What’s Buzzing – Page 6

Congress extends Medicare telehealth coverage through March 31, 2025

Shortly after the onset of the Covid pandemic, Medicare began covering telehealth services for all of its enrollees. It has been doing so ever since. Last week, Congress continued the Medicare telehealth program through the end of March 2025, reports Paula Span for the New York Times.

Medicare’s telehealth coverage allows older adults and people with disabilities to see their doctors without ever leaving their homes. Consequently, a cancer patient with severe pain in Indianapolis can receive palliative care from a physician in Manhattan, and Medicare will cover it. Palliative care focuses on the comfort and quality of life of the patient.

Experts believe that the incoming Republican administration will continue to support Medicare coverage of telehealth services. It has bipartisan support. Time will tell.

Today, about one in seven Medicare patients rely on telehealth services, way down from early pandemic days when about half of the Medicare population relied on telehealth for their care. But, use of telehealth services is substantially higher than in pre-pandemic days.

Telehealth can fill a range of medical needs, especially when specialists in an area are in short supply and for patients who are hard-pressed to travel. It can reduce travel for patients who might be able to get to the doctor for tests, but don’t need to see the doctor in person to discuss the test results. And, it can help people avoid a visit to the emergency room, in some cases.

The question remains as to the relative benefits and costs of telehealth. How effective is it? How much value does it deliver? How susceptible is telehealth to fraud? For example, pharmaceutical companies can market their drugs online and then use telehealth to fill more of their prescriptions.

For some people, accessing a video link to receive telehealth services is challenging. And, some data suggest telehealth patients cost Medicare somewhat more, driving up Medicare spending. But, overall, telehealth makes getting care a lot easier and faster, particularly for people who are hard-pressed to travel.

Here’s more from Just Care:

January 7, 2025

Millions of adults still carry significant student debt

The Biden Administration tried to eliminate some student debt. But, a federal appeals court stopped the Saving on a Valuable Education Plan (SAVE) from moving forward, while it considers its legality. Instead the eight million people who had enrolled in SAVE still face considerable debt. Oyin Adedoyin reports for the Wall Street Journal on the likely future for these people during a second Trump administration.

Millions of Americans are burdened by student loans, including nearly three million older adults. Older adults also owe more than $54 billion in medical debt. But, relief is nowhere in sight for them or for tens of millions of other Americans with student debt or medical debt.

People with student debt are at a loss as to what to do. Many are part of a public-service loan forgiveness initiative. They expected the balances on their loans to be eradicated once they had made 120 monthly payments. And, they had planned for that future.

People who are part of the SAVE program are in limbo at the moment. They need not pay anything on their loans, and they will not be penalized for doing nothing. But, until the lawsuit ends, they are stuck.

Around a million public-service workers in SAVE thought their monthly loan repayments would come down around $1,000 a year, on average, and, for some, go away entirely. Instead, at least for now, the Biden Administration is only able to help 55,000 public service workers through the Public Service Loan Forgiveness Program.

Many Republican policymakers in the states challenged the SAVE program on the grounds that it is expensive and illegal. Trump has called the program a “catastrophe.”

People in SAVE who have worked in public service for at least 120 months, but who have not made 120 loan repayments yet, could be able to “buy back” the right to loan forgiveness. They might have to pay in more. Or, they could sign up for a different repayment plan based on income.

Here’s more from Just Care:

January 6, 2025

Some of UnitedHealth’s many abuses in a nutshell

In a New York Times fluff piece, the head of the UnitedHealth Group, Andrew Witty, attempts to make the case that his company does not deserve to be maligned. (Here’s my letter to the New York Times in response. The American Economic Liberties Project has been tracking the publicly recorded illegal and wrngful conduct of UnitedHealth Group, including patient abuses, provider abuses and retail pharmacy abuses. UniteHealth Group (UHG) is the conglomerate that owns UnitedHealth insurance as well as more than 2,300 other companies. It is the biggest health care corporation in the country.

The types of companies that UHG owns include pharmacies, health insurers, pharmacy benefit managers, primary care and mental health providers, surgery clinics, home health and hospice agencies. Optum, one of UHG’s subsidiaries, employs 90,000 physicians, more than any other company. It is also one of the three biggest PBMs, which design formularies for insurance companies, choosing the drugs and patient copays.

