JustCare

Category: What’s Buzzing

  • More than 4 in 10 Americans face cost barriers to care

    More than 4 in 10 Americans face cost barriers to care

    At any given time, about 10 percent of Americans are responsible for 70 percent of health care spending. Since anyone can be hit by a car or diagnosed with cancer tomorrow, you could be among that ten percent facing very high health care costs, even with health insurance. Unfortunately, health insurers today too often do not provide people adequate coverage, leaving nearly a quarter of their enrollees underinsured, according to a new report by the Commonwealth Fund.

    In addition to underinsurance presenting a barrier to care for a large cohort of Americans, the Commonwealth Fund found that 12 percent of Americans went without health insurance during some point in the year. An additional nine percent of Americans surveyed were uninsured throughout the year.

    The Commonwealth Fund defines underinsurance as the plight of people with insurance who face high deductibles and copays relative to their income. As a result, these people are often inclined to forego or postpone care.

    All in, the Commonwealth Fund survey results show that almost half of Americans (44 percent) did not have insurance throughout the year and/or could not access affordable care even with insurance. Slightly more than half of Americans had insurance throughout the year with access to care they could afford.

    Some underinsured and uninsured Americans don’t need care or need little care and can manage. But nearly six in ten people (57 percent) who are underinsured and seven in ten who are uninsured reported going without needed care, including prescription medicines, medical tests, and medical procedures. The consequences of foregoing care can be dire, including preventable death and serious health conditions.

    Equally concerning, millions of uninsured and underinsured Americans face medical debt.

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  • Proposed Medicare Advantage rule aims to limit bad insurer behavior

    Proposed Medicare Advantage rule aims to limit bad insurer behavior

    Last week, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, proposed a new rule intended to limit some of the many insurance company bad acts, reports Rebecca Pifer for HealthcareDive. Unfortunately, Medicare Advantage plans all too frequently inappropriately delay and deny people’s care notwithstanding CMS rules. To protect MA enrollees, the government should penalize insurers who violate their obligations severely enough to deter bad acts; without strict penalties, more rules are unlikely to be of much help.

    The CMS proposed rule strives to address five of the biggest concerns with Medicare Advantage. The Trump administration will have the power to decide which, if any, of these proposals will be finalized.

    • Insurers’ use of artificial intelligence to deny care without consideration of patient needs. The rule is designed to make transparent to MA enrollees their insurers’ coverage policies. Insurers sometimes use artificial intelligence to engage in across-the-board denials of care, even when care is urgently needed. The  MA insurers use AI particularly to deny care for people with costly and complex conditions, such as people with cancer and people needing rehabilitation services. New CMS data reveals that more than 80 percent of denials are overturned on appeal, but only four percent of people appeal. The proposed rule also would require insurers to notify enrollees about their appeal rights.
    • Insurers’ publication of inaccurate provider directories that misrepresent which physicians and hospitals are in network. The rule strives to ensure that the provider directories do not mislead enrollees as they are wont to do.
    • Insurers’ misleading marketing. The rule strives to protect enrollees from misleading marketing.
    • Insurers’ coverage of supplemental benefits. The rule aims to ensure that enrollees are fully aware of these benefits and their limitations.
    • Insurers’ reporting of how much money they spend on patient care rather than administration and profits. Insurers are legally required to spend at least 85 percent of the money they are paid to cover enrollees on patient care. But, many appear to find ways to spend a lot less.

    In addition, if finalized, the proposed rule would for the first time require Medicare to cover weight-loss drugs for people who are obese, even if they don’t have other health conditions.

    Here’s more from Just Care:

  • If confirmed as head of HHS, RFK Jr. could end Pharma’s direct to consumer ads

    If confirmed as head of HHS, RFK Jr. could end Pharma’s direct to consumer ads

    If Congress confirms RFK Jr. to head the US Department of Health and Human Services (HHS), it might keep us from receiving needed vaccines, endangering our own health and the public health. But, it could also spell the end of direct-to-consumer marketing of prescription drugs, reports Andrea Park for Fierce Pharma. And, that’s good news for Americans, as the ads, much like the Medicare Advantage ads, can be extremely deceptive.

    When he was running for president several months ago, RFK Jr. declared that he would ban pharmaceutical company advertisements on TV through an executive order. President-elect Trump could follow his lead. Of course, the pharmaceutical companies will challenge this act, claiming it abridges their first amendment right to free speech, and they could prevail. That said, not until 1983 did pharmaceutical companies begin advertising their drugs to consumers on TV. Before that, they marketed their drugs exclusively to doctors and pharmacists.

    Today, Pharma spends buckets marketing their prescription drugs. And, for good reason. Their return on investment is tremendous, as much as five times for some drugs.

    The United States and New Zealand are the only two countries in the world that permit direct-to-consumer marketing of prescription drugs.

