JustCare

Tag: Benefit

  • Voters overwhelmingly support adding dental benefits to Medicare

    Voters overwhelmingly support adding dental benefits to Medicare

    Voters overwhelmingly support adding dental benefits to Medicare, reports BusinessWire. But, will Congress ever do so? Dentists are a big obstacle to receiving dental care as are the costs of dental care, yet the costs of not getting care for your teeth can be brutal.

    In a bipartisan poll, 92 percent of voters support adding a dental benefit to Medicare. And, for good reason. Your oral health can seriously affect your mental and physical health. Without proper dental care, millions of older adults have lost their teeth or struggle from gum disease and then struggle to get proper nutrition.

    Right now and historically, more than 30 million older adults and people with disabilities lack dental coverage.  A lot of the people who have dental coverage can’t use it, either because out-of-pocket costs are still prohibitively high or there are other limitations on their coverage. Although Medicare does not cover routine dental care and most other dental care, Medicare recently began to provide some cancer patients with some dental coverage.

    People often join Medicare Advantage plans because these plans often say they offer dental benefits. But, when you look under the hood, their dental benefits tend to be hollow. As a result, high percentages of people in Medicare Advantage plans have not gone to the dentist in the last year.

    Medicare dental benefits are a top priority for Democrats and Republicans alike. Americans support dental benefits as much as they support abortion rights.

    Congress is well aware of the need for a Medicare dental benefit, but has yet to pass a Medicare dental benefit. Senator Sanders introduced a bill in the Senate to expand Medicare dental benefits and improve them in Medicaid. The bill also gives dental benefits to veterans through the Veterans Administration.

    The dental industry, which does not want to see its rates regulated, opposes a dental benefit. Dentists already have a good supply of patients because there is a huge shortage of dentists in the US, with 58 million Americans living in dental deserts. And, they say they do not want to deal with Medicare’s administrative burdens.

    Increasingly, states are allowing dental therapists to treat cavities and other dental needs without supervision from dentists, as a way to help ensure people get dental care. Dental therapists can provide people with temporary crowns and remove teeth that have decayed. While they do not have as much training as a dentist, they have more training than a dental hygienist.

    Alaska, Arizona, Colorado, Connecticut, Idaho, Maine, Michigan, Minnesota, Nevada, New Mexico, Oregon, Vermont, Washington and, Wisconsin all permit dental therapists to provide certain dental care.

    Hundreds of thousands of Americans travel out of the country for their dental care. Mexico offers dental care at far lower cost than in the US.

    Here’s more from Just Care:

  • Washington State delays plans to give residents a long-term care benefit

    Washington State delays plans to give residents a long-term care benefit

    If the US does not already have a long-term care crisis, and there’s a good argument we do, it’s hard to imagine we won’t face a crisis shortly. As the cohort of older Americans grows, so does the need for long-term care, and the cost is likely to be prohibitive for most. While Congress is currently sitting on its hands, Washington State passed a state-based long-term care benefit, but its launch is now delayed until 2023, with coverage not beginning until 2026.

    Washington is the first state to pass a law offering residents long-term care coverage, albeit quite limited in scope. The benefit covers up to $36,500 in long-term care costs in an individual’s lifetime. It is designed to pay for aide services as well as home modifications and other needs, or 2o hours a week of home care for one year. It could be a huge help for many, and still not enough help for some.

    The Washington long-term care benefit, WA Cares Fund, has been delayed to July 2026. To cover the costs of WA Cares Fund, 3.1 million workers in Washington are expected to pay a small payroll contribution beginning in July 2023, much like they do with Medicare and Social Security. Annual costs will be about $302 for someone earning $52,000 or 0.58 percent of earned income. Costs will be far higher for wealthier individuals. You must pay in for at least three years to qualify for the benefit.

    Most people don’t realize that Medicare does not cover long-term care. It covers no more than 100 days in a skilled nursing facility for people who have been hospitalized for at least three days and who need daily skilled nursing or therapy services. It also covers some home health care services–between 20 and 30 or so hours a week–for people who are homebound and need skilled therapy or nursing services on an intermittent basis.

    Medicaid does cover long-term care. It is an invaluable benefit. But, in order to get Medicaid, your income and assets need to be extremely low. Thankfully, in many states, if your income and assets are above the eligibility level, your health care expenses need to bring your income and assets down to the eligibility level before Medicaid will kick in.

    Can the Washington state long-term care benefit work? It’s hard to know. With more than six in ten people needing long-term care at some time in their lives, it will take a lot of money to cover the cost of the benefit. And, many Washington state residents appear to be worried about paying in and not being able to get back what they invested.

    Nearly 500,000 Washington state residents have turned to buying private long-term care insurance as an alternative that exempts them from the requirement of paying into the state fund. Private long-term care insurance has always been a gamble, with premiums able to double out of nowhere and the benefit often more limited than people realize.

    Congress needs to step in to avert a long-term care tsunami. The population of people over 85 and the population of people with dementia are expected to double by 2042. The cost of long-term care is only rising. Countless people will die needlessly, in isolation, if nothing is done.

    Here’s more from Just Care:

  • Should Medicare pay for a phone visit with your doctor?

    Should Medicare pay for a phone visit with your doctor?

    In this age of Covid-19, telehealth and phone visits have been increasing significantly for everyone. Phone visits can last 20 minutes or more. Should Medicare cover a phone visit with your doctor and, if so, what should it pay?

    Today, Medicare pays around $27 for a 20-minute check-in phone visit and $14 for a 5-10 minute phone visit. It could be less than what you pay a repairman to fix your refrigerator. But, believe it or not, it’s on a par with what Medicare pays for an in-person visit to a primary care doctor.

    Medicare pays a lot more for evaluation and management phone visits, $55 for 5-10 minutes and $89 for 11-20 minutes. It’s also the same as what Medicare pays for the in-person visit.

    In a story for Kaiser Health News, Julie Appleby asks whether Medicare should pay for these virtual visits. And, if so, should it pay as much for a phone call as for an in-person visit? To be sure, the doctors are taking the same amount of time with the patient on a call as in-person. But, is a phone call the same value to the patient as an in-person visit?

    On one hand, if Medicare stops paying for phone check-ups, providers are likely to stop reaching out to patients via phone. On the other hand, if Medicare pays at the same rate as an in-person visit for these phone visits, some experts worry that doctors are likely to spend more time on the phone than needed with patients, driving up health care costs.

    Some believe that Medicare should pay for the phone call but not at the same rate as for an in-person visit. That means that a “virtual check-in” would need a new billing code. And, then the question becomes how to come up with a code that deters doctors from extending the five-minute call to 11 minutes in order to get a higher fee?

    Whatever Medicare pays for the visit, patients are expected to pay the 20 percent coinsurance unless they have supplemental coverage to pick up the cost.

    Some doctors argue that some patients live in areas without broadband and cannot participate in a video visit. Their only alternative is a long drive to the doctor’s office if Medicare won’t cover the cost of a phone call.

    But, then the question becomes whether Medicare should pay the same amount for a doctor’s phone visit as for a phone visit with the physician’s assistant or a nurse practitioner. At the moment, Medicare pays the same rate regardless of which provider is on the call.

    To keep doctors from using the phone visit code too often, Medicare won’t pay for phone visits within seven days of an in-person or telehealth visit. It also won’t pay for calls with patients who need to be seen in person by the doctor.

    Medicare’s coverage of evaluation and management phone visits is expected to end when the pandemic ends, most likely by next year. But, that could change if Congress or CMS decides it’s appropriate to continue paying for these calls when doctors are diagnosing and determining the best treatment for their patients. That said, virtual check-in codes are now permanent.

    Here’s more from Just Care:

  • Drugs with high prices are often no better than lower-cost drugs

    Drugs with high prices are often no better than lower-cost drugs

    The US famously pays far more for medications than other countries, putting stress on the health care system and individual patients who often bear this cost. The pharmaceutical industry often justifies these high prices by claiming that they create the opportunity for more innovation in the drug space, and that lowering prices would diminish the ability of drugmakers to create new and better drugs.

    Given this argument that higher prices leads to better drugs, one would expect that the price of a drug should be correlated with its clinical benefit. It’s common sense–if we are paying more for a certain drug, it should be because it works better.

    Unfortunately that does not appear to be the case, according to two recent studies on drug prices. In The Lancet Oncology, researchers at the University of Zurich analyzed the prices and clinical benefit of 65 cancer drugs approved by both the US Food and Drug Administration and the European Medicines Agency over the past ten years.

    The median monthly treatment costs for these new drugs in the US was $13,200, more than twice as high as in England, Switzerland, Germany, and France. However, they also found that cost of the drugs were not correlated with clinical benefit, according to value frameworks from the American Society of Clinical Oncology and the European Society of Medical Oncology.

    “We have so many drugs on the market and we found that some don’t have the value you’d expect,” said study author Kerstin Vokinger, in STAT News. “The prices of cancer drugs should be better aligned with their clinical importance in order to improve access.”

    It’s not only cancer drugs that are being priced regardless of effectiveness. In a recent piece in Health Affairs blog, Harvard Medical School professors Richard G. Frank, Jerry Avorn, and Aaron S. Kesselheim asked the question, “Are the drugs we approve in the US considered effective according to other countries’ assessments?” They looked at 46 new drugs approved by the FDA in 2017 and compared evaluations of the drugs’ effectiveness using assessments from independent boards in Canada, Germany, and France.

    Of the 27 drugs that were evaluated in these other countries, 17 of these drugs were found to offer little or no added clinical benefit by all of the boards that evaluated them. For 6 drugs, there was not consistent agreement between the different boards about the effectiveness of the drugs. Only 4 drugs were determined to have at least minor added benefit by all of the boards that evaluated them. These drugs were Fasenra for asthma, Dupixent for excema, Imfinzi for urothelial carcinoma, and Rydapt for leukemia.

    The authors noted that many of the drugs found to be not effective when evaluated by international boards are very expensive. Eli Lilly’s breast cancer drug Verzenio was found to have no added benefit in both Germany’s and France’s reviews; the list price of the drug is more than $12,000 a month. Gilead’s Vosevi, a combination drug to treat Hepatitis C, was found to have only minor clinical benefit by one of the international boards–the drug costs $26,000 for 28 pills.

    Figuring out whether a drug is priced “fairly” is tricky, but at the least we should agree that paying thousands more for drugs than other countries without a corresponding clinical benefit is a bad deal.

    This piece was originally published on May 8 on the Lown Institute blog.

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