UHG’s ownership of all these lines of business allows it to game the health care system in all sorts of ways to maximize profits and squeeze smaller companies out of business.

What types of abuses has UHG subsidiaries been found to engage in?

Overcharging: The Medicare Payment Advisory Commission (MedPAC), the Committee for a Responsible Federal Budget (CRFB), and many other organizations have reported that each year UHG and other large insurers charge the government more than they should for the services they deliver. This year alone, overcharges amounted to somewhere between $83 billion and $140 billion. UHG has a history of upcoding–submitting medical codes to federal programs for more serious and more expensive diagnoses or procedures than what was necessary, diagnosed, or performed. As a result, UHG overbills the federal government, wasting billions in taxpayer dollars.
Denials of care: The data show that UHG denies one out of every three requests for coverage, keeping patients from getting the care they and their treating physicians believe they need. They overrule their own network physicians in order to spend less on care and maximize profits.
Anticompetitive behaviors: Because UHG owns so many health-related companies, it can and does steer patients and physicians to the products and services their companies deliver.
Patient privacy violations: UHG uses patient data without patient consent, violating patient privacy.

Over the last seven year, UHG has been charged with engaging in these activities:

Eight reports and three lawsuits for overcharging the federal government.
10 reports and five lawsuits for denying patient care because of the cost rather than medical necessity.
Eight reports and seven lawsuits for steering patients and providers to companies that UHG owns.
Three reports of corrupt practices.
Two reports and one lawsuit for violating patient privacy.

For more information on UHG abuses, visit violationtracker.org.

Here’s more from Just Care:

December 18, 2024

Bipartisan bill would require big insurers to sell off their PBMs

At least some Republicans and Democrats in Congress agree that it is time to create distance between Pharmacy Benefit Managers (PBMs) and pharmacies. They should not be part of the same company. As Rebecca Pifer reports for HealthcareDive, it would be radical for Congress to pass legislation that breaks up these companies. It’s also necessary!

Senator Elizabeth Warren, a Democrat from Massachusetts, and Josh Hawley, a Republican from Missouri, introduced a bill in the Senate to break up the companies that own both PBMs and pharmacies. In effect, the companies that own both PBMs and pharmacies would have to sell off the pharmacy businesses within three years. Similar legislation was introduced in the House.

If passed, the legislation would reduce PBM revenue significantly. Companies currently use their PBMs to steer people to their pharmacies, undermining competition, driving up costs and generating massive profits for these companies.

Independent pharmacies would be a lot better off, in theory, no longer squeezed out of business by the PBMs. PBMs would be forced to partner with a lot more of them.

The independent pharmacies say that the PBMs have been paying them less than the pharmacies their companies own and steering business away from the independent pharmacies.

Some argue that it is unclear whether consumers will benefit from the breakup if it goes forward. But, it’s perfectly clear that the current system is broken and hurts consumers. The best solution for consumers, of course, would be for the government to negotiate all drug prices and put an end to the need for PBMs.

There is no shortage of attacks on PBMs for driving up the price of drugs. As it is, three PBMs, Optum Rx, Caremark and Express Scripts–owned by three big insurers, UnitedHealth, CVS and Cigna respectively–are responsible for 80 percent of prescription drugs.

Beyond steering business to their parent companies and away from independent pharmacies, PBMs can engage in spread pricing. Spread pricing appears to be a way that PBM parent companies are able to launder revenue to maximize profits–PBMs charge insurers more for a drug than they pay pharmacies for the drug, pocketing the difference.

PBMs bear responsibility for the closure of many retail pharmacies as a result of their practices. In the last 14 years, a third of all of retail pharmacies have shut down their businesses. Today, as a result of these closures, nearly half of all counties in the US are pharmacy deserts

“PBMs have manipulated the market to enrich themselves — hiking up drug costs, cheating employers, and driving small pharmacies out of business,” says Senator Warren. The PBM Act “will stop the insurance companies and PBMs from gobbling up even more of American health care and charging American families more and more for less,” explains Senator Hawley. “The insurance monopolies are ruining American health care,” Hawley added.

