Jordan Shapiro, The St. Louis Post-Dispatch, Author at �鶹Ů�� Health News

Former Medicare Chief Named Top Health Insurance Lobbyist

Jordan Shapiro, The St. Louis Post-Dispatch — Wed, 15 Jul 2015 19:39:57 +0000

The former head of Medicare will become the top lobbyist for health insurers, America’s Health Insurance Plans announced Wednesday.

Marilyn Tavenner will lead the trade group following the departure of former CEO Karen Ignagni earlier this year. Tavenner formerly led the Centers for Medicare & Medicaid Services and oversaw the implementation of President Barack Obama’s health law.

Marilyn Tavenner (Photo by Chip Somodevilla/Getty Images)

“There is no better individual than Marilyn to lead our industry through the increasingly complex health care transformation that is underway,” said America’s Health Insurance Plans board chairman Mark Ganz in a written statement.

It’s a turbulent time for health insurers. The largest companies are consolidating and firms are still struggling with the rollout of the federal health law. Already, Aetna and Humana have announced a merger, Clayton-based Centene Corp. is in the process of acquiring Health Net Inc., and Anthem is pursuing a deal with Cigna.

Tavenner played a crucial role in the rollout of the federal health law during her time with the government. She oversaw many of the new rules that now limit how health insurers can operate and led the troubled launch of HealthCare.gov.

“I am honored to join this association and to lead this industry that is deeply committed to improving care delivery and affordability for individuals and families,” Tavenner said in a statement.

America’s Health Insurance Plans, or AHIP, has also been rocked by recent changes. Last month, UnitedHealth Group Inc., the nation’s largest insurer, announced it was leaving the trade group. The insurer said the lobbying group no longer represented its diverse interests.

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Small Business Health Insurance Exchanges Are Off To A Rocky Start

Jordan Shapiro, The St. Louis Post-Dispatch — Fri, 10 Jul 2015 15:01:26 +0000

Millions of Americans have health insurance because of the Affordable Care Act, but there’s one area where enrollment has significantly dragged. Few small businesses are getting coverage through the law’s online insurance exchange.

Only 10,700 employers are currently enrolled in coverage through the Small Business Health Options Program, or SHOP, exchanges, the federal government announced this month. That figure represents about 85,000 Americans, the government said. Officials did not provide a state-by-state breakdown.

In contrast, more than 10 million Americans have signed up for health insurance through the exchanges created for individual consumers.

“While the enrollment numbers do not yet reflect the full potential of these marketplaces, we believe that SHOP is still an important option for small businesses looking for quality health coverage,” said John Arensmeyer, CEO of Small Business Majority, a major promoter of the small business exchanges.

The SHOP exchange is designed to allow employers with less than 50 full-time workers to compare competing plans. The company could then offer its employees a choice from among several policies. Businesses with fewer than 25 full-time workers can also qualify for a substantial tax credit if their employees enroll in SHOP plans.

But the exchanges have been mired by setbacks from the beginning.

Plans could be sold on the exchange starting in the fall of 2013 but only by paper application. Federal health officials delayed the launch of the website until last year in order to prioritize fixing HealthCare.gov, the individual exchange, after its disastrous launch in 2013.

When the SHOP website did finally launch last year, few employers knew about it.

“As with all new products, it will require time to educate businesses about all the features of SHOP Marketplaces,” the U.S. Department of Health and Human Services said in a written statement.

Other factors also are at play, especially in the St. Louis area.

For the two years that carriers could offer plans on the SHOP exchange, only one — Anthem BlueCross BlueShield — has elected to do so. That means local employers looking to use SHOP can only choose one carrier and one plan in each of the three “metal” levels that determine the quality of coverage.

Bill Hill, an insurance broker and president of the Missouri Association of Health Underwriters, said the lack of choice and difficulty in qualifying for the tax credit have doomed the exchange.

“Without that stuff, it is kind of hopeless,” he said.

The tax credit is generally only available to businesses with fewer than 25 full-time employees. Qualifying businesses must cover at least half of the cost of their employees’ insurance premiums and their average employee salary must be less than $50,000. The credit is worth 50 percent of the employer’s premium contribution.

Health and Human Services Secretary Sylvia Burwell listed changes to the tax credit for small businesses as a potential way to improve the health law during a conference call with reporters in June.

But even if employers qualify for the tax credit and want to enroll in SHOP coverage, they may not be able to. Most states, including Missouri, require 70 percent of workers to participate in their employer’s plan in order for it to be an option.

Despite the setbacks, federal officials are optimistic enrollment will improve. In addition to increasing awareness of the program, they point out more employers will be eligible to participate in SHOP during future enrollment cycles.

Starting in 2016, employers with fewer than 100 full-time workers will be considered “small businesses” under the law and thus qualify for SHOP. The expiration over the next few years of “grandfathered” insurance plans that are not compliant with the Affordable Care Act could also drive more businesses to use SHOP.