    It’s still unclear whether RFK Jr. will take on Pharma’s ads or direct his attention to US food policies. But, Trump’s pick to head the Food and Drug Administration (FDA), which is under HHS control, could also act to end Pharma consumer ads. Dr. Martin Makary published a study ten years ago finding that “Further investigation of provider advertising, its effects on quality of care, and potential oversight mechanisms is needed.”

    Here’s more from Just Care:

  • Humana could be penalized over misleading provider directories 

    Humana could be penalized over misleading provider directories 

    Keith Ellison, Minnesota’s attorney general, is trying to hold Humana accountable for misrepresenting the in-network providers in its Medicare Advantage plans, reports Rylee Wilson for Becker’s. It could be the first time that any state has acted to protect their older and disabled residents from misleading Medicare Advantage information. And, it’s about time.

    For more than a decade, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, has reported that insurers mislead older adults and people with disabilities through inaccurate provider directories. But, CMS has never done anything to correct the problem, much less penalize insurers for misleading their enrollees.

    In Minnesota, Ellison says that people considering joining a Humana Medicare Advantage plan are misled to believe that Humana will cover their care from Essentia Health, Avera Health, North Memorial Health and Sanford Health in 2025. But, all have said that they are leaving the Humana Medicare Advantage network at the end of this year.

    In addition to correcting all misinformation in its provider directories as quickly as possible, Ellison wants Humana to detail which Medicare Advantage out-of-network providers it incorrectly listed as in-network this annual open enrollment season. He also wants Humana to protect enrollees who joined based on this misinformation. He argues that Humana should cover their care from these providers.

    According to the Minnesota Star-Tribune, UnitedHealthcare also misleads people with Medicare about the providers in its network.

    Over the last several months, many health systems have ended their contracts with Medicare Advantage insurers. These health systems not only cite huge administrative burdens they face with MA insurers but also large numbers of inappropriate denials of care.

    If you enrolled in a Medicare Advantage plan because you cannot afford traditional Medicare, contact your Senators and representative in Congress. Urge them to add an out-of-pocket cap to traditional Medicare so that it is a meaningful choice for everyone with Medicare, not only a luxury for the wealthy. Only traditional Medicare covers your care from most doctors and hospitals anywhere in the country without requiring prior authorization or otherwise inappropriately delaying or denying medically necessary care.

    Here’s more from Just Care:

  • What will Dr. Oz do as head of Medicare agency?

    What will Dr. Oz do as head of Medicare agency?

    President-elect Donald Trump has nominated Mehmet Oz to be the next head of the Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare and Medicaid, reports the New York Times. The choice of Dr. Oz, a TV celebrity with no government or management experience is in keeping with Trump’s other picks for big government roles. The open question is what will Dr. Oz do as head of CMS?

    If the past is any indicator, Dr. Oz will put in place plans to eliminate the public traditional Medicare program. It would be a huge mistake and arguably not doable, given that Medicare Advantage doesn’t work for some people in some parts of the country and works poorly for people with serious conditions and people with low incomes in many parts of the country. Wealthy Americans who understand the health risks of a Medicare Advantage plan avoid it at all costs.

    Traditional Medicare covers your care from virtually any physician or hospital in the country, without delay or forcing you to go through prior authorization hoops. When you need costly care, as most of us will at some point, Medicare protects you and ensures you are able to get the care you need. Medicare Advantage, in sharp contrast, works well when you’re healthy and tends to delay and deny care inappropriately when you most need care. So, people in Medicare Advantage take a huge risk.

    Back when he ran against John Fetterman for a US Senate seat in 2022, Oz made clear that, unlike his opponent, he does not support “free health care for everyone.”  Oz advocates for Medicare Advantage for All, a health care system that gives full control over our healthcare to big private insurers and will ration care based on ability to pay.

    Oz has suggested a 20 percent payroll tax to cover the costs of his Medicare Advantage for All plan. It would be a huge windfall for the biggest corporate health insurers. It would also be a huge windfall for Oz, as he and his wife are reported to have millions of dollars invested in the health care industry.

    Senator Patty Murray of Washington State expressed deep concern about Dr. Oz’s nomination: “Even putting aside the raft of alarming pseudoscience Dr. Oz has previously endorsed, it is deeply disappointing to see someone with zero qualifications being announced to head up such a critical agency.”

    Here’s more from Just Care:
  • As HHS head, will RFK Jr. take on big insurers?

    As HHS head, will RFK Jr. take on big insurers?

    President-elect Donald Trump has nominated Robert F. Kennedy Jr. as the next head of the US Department of Health and Human Services, reports Sheryl Gay Stolberg and Susanne Craig for The New York Times. The choice is to be expected given RFK Jr.’s strong alliance with Trump. If the Senate confirms the nomination, as expected, what will it mean for the health of our nation?

