JustCare

Tag: Access

  • Health insurers spread lies to promote shareholder value

    Health insurers spread lies to promote shareholder value

    In a Washington Post op-ed, Wendell Potter, president of the Center for Health and Democracy and a former Cigna executive, explains that his job at Cigna was to spread lies to Americans about health care in order to promote value for Cigna’s shareholders. As a result, millions of Americans are uninsured or underinsured today. And, thousands of Americans have died preventable deaths from lack of care during this pandemic.

    In response to Michael Moore’s film, Sicko, in 2007, Potter worked in collaboration with executives at other health insurers to keep Americans from advocating against our for-profit health care system. Sicko claimed that the US corporate health care system was a failure, and Canada’s public health care system worked quite well. They hired a PR firm to develop talking points about the problems with Canada’s health care system. They pulled quotes from unreliable sources and spread falsehoods, misleading Americans to believe that the US health care system was best in class and other public health car systems were seriously flawed.

    As Potter explains, the US’ inability to contain the novel coronavirus and Canada’s relative success demonstrates the superiority of Canada’s system. The US is seeing three times more coronavirus infections per capita and has twice the mortality rate of Canada. The health insurers’ trade association, AHIP, continues to spread nonsense about wait times to get care in Canada when Canadians have far more doctors and better access to medical care than Americans.

    People in Canada have access to COVID-19 testing and treatment without having to worry about the cost. They have no out-of-pocket cost–no deductibles, no coinsurance, no copays. And, when they lose their jobs, they still have health insurance. This helps explain why so many fewer Canadians are dying than Americans.

    If you look at a variety of metrics, people get better health care in Canada. People in Canada are hospitalized less frequently as a result of a chronic condition. They have longer life expectancies, 82 v. 78.6. And, they spend half the amount we do per person on health care. Moreover, their hospitals rely on a global budget and are protected financially when fewer people seek treatment.

    We need a public health insurance system in the US if we care about ensuring Americans receive the care they need. Our private health insurance system is designed not to pay for care, to profit from imposing financial and administrative barriers to care.

    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:

  • What would Warren do to improve access to health care through executive power?

    What would Warren do to improve access to health care through executive power?

    If elected President, Medicare for All will only become law if both the US House of Representatives and the Senate pass Medicare for All legislation. If that does not happen, Presidents can use their executive powers to improve access to health care. Margot Sanger-Katz reports for the New York Times on how Elizabeth Warren says she would use that power.

    Warren‘s first priority is limiting corporate influence over Congress. That takes legislation. She says she would pursue anti-corruption reforms against health insurers and pharmaceutical companies. She wants to tax “excessive lobbying” by these companies and restrict their ability to effectively bribe members of Congress through campaign contributions. She would also use her power to protect people with pre-existing conditions.

    With her executive authority, Warren would undo many of President Trump’s executive actions on health care. She would strengthen the Affordable Care Act and she would expand premium tax credits to help people buy insurance coverage. She would restore funding to Planned Parenthood. She would end work requirements for people with Medicaid. And, she would limit corporate health insurance companies’ ability to sell health plans that do not cover all essential health benefits, “short-term health plans.”

    People with health insurance would have greater benefits and protections. Warren would cover dental care for people with Medicare. And, states would have the ability to expand Medicaid coverage. Warren would also expand mental health and substance abuse coverage.

    Warren would give more people help to pay for their health insurance, such as families of working people and legal immigrants who are not citizens. Transgender people and women who had had abortions would regain civil rights protections.

    To lower the cost of prescription drugs, Warren would use her executive authority to have HHS cancel pharmaceutical company patents on drugs developed with government funding. And, in the case of public health emergencies, she would use federal authority to have the government manufacture some prescription drugs, including insulin, antibiotics and hepatitis C medicines.

    Here’s more from Just Care:

  • Do you need care? Why should your health insurer decide

    Do you need care? Why should your health insurer decide

    In a Washington Post op-ed, William E. Bennett Jr., a gastroenterologist and associate professor of pediatrics at the Indiana University School of Medicine, makes the case that health insurers should not be allowed to practice medicine. They too often deny medically necessary care unless and until your doctor is willing to go through hoops with their medical staff. But, medical staff who work for health insurers have no clue whether you need care.

