JustCare

Tag: Cost

  • 2025: Will Congress extend Medicare telehealth coverage?

    2025: Will Congress extend Medicare telehealth coverage?

    Congress will decide whether to extend Medicare Coverage of telehealth services this year. Ruth Reader and Erin Schumaker report for Politico that cost should not be an issue. The latest findings, published in JAMA Internal Medicine, show that Medicare telehealth actually results in lower Medicare spending.

    Congress first expanded Medicare coverage of telehealth services to everyone with Medicare and for a range of services during the COVID pandemic. Until then, Medicare telehealth coverage was largely restricted to people in rural communities. At the end of March of this year, expanded Medicare telehealth coverage will expire unless Congress acts.

    Many policymakers appear to believe that telehealth is driving up Medicare spending and leading to worse health outcomes. But, this new research suggests otherwise. Researchers found that patients received less low-value care or, put differently, higher quality care at lower cost.

    The researchers looked at the records of 2.3 million people with Medicare across 286 health systems. Medicare spending for those patients using telehealth was lower. Patients in health systems using telehealth visited the doctor more but received fewer low-value tests and less unneeded care.

    What were the Medicare savings? The researchers projected at least $66 million. Telehealth visits generally cost less than in-person visits. That said, the Congressional Budget Office projects that two additional years of Medicare coverage of telehealth services will cost about $4 billion.

    Another study published in Health Affairs last year found that people who receive telehealth treatment saw their physicians on an ongoing basis and were more likely to comply with their prescription drug regimens. They also were responsible for fewer emergency room visits.

    Here’s more from Just Care:

  • Lower income Medicare cancer patients less likely to get optimal care

    Lower income Medicare cancer patients less likely to get optimal care

    A new study of Medicare cancer patients published in the Journal of Clinical Oncology finds that patients with lower incomes who receive a Medicare Part D Low-Income Subsidy (LIS) through the Extra Help program, are less likely to get optimal care, reports Medscape. These lower income individuals too often do not get systemic cancer therapy as compared to individuals with higher incomes not in the LIS program. People in the LIS program are more likely to get treatment that is not recommended.

    The goal of the Medicare Low-Income Subsidy or Extra Help program is to promote health equity. However, many people with low incomes who qualify for the program either do not know it exists or face too many barriers applying for it. As a result, around half of all people eligible are not enrolled in it.

    To qualify for Extra Help, you must apply through your state Medicaid office. However, you will be automatically enrolled if you have Medicaid, receive Supplemental Security Income benefits or are enrolled in a Medicare Savings Program.

    This new observational study of cancer patients suggests that those who are enrolled in the LIS program still face financial barriers to care that prevent them from getting the systemic cancer treatment they need. The LIS program helps offset the cost of oral prescription drugs under Medicare Part D for people with incomes up to 150 percent of the federal poverty level. The LIS program does not help offset the costs of drugs administered by physicians under Medicare Part B.

    However, many people in the LIS program also qualify for a Medicare Savings Program. There are a few programs to help with Medicare Part A and Part B out-of-pocket costs, depending upon your income. Some pay the deductibles and coinsurance. To apply, contact your state Medicaid office.

    Also, as of January 1, 2023, a new Medicare prescription drug law could help offset coinsurance costs for some drugs and biologicals under Medicare Part B.

    Of the group studied, more than 40 percent did not receive systemic therapy for their cancer. Those who did not receive systemic therapy were more likely to be among those in the LIS program. Moreover, of those who did receive systemic therapy, those in the LIS program were more likely to receive inferior care.

    The study authors posit that the inferior care for the LIS cohort stems from financial barriers.

    Here’s more from Just Care:

  • Even with Medicare, older adults struggle to afford their care

    Even with Medicare, older adults struggle to afford their care

    Maggie Shaw writes in AJMC  about new findings reported in the Annals of Internal Medicine that many older adults struggle to pay the $1,600 Medicare Part A deductible. These findings corroborate a slew of earlier findings that cost is a barrier to care for people with Medicare, be they in traditional Medicare or Medicare Advantage.

    Most people in traditional Medicare have supplemental coverage to pick up those costs, either through Medigap, insurance they buy to fill coverage gaps, Medicaid, if their income is low, or retiree coverage from their jobs. How many people in Medicare Advantage can afford their care?

