JustCare

Tag: Health insurance

  • Oncologists report excessive deaths from prior authorization

    Oncologists report excessive deaths from prior authorization

    A new survey from the American Society of Radiation Oncology illustrates the dangers of prior authorization. Prior authorization kills an “inordinate number” of people and harms others. Insurers often deny care to the detriment of patients when physicians first ask for authorization; when denials are appealed, insurers then approve care the vast majority of the time.

    About 225 of the 750 radiation oncologists polled reported adverse health outcomes from prior authorization.  Their patients ended up in the emergency room or hospitalized or with a permanent disability. One in fourteen of the oncologists polled said that one or more of their patients had died as a result of prior authorization.

    Prior authorization can have benefits, particularly in cases in which physicians are not well trained. Prior authorization can ensure physicians are treating patients appropriately, based on evidence. Prior authorization can also keep costs down.

    But, insurers use prior authorization without regard to its effects on quality of life for patients. And, while prior authorization can help protect against unnecessary treatment, there is no one protecting patients from insurers that use prior authorization inappropriately, in ways that harm patients.

    The oncologists polled suggested insurers’ use of prior authorization is only increasing. Moreover, it increases staff burnout.

    • More than nine in ten oncologists (92 percent) reported treatment delays from prior authorization and nearly seven in ten (68 percent) reported delays of at least 5 days;
    • More than eight in ten oncologists (82 percent) blamed prior authorization for patients receiving less than the best care;
    • Nearly six in ten (58 percent) oncologists said prior authorization kept them from following recommended guidelines;

    Those polled made clear that it’s critical to appeal prior authorization denials because more than 70 percent are reversed on appeal. But, patients and physicians sometimes do not have the resources to appeal. In some instances, the tradeoffs of appealing care denials, in terms of time spent, means physicians are unable to do their jobs.

    Moreover, insurers still have 72 hours to review an expedited appeal. For some patients with health insurance, the harm from such a delay is significant.  One doctor said that in that time, “I’ve had patients who’ve literally had a tumor growing out of their chest. Waiting 3 days for an appeal means there’s more cancer to treat, even just in the time between when I made the plan for them initially, and when I actually get to start their treatment. Sometimes it means the plan has to change because the tumor has gotten that much bigger in that time period. Every day matters.”

    Insurers shouldn’t be allowed to continue doing prior authorization for treatments that are virtually always approved on appeal.

    Here’s more from Just Care:

  • New physician survey finds prior authorization harms cancer patients

    New physician survey finds prior authorization harms cancer patients

    Here’s yet another reason to opt for traditional Medicare over insurer-run Medicare Advantage plans. A new survey by the American Society for Radiation Oncology (ASTRO) finds that insurers’ use of prior authorization can harm cancer patients, reports Renal+Urology News. Prior authorization also makes it hard for oncologists to do their job.

    Your insurance plan should provide good coverage for you today and in the future, whatever your health care needs. Sadly, as we get older, it becomes increasingly likely we will be diagnosed with cancer or some other serious health conditions. So, it’s not wise to gamble with your health insurance.

    According to the 754 oncologists surveyed in the last few months, in more than nine and out ten (92 percent) instances, prior authorization means that patients don’t get care as quickly as they otherwise could. Consequently, about one in ten patients end up forgoing treatment. Some patients end up in the ER or the hospital. Some end up with disabilities, which can be permanent. And, seven percent of respondents said that their patients died.

    More than half of patient radiation oncology services require prior authorization, even though insurers approve them more than seven in ten times initially. On appeal, nearly three quarters of denials are approved.

    Nearly six in ten (58 percent) physicians surveyed said that prior authorization kept them from being able to follow treatment protocols. More than eight in ten (82 percent) said that in some cases they ended up providing their patients with less good treatment as a result of prior authorization.

    Not only can prior authorization seriously harm patients’ primary treatment, it can also prevent them from or pose a significant barrier to their receiving treatment for side effects. For example, they might not be able to get pain or antinausea medicines.

    According to respondents, insurers are ramping up prior authorization requirements, not easing them. A typical delay is at least five days. It also requires more administrative staff.

    Howard M. Sandler, MD, chair of the ASTRO board of directors, sums up the survey findings: “These survey findings confirm what radiation oncologists witness daily: prior authorization policies are failing people with cancer, causing avoidable delays that are dangerous and, in too many cases, deadly.”

    Here’s more from Just Care: 

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

    Insurer provider directories misleadingly include physicians who are out of network

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

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

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

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

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

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

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

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

    Here’s more from Just Care:

  • US health care system ranks dead last among 10 of the world’s richest countries

    US health care system ranks dead last among 10 of the world’s richest countries

    The Commonwealth Fund this week released its biennial ranking of the health systems of 10 of the world’s richest countries, and once again the United States comes in dead last – as it has for the past 20 years – not just overall but on most performance measures, especially access and affordability.

    Throughout the report, it’s clear that one of the reasons the U.S. always brings up the rear internationally is the fact that far too many Americans – including those of us with health insurance – can’t afford to get the care we need. And tragically, so many of us who do seek care – with or without insurance – wind up deep in debt. As the Commonwealth Fund reports over the years have shown, that is a uniquely American tragedy.

    As KFF News has reported, more than 100 million Americans – 41% of adults – are mired in medical debt, and the vast majority of those people have both jobs and health insurance. The problem is that their “coverage” is just not nearly sufficient because of the ever-increasing out-of-pocket demands big insurance conglomerates (and the employers that hire them to administer health care benefits) saddle us with to boost their profits. (We’re the only country that allows for-profit insurance companies to run its health care system.)

    As the Commonwealth Fund’s report shows, we spend around twice as much for health care as the average of the other nine countries and almost twice as much as a percentage of GDP, yet we are the only one of the bunch that has not achieved universal coverage.

    Despite the big gains in coverage we’ve made since the enactment of the Affordable Care Act, more than 26 million of us remain uninsured. But just as unacceptable is the fact that far more than that – one of every four working adults in this country – are underinsured because of the uniquely American high-deductible plans that our employers and insurers have forced us into. For many of us they are not just high, they are sky-high. Forbes magazine has called people in such plans functionally uninsured.

    The Commonwealth Fund’s researchers note that unaffordable cost-sharing requirements – deductibles, copays and coinsurance obligations – “render many patients unable to visit a doctor when medical issues arise, causing them to skip medical tests, treatments, or follow-up visits, and avoid filling prescriptions or skip doses of their medications.” And when they do get the tests, treatments and medications they need, they all too often find themselves buried in debt.

    It has become such a problem that the Biden-Harris administration has made alleviating medical debt a priority. The White House is expected to lay out at least some of the steps the federal government can take to do that in the coming weeks.

    One important thing the administration already has done is ask Congress to pass legislation that would cap out-of-pocket costs for prescription drugs at $2,000 a year – and make sure that cap applies to all of us – not just Medicare beneficiaries. A $2,000 cap for people enrolled in Medicare Part D (and the private replacement plans marketed as Medicare Advantage) will go into effect in January.

    [This post was originally published in HEALTH CARE un-covered.]

    Here’s more from Just Care:

  • Republicans and Democrats alike love social insurance, why shouldn’t we all benefit from it?

    Republicans and Democrats alike love social insurance, why shouldn’t we all benefit from it?

    An opinion piece in MarketWatch by Brett Arends, a financial writer, makes the seemingly obvious case that if Americans love Medicare, as they do, they love social insurance. Yet, they are not far-left commies nor do they hate freedom. Given the failure of for-profit health care, shouldn’t we all benefit from Medicare?

    The failure of for-profit healthcare: If you have any doubts, read this lead New York Times story on the psychiatric hospital chain that is locking up patients who do not need hospitalization in order to continue to reap revenue from insurers. While you’re at it, take a look at John Oliver’s piece on for-profit hospices. And, check out these blockbuster stories on Medicare Advantage cash monsters and how Medicare Advantage insurers gouge taxpayers.

    Make no mistake, the price we pay for having for-profit health insurance and for-profit hospitals and for-profit pharmaceutical companies setting drug prices is not only financial. Yes, the high costs bankrupt all too many Americans; they also keep us from getting needed care. The for-proft health care industry causes extraordinary physical and emotional harm. According to one analysis in the National Bureau of Economic Review, Medicare Advantage plans lead to tens of thousands of needless deaths of older adults and people with disabilities each year.

    The government is far from perfect. We all know how much harm it can do. But, at it’s best, unlike the for-profit health care companies, it works for the people. It puts patients first, not profits. And, even when the government is not working as well as it should for Americans, government-administered traditional Medicare delivers easy access to good affordable care at far lower cost than privatized for-profit insurance.

    As Arends says, “we are forced to confront some shocking details. Senior citizens are happier with their communist Medicare than the rest of us are with our “freedom” insurance from private companies.” He goes on with some compelling data:

    “A higher share of Medicare beneficiaries was satisfied with their ability to find healthcare providers who accepted their insurance (96%) compared with privately insured people (91%),” MedPAC reported. “In addition, among beneficiaries who had received healthcare, a higher share of Medicare beneficiaries was satisfied with their ability to find healthcare providers that had appointments when they needed them (87%) compared with privately insured people (77%),” it added.

    Furthermore, MedPAC said, “In our focus groups, Medicare beneficiaries also reported high satisfaction with their insurance coverage, with the vast majority of participants rating their coverage as ‘excellent’ or ‘good.’”

    Other polls show that 81% of Americans support Medicare, including not only 89% of Democrats but even 79% of Republicans!”

    Here’s more from Just Care:

  • Medicare Advantage plans continue to endanger hospitals and patients

    Medicare Advantage plans continue to endanger hospitals and patients

    Jakob Emerson reports for BeckersHospital on the plight of hospitals dealing with Medicare Advantage plans. The insurers offering Medicare Advantage plans often try to maximize profits by denying payments to hospitals inappropriately. Or, they refuse to pay for patient inpatient stays and downgrade them to outpatients stays, which cost less. In short, Medicare Advantage plans continue to endanger hospitals and patients.

    Patients are beginning to feel the unhappy consequences of insurer misbehavior towards hospitals. In some cases, Medicare Advantage plans are denying patients needed care or forcing them to jump through multiple hoops in order to get critical care. Hospitals are cancelling their Medicare Advantage contracts, leaving patients to scramble to find other network providers. This year alone, at least 17 hospital systems have cancelled or will cancel their Medicare Advantage contracts.

    More than half the Medicare population is now enrolled in a Medicare Advantage plan, so hospitals tend to need the Medicare Advantage business. At the same time, they face financial risks when they contract with the insurers offering Medicare Advantage plans. S&P Global’s new report finds hospitals extremely vulnerable to Medicare Advantage bad acts.

    The risks to hospitals is only growing, as the insurers in Medicare Advantage are wildly overpaid. It is more than likely that Congress and the administration will do more to eliminate these overpayments. When that happens, the hospitals will likely face even more challenges getting paid appropriately by Medicare Advantage insurers.

    Another deep concern with Medicare Advantage is that there’s no counting on insurers to stay in business from one year to the next. Three big insurers, Centene, Aetna and Humana are saying they are pulling out of some of the Medicare Advantage markets in 2o25. The government and Medicare Advantage enrollees cannot rely on insurers to continue offering Medicare Advantage plans.

    If they continue in business, there’s also no counting on insurers to keep their Medicare Advantage provider networks, cost-sharing and additional benefits. Insurers can narrow their provider networks, increase cost-sharing, and eliminate additional benefits. Everything can change.

    “[W]e expect insurers to prioritize margin over membership, and we expect large insurers will use their scale and market clout to limit provider rate increases over what will prove to be a challenging contract negotiation season,” reports S&P Global.

    Here’s more from Just Care:

  • Nearly half of Americans can’t afford their health care

    Nearly half of Americans can’t afford their health care

    Time passes and health care costs rise, as do the number of Americans who can’t afford their health care, according to a new Gallup and West Health poll, reports Aimee Picchi for CBS News. Not surprisingly, people of color are struggling most to pay for their care, as are people in their 50’s and early 60’s, who are not yet eligible for Medicare. But, eight percent fewer people over 65 are able to afford their care now than just two years ago.

    Only about 55 percent of Americans between the ages of 50 and 64 are “cost secure.” They can afford care and prescription drugs. But, that percentage is dwindling quickly. Two years ago, 61 percent reported being “cost secure.

    Even with Medicare, just 71 percent of people are cost secure, down from 79 percent in 2022. Younger adults are the least cost secure. Fewer than half of them (47 percent) can afford their health care, down five percent from two years ago.

    The new poll found that 45 percent of respondents reported skipping care or not filling their prescriptions because of the cost or an inability to get them.  Eight percent of those people said that if they needed care now, they would not be able to get it at an affordable cost. Gallup termed these people “cost desperate.”

    Around one in three U.S. adults, more than 72 million people, said that they had not got care they needed in the past three months because of the cost. Of those 72 million, more than eight million are 65 or older.

    Black and Hispanic Americans are increasingly cost desperate. About one in seven Hispanic adults and one in nine Black adults are cost desperate. Seven percent of White adults are cost desperate.

    What’s causing this increase in the number of Americans who can’t afford their care? Inflation has driven up health care costs. And, doctors and hospitals can charge pretty much what they please, with little accountability. Moreover, insurers keep increasing their deductibles, the amount people must pay out of pocket before their insurance coverage kicks in.

    In 2022, the typical insurance deductible for a family was $3,800. That deductible reflects more than a 50 percent increase ($1,300) from 2013.

    Overwhelmingly, Americans believe that health care costs too much and they are not getting bang for their buck. But, they are not advocating for Medicare for all or even a government-regulated system that sets prices for health care services, which would bring their costs down.

    People are eating less to pay for their prescription drugs. We don’t know how many are dying prematurely because they can’t afford their heart and other medicines, but it’s a good bet thousands are each year.

    Today, the average annual cost of health care in the US per person is $12,555. In Germany, Italy and France, the average annual cost is around $6,651, almost half of what we spend.

    Insurers are keeping people from getting the health care they need. They deny and delay care inappropriately. They refuse to pay for medically necessary services.

    Here’s more from Just Care:

  • Three steps to prepare for an at-home emergency

    Three steps to prepare for an at-home emergency

    Jancee Dunn reports for the New York Times on how to prepare for an at-home emergency. When the ambulance arrives, in many instances, speed can be life-saving. If you or someone you love has suffered a heart attack or stroke, your brain can suffer irreparably within minutes.

    How to get emergency services at home: Sometimes, you’ll have to call 911. But, sometimes, you’ll be able to contact the ambulance company directly. So, before any emergency arises, contact the hospital you’d want to be admitted to in an emergency to learn which ambulance company you should use to get there, write down the company’s name and phone number and put it in a safe place.

    Keep your costs down: Double-check with your insurer that your health insurance will cover that ambulance.

    Keep in mind that hospital emergency rooms are not equal. Some are far better than others. Make sure you choose an emergency room that will meet your needs.

    If you call 911, let the ambulance company know the hospital you want to be taken to. The ambulance generally will take you to the nearest hospital. But, if you live in a city, there might be several hospitals within a short distance. If so, the ambulance should be able to take you to the hospital of your choice.

    Three steps to prepare for a trip to the ER:

    1. Put together your personal information–your name, birthdate and information about your health, including your blood type, the medications you are taking. Share the document with family and friends.
    2. If you’re home alone, make sure that your personal and health information is easy for a stranger to locate. Tape it to your front door. Enter it on your mobile phone medical ID page. Medical ID information does not require a password to access.
    3. If an ambulance is coming to your home, if possible, unlock the front door so it’s easy to enter.

    Here’s more from Just Care:

  • Medicare Advantage provides huge gross margins to insurers

    Medicare Advantage provides huge gross margins to insurers

    Page Minemeyer reports for Fiercehealthcare on a new Kaiser Family Foundation (KFF) analysis finding that insurers offering Medicare Advantage plans had the highest gross margins. Medicare Advantage plans in 2023 realized nearly twice the gross margins from their Medicare Advantage enrollees as they did from their enrollees in the individual market. When will government stop wasting billions of taxpayer dollars and stop overpaying insurers offering Medicare Advantage?

    According to KFF, insurers’ gross margins for each enrollee in Medicare Advantage in 2023 were $1,982 as compared to $1,048 in the individual market. While gross margins cannot be equated with profitability, they are a key metric for assessing a company’s financial performance. Gross margins do not account for administrative costs or taxes.

    And, even though insurers suggested that more enrollees in their Medicare Advantage plans in 2023 received costly services than enrollees in 2022, their gross margins were about the same in 2023 as in 2022, $1,977.

    The federal government theoretically caps the amount that insurers can profit through their Medicare Advantage plans. There is what is called a Medical Loss Ratio or MLR, which requires insurers to spend at least 85 percent of their government payment on care; they can keep as much as 15 percent for administrative costs and profits. But, in practice, the insurers have many ways to get around the cap.

    UnitedHealth has done a brilliant job of getting around the cap by acquiring physician practices. It can transfer 85 percent of its government payment to its provider subsidiary and then claim it has met its medical loss ratio requirement.

    Here’s more from Just Care:

  • Employer-based health care doesn’t work for people with lower incomes

    Employer-based health care doesn’t work for people with lower incomes

    About 60 percent of people who are not over 65 have employer-sponsored health insurance, reports the Kaiser Family Foundation. But, a significant portion of people eligible for employer coverage, primarily people with incomes under 200 percent of the federal poverty level, do not take it because of the cost.

    Nearly 165 million people or about half the US population has employer-based health insurance. More than four in five employers offer coverage. As health care costs continue to rise and insurers delay and deny care and narrow their health care provider networks, even with insurance it can be hard to get care.

    The high cost of health insurance and the ability of employers to charge their workers for it mean that our health care system discriminates against people with lower incomes even when they are eligible for employer coverage. Not even one in four (23.9 percent) people with incomes under 200 percent of the federal poverty level, who are eligible for employer-sponsored health insurance, elect it. Six in ten eligible (59 percent) people with incomes between 200 and 400 percent of the federal poverty level elect it. But, more than eight in ten (84,2 percent) people with incomes above 400 percent of the federal poverty level elect it.

    Similarly, people with incomes under 200 percent of the poverty level were far less likely to work at a job that offered employer-sponsored health insurance than people with incomes over 4oo percent of the poverty level, 60.6 percent versus 88.2 percent. Because employers do not have to offer health insurance to all their workers, people with lower incomes end up less likely to have a job that offers them health insurance. About half of workers (49.5 percent) with incomes under 200 percent of the poverty level were eligible for coverage as compared to 84.6% of workers with incomes above 400% of the federal poverty level.

    Employer-based health insurance also leads to racial discrimination, benefiting White individuals far more than non-White people. Black people, Hispanic people and American Indians are significantly less likely to take advantage of employer-based coverage than White people. Not even four in ten American Indians (39.6 percent) get employer-based coverage for which they are eligible, as compared to 68.4 percent of White people. Forty-five percent of Hispanic people and 52.6 percent of Black people get employer-based coverage.

    Disparities in access to health insurance also exist by profession. People working in different industries have significantly different access to employer-sponsored health insurance. People working in fishing, farming and forestry are least likely to be offered employer-sponsored health insurance. Only 41.4 percent of them had access to coverage. In stark contrast, more than 85 percent of people working as professionals or in finance, business and other management positions had access to employer-coverage.

    Here’s more from Just Care: