JustCare

Category: Health insurance

  • More hospitals providing care at home

    More hospitals providing care at home

    Julie Appleby reports for Kaiser Health News that, down the road, a lot of hospital care may be able to happen in the comfort of your home. Already, Medicare pays for some hospital care at home. And, many hospitals are exploring how to move a lot of inpatient hospital care to people’s homes.

    Hospitals would be able to serve more patients. To some extent, they would be able to do so virtually. And, they would save money on capital costs. Insurers would not have to spend as much on care, so it should bring costs down, though it is not clear by how much.

    • Who would benefit? As many as three in ten hospital patients. People with pneumonia, heart failure and other non-acute conditions. People needing surgery or care in an intensive care unit (ICU) would continue to receive care in hospital.
    • How would it work? People would be monitored around the clock, remotely. Health care professionals would visit them as needed.
    • Who would see patients at home? Hospitals would need a large number of nurses, paramedics and technicians.
    • Is hospital care at home as safe as hospital care in hospital? Many experts believe it is. In fact, they believe it can improve health outcomes. It can reduce the need for hospital readmissions and nursing home care.
    • What would the ideal home setting be? Most likely, patients would need a full-time caregiver at home with them to provide needed caregiving help, along with the ability to be in a private setting. Hospitals could provide aides to help with bathing etc.
    • Would every hospital provide care at home? Likely not. Some hospitals would want to fill their inpatient beds in order to maximize their revenues.

    Medicare started paying for hospital care at home in November. It wanted to protect older adults with non-COVID conditions from contracting COVID-19 in hospital. To date, Medicare is paying 100 hospitals to provide care at home.

    That said, Medicare coverage of hospital care at home will end when the pandemic is over. And, Medicare has been paying the same rate for hospital care at home as it pays for hospital care in-hospital. If Medicare continued covering this care, it’s hard to imagine it would keep paying current hospital rates.

    Here’s more from Just Care:

  • Medicare mental health care cost and access issues

    Medicare mental health care cost and access issues

    As a nation, the US has done a terrible job of meeting people’s mental health care needs. Both public and private health insurance cover mental health care, but they pay so little for mental health services that it is often hard to find mental health providers who accept insurance.  CNBC reports on mental health care cost and accessibility issues.

    Almost 20 percent of Americans have a mental health condition. And, spending on mental health care, including therapy, prescription drugs and inpatient care, is up 52 percent in the last 11 years. But, it’s hard to find mental health providers who take insurance.

    Nine in ten physicians providing physical health care take insurance. Fewer than six in ten psychiatrists, 56 percent, take insurance. More than five times as many people are forced to pay out of pocket for the full cost of their mental health care than for their physical health care.

    Mental health care tends to cost people a lot more than physical health care. People with depression typically spend $10,836 each year. People with diabetes on insulin spend less than half that, $4,800 a year.

    It’s also hard to find mental health care providers in many areas of the country. More than one-third of Americans live in areas where they are scarce.

    Between high costs and the difficulty of finding mental health providers, more than half of people who need treatment do not get the treatment they need. And, Black Americans have twice as much difficulty getting mental health care than white Americans.

    The US needs to do a far better job of ensuring people access to mental health care for their personal needs as well as for the economic health of the nation. Mental health conditions take a toll on workplace productivity. People miss work or cannot perform at their best level. Reduced productivity is estimated to cost an additional $44 billion a year.

    The 2008 Mental Health Parity and Addiction Equity Act improved access to mental health care. It requires insurers to cover access to mental health care on an equal level with physical health care. Put differently, insurers are not allowed to discriminate against people with mental health conditions. But, there are plenty of ways insurers can get around the law.

    There are a few ways that people who can’t see a psychiatrist can still get help. For one, their primary care doctors have the opportunity to identify and address their mental health care needs. That’s another reason why having a primary care doctor is so important. Also, at least for now, if you have Medicare or most private health insurance, you could see whether using telehealth services, which are easier to access and cost less, can help.

    Medicare coverage of mental health services has improved some, but it is still in need of significant improvement. There is coinsurance parity for outpatient mental health visits. It also now covers depression screenings through the annual wellness visit.

    But, more generally, Medicare offers poor coverage for mental health treatments and substance abuse counseling. And, at most, Medicare covers 190 days of inpatient mental health care services in a lifetime. Moreover, fewer than one in four psychiatrists accept Medicare’s rates.