    RFK Jr. is an anti-vaxxer, critical of our public health agencies, over which he will preside. It has been reported that he might try to end legal protection for pharmaceutical companies that release vaccines, likely deterring production of new vaccines. So, our public health is likely at serious risk.

    But, Kennedy also has promised to eliminate the corporate control of our federal food and health agencies, if confirmed. And, that is desperately needed.

    Kennedy correctly describes the Food and Drug Administration (FDA) as controlled by corporations. In his words, “The F.D.A. is just a sock puppet to the industries it is supposed to regulate.” The FDA gets “user fees” from pharmaceutical and medical device companies, which represent about half its budget. Not surprisingly, it behaves in ways that would make you question its independence.

    Pharmaceutical company stocks have fallen in value since Trump announced Kennedy as his pick for HHS Secretary. Big Pharma is likely right now trying to derail Kennedy’s nomination. But, it’s hard to imagine that the Republican Congress will oppose any of Trump’s cabinet nominees.

    It’s also clear that RFK Jr. will only have as much latitude to take on the big health care corporations as Trump allows him. What Trump will allow him to do remains an open question.

    Among some of RFK’s most extreme positions is a desire to prosecute The Lancet and the New England Journal of Medicine, two of the most respected medical journals in the country, under the federal anti-corruption statute. Kennedy claims that they publish “phony science.”

    Kennedy also has called for eliminating fluoride in public water supplies, a position counter to the science. The Centers for Disease Control and Prevention (CDC) calls water fluoridation one of the greatest public health achievements. It prevents tooth decay.

    Here’s more from Just Care:

  • Insurer provider directories misleadingly include physicians who are out of network

    Insurer provider directories misleadingly include physicians who are out of network

    Max Blau reports for Pro Publica on how the big insurers provide their enrollees with misleading directories of in-network providers, but nothing is done to fix the problem. We are in the age of tech, when accurate directories should be quick and easy. Insurers should be held accountable if they cannot keep an accurate provider directory, but neither the states nor the federal government is willing to hold the insurers accountable.

    Blau explains that insurers are not penalized for inaccurate directories and that it takes old fashioned cold-calling to figure out how misleading a provider directory is. Misleading directories are helpful to insurers since they encourage people to enroll; and, yet, the insurers won’t cover care from the providers they list who are not in-network.

    For more than ten years, the federal government has reported large inaccuracies in Medicare Advantage provider directories. Do not assume they are anywhere near accurate and up to date. Providers in the network today can leave the network at any time, and many have been leaving Medicare Advantage plans over the last few years.

    New York State government staff called health care providers listed in insurance company directories to determine whether they were actually seeing patients. They wanted to know two key things about the supposedly in-network providers: Do you accept insurance? And are you seeing new patients?

    But, the New York State staffers found that lots of physicians who were listed in the provider directories no longer accepted the insurance or were not taking new patients. Some of the time, staff didn’t even get a call back. As it turned out, insurers’ enrollees could not get treatment from more than eight in ten mental health providers listed in directories whom staff reached out to.

    The New York State law provides for penalties on insurers who do not keep accurate provider directories. But, New York State rarely penalizes insurers and, when it does, the penalty is tiny. When it comes to provider directories, New York State insurer behavior is no different from insurer behavior in other states. Misleading directories are the norm in most states, including Arizona, California and Massachusetts.

    The US Senate Finance Committee staff undertook an investigation a year ago of Medicare Advantage provider directories, and Senate Finance staff also found extremely misleading provider directories. As in the states, the federal government rarely holds the Medicare Advantage insurers accountable.

    The consequences of inaccurate directories can be dire for patients who cannot find providers to treat their conditions. For the insurers, it’s more money in their pockets. If their enrollees can’t get care, the insurers keep more money and grow profits.

    Here’s more from Just Care:

  • Amazon offers new health care products for a subscription fee

    Amazon offers new health care products for a subscription fee

    Amazon has decided that it can make money selling its Prime members monthly subscriptions for five health care services that insurance will not cover. Heather Landi reports for Fierce Healthcare that Amazon’s services are pay-per-visit and are available exclusively through telehealth. Here’s how it works.

    If you are looking for help with hair loss (men only), anti-aging skin care, erectile dysfunction, eyelash growth and motion sickness, Amazon One Medical offers a subscription solution. You pay upfront each month in exchange for a telehealth visit, a treatment plan and free delivery of the medications you are prescribed.

    Medicare does not cover these services, whether you are in traditional Medicare or a Medicare Advantage plan. They are not considered medically necessary. But, if you would like any of these services, it’s not clear why you are better off subscribing to Amazon’s service than getting a prescription for them from your physician.

    Your primary care physician typically can prescribe medicines for hair loss and motion sickness. And, you can find plenty of anti-aging skin care products without paying Amazon One Medical providers $10 a month or more.

    What do these new services cost? 

    • Anti-aging skin care is available for $10 a month
    • Men’s hair loss is $16 a month.
    • Erectile disfunction treatment costs $19 a month (a 92 percent savings, according to Amazon)
    • Eyelash growth treatment is $43 a month
    • Motion sickness care is $2 a use.

    If you are not prescribed a treatment, you don’t pay.

    Amazon Clinic is already available throughout the US. It provides telehealth services for many common conditions, including pink eye, flu and sinus infection. Messaging visits are $29. Video visits are $49.

    Here’s more from Just Care:

  • Medicare Advantage networks can be narrow and harmful

    Medicare Advantage networks can be narrow and harmful

    If you’re in a Medicare Advantage plan or thinking of joining one, you should worry about two things: Whether you will get the Medicare benefits you are entitled to when you need costly care and whether you’ll be able to use the doctors and hospitals you want to use. Cheryl Clark reports for MedPage Today on a recent Medicare Payment Advisory Commission (MedPAC) meeting in which commissioners criticized the Medicare Advantage networks as ever-changing and often too narrow and harmful to enrollees.

    You can’t trust Medicare Advantage (MA) provider directories to list in-network providers accurately. A lot of the time, the listed physicians and hospitals are not, in fact, in network. They’ve left the network. Or, they leave the network midyear. It can hurt enrollees, who lose continuity of care and must scramble to find new providers.

    When you buy health insurance, you should be thinking not simply about now but about what could happen to you in the future. Literally anything. A car accident, a fall on ice, a cancer diagnosis, a stroke. You might be away from home. Will your care be covered the way you want it to be in a Medicare Advantage plan? What will you pay out of pocket?

    Here are some of problems you can face in any Medicare Advantage plan when it comes to getting a provider to deliver care. These problems don’t exist in traditional Medicare, the government-administered program that covers your care from almost any physician or hospital in the US:

    1. The Medicare Advantage plan can leave the Medicare program at the end of any year. And, many have done so in the last couple of years.
    2. Physicians and hospitals can leave the Medicare Advantage network. Your care is not covered if you keep seeing these providers. You can pay out of your own pocket to see them or you need to find new providers.
    3. In-network physicians might not be willing to see you. They might have too many patients already.
    4. Cancer centers of excellence and specialists you need to see might not be in-network.

    The Medicare Advantage network directories are very often out of date and inaccurate. Moreover, government oversight to ensure the adequacy of Medicare Advantage plan networks leaves a lot to be desired. Plans know that they can offer inadequate networks without accountability. The government has never penalized a Medicare Advantage plan for offering an inadequate network.

    There’s little good about Medicare Advantage networks in practice, though in theory they should help ensure you are getting good coordinated care. Unfortunately, the insurance companies offering Medicare Advantage make more money keeping you from getting good costly care. So, except for some of the nonprofit Medicare Advantage plans, Medicare Advantage insurers’ incentive is to delay and deny you care from good quality physicians and hospitals when you need them.

    Here’s more from Just Care:

  • Why do people pay so much for Humira now that it’s off-patent?

    Why do people pay so much for Humira now that it’s off-patent?

    Humira, the exorbitantly priced drug taken by millions of Americans, finally lost its patent at the end of 2022, five years later than in Europe. But, even though biosimilar drugs are available, people’s out of pocket drug costs for this drug continued to be high. The drug rebate system in the US benefits drug middlemen and insurers and hurts patients, reports Joshua P. Cohen for Forbes.

    In short, pharmacy benefit managers (PBMs) make a fortune negotiating drug discounts from manufacturers. They usually see these discounts in the form of rebates, which they can pocket and/or share with the insurers offering prescription drug coverage. Americans rarely see the benefits of these rebates.

    Moreover, PBMs, which determine which drugs an insurer covers on its formulary and at what copay, can opt not to include drugs on the formulary. So, Humira’s manufacturer, AbbVie gave PBMs a huge rebate to include Humira on their formularies. The PBMs could then opt not to include biosimilar equivalents on their formularies or to make the biosimilars more expensive to enrollees, in order to maximize profits.

    That appears to be what’s happening. PBMs are not making it easy and inexpensive for people to get a biosimilar drug, even though there are more than ten of them available on the market. These biosimilars had only two percent of market share last March, after being available for 15 months.

    Now, more people are taking a biosimilar of Humira. The big PBMs are finally offering biosimilars. But, CVS and Express Scripts, two PBMs, are doing so with a biosimilar from which they receive a co-branded licensing fee and discounts, in order to continue to maximize their profits from the drug. They steer their customers to their biosimilars, which are often more costly than others.

    What you can do? Shop around. Check out Mark Cuban’s Cost Plus Drugs, Costco and other sources for a lower-cost biosimilar.

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