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Prescription Drug Price Battles Show No Sign Of Letting Up

Jordan Shapiro, The St. Louis Post-Dispatch — Mon, 15 Jun 2015 09:00:50 +0000

The decision last week by experts at the Food and Drug Administration to endorse a pair of medicines aimed at combating heart disease brought on the latest round of hand-wringing over prescription drug costs.

The drugs, which work to reduce cholesterol, are projected to cost anywhere from annually once on the market. Patients will bear some of that cost, but the bulk will be paid by private insurance companies or the government through Medicare and Medicaid.

The endorsement of alirocumab and evolocumab by FDA panels this week has renewed concerns about the affordability of new specialty drugs that offer hope to millions of Americans. Whether patients can access, or afford, these new drugs will be a sticking point for years to come.

It’s a familiar tale. As science and technology advance, drug companies are able to create therapies that are more effective than ever. But the cost of these treatments has skyrocketed and put a strain on the entire health care sector.

When a new line of hepatitis C drugs was approved starting in 2013, attention immediately focused on the price. The initial drug, Sovaldi, was dubbed a “miracle” because it can cure the chronic liver condition with a single treatment.

But its staggering cost of $1,000 per pill — $84,000 for a standard 12-week course — immediately raised concerns. The government, health insurers and pharmacies, fearing rising costs, rushed to drive down the price through market pressure and restrictions on who could get the drug.

The endorsement of the cholesterol treatments show the pricing debate won’t be limited to Sovaldi and other hepatitis C drugs. An analysis released last week details how the battle will continue over the next decade as new, potentially costly, drugs to treat anything from cancer to cystic fibrosis come to the market.

by Avalere Health found that 10 drugs designated by the FDA as “breakthrough” therapies could cost state and federal governments $50 billion over the next decade. Medicare, the government-funded insurance program for the elderly would carry the heaviest burden estimated at $31 billion, the study said.

Private insurance companies could be on the hook for similar amounts as their clients demand access to the newest, best therapies. Avalere Health’s study was funded by America’s Health Insurance Plans, or AHIP, an industry trade group representing health insurers. The consultancy maintained editorial control, according to the study.

“Patients rely on innovative, life-saving medications, but soaring prices jeopardize access for those who would benefit the most from these treatments,” AHIP interim CEO Dan Durham said in a written statement about the study.

The pharmaceutical industry disputed the study’s findings and pointed out that overall prescription drug costs are projected to remain relatively stable at 13 percent of total U.S. health spending over the next decade. It also criticized the study for only selecting certain drugs and not considering other factors, such as increased market competition, that could bring down prices.

“It’s another report that cherry-picks medicine to advance a narrative,” said Holly Campbell, spokeswoman for the industry group Pharmaceutical Research and Manufacturers of America, or PhRMA.

Although drug spending is projected to remain level relative to its share of overall health care costs, evidence suggests patients are shouldering more of the burden.

, the St. Louis County-based pharmacy benefit manager, found that 140,000 Americans had drug bills of more than $100,000 last year, a 63 percent increase from 2013.

Express Scripts has been in pricing for these new specialty drugs. It used its market clout to drive down the price of the hepatitis C drug and the company is poised to continue as more specialty drugs hit the market. Its decision to give preference to a cheaper Sovaldi competitor could save billions, the company said.

“If patients had to pay out of their own pocket there is no way the manufacturers could charge that kind of price,” said Dr. Glen Stettin, senior vice president at Express Scripts.

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New St. Louis Dental Clinic Looks To Close Gaps In Coverage

Jordan Shapiro, The St. Louis Post-Dispatch — Fri, 12 Jun 2015 09:00:50 +0000

The city of St. Louis hasn’t had a general dental school in nearly 25 years, and it shows. Too few dentists and lack of access have contributed to a measurable decline in dental health for many of the region’s residents.

Organizers of a $23 million dental clinic near Lafayette Square, which opens Monday, hope to reverse that trend.

A.T. Still University dental students applaud during the opening speeches and ribbon cutting ceremony for the new St. Louis Dental Education and Oral Health Clinic in St. Louis on Wednesday, June 10, 2015, in St. Louis. The clinic will see its first patients in July. (Photo by J.B. Forbes/St. Louis Post-Dispatch)

The culmination of a more than four-year partnership between Kirksville-based A.T. Still University and Affinia Healthcare, the facility at 1500 Park Avenue has 92 chairs and will host at least 60 dentists at any one time, once fully operational.

Under the partnership, A.T. Still University will supply third- and fourth-year dental students to practice in the clinic while Affinia Healthcare will perform the administrative functions. The clinic will cater to all types of patients, including the uninsured.

“We are here today to make a difference,” A.T. Still University President Craig Phelps told public health and education leaders who marked the clinic’s grand opening on Wednesday.