Today, one in three Americans are not filling their prescriptions because of the cost. PBMs bear considerable responsibility for people’s high out-of-pocket costs. But, Congress has yet to fix the problem.

Here’s more from Just Care:

December 18, 2024

What will happen to ACA subsidies in 2025?

The Trump administration, in partnership with the next Congress, will determine whether or not subsidies will continue for people getting health insurance through the state health insurance exchanges under the Affordable Care Act. Axios reports on the state of play.

Republicans in Congress, who will be the majority in both the House and the Senate, will spark a lot of rage among millions of people in the state health insurance exchanges, if they do not extend the subsidies. They will force millions of people to lose their insurance because, without the subsidies, they won’t be able to afford it. Without subsidies, the Republicans will force others to pay far higher health insurance premiums. Of note, the premium subsidies are most helpful to residents of Republican states that have not expanded Medicaid. So, Republicans in Congress could pay a big price if they eliminate the subsidies.

But, as of now, the Republicans are not biting. They would not agree to a Democratic proposal to extend the ACA subsidies for one year.

The Senate Finance Committee’s new Chairman, Mike Crapo (R-Idaho), is considering whether to include the subsidies in the budget reconciliation process that will happen in early 2025. He has not taken the subsidies off the table.

However, Republicans in the House are saying that they do not support the subsidies. Jodey Arrington, who chairs the House Budget Committee, does not see an extension of the subsidies in the future. His response, when asked about extending the subsidies, was “hell no.” But, who knows?

What would be the consequences of not extending the subsidies? Without the ACA subsidies in 2026, 2.2 million Americans are projected to lose their health insurance. In 2027, 3.8 million would lose their health insurance. People in the state health insurance exchanges would see their premiums rise 4.3 percent in 2026 and 7.7 percent in 2027.

As of yet it is unclear what the Republicans in Congress would do for the millions of uninsured Americans, particularly if they end the ACA subsidies.

Here’s more from Just Care:

December 17, 2024

Is Mehmet Oz fit to run Medicare agency?

Last month, Senator Elizabeth Warren, along with six other Democratic Senators, sent a letter to Dr. Mehmet Oz, whom President-elect Donald Trump has named as Administrator-Designate, Centers for Medicare & Medicaid Services (CMS), regarding Dr. Oz’s call for the elimination of traditional Medicare and his lack of qualifications for the CMS Administrator position. If Dr. Oz becomes head of CMS will we be playing with fire?

Dr. Oz has substantial investments in corporate health insurance companies. He has said that he wants everyone with Medicare in a Medicare Advantage plan, even though Medicare Advantage does not work for large swaths of the population. (People in rural communities who are in Medicare Advantage plans often must travel tens of miles to receive hospital care because their Medicare Advantage plans won’t pay their local hospitals appropriately. People with cancer in Medicare Advantage plans can’t see physicians at cancers centers of excellence because they are all out of network. People who travel and need care in multiple parts of the US can’t get the in-network coverage they need in Medicare Advantage. Amputees and other people needing rehab services too often can only get that care covered if they are in traditional Medicare.)

Dr. Oz also either does not appear to appreciate or does not care that traditional Medicare is far more cost effective than Medicare Advantage. He either does not know or does not care that Medicare is overpaying corporate health insurers operating Medicare Advantage plans tens of billions of dollars each year.

MedPAC projects that these insurers will overcharge CMS $83 billion relative to traditional Medicare in 2024 alone. To maximize profits, private insurers make their MA enrollees appear sicker than they actually are. The HHS Office of the Inspector General finds that insurers engage in constant inappropriate delays and denials of needed care and force physicians and hospitals to jump through hoops to deliver needed care. Dr. Oz does not seem to know about or ignores these abuses.

Dr. Oz also has a financial conflict of interest. He owns more than $550,000 of stock in UnitedHealth, which is under Justice Department investigation for antitrust abuses. But, his desire to eliminate traditional Medicare would double revenue for UnitedHealth to nearly $300 billion.

Senators Warren, Wyden, Cardin, Merkley, Durbin and Blumenthal ask Dr. Oz for answers to a series of questions by December 23, 2024:

Does he continue to believe traditional Medicare should be eliminated and, if so, why?
Will he commit to protecting Medicare, not privatizing it or cutting benefits?
Does he understand why Medicare Advantage is highly dysfunctional and, if not, what does he think about the upcoding and widespread delays and denials of needed care?
Will he sell off all investments in health insurance companies in order to ensure he has no financial conflicts of interest if he is confirmed as CMS Administrator?

Here’s more from Just Care:

December 17, 2024

Pharmacy middlemen are responsible for hundreds of pharmacy closures so far, in 2025

Benjamin Jolley writes for substack on how the big insurers are deploying their pharmacy benefit managers (PBMs) to decimate independent pharmacies. This year alone 2,275 pharmacies have closed to date. Why? Because the PBMs, who are responsible for designing insurer formularies and reimbursing pharmacies for dispensing prescription drugs, don’t pay independent pharmacies appropriately.

In case you’re wondering, United Health owns Optum Rx and steers lots of business to its subsidiary. It can and does apparently pay its subsidiaries high rates and other retail pharmacies low rates for the same drugs. That’s uet another way it can rip off consumers and benefit its shareholders. CVS and Cigna are alleged to engage in the same shenanigans through the PBMs they own.

Jolley composed a dataset of pharmacies active in the National Council of Prescription Drug Programs (NCPDP) database at the beginning of this year, which were not on the database eight months later. Here’s what he found:

1139 large chain pharmacies closed.
1136 independent pharmacies and small to mid-sized chain pharmacies closed.
298 pharmacies changed ownership.

Jolley then created a map:

Based on his findings, Jolley reports that employees at 2,300 pharmacies all lost their jobs. Consequently, he estimates that 23,000 people were affected, as pharmacies tend to employ an average of 10 people.

Because 857 new pharmacies opened during the first eight months of the year, net pharmacy closures total 1,720, or 2.8 percent fewer pharmacies.

Since January 1, 2024, according to Jolley:

~5 pharmacy owner-operators have closed their businesses permanently
~11 neighborhoods lost their pharmacy
~110 pharmacists and pharmacy technicians have been laid off

Why is this happening? PBMs are underpaying for drugs. Independent pharmacies are forced to pay the big prescription drug wholesalers a lot higher rates than the chain drug stores pay. Jolley supports bills in Congress to fix the PBM problem.

H.R. 9096, the Pharmacists Fight Back Act: If passed, this bill would make payments to pharmacies fair and predictable. It would ensure pharmacies are paid based on the actual cost of goods with a 2% markup plus a cost-of-dispensing fee.
A Glass-Steagall for Healthcare – Glass-Steagall created a wall between community banking and investment banking. We need to do something similar with health care so that big companies can’t take advantage of competitors through passing money and business through their subsidiaries. The same company should not own both PBMs and pharmacies. Insurers should not own providers. United Healthcare owns OptumRx, Optum Specialty Pharmacy and Optum Physicians Group. CVS/Caremark owns Aetna and CVS/Pharmacy. Health Insurers should not own physician practices.
Robinson Patman Act enforcement – a PBM should not be allowed to charge different prices for identical products.

Jolley explains that more than 70 percent of the money pharmacies receive is from government–Medicare, Medicaid, ACA and FEHBP and Tricare. Government needs to enact reforms to save independent pharmacies.

Here’s more from Just Care:

December 16, 2024

New physician survey finds prior authorization harms cancer patients

Here’s yet another reason to opt for traditional Medicare over insurer-run Medicare Advantage plans. A new survey by the American Society for Radiation Oncology (ASTRO) finds that insurers’ use of prior authorization can harm cancer patients, reports Renal+Urology News. Prior authorization also makes it hard for oncologists to do their job.

Your insurance plan should provide good coverage for you today and in the future, whatever your health care needs. Sadly, as we get older, it becomes increasingly likely we will be diagnosed with cancer or some other serious health conditions. So, it’s not wise to gamble with your health insurance.

According to the 754 oncologists surveyed in the last few months, in more than nine and out ten (92 percent) instances, prior authorization means that patients don’t get care as quickly as they otherwise could. Consequently, about one in ten patients end up forgoing treatment. Some patients end up in the ER or the hospital. Some end up with disabilities, which can be permanent. And, seven percent of respondents said that their patients died.

More than half of patient radiation oncology services require prior authorization, even though insurers approve them more than seven in ten times initially. On appeal, nearly three quarters of denials are approved.

Nearly six in ten (58 percent) physicians surveyed said that prior authorization kept them from being able to follow treatment protocols. More than eight in ten (82 percent) said that in some cases they ended up providing their patients with less good treatment as a result of prior authorization.

Not only can prior authorization seriously harm patients’ primary treatment, it can also prevent them from or pose a significant barrier to their receiving treatment for side effects. For example, they might not be able to get pain or antinausea medicines.

According to respondents, insurers are ramping up prior authorization requirements, not easing them. A typical delay is at least five days. It also requires more administrative staff.

Howard M. Sandler, MD, chair of the ASTRO board of directors, sums up the survey findings: “These survey findings confirm what radiation oncologists witness daily: prior authorization policies are failing people with cancer, causing avoidable delays that are dangerous and, in too many cases, deadly.”

Here’s more from Just Care:

December 11, 2024

Americans are not getting their money’s worth from our health care system

Elon Musk, the billionaire whom Trump has nominated to head the Department of Government Efficiency (DOGE) in his administration, asked on X why Americans are not getting their money’s worth from our health care system. Congresswoman Pramila Jayapal and Senator Bernie Sanders have an answer: If we want a cost-effective system, we need single-payer, one government-administered health care system for everyone. It’s that simple.

For years, Sanders and Jayapal have been outspoken in their critique of the US for-profit health care system. They welcomed Musk’s criticism of the current system that leads to out-of-control health care costs. And, they have asked him to support Medicare for all. Each year, they have introduced legislation to enact Medicare for all, but the needed support for the legislation is not yet there.

Most Americans agree with Musk that they are not getting their money’s worth. Insurer administrative costs alone for each American is now well over $1,000 a year. That’s more than three times higher than administrative costs in Canada, Japan, South Korea, and every European country. In Japan, administrative costs per person are $82. In the United Kingdom and Sweden, they are $97. In Germany, they are $306, higher than every other country except the US. Average administrative costs are $194 per person.

On top of exorbitant insurance premiums, insured Americans spend an average of $1,132 a year on out-of-pocket health care costs. Deductibles, coinsurance and copays are high.

In 2020, in the final year of the last Trump Administration, a Congressional Budget Office report found that a government-administered health insurance system would save the US about $650 billion each year.

Here’s more from Just Care:

December 10, 2024

Poll: Few Americans are happy with health care quality

Who could possibly be happy with the quality of care in the United States? Almost no one. A recent Gallup poll should raise alarm bells.

The cost of health insurance is insane. Insurer restrictions on the physicians and hospitals they will cover is limited and, with deceptive provider directories, misleading. Insurer requirements for preapproval of costly procedures is burdensome. Delays in prior authorization are often harmful to people’s health. And, copays can be exorbitant.

Findings from a December 6, 2024 Gallup poll underscore the degree of American dissatisfaction with our health care system. Notwithstanding the Affordable Care Act and high levels of insurance coverage, people in the US believe that the quality of care is the worst it has been since 2001, when Gallup first began asking the question.

1. 89 percent of Americans did not consider US health care to be “excellent.”

2. One third of Americans (33 percent) consider health care quality “good;” in 2020, 43 percent said it was good.

3. Nearly four in ten Americans (38 percent) said quality is “only fair.”

4. Sixteen percent of Americans consider health care quality to be “poor.”

5. Only about half of Democrats have a positive view of health care quality. Eight percent fewer Republicans had a positive view.

6. Americans think less of health care coverage in the US than health care quality. Not even one in three Americans (28 percent) rated health care coverage as “excellent” or “good.” People polled consider health care coverage worse by four points than in 2001.

7. As for health care costs, not even two in ten Americans (19 percent) were satisfied. People polled consider health care costs worse by three points than in 2001. Nearly one in four Americans (23 percent) said costs were the top health care problem. Health care access was the second biggest (14 percent) health care problem.

Here’s more from Just Care:

December 9, 2024

Category: What’s Buzzing