    Bennett appreciates our need for health insurance. He also recognizes that having health insurance is necessary but not sufficient for our well-being. To get his patients needed medicines and tests, he must request prior authorization from his patients’ insurers, which can needlessly delay their access to care for weeks. And, still, the insurers may deny needed care.

    Only if Bennett appeals to a doctor who works for the insurer and says the right key phrases, will the insurer reverse its denial. Most of the time, the doctor in the employ of the health insurer has little accurate information about the patient; the doctor has never had any contact with the patient. Bennet explains that the insurer’s doctor is unqualified to know whether the treatment or medicine is needed.

    There is nothing beneficial about this process for the doctor or the patient. It does not assure the patient gets the proper treatment. In fact, it keeps many patients from getting needed care. And, it burdens the doctor excessively and unreasonably.

    Bennett experiences the system from the patient’s side as well because his daughter has a serious health condition, and he has had to deal with an insurer that has limited her access to needed treatment. Appealing is a challenging process that requires Bennett to rely on the advocacy of his daughter’s doctors. It takes time and does not always work. In the meantime, his daughter suffers, even though his daughter’s treating physicians all know she would benefit from the treatment.

    In short, when health insurer denials are based on the insurer’s claim of lack of medical necessity, the system breaks down, and the most vulnerable patients are harmed. One study revealed that one health insurer denied claims for emergency visits that met a “prudent layperson” emergency coverage standard in more than 85 percent of cases. Patients can appeal the denials with a high likelihood of success on appeal. But, only a tiny number know they can appeal and have the wherewithal to do so.

    Bennet concludes that health insurers should not be able to decide the care people need: “When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.”

    Here’s more from Just Care:

  • Judge finds UnitedHealth illegally denied care to thousands

    Judge finds UnitedHealth illegally denied care to thousands

    CNN reports that UnitedHealth was found to have illegally denied care to thousands of its members. Policymakers in Washington should take note of the risk commercial health insurers may pose to Americans and question their viability. Why do the politicians behave as if they are fenced in?

    Judge Spiro of the US District Court for the Northern District of California has yet to set the punishment. What is clear, however, is that UnitedHealth—the largest mental health insurer—established mental health coverage guidelines that wrongfully and systematically denied its enrollees benefits to which they were entitled. It illegally denied its enrollees access to needed care–in this case, mental health care. The judge also found that UnitedHealth’s medical directors were misleading in their sworn testimony.

    Most important, the judge found that UnitedHealth focused on cost-cutting over appropriate treatment.  Cost-cutting through wrongful delays and denials of care appears to be widespread in commercial health plans. See this report from the Government Accountability Office.

    If United Health’s medical directors are wrongly denying mental health care, isn’t it reasonable to assume that its medical directors are wrongly denying other needed care? There’s good reason to believe that the wrongful denials affect not only the 50,000 enrollees needing mental health care but the hundreds of thousands of enrollees needing other care.

    United Health’s medical directors are supposed to adhere to particular effective treatment guidelines for people with mental health issues. They did not. As a result, these patients received a lower level of care than appropriate, putting them at risk of worse health outcomes.

    Now, UnitedHealth and other commercial insurers are trying to keep CMS from getting more patient encounter data from people enrolled in their Medicare Advantage plans. This data could help show whether enrollees are getting needed care or going without it. So, naturally, the insurers want to keep it from government scrutiny.  Taxpayer dollars pay for this care; the public should be able to see what it is paying for.

    The lack of accountability in the commercial health insurance system is untenable. It’s one of the key reasons that we pay more for our health care and get poorer health outcomes than people in other wealthy countries with government-administered health care,  We need Medicare for All.

    If you want Congress to pass Medicare for All, please sign this petition.

    Here’s more from Just Care:

  • US health care system ranks last in meeting patient’s health care needs

    US health care system ranks last in meeting patient’s health care needs

    A report, published in Health Affairs, analyzes 2016 survey data on patients’ experiences with the health care system in 11 countries. It finds that the US health care system ranks last–at the bottom of the barrel–in meeting the needs of patients, when compared with health care systems in other wealthy countries. All of the other countries have universal health care.

    Of the people surveyed across 11 countries, people in the US are less healthy and more likely to face material hardship, because of the health care system. US health care is less affordable and does a worse job of getting people quick access to medical care, except specialty care.

    People in the United States struggle more than others to access care. One in three adults in the US, a higher percentage than in any other country, reported difficulty accessing care because of the cost. Every other country does a better job protecting residents from the costs of health care.

    The UK does the best job of ensuring health care is affordable for everyone. Germans were the least likely to face financial barriers to care. The Netherlands had the best health system based on overall survey results.

    No country did a great job of engaging patients or managing chronic care, particularly patients with low incomes. But, the US led the pack on social challenges that affected health. More than people in other countries, Americans reported being “always” or “usually” concerned about having money to buy meals and pay for their housing. Germans were least concerned.

    In other countries, people were more likely to have difficulty affording dental care. But, affordability of dental care presented the greatest issues for Americans. People in the Netherlands, the UK and Germany had the least problem accessing dental care.

    On the issue of quick access to care, again the US ranked below other countries. In the Netherlands and New Zealand, eight in ten people said they could see a doctor within a day or two. Only in the Netherlands could most people (75 percent) get health care at night and on the weekends without having to go to the emergency room.

    Canadians struggled most to get primary care. Three in ten Canadians needed to wait at least two months. Nearly as many adults in Norway also waited at least two months for primary care. In France, Germany, the Netherlands, Switzerland, and the United States, only about one in ten adults waited that long.

    Of note, the US performed best in one category–doctors engaging patients in discussions about exercise and good nutrition–staying healthy. The report authors suggest that the US could further improve. And, they suggested that it may be that the US performs better because relative to the other 10 countries in the study we have higher rates of obesity and lead less active lives.

    People surveyed lived in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the US.

    To improve health outcomes in the US, we need Medicare for All. Please sign this petition.

    Here’s more from Just Care:

  • How to improve access to medicines? Fix incentives

    How to improve access to medicines? Fix incentives

    At the Lown Institute annual conference, Vinay Prasad, MD, Assistant Professor of Medicine at the Oregon Health and Sciences University, explained how to improve access to medicines–how to ensure that new prescription drugs that come to market are safe and effective and are priced fairly. In short, he says we must fix the incentives in the current system. Here are some of the key problems he highlighted:

    1. Drug companies can get FDA drug approvals based on a single trial.
    2. The drug trial does not usually need to be on people needing the treatment but can often be on surrogate endpoints, mice or young healthy people, with no evidence that the drug actually works on the people it is intended for.
    3. Drug companies do not need to show comparative benefits of a drug, only that it works a slight bit better than nothing.
    4. Drugmakers can earn a huge windfall from a new cancer drug, as much as $7 billion a year.

    Prasad explains that based on the way pharmaceutical companies are permitted to structure trials, they should be able to find a clinical benefit 5 percent of the time, no matter what they are testing, including spices!  Of course, the finding of clinical benefits in these cases are false positives. But, they still would be enough for FDA approval. It might cost the pharmaceutical company $20 million a trial, but with 20 trials, at a total cost of $440 million, the company would see a benefit to whatever it was testing. Since the typical revenue for a cancer treatment is close to $7 billion, a $440 million investment is not unreasonable.

    What is to be done? Prasad believes that people will do whatever they are incentivized to do. The likelihood of success in persuading them to do what they are not incentivized to do is extremely low. So, we need to change their incentives. To change incentives with drugs, we need to focus on five key elements in the drug development and distribution pipeline: the basic science, the clinical trials, the drug approval process, news coverage, and, the prices and marketing.

    Prasad recommends that the FDA change its drug approval process to better ensure drugs are safe and effective before they are marketed. The FDA should not rely as much on surrogate endpoints–mice or indicators that are not directly related to patient testing–to establish efficacy but rather on how the drug affects prospective patients. The FDA should expect more trials. And, it should take a much more active role in overseeing drugs after they go to market than it currently does.