The last comprehensive dental school in the city, operated by Washington University, closed in 1991. St. Louis University closed its main dental school decades earlier but it does host specialty dental education, including orthodontics and periodontics. (SIU School of Dental Medicine currently bills itself as the only dental school within a 200-mile radius of St. Louis, but its clinics are in the Metro East communities of Alton and East St. Louis.)

The lack of dentists who train, and later work, in the state has caused Missouri to fall behind in several oral health indicators. Only 61 percent of adults in the state see a dentist at least once a year, according to statistics from the . The national median is 67 percent.

Missouri also lags behind in other indicators. The state has higher instances of heart disease, strokes, arthritis and diabetes, which can be connected to poor oral health.

“We have a shortage of dentists in this state and oral health status is compromised in this state. So this is a very important endeavor,” said Alan Freeman, CEO of Affinia Healthcare, formerly known as Grace Hill Health Centers.

Freeman estimates that the clinic will serve 11,375 patients annually and will employ 85 staff at the 79,000-square-foot facility. Those patients without dental insurance will receive substantially discounted rates of up to 80 percent.

The university and Affinia Healthcare are counting on more patients’ being insured by the time the clinic hits full swing later this year. The state Legislature approved funding this year to allow about 250,000 low-income adults with Medicaid to receive dental services.

But that money won’t be available until this fall and it still could be restricted by Gov. Jay Nixon, who withheld funds for dental care last year.

University and public health officials say state funding of adult dental services through Medicaid could be pivotal for the success of the dental clinic and the entire education program.

The goal of A.T. Still University’s program is to train dentists in Missouri so they will stay and work after graduation. If Medicaid reimburses providers for dental care, they will have a larger pool of patients to serve.

In addition to working at the clinic during their final two years, students will also travel to rural health clinics across the state. There are 42 students in each graduating class.

“It offers us a good opportunity to retain these students in Missouri,” said Joseph Pierle, executive director of the Missouri Primary Care Association, which represents community health centers. “That is the ultimate goal.”

One of those students could be Daryl Grisby.

He’s a third-year student at A.T. Still University and will be working in the clinic starting this summer. Grisby is a St. Louis native, but moved to Atlanta when he was a teenager. He’s excited about working in the clinic for the next few years, but wants to stay even longer.

“I know of the need that is here, and I have a special connection to St. Louis, so it would be awesome to serve the community here,” he said.

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Missouri Consumer Group To Review Health Plan Rate Hikes

Jordan Shapiro, The St. Louis Post-Dispatch — Mon, 01 Jun 2015 15:00:34 +0000

A Missouri consumer advocacy group plans to take on the tedious task of reviewing health insurance rates with the goal of identifying and challenging hefty price hikes.

Missouri is one of the few states that does not allow its insurance regulators to review and approve health plan prices before they can be sold. As a result, local health advocates are planning for the first time to conduct that review themselves.

The Consumers Council of Missouri will lead the effort with financial backing from the Missouri Foundation for Health.

The council will only be able to review insurance plans sold to individuals through HealthCare.gov, the online federal marketplace where Missourians can buy health policies. About 250,000 Missourians currently receive coverage through HealthCare.gov plans.

“People should know what is going on with their insurance rates and if increases are justified,” said Joan Bray, executive director of the Consumers Council of Missouri.

The consumers group filed a lawsuit last year against the federal government seeking detailed plan information before the open enrollment season began Nov. 15. The information was released, but not until a few weeks before people could begin viewing and signing up for plans. The lawsuit is still pending.

But federal officials said rate information for next year’s plans is expected to be publicly available June 1. At that point, the consumers council, assisted by St. Louis University students, will begin diving into the information.

Bray said they hope to take a close look at rate increases, especially those more than 10 percent. Increases more than that amount are closely reviewed by federal regulators. Bray said the council could provide public comments supporting, or criticizing, such increases during the government’s review.

Last year, the second year that plans were sold on HealthCare.gov, St. Louis residents saw insurance rate increases above the national average. The monthly premium for the lowest-cost “bronze” plan — a plan that requires the highest level of customer cost-sharing — rose by nearly 12 percent.

That, along with the lack of authority for state regulators to examine prices, led to the new review effort.

“We hear people talk about rate increases every year, and this is an opportunity to bring transparency to that process,” said Ryan Barker, vice president for health policy at the Missouri Foundation for Health.”

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Missteps By Missouri Medicaid Become Ammunition For Expansion Foes

Jordan Shapiro, The St. Louis Post-Dispatch — Mon, 11 May 2015 13:01:20 +0000

Two years ago, Echo Garrett lost her job at a call center. Garrett, 35, of Cape Girardeau, Mo., was left to scramble without income and the health insurance she had counted on.

She was hired at a fast food chain in August, but the job has no health benefits, and she doesn’t make enough to purchase private health insurance.

Garrett also can’t qualify for Medicaid, the government-funded health care program for the poor, because she has no children.

Nearly 180,000 Missourians are in a similar predicament — they can’t afford private health insurance but they either make too much money or don’t have children, making them ineligible to join the state’s Medicaid rolls.

States have the option to alleviate this problem at a cost mostly borne by the federal government. But Missouri’s Republican-led Legislature has so far refused to use the federal dollars to expand Medicaid’s eligibility to cover Garrett and those like her.

For advocates pressuring the Legislature, Garrett’s story fits the bill as a compelling case. She can’t qualify for the current program no matter how little she makes because Missouri doesn’t cover adults without children. She has a job. And she has health needs — asthma and osteoarthritis — that require medical care.

But lawmakers have been resistant. They’ve cited fiscal concerns because the state would eventually need to pay 10 percent of the expansion’s cost. But they’ve also complained about the operation of the current program, saying it’s mismanaged and wastes money.

It turns out they might be right.

At the same time Garrett was losing her job and trying to get health insurance, a team of federal auditors was leading an investigation into Missouri’s Medicaid program.

The auditors would accuse Missouri of failing to collect required prescription drug rebates from manufacturers and improperly billing the federal government at least $34 million. Those conclusions were unveiled only last month. But to critics of Medicaid expansion, it was only the most recent drop in the bucket.

“There doesn’t seem to be any progress or remedial action taken on fixing the program we have in service,” House Speaker John Diehl, R-Town and Country, said in an interview after the audit was released. “Why would we add more [eligible people] if we can’t take care of the current ones?”

The audit followed a series of management missteps that came to light as lawmakers were considering Medicaid expansion. For example:

• in February 2014 that pregnant women had wait times as long as 90 days before their Medicaid applications were approved.

• in June 2014 Missouri answer how it would solve a backlog of thousands of other Medicaid applications stemming from the implementation of President Barack Obama’s health law.

• Missouri consumers faced in August 2014 when trying to reach a Jefferson City call center with questions about the program. Those times exceeded the amount allowed in Missouri’s contract with the call center vendor.

• The federal government recommended in October 2014 that Missouri for claiming improper Medicaid reimbursement for treatment of individuals with developmental disabilities.

• A state audit released in March found recoup $27 million in claims made in the names of dead people.

• And in April, the state refund more than $34 million to the federal government for failing to bill drug manufacturers for rebates.

These issues, combined with the politics of Medicaid and health care, have contributed to the Legislature’s reluctance to expand the program.

But for Garrett and those like her, the reasons are inconsequential. “I feel like I’m flailing in the ocean,” she said.

Getting Off The Ground

Medicaid was signed into law nearly 50 years ago. It is run jointly by the federal government and the states which both share responsibility for the program’s cost. The federal government lays out certain rules and procedures, but states have some flexibility when it comes to administering the program.

Missouri’s Medicaid program currently covers about 850,000 children, pregnant women, low-income parents, people with disabilities and the elderly.

It’s the single largest expenditure in Missouri, eating up more than a third of the state’s operating budget. The program in Missouri has grown 50 percent since fiscal year 2005, and total spending now is about $8.5 billion a year.

A key provision of the federal health care overhaul required states to expand Medicaid eligibility to cover residents with incomes above 133 percent of the federal poverty line, or $27,000 for a family of three. That would have provided coverage to an additional 300,000 Missourians, including Garrett and the other 180,000 people that fall into a coverage gap. But, in 2012, the U.S. Supreme Court said states could not be required to expand their programs. The ruling set off a state-by-state debate on whether to use mostly federal dollars to add more recipients to Medicaid.

Despite Gov. Jay Nixon’s enthusiastic endorsement of Medicaid expansion after his re-election win in 2012, fiscal conservatives and Republican critics of Obamacare were opposed.

Opponents seized on another line of attack — the current program was so mismanaged that more people couldn’t be added until the problems were fixed.

“We’ve seen the poor outcomes, the inefficiencies and the lost revenues from poor administration,” Rep. Sue Allen, R-Town and Country. “You can’t ignore it, and it has been part of the expansion debate.”

A Long Wait

One of the most damaging instances cited by lawmakers was the backlog of Medicaid applications stemming from the launch of HealthCare.gov.

Obama’s health law requires Americans to have health insurance or face a penalty. Those who are unable to get coverage from their employer can apply for insurance — and government subsidies — through government-run online exchanges. In states that chose not to set up their own exchanges, such as Missouri, residents apply through HealthCare.gov.

Because some of those applying for coverage would qualify for Medicaid, HealthCare.gov applications were sent to individual states.

Starting in January 2014, Missouri was inundated with applications, and had trouble keeping up.

The average wait time for residents to have their application reviewed doubled from 21 days in July 2013 to 42 days in January 2014. Average application wait time hit a peak of 79 days in both September and November of last year.

State officials were hindered by a new computer system for processing the applications and a departmental reorganization that occurred simultaneously. As the applications piled up, Nixon tapped his longtime aide, Doug Nelson, to sort out the mess.

In an interview with the Post-Dispatch, Nelson, who serves as Missouri’s Commissioner of Administration, blamed the Legislature for part of the fallout. He said lawmakers delayed funding for the new computer system for more than a year, putting the department behind.

The Nixon administration requested $50 million for the system in 2012, but lawmakers refused, citing concerns the money would be used to create a state-based health exchange. The Legislature ended up approving money the following year only after voters approved a ballot measure that prevented the governor from creating a Missouri exchange. Nelson said the delayed spending authority led to problems with processing applications.

“We were forced to build the airplane at the same time we had to fly it,” he said.

Moving Forward

The Nixon administration has stressed that things are improving when it comes to the applications.

The average application wait time dipped back to 42 days in March, state data show, cut nearly in half from its peak. But that’s still double the wait time from before the federal health law launched.

In a written statement to the Post-Dispatch, Nixon acknowledged some management issues in the Medicaid program. But he said that problems were being solved and pointed to the reduction in application wait times.

“Members of the Legislature are using an issue from last year as an excuse for doing the wrong thing today,” Nixon said in the written statement.

Supporters of Medicaid expansion have lauded the progress. But they disagreed that it should have been an issue when it came to the Medicaid expansion debate. “Measures are being taken to improve that system and it shouldn’t be a reason that we don’t provide coverage to those who need it,” said Michelle Trupiano, executive director of the Missouri Medicaid Coalition. The group represents hospitals, other medical providers and advocates who support the program’s expansion.

Others are less forgiving.

“There’s an attitude that the easiest way [to solve these problems] is to come back and get more money from the taxpayers,” Diehl, the House speaker, said.

Regardless of how the progress is viewed, Medicaid expansion could be a ways off for Missouri.

The debate didn’t get very far this year. Measures to approve the expansion failed in both chambers.

that would require recipients to work or enroll in job training to receive the health benefits. His announcement did little to sway Republicans.

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Audit: Missouri Medicaid Failed To Bill Drugmakers For More Than $50M In Rebates

Jordan Shapiro, The St. Louis Post-Dispatch — Tue, 14 Apr 2015 16:42:25 +0000

A new audit recommends that Missouri refund more than $34 million to the federal government because the state did not comply with Medicaid regulations.

For at least three years, the state failed to bill drug manufacturers for rebates the companies owed on drugs administered by physicians at a hospital, according to the audit scheduled for release Tuesday by the Office of Inspector General of the U.S. Department of Health and Human Services.

That failure enriched drug companies at the same time it deprived the program of millions of dollars that could have been used to care for Missouri’s neediest citizens.

A spokeswoman for the Missouri Department of Social Services said Monday the state disagrees with the audit findings and does not intend to make any repayments.

For a drug to be eligible for reimbursement under the Medicaid program, the drug’s manufacturer must agree to pay quarterly rebates to states. But each state has the responsibility to bill the manufacturer — and that’s where Missouri fell short, the audit said.

“If they had been invoiced by the states, the onus would have been on the drug companies to pay the drug rebates as required,” said Dan Bittner, one of the federal auditors who worked on the report.

The drugs under scrutiny could be anything from aspirin to antibiotics, so long as they are prescribed by a physician in a hospital setting.

States are supposed to collect rebates for these drugs by submitting utilization data to manufacturers that include National Drug Codes (NDCs) — specific numbers that are used to identify both the drug and the manufacturer.

The federal government requires states to get the data and codes from the providers who take care of Medicaid patients.

But in Missouri’s case, the Department of Social Services, which oversees the Medicaid program, failed to collect the necessary codes in claims it paid to providers totaling more than $50 million from 2009-2011, according to the federal audit.

“The state agency did not collect the drug utilization data necessary to bill the manufacturers for rebates associated with these physician-administered drug claims, and the claims were therefore ineligible for federal reimbursement,” the audit said.

As a result, the audit recommends that the federal government — which pays the bulk of the state-administered Medicaid program — get a refund from Missouri of more than $34 million because the drug claims were ineligible. Separately, it questions an additional $19.2 million in other payments that may have been ineligible for payment, which it says could result in an additional refund by Missouri totaling $13.2 million

Missouri officials, in an emailed statement to the Post-Dispatch on Monday, disputed the audit’s conclusions and said if the state needs to pay any refund it should be only about $7 million, which is the amount the state says it should have received in rebates from the drug manufacturers.

“The Department of Social Services disagrees with the audit finding and will not make any repayments based on the Office of Inspector General’s analysis,” Rebecca Woelfel, spokeswoman for the Department of Social Services, said in the email.

But Bittner, the federal auditor, said the amount of a refund would be determined based on the overall drug’s cost, not just the rebate amount. He said federal regulations prevent any Medicaid reimbursement for drugs that do not include the proper coding information.

State officials have 30 days to formally respond to the audit.

After that, the Centers for Medicare and Medicaid Services will determine whether the state will need to refund the federal government and how much. Should the state face a fine, CMS would likely deduct the amount from its regular Medicaid payments to Missouri.

State officials were able to review the draft findings and recommendations last year, and in a letter to the auditors dated Nov. 19, 2014, said the state’s hospitals were the ones that were unable to comply with the federal reporting requirement.

In the letter, Department of Social Services Director Brian Kinkade disagreed with many of the audit’s recommendations and said requiring Missouri to refund the federal government would place an “enormous hardship” on the state.

He wrote that Missouri had required hospitals and clinics to submit the proper information in a provider bulletin published by the department.

“Missouri hospitals encountered significant administrative and financial barriers in attempting to comply with the new NDC submission requirement,” Kinkade wrote in his November letter to Patrick J. Cogley, regional HHS inspector general for audit services.

Kinkade’s letter continued: “In the months following implementation of the requirement, Missouri denied over 77,000 claims for physician-administered drugs due to hospitals’ inability to identify and provide the required NDCs. The denial of such a large volume of claims created an enormous access problem for Missouri Medicaid enrollees. At the time, there was no bigger problem facing Missouri’s Medicaid program.”

Because of the difficulty the state encountered, it requested and received a waiver from the NDC reporting requirement in 2008 from the federal government. But it wasn’t extended and ended six months before the audit period began.

“This waiver expired more than six years ago, but the Department of Social Services has not taken the steps necessary to ensure that providers submit NDCs with physician-administered drug claims,” the audit said. It’s unclear why Missouri was able to deny 77,000 claims early in the rebate process, but stopped after the waiver expired.

The Missouri Hospital Association said it was operating under the assumption the waiver remained in place and added there was no formal state requirement for them to submit the drug codes in claim information.

Association spokesman Dave Dillon said hospitals face significant administrative burdens in tracking the drug information from the point-of-care. He added that the state’s technology infrastructure at the time made reporting even more difficult.

“Even if the hospitals had the capacity, I’m not sure the state had the ability to collect this information,” he said.

Federal auditors said Missouri lacked a proper record-management system that could have rejected claims that were missing the relevant drug information.

“The state agency notified providers that it would deny claims that did not include NDCs. However, the state agency did not have a system edit in place to reject all of the claims submitted without NDCs,” it said.

Missouri isn’t alone in grappling with the rebate issue. During the last few years, the federal government has been aggressively auditing drug claims in many states and is planning more.

Federal auditors found that Oklahoma and Louisiana complied with rebate requirements for a combined $10 million in drug claims during selected time periods over the last few years.

But they asked Maryland, Oregon, Idaho and Nebraska to each refund roughly $3 million for improper drug reimbursements. Missouri could face the largest refund of any state examined so far if the federal government’s recommendations hold.

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Missouri Health Plans Offer Inadequate Coverage For Smoking Cessation, Report Finds

Jordan Shapiro, The St. Louis Post-Dispatch — Tue, 14 Apr 2015 09:00:30 +0000

Insurers who sell plans on HealthCare.gov in Missouri are supposed to help people quit smoking but none offer adequate coverage, according to a new report by the .

Using information on the insurers’ publicly available websites, the report concluded that no plan offered on the government-run health exchange in Missouri covers all seven Food and Drug Administration-approved devices designed to help smokers kick the habit.

The findings, which insurance companies dispute, point to a continuing issue with the Affordable Care Act.

While the law requires health plans to cover certain “essential benefits,” such as tobacco cessation, enforcement is less than rigorous, especially in states like Missouri that rely on the federal government to act as watchdog.

Missouri is among the states that declined to create and run its own health insurance exchange, making the federal government provide that service instead. That meant Washington, instead of Jefferson City, was in charge of implementing this part of the Affordable Care Act. And that may have translated into less oversight.

The federal government’s role in regulating multiple insurance plans is “difficult from a resources standpoint as well as a logistical standpoint,” Georgetown University professor Sabrina Corlette said. “There are clearly shortcomings of having everything removed in Washington.”

Tobacco cessation hasn’t been the only issue where advocates and experts have urged more oversight from the federal government.

about how HealthCare.gov plans treat prescription drug coverage for those with HIV. They’ve accused insurance companies of charging high cost-sharing amounts for those drugs used to treat the condition, in effect discriminating against HIV patients. The Affordable Care Act prohibits insurers from charging more to consumers who have a medical condition with one exception for tobacco use.

The Affordable Care Act requires state and the federal government to take a more pronounced role in regulating health insurance coverage.

But the American Lung Association says the issue of smoking cessation may have fallen through the cracks.

Its report finds that only 17 percent of health insurance carriers covered all seven FDA-approved smoking cessation treatments at no cost to the consumers. None were in Missouri and only one carrier in Illinois was defined as “compliant” by the association. The seven devices are nicotine gums, patches, lozenges, nasal sprays and inhalers, as well as bupropion and varenicline.

Insurance companies were very critical of the lung association’s findings. They say that oftentimes smoking cessation treatments are covered under a policy but may not be listed on the publicly available drug formularies.

“It is important for members to understand that we do cover smoking cessation programs in accordance with the ACA and even though over-the-counter drugs or programs may not be in a formulary, they are still covered,” said Rohan Hutchings, a spokesman for Coventry Health Care.

James Martinez, a spokesman for the lung association, said information not included in the formulary was not factored into the report and could mean that more insurers are covering more tobacco cessation treatments than laid out in the study.

America’s Health Insurance Plans, an industry trade group, said carriers have had a long commitment to helping their customers quit smoking. It said insurers are following federal guidelines when it comes to tobacco cessation coverage and cited the government’s regulatory authority.

“All of these plans and products have to be reviewed by regulators and approved,” said Clare Krusing, a spokeswoman.

But to some, it’s the regulatory process that could lead to cracks in the system. Corlette said it’s unclear how often federal regulators are auditing the health plans for compliance. She also said that both the government and the insurance industry have been “drinking from fire hoses” since the health law was enacted, meaning some things have slipped through the cracks.

The problem is even more pronounced in Missouri, which doesn’t have a robust regulatory system on the state level. that told the federal government it did not have the ability to regulate the Affordable Care Act’s “market reforms.”

In an emailed statement to the Post-Dispatch, the federal Department of Health and Human Services said it would continue to work with health carriers to seek reductions in the smoking rate.

“We are committed to reducing the burden tobacco has on our nation and has made preventing and reducing tobacco use a priority,” the statement said.

Industry stakeholders acknowledged the challenge ahead.

“This is health care and it’s very complex. There are multiple different pieces to it and it’s relatively still new,” Martinez said.

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Patient-Doctor Relationship Forged Through Computer Screens

Jordan Shapiro, The St. Louis Post-Dispatch — Fri, 10 Apr 2015 09:00:24 +0000

Missouri’s largest health insurer recently launched a new online patient-doctor interface, a move that reflects the growing importance of telehealth as the industry looks to curb costs and enhance patient access.

More patients than ever are seeing their doctors through computer screens and smartphones. It’s a trend that shows no signs of subsiding as hospitals and insurance companies continue to roll out the latest technological advances.

For patients, they can see a doctor without the inconvenience of traveling to an office and sitting in a waiting room. For doctors, it allows them to see more patients in an efficient, cost-effective way.

Anthem BlueCross BlueShield in Missouri said these factors led them to develop , a telemedicine platform that became available to all members last month. The platform visually connects customers to doctors around the country from their computer, tablet or phone.

“This responds to a concern that people have raised,” said Dr. Jay Moore, the senior clinical director at Anthem. “It’s difficult sometimes for them to get care that is timely and efficient.”

A doctor is on call 24/7 and LiveHealth Online costs no more than a regular copay for an office visit. Patients that aren’t Anthem members can also use the platform for $49 a visit.

defines telemedicine as the “remote delivery of health care services and clinical information using telecommunications technology.” It says 200 networks and 3,500 service sites currently operate across the country.

It’s also one of the fastest growing sectors in the health care industry. The American Medical Association, which represents doctors, expects the telemedicine market to grow from $1 billion next year to $6 billion by 2020.

Lawmakers have also embraced telehealth. Missouri enacted a law in 2013 requiring insurance companies to reimburse for services rendered via telemedicine if the same service could be delivered in person. About 20 other states have similar laws.

The AMA provided a general endorsement for telehealth services last year while underscoring the continued importance of a patient-doctor relationship.

When telemedicine first took shape in the early 2000s, some patients and doctors were concerned the relationship between the two groups could suffer using the medium, to the detriment of health care.

But some say those fears haven’t panned out. Dr. Thomas Hale is the executive medical director for Mercy Health’s telehealth services. He says our culture has evolved to the point where interactions on the computer screen are considered real.

“The relationship with the caregiver is extremely important,” he said. “The virtual, visual encounter is now viewed by the patient as a relationship.”

Doctors also see telehealth as a way to reach patients in rural areas who don’t have regular access to a physician. It could even help alleviate longstanding concerns about a shortage of primary care doctors. ( estimates that by 2025 there will be a shortfall of between 12,500 and 31,100 primary care physicians.)

that will house 300 physicians, nurses, technicians, researchers and support staff to coordinate the Chesterfield-based health system’s telemedicine programs.

Mercy currently uses telehealth platforms to stroke-related consultations by neurologists and intensive care monitoring, among other functions. The center is expected to be completed this summer.

As technology continues to advance doctors are able to perform more tasks using the Internet.

Part of Anthem’s telemedicine program includes the installation of kiosks at workplaces. The kiosks include a computer screen to visually connect with a doctor, as well as hook-ups for thermometers, blood pressure monitors and dermal imaging cameras.

Stephanie Vojicic, Anthem’s regional vice president of sales, says the kiosks could provider care to workers while preventing them from missing time — and money — on the job going to a doctor’s office.

Hale also sees telehealth being used increasingly to monitor patient health to keep them out of the emergency room and hospital. He says monitors could be used to track a patient’s heart condition, for example.

“It’s all about getting more and more data,” said Dr. Chris Veremakis, medical director for Mercy’s telehealth programs.

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Policy Shift By Nation’s Largest Insurer Could Leave Some With Unexpected Bills

Jordan Shapiro, The St. Louis Post-Dispatch — Mon, 30 Mar 2015 09:00:37 +0000

Some St. Louis area residents face the prospect of getting stuck with hefty medical bills because of a recent change by the nation’s largest health insurer.

Minnetonka, Minn.-based UnitedHealthcare, which covers approximately one-fourth of Missourians, has changed the way it handles something known as “balance billing” — the difference between the provider’s charge and the amount allowed by the insurer.

The insurer’s move this year, designed to force down costs, means the insurer won’t pay the bills of some emergency room physicians and other specialists even though they work for hospitals in the UnitedHealthcare network.

That could leave a customer with health insurance coverage stuck with thousands of dollars in unexpected expenses.

“This is an issue that has been cropping up around the country,” said Cheryl Fish-Parcham of Families USA, an advocacy group. “We are very concerned about it.”

A Post-Dispatch analysis of UnitedHealthcare’s network and data provided by insurance brokers shows that about one-fifth of area hospitals in the carrier’s network had out-of-network emergency room doctors as of last month. A smaller number of UnitedHealthcare hospitals also have out-of-network anesthesiologists, radiologists and pathologists.

UnitedHealthcare previously would pay almost all of the bill from the emergency room doctors who performed services at an in-network hospital. But now UnitedHealthcare says it would scale back how much it would pay. It will now only pay the prevailing out-of-network rate, leaving the remainder of the bill to patients.

UnitedHealthcare blames the hospitals that contract out their emergency care to other providers who may or may not be in the insurer’s network.

In a statement to the Post-Dispatch, UnitedHealthcare said it is “deeply concerned that some hospital-based physicians are establishing out-of-network strategies to seek excessively high reimbursement levels, sometimes more than 10 times what an in-network physician would charge for the same service.”

UnitedHealthcare and other insurers say those prices are what lead them to alter their practice when it comes to paying the out-of-network bills.

A 2011 study by America’s Health Insurance Plans, an industry trade group, found that the amount billed for out-of-network emergency room care was on average 1,355 percent higher than what Medicare would have paid.

Not all UnitedHealthcare customers will be affected by the change. It does not alter coverage for those with individual plans or those whose employer is self-insured.

For workplaces with fewer than 50 workers, the billing change took effect on Jan. 1. Larger businesses will see the effects for bills after March 1.

Consumers have little recourse when hit by balance billing. They can negotiate directly with the provider and try to get a lower bill. Or they can just pay up. UnitedHealthcare added that it is “committed to supporting our members with information to help them avoid out-of-network bills whenever possible.”

The Missouri Department of Insurance said consumers can call the state’s complaint hotline at 1-800-726-7390 if they have a problem with their claim. A spokesman said balance billing cases would be examined on a case-by-case basis.

One way to resolve the issue would be for the out-of-network emergency room contractors to join UnitedHealthcare’s network.

Many of the local UnitedHealthcare-network hospitals with out-of-network emergency room doctors are run by SSM Health. SSM contracts with the Louisiana-based Schumacher Group for emergency services.

In a statement to the Post-Dispatch, Schumacher said patients are not currently being balance billed and that they are only responsible to meet coinsurance and deductible obligations. It said it’s looking for ways to join insurance networks.

“On behalf of the health care providers, we cooperatively negotiate with every insurance company in good faith to obtain fair and reasonable rates of reimbursement that adequately recognize the high-quality emergency care delivered every day,” the Schumacher Group said in a statement.

Other insurers have struggled with balance billing. A few years ago Anthem Blue Cross Blue Shield, Missouri’s largest insurer, reduced the amount it paid when members were billed by an out-of-network doctor. It resolved the backlash by entering into agreements with providers.

“We work very hard to keep all ER physicians in our networks so that members are not surprised with a non-network ER physician,” said Anthem spokeswoman Deb Wiethop. “All of the ER physicians in the greater St. Louis area have contracts with Anthem.”

But Coventry Health Care said it still covers the whole cost of balance billing.

“For us, members will be covered if they are treated by an out-of-network ER doctor and won’t be held responsible for balance billing from an out-of-network ER doctor,” said Rohan Hutchings, a spokesman.

States have also sought to regulate the practice. Most states ban balance billing for Medicaid managed care recipients. Roughly half bar it for private insurance customers.

Missouri prevents companies from balance billing some of its Medicaid population, but it has no restriction for private plans.

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