    In addition, Medicare does not cover care delivered by mental health counselors. And, people in Medicare Advantage plan have particularly poor access to mental health providers.

    Right now, if you need mental health services, NAMI, the National Alliance on Mental Illness, has a free helpline at 1-800-950-6264. And, you can find other lower-cost places to go for treatment through the Substance Abuse and Mental Health Services Administration. If neither of these resources provide you with the information you need, try the National Association of Free & Charitable Clinics or the Open Path Psychotherapy Collective.

    Here’s more from Just Care:

  • Insurers use prior authorization to keep people from getting care

    Insurers use prior authorization to keep people from getting care

    Private insurers are increasingly using prior authorization as a tool to keep people from getting needed care. Allison Bell reports for Think Advisor on what physicians are saying about the hoops they must jump through to ensure their patients’ care is covered. If you are enrolled in traditional Medicare, you do not have to worry about prior authorization rules; you and your physicians do not have to seek approval for care in advance of treatment. If you are enrolled in a Medicare Advantage plan, you might find that prior authorization rules make it harder for you to get needed care.

    In a survey for the American Medical Association, one in three physicians do not believe that there is clinical validity to insurers’ prior authorization programs. The rules are virtually never or never based on medical society guidelines. One in 11 physicians say that these programs hurt patients. Nearly one in four physicians say patients often do not comply with medical guidance because of prior authorization rules.

    Prior authorization rules are burdensome and time-consuming for physicians. They say that they typically have 40 procedures for which they need to secure prior authorization each week.

    One big issue is that the insurers do not disclose the terms of their prior authorization programs. Because they are not open to public scrutiny, they can impose them without having to justify them. Moreover, they can impose them with little worry of a big expose on their lack of validity.

    For sure, prior authorization requirements lower health care spending; they keep people from getting care. But, there is no comprehensive reliable evidence insurers can point to that shows that these requirements improve quality. Indeed, if you believe the physicians, they lower quality, delay care and force physicians to spend more time on paperwork that they could be spending with their patients.

    Recently, CMS removed barriers to prior authorization in most federal programs, but not Medicare Advantage. It’s time to go the next step. Congress should either prohibit their use or require full disclosure and justification for each rule insurers use.

    Here’s more from Just Care:

  • Avoid buying junk insurance

    Avoid buying junk insurance

    The Obama administration banned the sale of junk health insurance–policies that offer only limited coverage–as an alternative to comprehensive coverage because junk insurance provides very limited coverage. President Trump lifted that ban so that insurers could sell people policies that cost less than comprehensive coverage. But, when it comes to health insurance, less does not offer the protection people need, causing much pain and financial distress. Who should beware?

    Fortunately, people with traditional Medicare or a private Medicare Advantage plan are not buying junk insurance. Health insurers are not allowed to sell junk insurance to older adults and people with disabilities with Medicare. People with Medicare have “comprehensive” coverage.

    However, if you get really ill and need costly care, beware of denials from your Medicare Advantage plan and/or out-of-pocket costs that could be as high as $7,550 a year beginning in 2021. In traditional Medicare, you need supplemental coverage to protect yourself from financial risk. With that, you should have few out-of-pocket costs.

    Younger people need to recognize the difference between junk health insurance and comprehensive coverage. Michelle Andrews reports for Kaiser Health News on the fate of a 31-year old man whose insurance broker convinced him to buy junk insurance because it was less expensive than insurance available to him on his state health insurance exchange. When he was diagnosed with stage four cancer, his insurance would not cover his costly care. His junk insurance only provided limited benefits and did not cover treatment for his “pre-existing conditions.”

    Keep in mind that big insurers market their junk health insurance wherever they can and don’t explain to you that they do not offer comprehensive coverage. In the case of this man, his junk insurance was issued by UnitedHealthcare. And, it did not cover the stem-cell transplant he needed or, for that matter, $800,000 in bills he incurred to treat his cancer.

  • Is it valuable to have health plan choice?

    Is it valuable to have health plan choice?

    Is choice of health plans what any American wants, asks Austin Frakt in a New York Times piece. Or do people simply want affordable choice of doctors and hospitals?

    Why would anyone want choice of health plans might be a better question. The principal reason people need choice today is financial–to be able to afford their care. But, what everyone should want is the knowledge that they can see the doctors they want to see when they want to see them, without worry about the cost. And no private health insurance plan offers them that choice.

    Put differently, it is valuable to have a health plan that delivers you the care you want at a price you can afford each and every time you need care, no matter what care you need or where you need it. If no health plan offers you that choice, what does choice give you?

    Take Medicare Advantage, private health insurance plans that offer Medicare benefits. People with Medicare have the choice of many Medicare Advantage plans. But, none offer them an open network of doctors at low or no out-of-pocket cost. In fact, people’s costs are not even predictable. Some Medicare Advantage plans deny care inappropriately and often. Who wants these choices?

    Many people sign up for Medicare Advantage plans because they do not understand what they might be giving up when they do–access to the care they need when they need it at a price they can afford. Or, they are willing to gamble that they will not need a lot of care so that they can save money. Traditional Medicare gives people the choice of almost any doctor anywhere in the country. But, it has no out-of-pocket cap. Unless you have Medicaid or retiree coverage, you must buy supplemental coverage in order to protect yourself from high out-of-pocket costs if you need care. And, supplemental coverage is pricey.

    Frakt notes that when you are choosing among private health plans, each with their own cost structure and restricted network of health care providers, it is easy to make a mistake. You can pick a plan that ends up keeping you from seeing the doctors you want to see and charging you more for your care than you ever would have imagined. People do not want to be gambling in that way if they do not need to.

    Frakt makes the wrong point. There is no way to avoid making mistakes when choosing a health plan, so long as Congress allows private health plans to offer people poor health plan choices. And, it allows health plans to keep people from knowing the ways they restrict care until they need care.

    For people to choose a health plan that meets their needs, Congress would have to determine people’s provider networks, coverage rules, and out-of-pocket costs. Congress would need to protect Americans from insurers that would otherwise not cover the care they need. Congress does not do that today, nor do the states.

    Frakt suggests that with some assistance, people could understand their health plan choices. That’s a myth. No amount of assistance will ensure people make a good health plan choice; that’s only possible if there are good choices. But, for-profit private health insurers have a disincentive to offer people good health plan choices, since giving people with costly conditions the care they need at a price they can afford would eat into private health insurer profits.

    Frakt does recognize that choice of health insurance brings with it poor health plan choices and unaffordable choices. He just doesn’t recognize that there is no way to know whether there is a good health plan choice.

    Like traditional Medicare, Medicare for All gives people the freedom to know that they will be guaranteed affordable health care coverage and be able to see the doctors they want to see. Everyone would have a good health plan choice.

    Here’s more from Just Care:

  • Hospital rates out of control with private health insurance

    Hospital rates out of control with private health insurance

    Hospital rates are out of control for people with private health insurance. Medicare, in sharp contrast to private health insurers, has the power to rein in provider rates for its recipients, even when hospitals have monopoly power. Consequently, private insurers today pay hospitals much higher rates than Medicare, and health care costs are unsustainable for working Americans. 

    On average, it costs more than $2,500 a day to stay overnight in the hospital. Prices keep going up, and more people are choosing not to get care. Congress needs to rein in hospital rates to ensure Americans under 65 access to care–and, soon. The higher these rates go, the more people will forego needed care and the harder it will be to rein in hospital rates.

    Higher hospital rates mean higher expenses–more staff, higher salaries, more investments. So, if Congress decides to step in to control these rates, reducing rates could mean layoffs and other stressors on health care providers. N.B. Congress has no plans to do so as of yet.

    To date, hospitals have gambled on generating the revenues they need for fancy equipment and high executive salaries from private health insurers. For some time they did well. Now, it looks as if many of them made a bad calculation.

    The novel coronavirus has cut into hospital revenues significantly. Even before the novel coronavirus pandemic, many hospitals–particularly rural hospitals–were closing down, and now many more hospitals are folding. If the hospitals operated on global budgets, with government guaranteed annual income, the future of hospitals would be far more secure.

    How do private insurer rates compare with Medicare rates today? Kaiser Family Foundation (KFF) looked at 19 studies.

    Because private health insurers and providers are able to claim their data as proprietary, there is no national data on private health insurer rates to analyze and compare with Medicare rates. Researchers have only been able to compare some private insurer rates to Medicare rates; but, hospitals generally prohibit them from disclosing the specific rates particular providers are charging particular insurers.

    KFF’s key findings:

    1. Overall, private insurers pay nearly 50 percent more than Medicare for physician services.
    2. Private insurers pay more than two and a half times Medicare rates for outpatient hospital services (264 percent) and nearly twice as much as Medicare (189 percent) for inpatient hospital services.
    3. Private insurers pay about twice Medicare (199 percent) for hospital services overall.

    Allowing hospitals and doctors to keep raising rates is hurting Americans, keeping them from affording health insurance and from getting needed care. If Congress stepped in and negotiated lower hospital and doctor rates for everyone, many providers likely would claim they could not manage. But, right now, they have less incentive to operate efficiently than they would if their rates came down.

    Hospital rates make no sense. Within a community and throughout the country, hospital rates vary wildly. Market power influences rates significantly. Bigger hospitals might operate more efficiently than smaller hospitals, but they also generally command higher rates from private health insurers than smaller hospitals.  They have more market power. In areas where private insurers have greater market power, they are able to negotiate lower rates.

    Hospitals with strong market power today deploy it to command high prices from private health insurers because they can, even if they are non-profit. Their goal is to maximize revenues. The rates they charge private health insurers are not high because of Medicare rates. They seek the highest possible rates regardless of what Medicare pays them.

    Kaiser Family Foundation explains that “much of the literature suggests that providers negotiate prices with private insurers irrespective of Medicare rates, and that providers with substantial market power are best positioned to command high prices, allowing them to evade financial pressure to become more efficient.”

    Hospitals that operate efficiently manage with Medicare rates. MedPAC, the independent agency that provides Congress with policy advice on Medicare, believes that hospitals that claim they lose money on Medicare could do a better job of containing costs.

    The federal government could ensure the financial viability of hospitals if it enacted Medicare for all. Hospitals would be assured annual revenues through global budgets. And, they would save a huge amount in administrative expenses, largely from not engaging in hundreds of negotiations with private health insurers. Most important, health care spending would fall and everyone in the US would be guaranteed access to the health care they need.

    Here’s more from Just Care:

  • Coronavirus: Labs can charge what they please for COVID-19 tests

    Coronavirus: Labs can charge what they please for COVID-19 tests

    Sarah Kliff reports for the New York Times that labs around the country are charging wildly varying prices for COVID-19 tests. Why not? They can legally charge whatever they please, and Congress has required health insurers to pay. How is this not the definition of an insane health care pricing system?

    Unlike in any other wealthy country, the US health care system is designed to let health care providers charge corporate health insurers and the uninsured pretty much what they will. And, because corporate health insurers can profit more from high prices, they are not advocating for government price regulation. So, it’s not surprising–though it is shocking–that Gibson Diagnostic Labs in Irving, Texas is charging a bloody fortune for its COVID-19 tests, which are no different from tests that cost $100.

    Because Congress does not regulate health care prices, Gibson Diagnostic Labs can legally charge health insurers $2,315 for individual coronavirus tests, even though its cash price for the test is $150. And, likely its cost for the test is far less than $150.

    Kliff says that the laboratory is taking advantage of a federal law that requires insurers to pay the full cost of all COVID-19-related testing. But, the truth is that insurers pay insanely high rates even when Congress does not require them to.

    Health care prices in the United States are easily twice as much as prices in other wealthy country. The average charge for an appendectomy here is $13,020. In England, it’s $3,050.  

    Health care prices also vary wildly in the US. Kliff points to one study showing that the cost for a simple appendectomy in California ranged from $182,955 to $1,529.

    Even if you have insurance, you should know that you are paying these insane prices in the form of high health insurance premiums and out-of-pocket costs. Insurers pass these costs along to their members. Most likely, 2021 health insurance premiums will reflect astronomical testing and treatment costs, though health care spending overall has dropped significantly because so few people have been getting elective services.

    And, because doctors tend to provide a sea of services on top of the primary service their patients receive, many people receiving free COVID-19 testing are getting high medical bills  for unexpected services. Understandably, a Kaiser Family Foundation poll shows that Americans tend to be worried about the affordability of COVID-19 care.

    Here’s more from Just Care:

  • Medicare for all would save $600 billion a year in administrative costs

    Medicare for all would save $600 billion a year in administrative costs

    A new paper by Steffie Woolhandler et al. in the Annals of Medicine exposes our health care system’s grave inefficiencies. It finds that the US currently spends more than $800 billion a year on administrative costs. Medicare for All would eliminate almost three-quarters of these costs and save more than $600 billion a year.

    The vast majority of Medicare for All’s savings would come from doing away with almost all provider-rate negotiations and bureaucratic headaches that come with having commercial health insurance. Today, literally thousands of health insurers must establish their own payment rates and their own set of rules for covering particular services. On top of that, the overwhelming majority of health insurers make a significant profit.