    We also should do away with pharmaceutical company direct-to-consumer advertising. These ads are often misleading. Prasad points out that he saw one ad for a new prescription drug claiming its benefits were “clinically meaningful” when in fine print the pharmaceutical company noted that the benefits were not statistically significant.

    In addition, pharmaceutical companies should not be allowed to design the trials or influence how they are conducted, as they generally do now. The trials should be conducted by independent non-conflicted entities. And, finally, a public drug development and distribution chain should compete against the private drug companies to drive competition and lower drug prices.

    This all requires a dramatic change to our health care system. When will we have the political conditions that will allow these changes?

    Here’s more from Just Care:

  • If you want easy health care access and good quality care, you probably want traditional Medicare

    If you want easy health care access and good quality care, you probably want traditional Medicare

    When you’re considering your Medicare health plan options, if you want easy health care access and good quality care, you should seriously consider traditional Medicare. It is likely your only option that will ensure you get the care you want and need. Traditional Medicare generally covers your care hassle-free whenever you need it, wherever you are in the US.

    Traditional Medicare with supplemental coverage offers the greatest choice of doctors and hospitals anywhere in America and allows you to budget for your health care. Supplemental coverage picks up most if not all of your Medicare out-of-pocket costs. Often, retiree coverage from a former job offers people this supplemental coverage. And, in many states, people with Medicaid can rely on Medicaid as their supplemental coverage.

    If you don’t have retiree coverage or Medicaid, you can buy Medicare supplemental coverage or Medigap in the individual market. The cost can easily be $250 a month, which is significant. But, for anyone who ends up in the hospital, choosing traditional Medicare and buying supplemental coverage generally allows you to: 1. See the doctors you know and trust wherever you are in the US with little or no out-of-pocket costs, 2. Receive whatever care your doctors think you need, and 3. Keep your health care costs down.

    In sharp contrast to traditional Medicare, a Medicare HMO or other private Medicare Advantage plan 1. restricts your access to doctors and hospitals, 2. determines what care they will cover, and 3. can leave you responsible for paying hundreds or even thousands of dollars every time you need care.

    To be clear, upfront costs for Medicare HMOs and other Medicare Advantage plans are generally lower than those for Medicare supplemental coverage. But, there’s absolutely no way to budget for your care. You cannot know whether a private Medicare Advantage plan with a limited network of doctors and hospitals will meet your unforeseeable care needs—the care you want at a price you can afford from doctors and hospitals you want to use, wherever you are in the US.

    For example, with rare exceptions, in a Medicare Advantage plan, you will not have coverage outside your community, you will not have coverage from doctors outside the health plan’s network, and you may find that high deductibles and copays as well as health plan denials of coverage prevent you from getting the care you need. For costly care, you will generally need to go through a prior authorization process, during which your plan will decide whether it will cover your care.

    With a Medicare Advantage plan, if you need costly services you could end up spending as much as $6,700 out of pocket for in-network services alone.  And, you will likely end up spending far more if the doctors and hospitals you use are out of network; in those cases, you will generally be liable for the full cost of their care. Moreover, if you are hospitalized, it’s more than likely that some of your doctors will be out of network. (Here are four things to think about when choosing between traditional Medicare and a Medicare Advantage plan.)

    A Kaiser Family Foundation study examines the literature comparing access and quality in traditional Medicare and Medicare Advantage plans. The data is limited.  But, not surprisingly, data from people with complex and costly conditions rate the private Medicare Advantage plans “substantially lower” than traditional Medicare on access and quality.

    Here’s more from Just Care:
  • Medicare and Medicaid are more cost effective than commercial insurance

    Medicare and Medicaid are more cost effective than commercial insurance

    In his latest post for the New York Times, Austin Frakt makes the case that both Medicare and Medicaid for all would bring down health care spending and deliver as good care as commercial insurance (private insurance). In short, Medicare and Medicaid pay less than private insurers for the same care and are more cost effective.

    To establish the cost-effectiveness of Medicare and Medicaid, Frakt looks at three studies. A JAMA Internal Medicine study of 26 health care services that have been deemed unnecessary or “low value” finds that they represent about 2.7 percent of Medicare spending. A second study compares Medicare and commercial insurance spending on low-value services in 2009, 2010 and 2011. That study finds that both types of insurance cover these services at about the same frequency.

    The third study, also in JAMA Internal Medicine, compares the delivery of low-value care for patients with Medicaid or who are uninsured and patients with commercial insurance, between 2005 and 2011. It too finds the same rate of low-value care for both patient populations. It also finds the same rate of high-value care.

    Frakt posits that while you might think that doctors perform more services on patients whose insurers pay them more, these three studies suggest that it is not the case. Rather, it appears that doctors generally treat patients the same regardless of the insurer paying for their services. The differences in the rate of delivery of low-value care stem primarily from local practice patterns and not which insurer is paying for the care.

    To be clear, your particular health insurance may not affect the care your doctors will deliver. But, it will determine your access to care–which doctors and hospitals will see you with that insurance. So, the quality of your care through Medicaid may be as good as the care you receive through private insurers. But, with Medicaid, you may struggle to access that care. (Click here to learn why Medicaid matters to all of us.)

    Here’s more from Just Care:

  • Drug importation could drive down price of generics

    Drug importation could drive down price of generics

    Generic drugs used to be synonymous with low prices, but lately drug shortages and price increases have driven up the price of many generic drugs. There are a range of market failures in the generic drug marketplace.  A May 2017 Hutchins Center Working Paper by Thomsas Bollyky and Aaron Kesselheim considers ways to drive down the price of generics through drug importation.

    Market failures in the generic drug marketplace need addressing so that Americans have access to affordable drugs. There is far less competition than desirable as generic drug companies have been acquired or merged with other companies. And, incentives for generic drug manufacturers to enter the market appear to be inadequate; 130 drugs that have gone off patent (10 percent of the 1,328 branded drugs) have no company seeking FDA approval to manufacture them.

    Even when pharmaceutical companies want to distribute a generic drug, there can be huge challenges. Sometimes the brand-name manufacturer refuses to supply the generic manufacturer with its drug so that it can test for bioequivalence and get FDA approval to market the drug. Sometimes, the brand-name manufacturer takes its drug off the market before the patent expires and replaces it with a second version of the drug–e.g., once a day pill replaces a twice daily pill–delaying the introduction of a generic for the patent life of the second version of the drug.

    To address these and other market failures, Senators Grassley, McCain and Klobuchar have requested that Secretary Tom Price allow drug importation from Canada for certain high-priced drugs. And others in Congress have asked the FDA to allow importation from countries that have highly regulated markets when there is inadequate competition. The FDA already can allow importation when there are generic drug shortages. Kesselheim and Bollyky propose a three-part strategy of their own:

    1. Passing the Generic Drug User Fee Act Reauthorization (GDUFA) would give the FDA the needed funds to speed up approval of generic drugs and help to eliminate the backlog of requests. Priority should go to drugs for which there is only one manufacturer.
    2. Allowing the FDA to work with other countries with similar regulatory standards to create a way for drug manufacturers to submit one application for all regulatory authorities, while leaving it to each government authority to determine whether to approve the drug. The data suggest that a number of countries have similar standards for drug regulation.
    3. When there are three or fewer drug competitors in the U.S., allowing the FDA to grant approval of generic drugs for use in the U.S. because they were approved in another country with similar strict efficacy and safety standards, “reciprocal approval.”  As it is, we import one fourth of our drugs–$86 billion in imports.  And four-fifths of the active ingredients in our drugs are imported, along with two-fifths of the finished drugs.

    Studying generic drugs for which there is no competition in the U.S. today, Bollyky and Kesselheim found that about two-thirds had competition outside the U.S. These international generic drug sources, if permitted to be sold in the U.S., could help spur competition in the U.S., increasing the supply of these generic drugs, bringing down their prices and ensuring access to critical medicines in the U.S.

    Here’s more from Just Care: