reporters, he did it during a recession.

“It’s a question of what do you value, what you prioritize,” he said last week when asked how the state could afford both universal health care and his call for universal preschool.

Newsom’s campaign did not respond to questions about how he would expand coverage absent single-payer. But, earlier this year, his spokesman told California Healthline that proposals to give coverage to undocumented immigrants and earmarking state dollars to help consumers buy insurance coverage were “two major parts” of his plan to deliver health coverage to all state residents. The state’s estimated 1.8 million unauthorized immigrants, for example, make up roughly 59 percent of the state’s remaining uninsured residents, according to Covered California.

The Democratic-dominated legislature would have to approve these moves.

“We’re going to be looking at a variety of ways that we might be able to get everyone covered,” Wood said. But, he added, “it will be significantly expensive to do that.”

Wood and state Sen. Richard Pan, chair of the Senate Health Committee, said lawmakers should look at the structural issues in health care — how prices for services and pharmaceuticals are regulated and how efficiencies, improved access and curbs on costly care of chronic diseases might be achieved.

“I think it’s clear the health care landscape is a focal point for the California legislature,” said Erin Trish, associate director of health policy at University of Southern California’s Schaeffer Center. “They don’t have to push for a single-payer system to push for expanded coverage.”

Expanding health care coverage would require more state spending, but that wouldn’t necessarily mean a hit to the state economy, experts said.

After California implemented the Affordable Care Act (albeit with significant federal assistance), the state’s economy continued to grow and the number of uninsured residents fell to 7.2 percent in 2017, according to the U.S. Census Bureau.

“We’ve expanded coverage and our economy has continued to flourish,” said Dr. Andrew Bindman, a primary care physician who is also a professor at the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco, who helped draft the federal health care law. “These things are achievable, and I think California is a model of that.”

Pan, the chair of the Senate Health Committee, said he looks forward to engaging Newsom, someone who proved he could move beyond rhetoric by signing the San Francisco measure that offered more city residents health coverage.

“Hopefully, we have an opportunity to get something done,” Pan said.

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

Beyond The Buzz: What Do Americans Mean By ‘Medicare-For-All’?

November 06, 2018

https://kaiserhealthnews.files.wordpress.com/2018/11/medicare_for_all_bb.mp3
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Kaiser Health News Editor-in-Chief Elisabeth Rosenthal discussed “Medicare-for-all” and how the U.S. health system differs from others around the world on a recent episode of KERA’s “Think,” a public affairs radio talk show in Dallas. The wide-ranging interview with KERA’s Krys Boyd touched on the ideas Rosenthal and KHN correspondent Shefali Luthra wrote about in a news analysis piece co-published by The New York Times. Times readers, including several physicians, also wrote interesting responses to the analysis.

KHN’s Samantha Young also explored why many voters say they’re “just confused” as politicians across the country toss around health care catchphrases, sometimes interchangeably.

Quick: What’s The Difference Between Medicare-For-All and Single-Payer?

November 05, 2018

MODESTO, Calif. — Betsy Foster and Doug Dillon are devotees of Josh Harder. The Democratic upstart is attempting to topple Republican incumbent Jeff Denham in this conflicted, semi-rural district that is home to conservative agricultural interests, a growing Latino population and liberal San Francisco Bay Area refugees.

To Foster’s and Dillon’s delight, Harder supports a “Medicare-for-all” health care system that would cover all Americans.

Foster, a 54-year-old campaign volunteer from Berkeley, believes Medicare-for-all is similar to what’s offered in Canada, where the government provides health insurance to everybody.

Dillon, a 57-year-old almond farmer from Modesto, says Foster’s description sounds like a single-payer system.

“It all means many different things to many different people,” Foster said from behind a volunteer table inside the warehouse Harder uses as his campaign headquarters. “It’s all so complicated.”

Across the country, catchphrases such as “Medicare-for-all,” “single-payer,” “public option” and “universal health care” are sweeping state and federal political races as Democrats tap into voter anger about GOP efforts to kill the Affordable Care Act and erode protections for people with preexisting conditions.

Republicans, including President Donald Trump, describe such proposals as “socialist” schemes that will cost taxpayers too much. They say their party is committed to providing affordable and accessible health insurance, which includes coverage for preexisting conditions, but with less government involvement.

Voters have become casualties as candidates toss around these catchphrases — sometimes vaguely and inaccurately. The sound bites often come across as “quick answers without a lot of detail,” said Gerard Anderson, a professor of public health at the Johns Hopkins University Bloomberg School Public Health.

“It’s quite understandable people don’t understand the terms,” Anderson added.

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For example, U.S. Sen. Bernie Sanders (I-Vt.) advocates a single-payer national health care program that he calls Medicare-for-all, an idea that caught fire during his 2016 presidential bid.

But Sanders’ labels are misleading, health experts agree, because Medicare isn’t actually a single-payer system. Medicare allows private insurance companies to manage care in the program, which means the government is not the only payer of claims.

What Sanders wants is a federally run program charged with providing health coverage to everyone. Private insurance companies wouldn’t participate.

In other words: single-payer, with the federal government at the helm.

Absent federal action, Democratic gubernatorial candidates Gavin Newsom in California, Jay Gonzales in Massachusetts and Andrew Gillum in Florida are pushing for state-run single-payer.

To complicate matters, some Democrats are simply calling for universal coverage, a vague philosophical idea subject to interpretation. Universal health care could mean a single-payer system, Medicare-for-all or building upon what exists today — a combination of public and private programs in which everyone has access to health care.

Others call for a “public option,” a government plan open to everyone, including Democratic House candidates Antonio Delgado in New York and Cindy Axne in Iowa. Delgado wants the public option to be Medicare, but Axne proposes Medicare or Medicaid.

Are you confused yet?

Sacramento-area voter Sarah Grace, who describes herself as politically independent, said the dialogue is over her head.

“I was a health care professional for so long, and I don’t even know,” said Grace, 42, who worked as a paramedic for 16 years and now owns a holistic healing business. “That’s telling.”

In fact, most voters approached for this article declined to be interviewed, saying they didn’t understand the issue. “I just don’t know enough,” Paul Her of Sacramento said candidly.

“You get all this conflicting information,” said Her, 32, a medical instrument technician who was touring the state Capitol with two uncles visiting from Thailand. “Half the time, I’m just confused.”

Paul Her, 32, a medical instrument technician from Sacramento, says he’s “just confused” by the conflicting health care pitches he hears from politicians. (Samantha Young/KHN)

The confusion is all the more striking in a state where the expansion of coverage has dominated the political debate on and off for more than a decade. Although the issue clearly resonates with voters, the details of what might be done about it remain fuzzy.

A late-October poll by the Public Policy Institute of California shows the majority of Californians, nearly 60 percent, believe it is the responsibility of the federal government to make sure all Americans have health coverage. Other state and national surveys reveal that health care is one of the top concerns on voters’ minds this midterm election.

Democrats have seized on the issue, pounding GOP incumbents for voting last year to repeal the Affordable Care Act and attempting to water down protections for people with preexisting medical conditions in the process. A Texas lawsuit brought by 18 Republican state attorneys general and two GOP governors could decimate protections for preexisting conditions under the ACA — or kill the law itself.

Republicans say the current health care system is broken, and they have criticized the rising premiums that have hit many Americans under the ACA.

Whether the Democratic focus on health care translates into votes remains to be seen in the party’s drive to flip 23 seats to gain control of the House.

The Denham-Harder race is one of the most watched in the country, rated too close to call by most political analysts. Harder has aired blistering ads against Denham for his vote last year against the ACA, and he sought to distinguish himself from the incumbent by calling for Medicare-for-all — an issue he hopes will play well in a district where an estimated 146,000 people would lose coverage if the 2010 health law is overturned.

Yet Harder is not clinging to the Medicare-for-all label and said Democrats may need to talk more broadly about getting everyone health care coverage.

“I think there’s a spectrum of options that we can talk about,” Harder said. “I think the reality is we’ve got to keep all options open as we’re thinking towards what the next 50 years of American health care should look like.”

To some voters, what politicians call their plans is irrelevant. They just want reasonably priced coverage for everyone.

John Byron, a 73-year-old retired grandfather from Modesto, wants a government-run health care system that doesn’t include private insurance companies. What politicians call the program is irrelevant to him, he says. (Samantha Young/KHN)

Sitting with his newspaper on the porch of a local coffee shop in Modesto, John Byron said he wants private health insurance companies out of the picture.

The 73-year-old retired grandfather said he has seen too many families struggle with their medical bills and believes a government-run system is the only way.

“I think it’s the most effective and affordable,” he said.

Linda Wahler of Santa Cruz, who drove to this Central Valley city to knock on doors for the Harder campaign, also thinks the government should play a larger role in providing coverage.

But unlike Byron, Wahler, 68, wants politicians to minimize confusion by better defining their health care pitches.

“I think we could use some more education in what it all means,” she said.

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

Billions In ‘Questionable Payments’ Went To California’s Medicaid Insurers And Providers

November 01, 2018

California’s Medicaid program made at least $4 billion in questionable payments to health insurers and medical providers over a four-year period because as many as 453,000 people were ineligible for the public benefits, according to a state audit released Tuesday.

In one case, the state paid a managed-care plan $383,635 to care for a person in Los Angeles County who had been dead for more than four years, according to California State Auditor Elaine Howle.

She said she found “pervasive discrepancies” in Medicaid enrollment in which state and county records didn’t match up from 2014 to 2017, leading to other errors that persisted for years. The bulk of the questionable payments, or $3 billion, went to health plans that contract with the state to care for 80 percent of enrollees in California’s Medicaid program, known as Medi-Cal.

The program for low-income residents is the nation’s largest and funded by both the federal and state governments. The state findings echo similar problems cited by federal officials and come at a time when the Trump administration has applied extra scrutiny to California’s spending on Medicaid.

In the report, the state auditor said it’s critical for the state to have accurate information on eligibility “because it pays managed care plans a monthly premium for an increasing number of Medi-Cal beneficiaries regardless of whether beneficiaries receive services.”

(Story continues below.)

California paid a managed-care plan $383,635 to care for a person in Los Angeles County who had been dead for more than four years.

California’s Medicaid program has 13.2 million enrollees, covering about 1 in 3 residents. It has an annual budget of $107 billion, counting federal and state funds. Nearly 11 million of those enrollees are in managed care plans, in which insurers are paid a monthly fee per enrollee to coordinate care.

The state’s Medicaid enrollment soared by more than 50 percent since 2013 due to the rollout of the Affordable Care Act and the expansion of Medicaid. Enrollment grew from 8.6 million in December 2013 to more than 13 million in December 2017, according to the audit report.

In the case of the dead patient, a family member had notified the county of the enrollee’s death in April 2014. However, the person’s name remained active in the state system, and California officials assigned the patient to a managed-care plan in November of that year.

From then on, the state kept making monthly payments of about $8,300 to the health plan until August 2018, shortly after the auditor alerted officials of the error. Auditors didn’t identify the health plan.

There also were costly mistakes in cases in which Medi-Cal pays doctors and hospitals directly for patient care – a program known as “fee for service.”

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For instance, the state auditor found that Medi-Cal paid roughly $1 million in claims for a female patient in Los Angeles County from June 2016 to December 2017 even though the county office had determined in 2016 that she was ineligible.

In a written response to the auditor, the California Department of Health Care Services said it agreed with the findings and vowed to implement the auditor’s recommendations. However, the agency warned it may not meet the auditor’s timeline, which called for the main problems to be addressed by June 2019.

In a statement to California Healthline, the agency said it is implementing a quality control process and “where appropriate, DHCS will recover erroneous payments.”

Early on in 2014, as the ACA rolled out, the state struggled to clear a massive backlog of Medi-Cal applications, which reached about 900,000 at one point. There were widespread computer glitches and consumer complaints amid the increased workload at the county and state level.

In addition to questionable payments for care of ineligible enrollees, Howle and her audit team also discovered some patients who may have been denied benefits improperly. The state auditor identified more than 54,000 people who were deemed eligible by county officials but were not enrolled at the state level. As a result, those people may have had trouble getting medical care.

In February, a federal watchdog estimated that California had signed up 450,000 people under Medicaid expansion who may not have been eligible for coverage.

The inspector general at the U.S. Department of Health and Human Services said California made $1.15 billion in questionable payments during the six-month period it reviewed, from Oct. 1, 2014, to March 31, 2015.

In August, Seema Verma, administrator of the U.S. Centers for Medicare and Medicaid Services, told a U.S. Senate committee that she was closely tracking California to ensure the state “returns a significant amount of funding owed to the federal government related to the state’s Medicaid expansion.”

Verma expressed concern that states had overpaid managed-care plans during the initial years of Medicaid expansion, resulting in “significant profits for insurance companies.” By year’s end, she said she expects the federal government to recoup about $9.5 billion from California’s Medicaid program, covering overpayments from 2014 to 2016.

Tony Cava, a spokesman for Medi-Cal, said the state has already returned about $6.9 billion to the federal government and expects more than $2 billion more to be sent back by December.

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

Pricey Precision Medicine Often Financially Toxic For Cancer Patients

November 01, 2018

Kristen Kilmer hugs her 12-year-old daughter at their home in Spearfish, S.D.(Kristina Barker for KHN)

When Kristen Kilmer was diagnosed with incurable breast cancer at age 38, her first thought was of her 8-year-old daughter. Kilmer lost her own mother as a teenager and was determined to get more time with her only child.

Kilmer searched for experimental treatments, opting for an unproven approach in which researchers select drugs based on the genes in patients’ tumors. Doctors have selected her treatments for the past three years based on the unique, ever-changing DNA of her cancer cells. Now 41, Kilmer has responded better than anyone dared to hope. Her cancer has gone into hiding; her tumors are no longer visible on medical scans.

This story also ran on USA Today. This story can be republished for free (details). Researchers call the strategy “precision medicine.”

Kilmer’s insurance company calls it experimental. As a consequence, her insurer has covered only a fraction of her care, forcing Kilmer to make an agonizing choice: stop taking a drug that costs nearly $17,000 a month or pay out-of-pocket, burdening her family with tremendous debt.

“When you are looking at your daughter, you ask yourself, ‘Do I take a medication that might allow me to see her graduate high school?’” asked Kilmer, of Spearfish, S.D. “Or do you stop taking it to avoid causing her financial harm?”

Kristen Kilmer says she would rather go without her cancer treatment than financially burden her daughter and husband, Chet Kilmer.(Kristina Barker for KHN)

The high cost of cutting-edge tests and treatments is threatening to keep precision medicine — one of the most celebrated areas in cancer research — out of reach for many patients. Patients who pay for these new treatments on their own “could be in debt for decades,” said Dr. Scott Ramsey, director of the Hutchinson Institute for Cancer Outcomes Research in Seattle.

Already cancer care is hugely expensive. A recent study in the American Journal of Medicine found that 42 percent of patients depleted 100 percent of their assets — an average loss of $92,000 — within two years of diagnosis.

Precision medicine involves running expensive tests called genomic sequencing, which scan the DNA of tumors to find mutations that might be susceptible to available drugs. Although the field is relatively new, hundreds of thousands of cancer patients have had their tumors sequenced to identify cancer-related mutations, according to testing companies.

Medicare, the government insurance plan for people 65 and older, announced in March that it will pay for genomic testing for people with advanced cancers — a decision that could add $2.5 billion to federal health care costs, according to a May analysis in Health Affairs.

Few private insurers cover the tests, leaving some patients with surprise medical bills.

Carrie Wyman, who also has advanced breast cancer, discovered that her insurance plan doesn’t cover genomic sequencing only after she received a $5,800 statement.

“I just assumed it would be covered,” said Wyman, 50, a resident of La Plata, Md., who has six children and stepchildren. “I was blindsided, to be honest with you.”

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Looking For Financial Assistance

Yet paying for that initial test is just the beginning. As Kilmer learned, finding the money for ongoing treatment is far more challenging, said Dr. Gary Lyman, who studies way to improve health care quality at Seattle’s Fred Hutchinson Cancer Research Center.

In some cases, genomic tests match patients to experimental drugs available only in clinical trials. Although these trials sometimes provide free medications, many cancer patients can’t afford to travel to participate in them. Kilmer drives 12 hours round-trip every month to participate in a clinical trial in Sioux Falls, S.D. The expenses add up quickly, she said.

Kilmer, who was diagnosed with incurable breast cancer at 38, takes Lynparza, which costs nearly $17,000 per month. (Kristina Barker for KHN)

Kilmer spreads out her daily medications, including Lynparza (center).(Kristina Barker for KHN)

Kilmer’s genomic tests identified a rearrangement in the PALB2 gene. Preliminary studies suggest that tumors with this genetic rearrangement could be susceptible to the drug Lynparza, but those effects haven’t been definitively proven in large-scale studies. The Food and Drug Administration has approved Lynparza only for breast cancer patients with a mutation called BRCA.

Legally, doctors can prescribe Lynparza “off label” to anyone with cancer. But insurance programs are reluctant to cover off-label treatments, unless they’re specifically recommended in expert guidelines.

Kilmer has spent much of the past three years battling insurance officials and begging drug companies for financial assistance. The drugmakers have been generous, allowing her to take a rotating cocktail of experimental drugs for free because of her modest income.

In September, however, AstraZeneca decided to end Kilmer’s financial aid. Kilmer appealed the drug company’s decision.

Paying thousands of dollars a month is not an option, Kilmer said. Her family already carries significant credit card debt from earlier cancer treatments. She estimates that she has spent about $80,600 out-of-pocket treating her illness, including $23,600 on her early breast cancer therapy and $57,000 treating metastatic disease.

Kilmer said she would rather stop taking Lynparza than financially burden her daughter and husband, a truck driver.

“It’s not worth it,” Kilmer said. “I will not put my family into that kind of debt.”

Kristen and Chet Kilmer, a truck driver, outside their home in Spearfish, S.D.(Kristina Barker for KHN)

Uncertain Benefits

Insurers say costs aren’t their only concern. Evidence is lacking that the precision medicine approach will work consistently, they argue.

America’s Health Insurance Plans, an industry group, said genetic sequencing remains unproven.

Cathryn Donaldson, the group’s spokeswoman, described recent scientific advances as “remarkable and noteworthy.” But she said insurers “need a more definitive answer” about whether the tests help the average patient live longer.

The South Dakota State Employee Health Plan — which runs Kilmer’s insurance plan — said it bases its coverage decisions on science and reviews “published, randomized data about the safety and efficacy of the requested drugs.”

Although genetic testing has become the standard of care for melanoma and a common type of lung cancer, no one knows if genomic sequencing will extend the lives of people with other types of cancer, said Dr. Carolyn Presley, an assistant professor at the Ohio State University Comprehensive Cancer Center.

In early October, after Kaiser Health News began researching Kilmer’s story, she learned that AstraZeneca has agreed to continue providing Lynparza for free.(Kristina Barker for KHN)

Without insurance coverage, some cancer patients simply give up on treatment.

A study of more than 1,000 women with advanced breast cancer — presented at a September meeting of the American Society of Clinical Oncology — found that 54 percent had stopped or refused treatment due to cost. The women in the study may have been more vulnerable than most, because 30 percent were uninsured, about twice the national rate.

In an August study in JAMA, researchers found that relatively few of those who hoped to benefit from precision medicine actually ended up on a medication. Just 15 percent of those who underwent genomic sequencing ended up taking a targeted therapy, according to the study. The study didn’t ask participants why they failed to get a targeted drug, but Presley, the lead author, said it’s likely that some patients couldn’t afford them.

“We’re finding the mutations, but patients aren’t getting the drugs,” Presley said. Without insurance, she said, “you and I would not be able to afford these medications. It’s a huge barrier.”

Within hours of the publication of this story, AstraZeneca called Kilmer to notify her that it would continue to provide financial aid. Her medication arrived in the mail the next day.

“It’s a huge relief,” Kilmer said.

KHN’s coverage of these topics is supported by Laura and John Arnold Foundation and Gordon and Betty Moore Foundation

That’s A Lot Of Scratch: The $48,329 Allergy Test

October 29, 2018

Janet Winston had a rash that wouldn’t go away.

The English professor from Eureka, Calif., always had been sensitive to ingredients in skin creams and cosmetics. This time, however, the antifungal cream she was prescribed to treat her persistent rash seemed to make things worse. Was she allergic to that, too?

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Winston, 56, who works at Humboldt State University, knew the dermatologist in her rural Northern California town was booked months in advance. So, as she often does for specialized treatment, she turned to Stanford Health Care, a nearly six-hour drive south. She hoped to finally clear up her rash and learn what else she might be allergic to — for years, she had avoided lipstick and other skin products.

Winston said that 119 tiny plastic containers of allergens were taped to her back over three days of testing. Winston ultimately learned that she was allergic to — among other things — linalool (a compound of lavender and other plants), the metals gold, nickel and cobalt, the ketoconazole cream prescribed to treat her persistent rash, the antibiotic neomycin, a clothing dye, and a common preservative used in cosmetics.

Her Stanford-affiliated doctor had warned her that the extensive allergy skin-patch testing she needed might be expensive, Winston said, but she wasn’t too worried. After all, Stanford was an in-network provider for her insurer — and her insurance, one of her benefits as an employee of the state of California, always had been reliable.

Then the bill came.

Patient: Janet Winston, 56, of Eureka, Calif., English professor at Humboldt State University

Total Bill: $48,329, including $848 for the time Winston spent with her doctor. Winston’s health insurer, Anthem Blue Cross, paid Stanford a negotiated rate of $11,376.47. Stanford billed Winston $3,103.73 as her 20 percent share of the negotiated rate.


Service Provider: Dr. Golara Honari of Stanford Health Care’s outpatient dermatology clinic in Redwood City, Calif.

Medical Procedures: Extensive allergy skin-patch testing to determine what substances caused Winston’s contact dermatitis, or skin rashes.

Winston, a professor at Humboldt State University, pores over her bill at home.(Alexandra Hootnick for KHN)

“I was grateful I had such wonderful care at Stanford,” Winston said, “but I was pretty outraged they could charge that. … No one cut into me. No one gave me anesthesia. I had partly open plastic containers filled with fluid taped to my back.”

What Gives: Medical billing analysts told Kaiser Health News that Stanford’s charges for Winston’s allergy patch test appeared excessive. They were surprised to hear that Winston’s insurer, Anthem Blue Cross, paid Stanford more than $11,000 for the treatment.

Stanford’s list price, however, is a whopping $399 per allergen.

“That charge is astronomical and nuts,” said Margaret Skurka, a retired professor of health informatics at Indiana University and a medical coding and billing consultant who advises hospitals and providers. She reviewed Winston’s bill.

The “usual, customary and reasonable” charge for testing a single allergen in the high-cost San Francisco Bay Area is about $35, said Michael Arrigo, a San Francisco-based medical billing expert witness who also reviewed Winston’s bill. “The data seems pretty conclusive that the charges in this case are inflated.”

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For the type of allergy skin-patch testing Winston received, the average charge physicians submitted to Medicare — an important data point for private insurers — was about $16 per allergen in 2016, according to Medicare payment data.

An Anthem spokesman noted that one of the insurer’s examiners did review the bill but could not say whether it received extra scrutiny because of its high cost. “We try to strike a balance between protecting affordability and providing a broad network of providers to create choices,” Eric Lail said in an emailed statement.

Winston’s case highlights how some health providers set exorbitant rates, knowing they’ll ultimately be paid a lesser amount. Patients rarely pay these rates — known as “chargemaster” or list prices — and they can generate headlines for the $100 aspirin. But such list prices, as the starting point for negotiations and discounts, do help determine the amounts insurers pay, and ultimately what patients pay as their share of cost.

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Stanford Health Care also has a lot of power in dealing with insurers like Anthem Blue Cross. The academic medical system includes hospitals and outpatient clinics across the San Francisco Bay Area as well as a number of large doctor practices in the region. That kind of consolidation and market power can raise health care prices. Insurers in the region have long grappled with Stanford’s high costs, at times withdrawing the health system from their networks. But the breadth and depth of the academic medical system — not to mention its popularity with high-end customers in the Bay Area — makes it difficult for insurers to exclude a powerhouse like Stanford from a network for long.

Some of the products that Winston’s allergy skin-patch testing revealed she can no longer use.(Alexandra Hootnick for KHN)

A study recently published in Health Affairs found that such consolidation in California has caused health care costs to spike for both patients and insurers.

Patrick Bartosch, a spokesman for Stanford Health Care, said that Winston’s doctor customized her treatment rather than using off-the-shelf patch tests. The university health system operates a large allergen bank of its own, he said.

“In this case, we conducted a comprehensive evaluation of the patient and her environmental exposures and meticulously selected appropriate allergens, which required obtaining and preparing putative allergens on an individual basis,” Bartosch said in an emailed statement.

Leemore Dafny, a Harvard University health care economist, said big health systems like Stanford’s — which owns multiple hospitals and outpatient clinics — can pressure insurers to pay big.

“Everyone wants to point fingers at the providers, but … a lot of times [insurers] roll over and pay the rates,” she said.

In other words, Stanford charged Winston’s insurer $48,000 because it could.

Janet Winston’s original bill from Stanford Health Care. The bill detailed costs of $48,329.00 for allergy skin-patch testing. Winston negotiated her share of the bill down by 50 percent.(Alexandra Hootnick for KHN)

Resolution: After some bargaining with Stanford’s billing department, Winston ultimately paid $1,561.86 out-of-pocket. She made the argument that her doctor had told her the cost per allergen would be about $100, not nearly the $400 Stanford ultimately charged her insurer.

The Takeaway: Insurers often tell patients to “shop around” for the best price and to make sure they choose in-network providers to avoid surprises. Winston did everything right and still got caught out. As a state employee, she had great insurance and Stanford was an in-network provider. Winston said her doctor warned her the test would be expensive, but she never anticipated that could mean close to $50,000. So don’t be afraid to ask for specific numbers: “Expensive” and “cheap” can have hugely different meanings in the high-priced U.S. health system.

Clearly uncomfortable with the charges, Winston’s physician advised her — in advance — to contest it with Stanford’s billing department. So she did, and Stanford gave her a nearly 50 percent discount for her coinsurance share of the bill. It never hurts to ask.

The allergy skin-patch testing Winston underwent revealed she is allergic to numerous metals and other substances, including linalool, a naturally occurring terpene alcohol in many flowers and spice plants. Winston still can handle roses from her garden, which contain linalool, but she cannot wear perfumes and cosmetic products that contain the compound.(Alexandra Hootnick for KHN)

Still, Stanford received more than $12,000 total from Winston and her insurer for allergy patch tests — a cost that is borne by insurance policyholders and taxpayers. Researchers have linked consolidation by Northern California providers such as Stanford and Sutter Health to higher health costs for the region’s consumers. A local health workers union also has taken aim at Stanford’s costs with two city ballot initiatives that attempt to rein in what Stanford and other health providers can charge patients in Palo Alto and Livermore.

“I was grateful I had so much insurance, and that it was in-network, and I could afford the [final] bill,” Winston said. “On the other hand, I thought, ‘How can they get away with this?’ Most Americans could never afford this procedure, at least at this facility, and it made me think about the grand piano in the lobby.”

NPR produced and edited the interview with Elisabeth Rosenthal for broadcast. April Dembosky, from member station KQED, provided audio reporting.

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR Bill-of-the-Month Club and tell us about your experience.

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

Readers And Tweeters: Are Millennials Killing The Primary Care Doctor?

October 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.

Health Care Wasted On The Young

I feel Sandra Boodman’s thesis is inadequate without a historical comparison to how young people accessed health care five, 10 or 20 years ago (“Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model,” Oct. 9). As a family medicine doctor practicing for 33 years, my experience is that healthy young people use medical services only for urgent care and pregnancy until they develop chronic conditions. And, as a society in general, we have become more demanding about receiving services “now.”

Why should medical care not change as our expectations change? Certainly we have the technological ability to provide a portable health record one could take from site to site to improve continuity. We also have the ability to have a single electronic medical record or shared information hub so one’s health info can be accessed by any provider anywhere.

However, demanding “now” care at any convenient site does not allow one provider to get to know a person in a way to better inform them of how that individual’s situation (emotional-social-economic) impacts their health. So, convenience has its price.

— Dr. Kevin Walsh, Ellensburg, Wash.

Family physician Ajoy Kumar of Florida led a lively debate on Twitter and, in a series of tweets, emphasized how important it is to build doctor-patient relationships early because “nobody is young and healthy forever.”

“In the first 30 years of your life, you make your habits. For the last 30 years of your life, your habits make you.” Sure, everyone looks and feels great when they are young, and while you may think it will be that way forever choices and lifestyle in adulthood creep up on you.

— Ajoy Kumar, MD, FAAFP (@ajoykumarmd) October 10, 2018

— Dr. Ajoy Kumar, St. Petersburg, Fla.

It’s not so much the new generation as it is the age group. I didn’t have a primary care physician from the time I entered university until I was 42. I also only went to the doctor when I had a particular problem to deal with. Even back then (25-30 years ago), a $200 deductible meant I could pay for insurance but could not afford to use it for anything other than a dire emergency. Of course, back then almost everything was traditional indemnity, so we all paid full-freight unless you were covered by one of the nascent HMOs (which often controlled costs by denying care).

— Brenda F. Bell, North Plainfield, N.J.

Another primary care doctor bemoaned the trend as part of a larger move away from generalized medicine:

Part and parcel with how much medicine has changed with regards to specialization and fragmentation of care . As a primary care physician for over 20 yrs, I find this trend less satisfying

— H Mitchell (@Hollyfrog88) October 10, 2018

— Dr. Holly Mitchell, Amarillo, Texas

As long as we are talking about new models for medicine, here’s a plea for “human-centered design thinking”:

The young immortals are clear about how they want to access care. Now how to support Primary Care in making the connection? Seems ripe for Human Centered Design Thinking. Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model https://t.co/FNosdacs6o via @khnews

— Julie Schilz (@J_Schilz) October 10, 2018

— Julie Schilz, Northglenn, Colo.

Laryngitis On The Campaign Trail?

It isn’t surprising that health care is a priority issue for voters (“Health Care Tops Guns, Economy As Voters’ Top Iissue,” Oct. 18). After all, the chief cause of personal bankruptcy is medical bills. Nor is it surprising that voters have not heard much about health care from midterm election candidates, who know the future success or failure of the health system and their political futures depend on how they respond to voters’ top concerns. It is much safer for our political leaders to leave the administration of the health system to the insurance companies.

But, so far, private insurers have shown they are more concerned with shareholders’ concerns than patients’. The result is a fragmented, impersonal health system overrun by multiple insurance plans, each with different copays, deductibles and insurance panels — where doctors are held captive by insurers’ regulations. If we vote people into office because we believe they will respond to our needs, why are so many of them so quiet on health care?

— Dr. Edward Volpintesta, Bethel, Conn.

Metrics Show Medicaid Is True To Its Mission

Both Medicaid enrollees and taxpayers see real results from Medicaid health plans — despite contrary claims (“As Billions In Tax Dollars Flow To Private Medicaid Plans, Who’s Minding The Store?” Oct. 19). Medicaid plans are held to high standards by the states, improving health, quality and savings for millions of Americans, including children, veterans, seniors and people with disabilities.

Medicaid plans run many programs to improve patient health — driving quality, coordinating care, and helping patients stay compliant with treatment. The vast majority of every Medicaid dollar pays for care, while Medicaid plan profit margins average less than 2 percent.

Medicaid plans report metrics that are made public. Results show that insurance providers saved states about $7 billion in 2016 alone — helping states realize the highest value for their Medicaid investment. Research shows that Medicaid enrollees have access to care that is similar to those who have coverage through their jobs, and are satisfied with their coverage.

Medicaid serves nearly 75 million Americans. Insurance providers know that Medicaid must work for those who rely on it — and the hardworking taxpayers who pay for it. We are committed to working together to ensure that Medicaid is effective, affordable and accountable.

— Matt Eyles, president and CEO of America’s Health Insurance Plans (AHIP), Washington, D.C.

A tweeter reading the same story noted the outsize level of Medicaid oversight compared with that of corporate America.

For people getting healthcare via Medicaid: tight scrutiny, work requirements, etc. For corporations getting hundreds of billions (more than military contractors!), not so much. https://t.co/xMxA6BRXiL via @khnews

— Fran Quigley (@FranQuigley) October 19, 2018

— Fran Quigley, Indianapolis

Imagine No Big Pharma

I know that we are all supposed to think the pharmaceutical industry is the savior of our country and that without them life itself would not be possible. What if we instead began to think of them as just the manufacturers of medication? What if we did our own drug research (maybe researching medication to treat millions instead of medication to make millions) and collected bids from every drug manufacturer for production only? What if we used tax dollars to pay for the manufacturing of the medications, and patients had to pay only a token pharmacy fee? I wonder what that would look like.

— Dr. David Herring, Staunton, Va.

Unamusing Cartoon

The publication by Kaiser Health News of a Nick Anderson cartoon with the caption “Inadequate Mental Health Services” above a picture of a prescription bottle reading “RX for Violence” from which bullets spill forth, is both surprising and deeply disappointing (‘Alternative Treatment’? Oct. 18).

How easy it is to imply that gun violence, indeed violence of any type, is largely attributable to untreated or undertreated, mental health conditions. But the facts, which I and millions of readers have come to expect from KHN, say otherwise. Mass shootings, the thought of which this cartoon invokes, account for less than 1 percent of gun violence, and for which mental health is a factor in but a small minority of cases. And while suicides are in fact increasing, and 85% of completed suicides involve guns, this too is only a small fraction (about 2%) of gun violence in the U.S.

It would be expected that KHN editors would be familiar with the oft-cited statistic that only about 4% of all violence may be attributed to people with serious mental illness, and the fact people with mental health conditions are far more likely to fall victim to violence than to perpetuate it against others.

As a trusted source of factual news, it is shocking that Kaiser would perpetuate and reinforce the erroneous, albeit widely held belief, that mental illness (treated or not) equates to gun violence.

— Debbie Plotnick, vice president for mental health and systems advocacy, Mental Health America, Alexandria, Va. 

I appreciate the perspective that inadequate mental health services can lead to negative consequences for the individual and, ultimately, for society. However, the implied connection between mental illness and violence is unfairly stigmatizing and not supported by evidence. In addition, the use of a prescription bottle seems to suggest that medication is the prescription for “adequate mental health services,” which vastly oversimplifies the need for a range of services that should be included in an effective, comprehensive system of care. I hope that you will consider removing this cartoon from your website, as it is harmful to engaging and truly supporting people with mental health needs.

— Jenifer Urff, Northampton, Mass.

A Call For Deeper Reporting

I was disappointed by Phil Galewitz’s reporting on the negative aspects of Medicare Advantage HMOs (“Medicare Advantage Plans Shift Their Financial Risk To Doctors,” Oct. 8), although it was nice that he quoted me and that you incorporated “risk shifting” into the headline. Galewitz cites a Health Affairs report but should have mentioned years of reports by the Government Accountability Office and the Medicare Advisory Payment Commission detailing overpayments and risk analysis and overpayments. There is a big dark side to Medicare Advantage plans that patients/consumers do not understand. They think it’s all about “free” care. It is hard to sue these HMOs for medical malpractice and failure to coordinate and manage care — which is what they promise to do. Medicare Advantage needs more critical reporting.

—Dr. Brant S. Mittler, San Antonio, Texas

For a Georgia reader, the story raised more questions:

Isn't this just going to encourage doctor's to do the cherry picking now that insurance companies can't? And what happens when those patients age and have serious health issues? Will those doctors just close practices and dump those patients?

— cminmd (@cminmd) October 9, 2018

— Colleen Mahaney, Woodstock, Ga.

On Shooting Down Sky-High Bills …

We in Montana were frustrated in our process to address the balance billing issues for air ambulance, with little success (“Will Congress Bring Sky-High Air Ambulance Bills Down To Earth?” Sept. 27). But the issue arises from insurance companies inserting a coverage cap in the policy, stacking deductibles for in- and out-of-network carriers. Much about this issue is aimed at air companies. They are solely responsible for their charge practices. But insurers also share the responsibility for their decisions to put those who are insured at risk as they seek to constrain premiums by policy design.

— Bob Olsen, Helena, Mont.

… And Missing The Mark?

The Oct. 19 Facebook Live broadcast (“Facebook Live: What About Those Sky-High Air Ambulance Bills?”) failed to note critical facts and provided misinformation. Alarmingly, this may cause patients to question whether they should board an air medical flight even when their physicians or first responder requests the transport based on patient need. We’d like to set the record straight.

1. Insurance Coverage

FACT: Dr. Naveed Kahn’s insurer’s payment was far lower than the actual bill, and air medical services, like all health care providers, are required by federal law to “balance bill” the patient the remainder. Dr. Kahn’s insurance company failed to adequately cover his bill.

[Editor’s note: KHN’s coverage did not focus on the mechanics of “balance billing,” but rather the prohibitive amount of the original bill.]

2. State Regulation

FACT: States can and do regulate air ambulances. Court decisions and Department of Transportation opinions have reaffirmed states’ authority to regulate all medical aspects of air medical transportation. This includes standards and coordination of patient care, including protocols controlling which air medical operator is called to a scene. Air medical operators never self-dispatch; they are called by trained first responders and medical personnel, operating under state authority.

3. Medicare Fee Schedule

FACT: The implementation of the Medicare Fee schedule did not increase rates for air ambulance services; it changed the way air ambulances are reimbursed, increasing the rates for some and dramatically decreasing the rates for others. While the data demonstrates the industry has grown over the last 37 years, according to “An Economic Analysis of the U.S. Rotary Wing Air Medical Transport Industry”, 22 of those growth years occurred before the implementation of the Medicare Fee Schedule.

Industry growth, over a 30-year period, reflects growth in demand for air medical transport services in response to continued closures of rural hospitals and trauma centers. Air ambulances are filling that gap — more aircraft means better coverage and better outcomes.

— Carter Johnson, SOAR (Save Our Air Medical Resources) Campaign, Washington, D.C.

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

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