    Cost is a barrier to care for far too many people with Medicare, whether they are in traditional Medicare or Medicare Advantage. Traditional Medicare needs an out-of-pocket limit so that people who cannot get supplemental coverage still have financial protection. Usually, they sign up for Medicare Advantage, thinking they have protection because it does have an out-of-pocket cap.

    But, in Medicare Advantage, people are too often denied the care they need or forced to go through too many hoops to get their Medicare Advantage plan to cover their care. Moreover, when it is covered, they can have high out-of-pocket costs and they can’t get supplemental coverage to fill cost gaps. We have only a limited understanding of how often that leads Medicare Advantage enrollees to forego needed care.

    The AJMC study found that between a third and a half of all people with Medicare lack financial stability. Black and Hispanic adults with Medicare are particularly at risk financially; many do not have supplemental coverage. An NBER study a few years back found that even a $10 copay increase for prescription drugs under Medicare Part D led many to stop filling their prescriptions.

    The people most at risk in Medicare have incomes too high to qualify for Medicaid, up to 400 percent of the federal poverty level. Some of them qualify for Medicare Savings Programs that help with their costs. But, this help is not automatic and too often they do not apply for these programs. It’s a hassle.

    Instead, people with Medicare are left without needed care. The authors recommend that policymakers either make it easier for people with low incomes to qualify for help with their out-of-pocket costs or add an out-of-pocket maximum to Medicare.

    Here’s more from Just Care:
  • To protect older adults and people with disabilities, Congress must add an out-of-pocket cap to Traditional Medicare

    To protect older adults and people with disabilities, Congress must add an out-of-pocket cap to Traditional Medicare

    To promote health equity, meaningful choice, competition between Traditional Medicare and Medicare Advantage plans, as well as to protect older adults and people with disabilities, Congress should limit people’s out-of-pocket expenses in Traditional Medicare by adding an out-of-pocket cap. Congress also should eliminate the enormous overpayments to Traditional Medicare in order to ensure the sustainability of the Medicare Trust Fund and bring down Part B premiums.

    Health equity:  People of color and people with limited means are usually forced to choose among Medicare Advantage plans without being able to know which will cover their care appropriately. They are at serious risk. They are often locked into Medicare Advantage plans with very narrow networks and excessive prior authorization requirements because Traditional Medicare does not have an out-of-pocket limit and they cannot afford supplemental coverage.

    Medicare Advantage insurers are able to decide which Medicare Advantage plans offer more or fewer prior authorization requirements and better provider networks; but, there’s no way for consumers to know. The Medicare Advantage star-rating system is a farce; five-star plans can be bad actors, with ghost networks and widespread inappropriate delays and denials of care. The Centers for Medicare and Medicaid Services (CMS) has no way to protect vulnerable Medicare Advantage enrollees. Without an out-of-pocket cap in Traditional Medicare, they generally do not have it as an option.

    Choice: An out-of-pocket cap in Traditional Medicare would give people a meaningful choice of Traditional Medicare. It would allow people to enroll in Traditional Medicare without financial risk. Low and middle-income people and people of color lack this choice today because they cannot get the supplemental coverage they need to protect themselves financially. Supplemental coverage is either unaffordable or unavailable. 

    Indeed, today, people living in communities that insurers do not see as profitable, typically lower-income communities, can be left without any MA plan options and no meaningful Traditional Medicare option.

    Competition: An out-of-pocket cap would help level the playing field between Traditional Medicare and Medicare Advantage, driving competition.

    Cost savings: In 2024, Medicare Advantage plans cost as much as 22 percent more per person than Traditional Medicare, eating into the Medicare Trust Fund and driving up Part B premiums. Traditional Medicare is far more cost-effective than Medicare Advantage. An out-of-pocket cap in Traditional Medicare would enable more people to enroll, reducing Medicare spending.  

    Coverage: An out-of-pocket cap would protect people in Medicare Advantage plans who are too often inappropriately denied the reasonable and necessary services to which they are entitled. It would enable them to switch to Traditional Medicare. Today, the government cannot protect them from bad actor Medicare Advantage plans. The most vulnerable Medicare subpopulations are hardest pressed to navigate the rules and narrow networks in Medicare Advantage and get the care they need. 

    Here’s more from Just Care:

  • Are weight-loss drugs cost effective?

    Are weight-loss drugs cost effective?

    Millions of Americans now take weight-loss drugs, some as a treatment for diabetes but, increasingly, simply to lose weight.  A new study funded by the Blue Cross Blue Shield Association suggests that these drugs might not be cost effective, reports Joshua Cohen for Forbes. Nearly six in ten people stop taking them before they lose significant weight.

    People who take weight-loss drugs—GLP1s—can improve their health, particularly if they eat well and exercise. The drugs can help reduce the risk of heart attacks. They can also help people with chronic kidney disease and non-alcoholic fatty liver disease.

    Some believe GLP1s also can benefit people with sleep apnea and people with joint issues. As of now, Medicare only covers these drugs for people with diabetes and a small group of overweight people at risk for serious heart events.

    To be effective, people must continue to take these drugs, if not for the rest of their lives, for a prolonged period. People who go off them before they have shown clinical benefit tend to regain the weight they lost.

    People with diabetes are less likely to stop taking these medicines, Still, 58 percent of people who start taking them stop before they’ve experienced any real benefit. And three in ten people don’t renew their prescriptions after taking them for just one month.

    Only 32 percent of people who start on a weight-loss drug appear to continue taking them after a year. About one in three working people do not have health insurance coverage for these drugs if they don’t have diabetes. These drugs cost so much that businesses who cover them will drive up insurance costs significantly.

    So, insurers don’t cover these drugs because of their cost, which is insanely high. Moreover, most people don’t continue on them long enough to benefit their health. And, their benefits for those who stay on them appear to be marginal.

    Even people who take weight-loss drugs on an ongoing basis appear to lower their risk of heart failure by just 1.5 percent, according to one recent study. Put differently, one in 67 people on these drugs avoid a serious heart event and virtually none avoid death any more so than people who don’t take these drugs.

    Bottom line, it’s still too early to make a compelling case that insurers should cover weight-loss drugs for people who are not diabetics. At least for now, the data suggest that the costs might outweigh the benefits.

    Here’s more from Just Care:

  • Save money, avoid hospital-owned outpatient facilities

    Save money, avoid hospital-owned outpatient facilities

    One of the ways hospitals are generating more revenue is through ownership of doctors’ practices, outpatient surgical clinics and diagnostic centers. Hospitals can charge far higher fees for care you receive at these hospital-owned providers, even though they have no evident tie to the hospitals. You literally can save thousands of dollars on an outpatient service by seeing physicians who are not part of a hospital system; Medicare could save billions by paying outpatient facilities the same rate as independent facilities.

    What’s going on? Hospitals are permitted to add a “hospital facility fee,” to your doctors’ charges or the charges at an outpatient facility that they own. The hospitals consider these facilities “outpatient hospital departments.” And, the charges can be $154.52 for a visit to the doctor to get a flu test or $15,000 for some services at some hospitals, reports Jessica Glenza for The Guardian.

    United States of Care, a non-profit organization, just released a report, Behind the Bill, on these hospital upcharges. It’s one way that consolidation in the health care sector is driving up costs.

    The American Hospital Association (AHA) supports facility fees and has helped to ensure they remain part of a patient’s bill at an outpatient facility owned by a hospital. The AHA argues that hospitals have a lot of unfunded costs, such as emergency room care they provide, regardless of whether patients are insured. The facility fee helps offset these costs.

    As recently as two years ago, more than four in ten doctors were connected with a hospital. A decade earlier, three in ten doctors had hospital ties. Charges for physician services keep rising. One researcher found that hospitals charge 150% more for the same outpatient services as ambulatory surgical centers in the same region that are not hospital-owned.

    Another study found that when a physician group merged its practice with a hospital, charges increased 14.1 percent on average. But, don’t think you can predict them; no one discloses them. They depend entirely on the hospital adding them to the bill and bear no relation to the cost of a service. 

    Medicare payment policy has fueled hospitals’ purchase of outpatient facilities. Medicare pays the same price for a service performed in hospital as in an outpatient facility owned by a hospital, even though the outpatient facility service should cost a lot less. Though some in Congress want to address this issue, nothing has been done to date.

    The AHA blames insurers for health care cost increases. But, hospitals are also responsible. Politics clearly has kept Medicare from adjusting its payments for outpatient services at facilities owned by hospitals down to the same level as it pays for outpatient services at facilities that are independent.

    Here’s more from Just Care:

  • If you use an inhaler, your out-of-pocket costs should come down soon

    If you use an inhaler, your out-of-pocket costs should come down soon

    As of Saturday June 8, many people in the US will pay $35 a month out of pocket for their asthma medications, reports NBC News. AstraZeneca and Boehringer Ingelheim have agreed to limit people’s out-of-pocket costs for inhalers. GlaxoSmithKline says it will also limit people’s out-of-pocket costs but not until next year. The cap does not apply to people with Medicare.

    People in other developed countries pay far less than Americans for their inhalers. Americans have been paying 13 times what Brits pay for AstraZeneca inhalers, $645 as compared to $49. Teva charges Americans $286 for their inhalers and Germans $9.

    And, we’re talking millions of Americans are paying insane costs for inhalers. Twenty-seven million Americans suffer from asthma. Five million of them are children.

    Today, even with insurance, many Americans cannot afford their asthma medicines. Costs for insured people with asthma can easily be $350 a month in the US, when you fold in the cost of additional medications such as albuterol.

    Black Americans are more at risk than white Americans. Black Americans have far worse health outcomes. Black children with asthma are 4.5 times more likely to end up in the hospital and 7.6 times more likely to die because of their asthma.

    If you have insurance: Your pharmacy should adjust the price of your inhalers to $35 a month, if it participates in the pharmaceutical companies’ programs.

    If you don’t have insurance or your pharmacy is not participating in the program: You can visit your drug company’s website online and sign up for a $35 copay card.

    It’s still not clear whether people who use multiple medications for their asthma will have to pay $35 a month for each asthma medicine. Some people need a rescue inhaler in addition to a maintenance inhaler.

    It’s great that some pharmaceutical companies have agreed voluntarily to lower people’s asthma medicine costs. But, it’s terrible policy that pharmaceutical corporations can charge pretty much what they will for their drugs, and we have to rely on their voluntary gestures for our drugs to be affordable. Right now, too many Americans are forced to choose between their child’s inhaler and food or rent.

    Here’s more from Just Care:

  • Want surgery? Some hospitals make you pay upfront

    Want surgery? Some hospitals make you pay upfront

    Melanie Evans reports for the Wall Street Journal on the rise of hospitals requiring patients to pay upfront  for their surgery. In one case, a hospital wanted $2,000 from a patient’s mother. It said it would postpone her daughter’s surgery if she could not come up with the money. While the patient is insured, she has a high deductible so her insurance would not cover the treatment.

    The good news: If you have Medicare, you should never have to pay upfront for your care. Upfront payment issues are greatest for insured Americans with high-deductible health plans. That said, one recent study by the Consumer Financial Protection Bureau found that older adults owe $54 billion in medical debt.

    Paying upfront is a challenge for millions of working Americans. In a Kaiser Family Foundation survey, half of adults said they could not pay an unexpected bill for $500 for their care without having to borrow money. GoFundMe is too often a solution. People do not have enough savings.

    Some hospitals have essentially flipped the way they do their billing. Rather than waiting until after a procedure to bill a patient, they are refusing to perform the procedure without a payment in advance. They don’t want to be dealing with patients who won’t or can’t pay the bill after they have been treated.

    Many people are in a bind, without the money they need to get care for themselves and their families. Sometimes they must delay critical care. Other times they find that the hospital overcharged them and need to spend their time getting the refunds they are due.

    People giving birth, needing knee replacements and CT scans are increasingly being asked to pay in advance for these services.

    Which hospitals are requiring these upfront payments? It appears that hospitals owned by UnitedHealth are among them. While hospitals cannot turn away patients who need emergency care, they can refuse to treat people needing elective care.

    Today, hospitals collect nearly a quarter (23 percent) of patient bills in advance of treatment. That’s up from one fifth (20 percent) just two years ago.

    Hospitals do not want to be forced to write off debt. And, even patients with insurance today are not able to cover their costs. Advance payments are how hospitals are getting around this issue to the detriment of many patients and their families.

    Some claim the benefit to these upfront charges is that they let the patients know their costs so that they can possibly comparison shop. That is generally an impossible task, as it can mean switching doctors or traveling too great a distance to get needed care.

    Before you pay a hospital bill upfront:

    • Ask about other options. Non-profit hospitals must offer charity care for people who can’t afford to pay. Dollar For is a non-profit that can assist you in getting charity care.
    • If the cost is high, ask whether there is a way to pay a lower price or to pay in installments with no interest.

    Here’s more from Just Care:

  • Billions in Medicare savings from Medicare drug price negotiation by 2031

    Billions in Medicare savings from Medicare drug price negotiation by 2031

    A new report from Nicole Rapfogel at the Center for American Progress (CAP) finds that the Inflation Reduction Act’s provision allowing Medicare to negotiate drug prices for its highest cost drugs will reduce drug spending by tens of thousands of dollars a year for millions of people with Medicare and save Medicare millions of dollars a year.

    On September 1, 2024, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, will announce the prices it has negotiated with pharmaceutical corporations on ten drugs that treat, among other things, diabetes, kidney disease, blood clots and heart failure. Beginning in January 2026, the cost of these drugs should drop considerably.

    The ten drugs cost Medicare significantly more than other drugs it covers either because they have very high prices or because they are widely used. A total of nine million people currently use their Part D drug benefit to fill prescriptions for these drugs. These ten drugs represent roughly 20 percent of Medicare’s annual drug spending under Part D.

    CAP projects that the price of one insulin product, NovoLog FlexPen will fall $30 a month and the price of one cancer drug, Imbruvica, will fall $6,548 a month. The price of Eliquis, which 3.5 million people with Medicare take, could drop by $123 a month.

    Currently, Americans pay many times more than people in other wealthy nations for several of these drugs. For example, a dose of Stelara, another drug whose price Medicare is negotiating, which treats people with autoimmune conditions, costs $2,900 in the United Kingdom and $16,600 in the US. Moreover, Americans paid $6.5 billion in taxpayer dollars for the development of Stelara.

    While Medicare is only negotiating the price of 10 drugs this year, by 2030 it will have negotiated the price of 80 drugs. CAP estimates that Medicare will save $25 billion as a result of drug price negotiation in the six years between 2026 and 2031.

    Of course, the pharmaceutical corporations are trying to block these price negotiations in the courts, claiming that the government should not be interfering with the prices private corporations set. What they fail to say is that they developed these drugs with $11.7 billion in taxpayer dollars, The Lever reports. And, the pharmaceutical corporations made $70 billion on these drugs in 2022.

    Here’s more from Just Care:

  • Free preventive care: New avenue for health care price gouging

    Free preventive care: New avenue for health care price gouging

    Watch out. Don’t assume that the free preventive care services to which you are entitled under the Affordable Care Act (ACA) will not cost you a bundle. Samantha Liss reports for KFFHealthNews on how a free colonoscopy service turned into a huge bill.

    One couple with coverage through the Illinois state health insurance exchange were charged $600 for their “free” preventive care colonoscopies. Of course, the health care facility did not bill them for their colonoscopies, since that would be illegal.

    Rather the health care facility, seemingly in cahoots with the couple’s insurer, billed the couple for “supply trays.” The story exposes how providers and insurers game the system at the expense of patients in our current out-of-control health care system.

    Here’s what happened: At 45, the couple went to a facility for what they believed to be free colonoscopies. The bill for the two procedures was $4,068. The insurer discount brought the bill down to just under $800—the insurers’ cost.

    Afterwards, the couple were each billed $600 by the facility for “supply trays.”  Their insurer brought their charges down to $250 each. But, their bill still totaled $500 for the two “free” colonoscopies and the couple appealed.

    What happened? The story suggests that the gastroenterology practice, owned by a private equity company, did an end-run around the ACA. It does not make clear whether charging for supply trays is legal, although it’s hard to believe it is. It also appears that the couple’s insurer was in on the game since the gastroenterology practice had arranged this charge with the couple’s insurer. The more revenue the gastroenterology practice can get from patients, the less it needs to get from their insurers.

    The couple filed complaints. Federal law does not protect people in these cases, even though the ACA is federal law. States are in charge. The couple were at the mercy of their insurer.

    Here’s more from Just Care: