Insuring Your Health Archives - �鶹Ů�� Health News

Shifting Gears: Insuring Your Health Column — Born With The ACA — Draws To A Close

Michelle Andrews — Tue, 28 Aug 2018 09:00:17 +0000

Until I started writing the Insuring Your Health column eight years ago, I had no idea what a medical loss ratio was, and I’d surely never used the words “benchmark silver plan” in a story. If asked, I would have guessed that “ACA” stood for the (which is actually a thing, by the way).

Now I know better. Way better, having written once or twice a week for several years about how the Affordable Care Act has affected consumers’ health care coverage and costs.

I’ve delved into other coverage issues along the way as well, but the huge changes brought about by the 2010 health law have been a constant focus.

Now it’s time to shift gears. This is the last Insuring Your Health column. But it isn’t the last time you’ll hear from me at Kaiser Health News. I’ll continue writing regularly about consumer health care for KHN, just not every Tuesday. With the added flexibility I want to be able to now and then take a broader look at some of the consumer health areas I’ve been writing about over the years. I hope you will keep reading and giving me feedback.

I couldn’t do this work without a lot of help. Thanks to the many, many smart and thoughtful pros who’ve carved out time to talk with me again and again to help me understand the devil-in-the-details of medicine, health law and policy. I expect I’ll be calling on some of you this week to chat.

Thanks also to the amazing team of committed journalists at KHN who produce such great work day in and day out. They are an inspiration.

Most of all, I’d like to thank the many people who’ve shared their stories with me over the years and allowed me to write about them. People like Kristen Catton, who faced thousands of dollars in bills when her health plan changed how it covered her multiple sclerosis drug. Or Phyllis Petruzzelli, who avoided a hospital stay for pneumonia by being “admitted” to her living room through a hospital-at-home program. Those experiences explain health policy in personal terms for readers, and I’m so grateful to the many people who’ve trusted me to tell their stories.

And I hope you’ll keep on doing so! Hearing from real readers about their boots-on-the-ground experiences in the health care trenches, as it were, is invaluable.

Please let me know what’s on your mind and how the system is working for you. You can reach me at Andrews.KHN@gmail.com. I look forward to hearing your thoughts and ideas.

�鶹Ů�� Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at �鶹Ů��—an independent source of health policy research, polling, and journalism. Learn more about .

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Biorhythms And Birth Control: FDA Stirs Debate By Approving ‘Natural’ App

Michelle Andrews — Tue, 21 Aug 2018 09:00:05 +0000

The Food and Drug Administration took a “big tent” approach earlier this month when it approved two new forms of birth control that prevent pregnancy in very different ways.

Women’s health advocates applauded the availability of that could be used for up to a year. But some questioned the that helps women avoid pregnancy by tracking their body temperature and menstrual cycle, a type of contraception called “fertility awareness.”

Critics that three dozen women in Sweden got pregnant despite monitoring their cycle with the app. They also fear that the FDA approval of the app may encourage patients to think that , which include a range of practices to track ovulation, and avoid unprotected sex during that time, are just as good at preventing pregnancy as some highly effective types of birth control, like the intrauterine device, or IUD. While “natural” methods can be successful, they generally require close daily attention.

There’s still room for improvement in contraceptive use by women and men. Nearly half of the 6.1 million pregnancies in the United States — 45 percent — in 2011 were unplanned, published in the New England Journal of Medicine. That figure is lower than the 51 percent rate in 2008, but is higher than the rate in many other industrialized countries.

The FDA has approved nearly two dozen contraceptive methods, including the pill, the patch, IUDs and hormonal implants and shots, among others. Insurance is required to cover all FDA-approved methods without charging women anything out-of-pocket.

The new vaginal ring, releases hormones that prevent ovulation and after three weeks for seven days, then reinserted. It can be used for a year. The device will not be on the market until at least late 2019, and the price hasn’t been released by the manufacturer.

�ճ�� instructs women to take their temperature at the same time every morning when they awake and record it in the app. They also track information about their menstrual cycle. Based on slight temperature changes around ovulation, the app signals when women should avoid unprotected sex. It costs about $80 a year.

Both of the new methods require more attention on the part of the user than say, an IUD, which once inserted can be ignored and is designed to prevent pregnancy for five to 10 years, depending on the brand.

Still, some women’s health experts worry that the FDA stamp of approval may be misinterpreted by some women.

“People will interpret this to mean that the FDA approves this and thinks it’s a good method,” said , vice president of practice activities for the American College of Obstetricians and Gynecologists.

“That’s why counseling is so important,” he said, noting that doctors should discuss all forms of birth control with women, and the conversation should include the efficacy of different methods.

But Dr. Gillian Dean, senior director of medical services at Planned Parenthood Federation of America, welcomes the approval of both new methods.

“More options are always better,” she said. “It isn’t one size fits all, and more options increases the likelihood that women will find a method that works for their needs.”

The right contraceptive depends on a woman’s goals, Dean said, including her reproductive plans, what her menstrual cycle is like, the number of partners she has and how important it is for her not to get pregnant. She said most women who visit Planned Parenthood clinics ask for and receive birth control pills, but an increasing number are asking for long-acting reversible methods of contraception, such as IUDs and hormonal implants.

The IUD and hormonal implants have a “failure rate” of less than 1 percent, making them among the most effective (on par with permanent sterilization). Birth control pills, the patch and the vaginal ring have effectiveness rates of about 91 percent, according to the federal Centers for Disease Control and Prevention.

Fertility awareness methods, on the other hand, have a failure rate of about 24 percent, according to the CDC. But that figure is widely misunderstood, said a senior research scientist at the Guttmacher Institute, a sexual and reproductive health research and advocacy organization.

Polis co-authored of fertility awareness-based contraceptive methods that was published in August in the journal Obstetrics and Gynecology.

The 24 percent figure, she said, primarily reflects the expected failure rate for women who used the rhythm method, a calendar-based approach to calculating when ovulation occurs, rather than newer biometric methods that track body temperature, cervical mucous or urinary hormones. Some of those methods may be more effective, she said.

Based on a review of published studies, Polis and colleagues reported that the Natural Cycles app had a 9.8 percent unintended pregnancy rate. The FDA announcement, which includes the results of an additional study, noted a 6.5 percent rate.

Polis said that about 3 percent of women who use contraception practice fertility awareness-based methods, either alone or with other types of birth control, and their numbers

“I think [the app approval] is largely a positive step forward,” Polis said. “I’m relieved that the FDA has a regulatory pathway to evaluate these uses and claims.”

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Feds Urge States To Encourage Cheaper Plans Off The Exchanges

Michelle Andrews — Tue, 14 Aug 2018 09:00:51 +0000

For those who make too much money to qualify for health insurance subsidies on the individual market, there may be no Goldilocks moment when shopping for a plan. No choice is just right.

A policy with an affordable premium may come with a deductible that’s too high. If the copayments for physician visits are reasonable, the plan may not include their preferred doctors.

These consumers need better options, and in early August federal officials offered a strategy to help bring down costs for them.

is from the Centers for Medicare & Medicaid Services, which oversees the insurance marketplaces set up by the Affordable Care Act. CMS is encouraging states to allow the sale of plans outside of those exchanges that don’t incorporate a surcharge insurers started tacking on last year.

Many insurers added the premium surcharges last fall It was a response to the Trump administration’s announcement that it would no longer pay the companies for the “cost-sharing reduction” subsidies required under the health law. The subsidies help cover deductibles and other out-of-pocket costs for lower-income consumers who buy marketplace plans.

Insurers typically added the cost to silver-level plans because those are the type of plans that consumers have to buy in order to receive the cost-sharing subsidies. “Silver loading,” as it’s called, added an estimated to the cost of those plans, according to the Congressional Budget Office.

People who qualified for federal premium subsidies — those with incomes up to 400 percent of the federal poverty level (about $48,000 for one person or $100,000 for a family of four) — were shielded from the surcharge because their subsidies increased to cover the cost.

But people with higher incomes faced higher premiums. The new guidance is geared to help them.

“It encourages states to encourage silver loading only on the exchange,” said Aviva Aron-Dine, vice president for health policy at the Center on Budget and Policy Priorities.

But some analysts say they’re unsure if the new federal policy will make a difference since states have already implemented similar strategies.

Many states moved last fall to limit silver loading to plans sold on the exchanges, while allowing or, in the case of California, requiring, very similar plans to be sold off the exchanges without the extra premium charge.

Yet CMS’ endorsement of the strategy states may have had, said a research associate at Duke University’s Margolis Center for Health Policy who has tracked the issue.

of people who bought a plan during the open-enrollment period for 2018 qualified for premium tax credits. The average monthly premium per subsidized enrollee was $639; after accounting for premium tax credits, however, enrollees owed just $89 on average. That amount was than the monthly premium the year before.

For people who don’t qualify for premium tax credits, the picture is very different. The average monthly premium for 2018 was $522. That total was 28 percent higher than the previous year’s total of $407, according to an analysis by the Center on Budget and Policy Priorities of CMS enrollment data.

In general, that insurers charge the same rates for identical qualified health plans that are sold on and off the exchanges. The CMS guidance suggests that the unloaded plans could be tweaked slightly in terms of cost sharing or other variables so that they are not identical to those on the marketplaces.

Tracing what type of coverage is purchased off the exchange is difficult because there is no centralized source. Consumers can buy plans directly from insurers, or they may use a broker or an online web portal. According to one such portal, eHealth, 28 percent of unsubsidized consumers on its site bought silver plans in 2018, while 42 percent bought bronze plans, whose coverage is less generous than silver plans and typically have lower premiums. Conversely, on the exchanges bought silver plans in 2018 while 29 percent bought bronze plans, according to federal data.

If fewer insurers add the CSR load to silver plans sold off the exchange, those plans may be more affordable next year than they were in 2018, said Cynthia Cox, director of health reform and private insurance at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“This makes silver plans an option for [unsubsidized] people who wanted to buy a silver plan but might have been pushed off onto a bronze plan,” she said.

Consumers who want to consider off-exchange plans have to find them first. Some experts suggest checking with insurers that are selling on the marketplace in an area, because it’s possible that they’ll also be selling plans off the exchange.

But that’s not a given. A health insurance broker can help people find and evaluate plans sold off the exchange. But experts urge consumers to stay on their toes and make sure they understand whether the plans they’re considering provide comprehensive coverage.

Starting in October, insurers can offer short-term plans with limited benefits that last up to a year.

“Differentiating between the two may not be easy, and the off-exchange unsubsidized market is the target market for short-term plans,” said Anderson.

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How Genetic Tests Muddy Your Odds Of Getting A Long-Term-Care Policy

Michelle Andrews — Tue, 07 Aug 2018 09:00:42 +0000

This week, I answer questions from readers who are concerned about Medicare and insurance for long-term care.

Q: Can getting a genetic test interfere with being able to buy long-term-care insurance in the future? If you do get a plan, can the insurer drop you after you find out the results of a genetic test?

In general, long-term-care insurers can indeed use genetic test results when they decide whether to offer you coverage. The federal Genetic Information Nondiscrimination Act prohibits health insurers from asking for or using your genetic information to make decisions about whether to sell you health insurance or how much to charge. But those rules don’t apply to long-term-care, life or disability insurance.

When you apply for long-term-care insurance, the insurer may review your medical records and ask you questions about your health history and that of your family. It’s all part of the underwriting process to determine whether to offer you a policy and how much to charge.

If the insurer asks you whether you’ve undergone genetic testing, you generally have to disclose it, even if the testing was performed through a direct-to-consumer site like 23andMe, said Catherine Theroux, a spokeswoman for LIMRA, an insurance industry trade group.

Consumers applying for a long-term care policy should release any medically relevant information, she said.

Some states provide extra consumer protections related to genetic testing and long-term-care insurance, said Sonia Mateu Suter, a law professor at George Washington University who specializes in genetics and the law. But most follow federal law.

If you get genetic testing after you have a policy, the results can’t affect your coverage.

“Once the policy has been underwritten and issued, the insurer doesn’t revoke the policy if new medical information comes to light,” Theroux said.

Q: Can I switch Medigap insurance companies midway through the year? I found a less expensive policy.

It depends. Under federal law, when people turn 65 and first enroll in Medicare Part B to sign up for a Medigap plan. Medigap plans pick up some of beneficiaries’ out-of-pocket costs for services under , which covers hospitalization, and , which covers outpatient services. During that six-month period, insurers have to accept people even if they have health problems.

If you’re still in that six-month period now and you want to switch plans, go right ahead.

But if you’re past the six-month window, under federal law insurers are required to sell you a plan only in certain circumstances, such as if you lose your retiree coverage or Medicare Advantage plan. If you don’t meet the criteria, insurers can decline to cover you or charge you more for preexisting medical conditions.

Many states have provided more robust protections, however. Three states — Connecticut, Massachusetts and New York — have year-round open enrollment and require insurers to offer coverage. And Maine requires a one-month “guaranteed issue” open-enrollment period every year.

Some states guarantee current policyholders a chance to switch Medigap plans at certain points during the year. Other states have additional qualifying events that allow people to switch Medigap plans, from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“The first thing the person should do is check with her state insurance department to find out her rights related to buying a Medigap plan,” said Brandy Bauer, associate director at the Center for Benefits Access at the National Council on Aging. If someone decides to go ahead and switch, it is wise to sign up for a new plan before terminating your current policy, she said.

Q: I did not enroll in Medicare Part B when I turned 65 because I already have a regular plan that covers everything. I was told that the insurer would keep paying as usual, but now the company says it will pay only part and that I have to buy Medicare Part B. I didn’t want to pay for two policies. Is there anything I can do to avoid that?

From your description, it’s hard to know exactly what’s going on, but we can make educated guesses. Typically, when people turn 65, it makes sense to sign up for Medicare unless they or their spouse are working and getting health insurance from an employer. For others, at age 65, Medicare typically becomes their primary insurer and any other coverage they have becomes secondary, filling in gaps in Medicare coverage.

That’s how it generally works with retiree coverage, said Tricia Neuman, director of the Program on Medicare Policy at the Kaiser Family Foundation.

If you have an individual policy that you bought on the health insurance exchange and decide to hang on to it instead of signing up for Medicare, your premiums and other costs could be higher than they would be on Medicare, depending on your income.

But if you’re not receiving employee coverage and you don’t enroll in Medicare Part B, you could be subject to a of 10 percent for every 12 months that you could have signed up for Part B but didn’t. You could also owe a premium penalty for not signing up for a Part D prescription drug plan. (Most people don’t owe any premium for Medicare Part A, so there’s no penalty for late sign-up.)

“Without knowing more, it sounds like she should drop the [current] plan and sign up for Part B and D,” Neuman said. “But we need more information to know for sure.”

Your best move now may be to call 800-Medicare or visit your local to help sort out your coverage issues.

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For Many College Students, Hunger Can ‘Make It Hard To Focus In Class’

Michelle Andrews — Tue, 31 Jul 2018 09:00:31 +0000

As students enter college this fall, many will hunger for more than knowledge. Up to half of college students report that they were either not getting enough to eat or were worried about it, according to .

“Food insecurity,” as it’s called, is most prevalent at community colleges, but it’s as well. Student activists and advocates in the education community have drawn attention to the problem in recent years, and the that have sprung up at hundreds of schools are perhaps the most visible sign.

Some schools are also using the program, which allows students to donate their unused meal plan vouchers, or swipes, to other students to use at campus dining halls or food pantries.

Those “free dining passes have given me chances to eat when I thought I wouldn’t be able to,” one student wrote to the program. “I used to go hungry and that would make it hard to focus in class or study. [The passes] really helped my studying and may have helped me get my GPA up.”

Pantries and food passes are good band-aids, but more system-wide solutions are needed, advocates say.

“If I’m sending my kid to college, I want more than a food pantry,” said Sara Goldrick-Rab, professor of higher education policy and sociology at Temple University in Philadelphia, who founded the . “I want to know that they’re addressing high food prices on campus and taking steps to ensure no student goes hungry.”

Part of the disconnect may stem from a misperception about what today’s students are really like, said Katharine Broton, an assistant professor in educational policy and leadership studies at the University of Iowa who has published research on food and housing insecurity in colleges. Many of them don’t fit the profile of a “typical” student who attends a four-year institution full time and doesn’t have a job, Broton said. Rather, about 40 percent of students today are working in addition to going to school, and nearly .

The juggling act can be hard to maintain. “Most of the students, we find, are working and receiving financial aid, but still struggling with food insecurity,” Broton said.

Adding to the stress is the fact that while tuition and fees continue to rise, financial aid hasn’t kept pace. In the , after accounting for grant aid and tax benefits, full-time students at two-year colleges had to cover $8,070 in room and board on average, while those at four-year public institutions faced an average $14,940 in room, board, tuition and fees.

Anti-hunger advocates credit students with both sounding the alarm about hunger on campus and in some cases offering ingenious solutions.

Rachel Sumekh, who founded with friends at UCLA several years ago, said they wanted to do something useful with the unused credits from the meal plans that they were required to buy. The program now counts 48 schools as participants, and Sumekh said in the past year they’ve seen a “dramatic” increase in the number of colleges that are reaching out to them about getting involved.

The University of California-Berkeley , as the program is known. It’s one element in a multipronged effort that targets students who may need extra support to meet their basic housing, food and other needs, said , a university employee who chairs the campus’s basic needs committee. (He also co-chairs a similar committee for all 10 UC campuses.)

According to a survey of Berkeley students, 38 percent of undergraduates and 23 percent of graduate students deal with food insecurity at some point during the academic year, Canedo said. The school targets particular types of students, including those who are first-generation college-goers, parents, low-income or LGBT.

Canedo said a key focus this fall will be to enroll eligible students in CalFresh, the California version of the federal (SNAP), formerly known as food stamps.

Under federal rules, students generally must work at least 20 hours a week to qualify for SNAP, something many cannot manage. But states have flexibility to designate what counts as employment and training programs, said Elizabeth Lower-Basch, director of income and work supports at CLASP, an anti-poverty advocacy organization. In California, for example, students who participate in certain educational programs at school for CalFresh.

“That’s our first line of defense,” Canedo said. “Students are being awarded about $192 per month.”

For students who don’t qualify for CalFresh, the a parallel food assistance program that also provides benefits.

There’s a food pantry that offers regular cooking demonstrations. But what Canedo said he’s particularly proud of is a 15-week nutritional science course that students can take that teaches them about healthy eating, prepping food, budgeting and grocery shopping, among other things. Some of those skills can help students learn to manage their money and food to get them through their time at school without running short.

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Hospitals Gear Up For New Diagnosis: Human Trafficking

Michelle Andrews — Tue, 24 Jul 2018 09:00:40 +0000

The woman arrived at the emergency department at Huntington Hospital on New York’s Long Island after she was hit by her boyfriend during an argument. Her situation raised concerns among the medical staff, which had recently been trained to be on the lookout for signs of sex trafficking.

An undocumented immigrant from El Salvador, she worked at a local “cantina” frequented by immigrants. Her job was to get patrons drinks and to dance with them, but many workers in those jobs are expected to offer sex, too. Her boyfriend didn’t want her to work there, and that led to the fight, one doctor recalled.

As part of the intake process, the emergency staff asked the 36-year-old woman a series of questions about whether she’d ever had sex for money, or whether she had to give someone else part of what she earns, among other things. The screening questions were part of a , a 23-hospital system in the New York metro area that includes Huntington Hospital, to train staff and provide them with tools to identify and support victims of human trafficking.

There are no hard figures for how many people are involved in , the term used when individuals are forced to work or have sex for someone else’s commercial benefit. Polaris, a Washington, D.C.-based nonprofit that advocates for these people and runs help lines for them, said calls and texts to its national hotlines have steadily ticked up in recent years, 13 percent between 2016 and 2017, to 8,759.

But health care providers frequently fail to recognize these patients’ situation. According to a of about 100 survivors of sex trafficking, 88 percent said that while they were being trafficked they had contact with a health care provider, typically someone in an emergency department.

“When trafficking victims come through the health care system but we don’t identify them, it’s a big missed opportunity,” said Dr. Santhosh Paulus, a family physician who is the site director of the Huntington Hospital’s family medicine residency program and who started the program at Northwell.

Northwell is one of a growing number of hospitals and health care systems that are putting such programs in place. They want to alert staff to be on the lookout for trafficking, much as they watch for signs of child abuse, domestic violence and elder abuse.

Since last spring, nearly 300 staff members at Huntington Hospital and a family clinic have received training in how to spot trafficking victims and how to help them.

Training is given not only to doctors and nurses but also to registration and reception staff, social workers and security guards. Restore NYC, an organization that assists people caught up in sex trafficking, provided the initial training to key staff, and a hospital task force trains the others. During the next few years, similar efforts will be rolled out at all of Northwell’s 23 hospitals, Paulus said.

Identifying victims of trafficking is not unlike identifying victims of other forms of violence, said Dr. Wendy Macias-Konstantopoulos, director of the at Massachusetts General Hospital.

One of the big red flags is when people delay coming in for medical care, such as waiting weeks to come in to get an injured ankle or sexually transmitted infection checked out, Macias-Konstantopoulos said. Or it may be a pattern of injuries that don’t make sense. Sometimes people are reluctant to explain their injury, or they come in with someone who seems overbearing.

“Having a high index of suspicion is the first step,” she said. “If we’re not asking about it, we’re just not going to see it.”

Starting in October, health care providers can also use in their records that differentiate trafficking from other types of abuse. This will help track the number of victims and provide appropriate treatment.

Asking may not be enough, however. Depending on what’s going on in their lives, these patients may not be willing or ready to acknowledge that they need help, said Holly Gibbs, human trafficking response program director for Dignity Health, a health care system with nearly 40 hospitals in California, Nevada and Arizona.

Holly Gibbs, who directs the human trafficking response program for Dignity Health, a health care system with nearly 40 hospitals in the western U.S., said patients may not be willing or ready to acknowledge that they need help. (Courtesy of Holly Gibbs)

Gibbs knows the issue well. She was in Atlantic City, N.J., after meeting a man at a shopping mall as a 14-year-old and running away with him. The man persuaded Gibbs to go with him with promises of a new, glamorous life as a musician or model. At the time, Gibbs said, she thought that what happened to her was her own fault, a result of choices she made. No health care or law enforcement professional connected her to social services that could have helped her understand otherwise. She was reunited with her family by law enforcement personnel, who arrested the man. He was was later convicted.

Dignity Health has implemented a human trafficking response program in the emergency departments and labor and delivery areas of each of its hospitals. Now it’s rolling out the program at clinics and physicians’ offices as well.

A key priority is to help clinicians know how to talk to patients about any violence they may be facing and to connect the patients with outside sources of help.

But in the end, if these patients don’t want assistance, “you respect their wishes,” Gibbs said. “They may not be ready to accept help now, but you may plant seeds so they’ll be able to accept it later on.”

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Staggering Prices Slow Insurers’ Coverage Of CAR-T Cancer Therapy

Michelle Andrews — Tue, 17 Jul 2018 09:00:14 +0000

Patients whose blood cancers have failed to respond to repeated rounds of chemotherapy may be candidates for a new type of gene therapy that could send their cancers into remission for years.

But the two approved therapies, with price tags of hundreds of thousands of dollars, have roiled the insurance approval process, leading to delays and, in some cases, denials of coverage, clinicians and analysts say.

The therapy involves collecting patients’ own T cells, a type of white blood cell, genetically modifying them, and then infusing them back into patients, where they hunt down and kill cancer cells. Known as , it has been called a “living drug.”

Two drugs, Kymriah and Yescarta, were approved last year to treat patients whose blood cancers haven’t responded to at least two other rounds of treatment. Kymriah is with a form of acute lymphoblastic leukemia, the most common cancer in children. and are both approved for adults with advanced lymphomas.

Researchers report that some critically ill patients who received the therapy have remained cancer-free for .

“This is what patients need,” said Dr. Yi Lin, a hematologist who oversees the CAR-T cell practice and research for the Mayo Clinic. “With the likelihood of getting patients into durable survival, we don’t want to deny them the therapy.” She said she receives no personal financial support from the drugs’ makers.

But it comes at a cost. The drugs are hugely expensive. Kymriah and Yescarta cost $373,000 to treat adults with advanced lymphomas, while Kymriah costs $475,000 to treat acute lymphoblastic leukemia in children and young adults. In addition, many patients experience serious side effects that can land them in a hospital intensive care unit for weeks, pushing treatment costs .

All of this gives government and private insurers pause.

Most commercial insurers are covering CAR-T therapies now, but they do so on an individual basis, writing single-patient agreements each time, said cancer experts. Large insurers that are already familiar with complicated therapies like stem-cell transplants are getting speedier at handling CAR-T treatment requests, they said. But that’s not always the case at smaller or regional plans, where delays can add weeks to the approval process.

“A request for CAR-T may end up with somebody on the payer authorization team who doesn’t understand the technology or the urgency of the request, when somebody has only weeks or months to live,” said Stephanie Farnia, director of health policy and strategic relations at the American Society for Blood and Marrow Transplantation.

Farnia is in contact with many of the more than 50 medical centers that are authorized to provide treatment. The process of getting to a treatment center and evaluated for therapy is involved, she said, “to then be substantially delayed due to paperwork is incredibly frustrating” for patients.

Medicare and Medicaid often pose greater coverage challenges than do private insurers, according to insurance experts.

Some Medicaid programs don’t cover the treatment, said Dr. Michael Bishop, director of the cellular therapy program in the hematology-oncology section at the University of Chicago. Medicaid, the state-federal health program, covers children in low-income households and some adults.

“Medicaid has been very tough,” he said. “Certain states just deny coverage, even states with balanced budgets.”

Matt Salo, executive director of the National Association of Medicaid Directors, said states have to evaluate the . “Medicaid is a finite pot of money, and it’s stretched threadbare even on a good day,” he said.

People who are on Medicare, the health insurance program for people age 65 and older and some people with disabilities, typically haven’t faced coverage denials to date, clinicians say. But the government’s reimbursement rates are raising concerns for providers.

Last spring, Medicare announced payment rates for providers who administer Yescarta and Kymriah on an outpatient basis. The payments would more than cover the costs of the drugs. Medicare beneficiaries’ out-of-pocket costs would be capped at $1,340 plus their Part B deductible, if it hasn’t been met, the agency said.

The problem with this plan: Facilities typically provide treatment on an inpatient basis, because of the potential for severe, systemic side effects.

“There’s a lot of toxicity and questions about whether it can even be provided in an outpatient setting,” said Gary Goldstein, the business manager at the blood and marrow transplant program at Stanford Health Care in Stanford, Calif.

For inpatient care, “CAR T-cell therapy … would be paid at a much lower amount compared to outpatient hospital use,” according to officials at the Centers for Medicare & Medicaid Services.

The agency is considering how to handle payment for inpatient CAR-T care for the upcoming fiscal year that starts in October. For now, some medical centers are absorbing whatever Medicare doesn’t pay.

“How can you tell a patient who’s 66, ‘If only you’d gotten lymphoma when you were 64’? Goldstein asked.

But the current approach can’t continue indefinitely, he said.

“Even if there aren’t any centers that are making that decision today, if coverage doesn’t change for Medicare, it absolutely is going to be a problem tomorrow,” said Goldstein.

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Can Insurers Use Genetic Testing Results? A Reader Wants To Know

Michelle Andrews — Tue, 10 Jul 2018 09:00:12 +0000

This week, I answer questions from readers concerned about health insurance roadblocks in the face of a serious illness or medical crisis.

Q: I think genetic testing could be a great tool for . My fear is what the insurance industry will do with the information, especially in today’s political climate. Could they decide that you have a preexisting condition and charge a higher rate, or not cover you at all?

No, they can’t do that — not now, anyway. Under the (GINA) of 2008, health insurers can’t use your genetic information, including your family medical history, genetic test results and genetic counseling or other genetic services, to discriminate against you.

That means health insurers can’t use your genetic information when making decisions about your eligibility for health insurance, coverage terms or how much you’ll pay.

If you develop symptoms of a disease or are diagnosed with a medical condition, however, GINA no longer protects you. That’s where the Affordable Care Act steps in. It prohibits health plans from turning people down or charging them more because they have a preexisting condition.

“GINA did something good, and the ACA was the next important step,” said , a law professor at George Washington University who specializes in genetics and the law.

However, last month the Trump administration said it won’t defend that part of the law, which is being challenged in a lawsuit brought by the attorneys general of 20 states.

The said that since the penalty for not having health insurance has been eliminated starting in 2019, the provisions that guarantee coverage to people with preexisting conditions and prohibit insurers from charging them higher premiums should be struck down as well.

The issue is a priority with voters. In a June by the Kaiser Family Foundation, two-thirds of voters said that continuing protections for people with preexisting conditions was either the single most important factor or very important in their vote during the elections this fall. (Kaiser Health News is an editorially independent program of the foundation.)

Q: My husband fainted in the middle of the night. He received an MRI at a hospital emergency department in Kingston, N.Y., that is not in our insurance network.

Two months later, we received a bill for $23,657.39. Our insurance company paid $3,226.40, or 90 percent of what they considered to be a cost for the services provided. Our bill was for the balance.

Even though New York has a law that protects consumers against surprise medical bills, I learned that it doesn’t apply to us because our health plan is “self-funded.” Is there anything else that we can do?

You’re in a tough spot. The ACA prohibits most plans from charging consumers more in copayments and coinsurance for out-of-network than they’d owe if they were at an in-network facility.

But federal law doesn’t prevent out-of-network providers from billing consumers for the balance when a health plan doesn’t pay in full. This can happen because the plan doesn’t have negotiated rates with providers that aren’t in the network.

New York is one of six states that have laws with comprehensive protection for consumers against so-called surprise bills, according to an by researchers at Georgetown University’s Health Policy Institute that was published by the Commonwealth Fund last year.

The others are California, Connecticut, Florida, Illinois and Maryland. Another 15 states have limited consumer protections in this area.

But self-funded plans such as yours, in which your employer pays medical claims directly instead of buying an insurance policy for that purpose, are exempt from this type of state regulation.

In this circumstance, your company’s human resources department may be your best bet, said Jack Hoadley, research professor emeritus at Georgetown’s Health Policy Institute, who co-authored the Commonwealth analysis.

“The employer may say, ‘I feel an obligation to my employee and we’ll cover this,’” he said. “But they can choose not to do that.”

Q: My wife has been taking Avonex for multiple sclerosis for 20 years. Our health plan’s coverage changed this year, but Express Scripts, which manages our pharmacy benefit, didn’t communicate the change until after it took effect. They mailed us a month’s worth of Avonex in February, and a few weeks later we received an invoice for $6,000. Express Scripts would not let us return the medicine for a refund. They said that they explained we would be billed that amount when they called to remind us we were due for a refill, but that’s not true. Do we have any recourse?

There is no easy answer for you. If you go to a brick-and-mortar pharmacy to pick up a prescription and you think the cost is too high, you can refuse the medication at the counter and walk away. But that’s not generally possible with a mail-order prescription. Once it arrives, it’s yours.

“The chain of custody is broken,” said Jennifer Luddy, a spokeswoman for Express Scripts, which manages the pharmacy benefits for companies and insurers. “We don’t know if it’s been opened or tampered with.”

Luddy said that typically employers communicate changes to workers’ pharmacy benefits for the upcoming year during the annual open-enrollment period. On an ongoing basis, drug copayment information is also available through the Express Scripts’ website, mobile app or by phone, she said.

However, there may be other factors to consider, say patient advocates. For example, about half of people with multiple sclerosis have cognitive problems, said Bari Talente, executive vice president of advocacy at the National Multiple Sclerosis Society.

“People need to make sure that the person who’s taking the drug really understands that the cost is changing,” Talente said.

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More Nurse Practitioners Now Pursue Residency Programs To Hone Skills

Michelle Andrews — Tue, 03 Jul 2018 09:00:27 +0000

The patient at the clinic was in his 40s and had lost both his legs to Type 1 diabetes. He had mental health and substance abuse problems and was taking large amounts of opioids to manage pain. He was assigned to Nichole Mitchell, who in 2014 was a newly minted nurse practitioner in her first week of a one-year postgraduate residency program at the Community Health Center clinic in Middletown, Conn.

In a regular clinical appointment, “I would have been given 20 minutes with him, and would have been without the support or knowledge of how to treat pain or Type 1 diabetes,” she said.

But her residency program gives the nurse practitioners extra time to assess patients, allowing her to come up with a plan for the man’s care, she said, with a doctor at her side to whom she could put all her questions.

A few years later, Mitchell is still at that clinic and now mentors nurse practitioner residents. She has developed a specialty in caring for patients with HIV and hepatitis C, as well as transgender health care.

The residency program “gives you the space to explore things you’re interested in in family practice,” Mitchell said. “There’s no way I could have gotten that training without the residency.”

Mitchell is part of a growing cadre of nurse practitioners — typically, registered nurses who have completed a master’s degree in nursing — who tack on up to a year of clinical and other training, often in primary care.

Residencies may be at federally qualified health centers, Veterans Affairs medical centers or private practices and hospital systems. Patients run the gamut, but many are low-income and have complicated needs.

Proponents say the programs help prepare new nurse practitioners to deal with the growing number of patients with complex health issues. But detractors say that a standard training program already provides adequate preparation to handle patients with serious health care needs. Nurse practitioners who choose not to do a residency, as the vast majority of the each year do not, are well qualified to provide good patient care, they say.

As many communities, especially rural ones, struggle to attract medical providers, it’s increasingly likely that patients will see a nurse practitioner rather than a medical doctor when they need care. In 2016, nurse practitioners made up a quarter of primary care providers in rural areas and 23 percent in non-rural areas, up from 17.6 and 15.9 percent, respectively, in 2008, according to a in the June issue of Health Affairs.

Depending on the state, they may practice independently of physicians or with varying degrees of oversight. has shown that nurse practitioners generally provide care that’s comparable to that of doctors in terms of quality, safety and effectiveness.

But their training differs. Unlike the three-year residency programs that doctors must generally complete after medical school in order to practice medicine, nurse practitioner residency programs, sometimes called fellowships, are completely voluntary. Like medical school residents, though, the nurse practitioner residents work for a fraction of what they would make at a regular job, typically about half to three-quarters of a normal salary.

Advocates say it’s worth it.

“It’s a very difficult transition to go from excellent nurse practitioner training to full scope-of-practice provider,” said , a nurse practitioner who is senior vice president and clinical director of , a network of community health centers in Connecticut.

“My experience was that too often, too many junior NPs found it a difficult transition, and we lost people, maybe forever, based on the intensity and readiness for seeing people” at our centers.

Flinter started the first nurse practitioner residency program in 2007. There are now more than 50 postgraduate primary care residency programs nationwide, she said. Mentored clinical training is a key part of the programs, but they typically also include formal lectures and clinical rotations in other specialties.

Not everyone is as gung-ho about the need for nurse practitioner residency programs, though.

“There’s a lot of debate within the community,” said , president of the American Association of Nurse Practitioners. Knestrick practices in Wheeling, W.Va., a rural area about an hour’s drive from Pittsburgh. She said that there could be a benefit if a nurse practitioner wanted to switch from primary care to work in a cardiology practice, for example. But otherwise she’s not sold on the idea.

A from the Nurse Practitioner Roundtable, a group of professional organizations of which AANP is a member, offered this assessment: “Forty years of patient outcomes and clinical research demonstrates that nurse practitioners consistently provide high quality, competent care. Additional post-graduate preparation is not required or necessary for entry into practice.”

“We already have good outcomes to show that our current educational system has been effective,” Knestrick said. “So I’m not really sure what the benefit is for residencies.”

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Thinking About An Association Health Plan? Read The Fine Print

Michelle Andrews — Tue, 26 Jun 2018 09:00:58 +0000

If you own a restaurant, plumbing company or other small business, you may be intrigued by the expected expansion of association health plans under a new rule that got a stamp of approval from the Trump administration last week.

Will they meet your needs? Save you money?

Those are important questions for small businesses and self-employed people who struggle to buy affordable insurance for themselves and their workers.

Federal officials said would help level the playing field for these businesses, giving the kind of flexibility on benefits and leverage to negotiate with providers that large companies may have.

When on June 19, President Donald Trump said it would “result in very low prices, much more choice, much more freedom, including in many cases new opportunities to purchase health insurance. You’ll be able to do this across state lines.”

But detractors say the plans may not provide the full protection that workers need, plus the changes likely will drive up costs in the regular individual and small-group markets, where people who need comprehensive coverage would be forced to seek insurance.

Critics also point to “the long history of fraud and scams and insolvencies” for these plans, said Timothy Jost, emeritus professor of law at Washington and Lee University in Virginia.

“I think consumers are going to be in for a pretty wild ride,” Jost said.

Here are some details about what association health plans could mean for you.

Q: What are association health plans and what did the administration change?

Association health plans (sometimes called AHPs) allow small businesses to band together to buy insurance. Some plans have been in place for years, and those plans can continue to operate after the new rule takes effect. But the Trump administration’s regulation loosens the rules for additional plans to enter the market, allowing more small businesses, including individuals who work for themselves, to join these plans.

In contrast to earlier AHPs that generally required the association’s members to share an economic or other common purpose beyond enrolling in health insurance, new AHP members can be connected by geography alone or by business and professional interests. And under the new rule, providing members with insurance can be the main purpose of the association health plans.

Q: When will the plans be available?

The new rule will be phased in starting in September. It’s uncertain how soon after that date plans will be offered.

Q: The ACA added some popular protections, including requiring plans to cover preventive care without charging consumers anything out-of-pocket and allowing people to keep their kids on their plan until they reach age 26. How will these provisions be handled under association health plans?

Those provisions still apply to association health plans.

Q: How are preexisting medical conditions handled in the new rule?

Association health plans that are established under the new rule won’t be allowed to discriminate against individuals if they’re sick. But that doesn’t necessarily mean that people with preexisting medical conditions won’t encounter roadblocks in finding affordable, comprehensive coverage.

In the final rule, the administration lays out a variety of circumstances that could affect affordability. For example, an association plan could charge companies that employ construction workers higher premiums than firms that are in the hospitality business. The rule also allows plans to charge different rates based on gender, age and location.

Q: Will the plans cover a broad range of benefits?

It’s unclear. Association health plans are for small businesses in part by giving them the same kind of flexibility that large companies have in choosing which benefits they offer.

Flexibility may have a downside, though. AHP insurers don’t have to include the 10 “essential health benefits” that are required under the health law for plans in the individual and small-group market, typically companies with fewer than 50 employees. They might exclude coverage for prescription drugs or rehab services, for example.

Even though they’re not required to, large companies typically provide comprehensive benefits to compete for top talent. Smaller companies with fewer resources may find it tougher to afford generous employee perks.

Association health plans that cover employers with at least 15 employees — one of the ACA’s essential health benefits — under the new rule. But smaller employers could skip that requirement.

The plans have to abide by the for the essential health benefits they decide to cover, and they can’t impose annual or lifetime limits on coverage of those benefits.

But since plans don’t have to cover all the essential health benefits, those protections aren’t as meaningful, some say.

“It waters down the out-of-pocket cap protection if you don’t have essential health benefit coverage requirements,” said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Q: How could premiums be affected?

The new rule allows health insurers to use several factors that may provide clues that people are likely to be expensive to insure, including gender, age, industry and geography, when setting rates for employers. A company with older workers who are more likely to have chronic conditions, for example, could face higher rates — as might one that employs lots of women, who might rack up charges for maternity care. In addition, individuals within a company could be charged different premiums based on their occupation or other factors not related to their health status if the employer chooses to do so, Jost said.

Q: Who’s likely to benefit under the rule?

Companies that have relatively young, healthy employees could fare well.

“For young men in certain low-risk industries, who are currently healthy, they’re likely to encounter a relatively low premium,” said Justin Giovannelli, an associate research professor at Georgetown University’s Center on Health Insurance Reforms.

The Blue Cross Blue Shield Association, when said association health plan premiums for women in their early 30s might be more than 30 percent higher than rates under regular individual and small-group rules. It also estimated that rates for young men of a similar age could be more than 40 percent lower than ACA rates.

Similarly, companies in some industries could see lower premiums than others, according to BCBS. Rates for engineering companies could be about 9 percent lower than what insurers would charge on the individual and small-group market, for example, while those for the taxicab industry could be nearly 15 percent higher.

Q: What if an employer offers a really skimpy plan? Are workers stuck with it?

That depends. If an employer offers coverage that doesn’t meet minimum standards, workers can shop for subsidized health insurance on the marketplace, and the employer may face penalties. (Companies with fewer than 50 workers from penalties, however.) In 2018, that means that single coverage of their entire household income and plans have to pay at least 60 percent of the cost of covered benefits. The same rules apply if an employer offers coverage through an association health plan.

Some policy experts say they’re worried that people who work for small businesses may get burned if their companies, which do not offer any plans now, start offering coverage through an association health plan. The new plan may be skimpier and more expensive than the comprehensive coverage they’ve been getting on the ACA exchange.

“Even though the AHP coverage might be skimpy, employees would no longer be eligible for subsidized coverage on the exchange,” said Katie Keith, a health policy consultant who

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Shifting Gears: Insuring Your Health Column — Born With The ACA — Draws To A Close

Khnlexiev — Tue, 28 Aug 2018 09:00:17 +0000

Now I know better. Way better, having written once or twice a week for several years about how the Affordable Care Act has affected consumers’ health care coverage and costs.

I’ve delved into other coverage issues along the way as well, but the huge changes brought about by the 2010 health law have been a constant focus.

Thanks also to the amazing team of committed journalists at KHN who produce such great work day in and day out. They are an inspiration.

And I hope you’ll keep on doing so! Hearing from real readers about their boots-on-the-ground experiences in the health care trenches, as it were, is invaluable.

Please let me know what’s on your mind and how the system is working for you. You can reach me at Andrews.KHN@gmail.com. I look forward to hearing your thoughts and ideas.

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Biorhythms And Birth Control: FDA Stirs Debate By Approving ‘Natural’ App

Terry Byrne — Tue, 21 Aug 2018 09:00:05 +0000

The Food and Drug Administration took a “big tent” approach earlier this month when it approved two new forms of birth control that prevent pregnancy in very different ways.

Still, some women’s health experts worry that the FDA stamp of approval may be misinterpreted by some women.

But Dr. Gillian Dean, senior director of medical services at Planned Parenthood Federation of America, welcomes the approval of both new methods.

“More options are always better,” she said. “It isn’t one size fits all, and more options increases the likelihood that women will find a method that works for their needs.”

Polis co-authored of fertility awareness-based contraceptive methods that was published in August in the journal Obstetrics and Gynecology.

Polis said that about 3 percent of women who use contraception practice fertility awareness-based methods, either alone or with other types of birth control, and their numbers

“I think [the app approval] is largely a positive step forward,” Polis said. “I’m relieved that the FDA has a regulatory pathway to evaluate these uses and claims.”

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Feds Urge States To Encourage Cheaper Plans Off The Exchanges

Terry Byrne — Tue, 14 Aug 2018 09:00:51 +0000