    In 2017, the US spent about one in three health care dollars (34.2 percent) on health care administration, $812 billion. In dollar terms, administrative costs added more than $2,497 to health care spending per person. Compared to Canada, which spent $551 per person on health care administration, the US spent almost five times more. Administrative functions represented just 17 percent of Canada’s health care spending.

    Administrative expenses in the US break down as follows: Insurers’ overhead accounts for $844 of per capita spending as compared to $146 in Canada. Hospital administration accounts for $933 of per capita spending as compared to $196 in Canada. Administrative costs for physicians adds still more to costs in the US.

    The cost of US health care administration has risen by 3.2 percentage points over an 18-year period. Administration had been 31 percent of health care spending in 1999. Three-quarters of the increase in administrative costs stems from high overhead in commercial Medicare and Medicaid managed-care plans.

    Commercial Medicare and Medicaid health insurance plans have far higher administrative costs than the public traditional Medicare program. Medicare Advantage plans, for example, spend about 12% of their premiums on health care administration, easily $1,155 per person more than traditional Medicare. Traditional Medicare spends under two percent on overhead.

    Medicare for All would drive down US administrative costs dramatically. If per person administrative costs in the US were at Canada’s level, $551 a person rather than $2,497, the US would save more than $600 billion a year.

    Here’s more from Just Care:

  • Free local resources to help older adults

    Free local resources to help older adults

    If you’re looking for free local resources to help older adults, your local Area Agency on Aging is a great place to begin. Area Agencies on Aging (AAAs) develop, coordinate and deliver aging services throughout the country. They serve people over 60 at every income level. In fact, they help more than eight million people a year with long-term care choices, transportation options, benefits information and caregiver issues. You can find them in almost every community.

    Most Area Agencies on Aging are also Aging and Disability Resource Centers (ADRCs). ADRCs provide a hub for information on long-term services and supports to help older adults, their caregivers and families; they work to ensure that older adults are better able to live alone in their homes for as long as possible. They are government agencies that work to meet people’s long-term care needs.

    To contact your local Area Agency on Aging for free local resources for older adults or simply to understand available benefits, call the Eldercare Locator 800.677.1116. The Eldercare Locator is a program of the Administration on Community Living. You can also visit the website at www.eldercare.gov.

    LeadingAge, an association of 6,000 community-based non-profit organizations in the U.S., offers another great resource. It has developed on online tool to help you locate non-profit agencies, agencies that “put people before profits,” that provide services and living facilities for older adults.

    By entering a zip code or city, LeadingAge’s Aging Services Directory will let you know about non-profit resources in the community. You can choose from a list of 18 resources, including nursing, transportation, home-delivered meals and dementia care. You can also learn about retirement communities, assisted living, and subsidized housing.

    And, if you need help navigating Medicare, you should contact your State Health Insurance Assistance Program or SHIP.  For the number of the SHIP in your area, click here. Or, for free help, call the Medicare Rights Center national hotline at 800-333-4114.  For other free and low-cost services for older adults, check out Just Care’s Get Help page.

    Here’s more from Just Care:

  • To save money on your care, consider using a free health clinic

    To save money on your care, consider using a free health clinic

    Because health insurance no longer covers large portions of people’s health care costs, millions of people with insurance are struggling to pay their premiums, deductibles, copays and costs for out-of-network care. Did you know that even if you have insurance, you may be able to save money on your care by using a free local clinic? According to Kaiser Health News, many people rely on free health clinics and these clinics are growing to meet their needs.

    There are 1200 free and charitable health clinics across the United States. Using a free clinic for your care could save you hundreds of dollars a year. If you qualify for care, you could get lower-cost prescriptions through these clinics as well as lower-cost primary medical care. Some clinics also offer mental health care and dental care.

    Many free health clinics serve the underinsured–people with health insurance whose out-of-pocket costs for premiums and deductibles amount to at least 10 percent of their income–as well as the uninsured. So, it’s worth looking into them even if you have insurance.

    The Commonwealth Fund found that in 2014 almost one in four adults under 65 were underinsured, 31 million people; people who are underinsured may have a deductible that is at least five percent of their annual income, or they may spend at least ten percent of their income on out-of-pocket costs, excluding their premiums.

    If you’re struggling to get an appointment with a doctor, using a free health clinic also may enable you to get an appointment more quickly.

    To find a free or charitable health clinic near you, visit the National Association of Free and Charitable Clinics.

    Here’s more from Just Care on free and low-cost care: