By Wendy Ruderman, The Philidelphia Inquirer, Nov. 15, 2023.

Six years ago, a nurse at a Tennessee hospital accidentally gave a patient a powerful muscle-paralyzing drug. The patient stopped breathing and later died.

The nurse, RaDonda Vaught, was convicted of negligent homicide and sentenced last year to three years’ probation. Criminal charges over medical errors are rare, and the prosecution evoked fear in nurses nationwide. Patient safety advocates argued it sent the wrong message and would deter hospitals from admitting mistakes, which would not protect patients from medication errors.

Four years after Vaught’s deadly error, a similar mistake at Mercy Fitzgerald Hospital in Darby, nearly killed patient Didier Epopa and left him with irreversible brain injuries.

Epopa, 55, recently filed a medical malpractice lawsuit against the hospital. His lawyer, Eric Zajac, said the suit is among a growing number of Pennsylvania cases related to serious medication errors that he’s filed in recent years.

Zajac noted the drug errors in his caseload share a common denominator: They’re preventable.

“The health-care provider, whether it’s a pharmacist, hospital or doctor, either doesn’t have safeguards in place — or, they have them in place, but they aren’t following them,” said Zajac, whose practice, Zajac & Padilla, is based in Ardmore.

Life-and-death drug errors

In both the Tennessee case and Epopa’s, the errors were made in the use of neuromuscular-blocking drugs, which hospitals classify as “high-alert medications” because mistakes in their use can cause catastrophic harm or death.

Vaught, then a nurse at Vanderbilt University Medical Center in Nashville, mistakenly withdrew a vial of the paralytic vecuronium from a computerized medication cabinet. She typed “VE” into the search function, intending to take out Versed, a sedative to calm the 75-year-old patient who was about to be scanned in an MRI-like machine.

In the Philadelphia-area case, a lawyer for Mercy Fitzgerald revealed in a court filing that a pharmacy intern had mislabeled an IV bag. It was supposed to contain an antiviral but instead consisted of cisatracurium, a muscle-paralyzer similar to vecuronium.

Hospitals use these paralytics to keep patients still during surgery or to relax the throat when inserting a tube through the windpipe, known as endotracheal intubation. Even then, the drug is typically administered under the supervision of an anesthesiologist.

Cruel ‘air hunger’

Cisatracurium has also been at the center of controversy over lethal injections.

In 2018, Nevada prison officials intended to use it as part of a three-drug execution protocol, in conjunction with the sedative midazolam and the synthetic opioid fentanyl, to put a prisoner to death.

The pharmaceutical companies that make the medications sued Nevada because they didn’t want their products used in lethal injections.

A state judge ruled against the use of cisatracurium after hearing medical testimony that it could cause agonizing “air hunger” in fully alert prisoners — a violation of the U.S. Constitution, which prohibits “cruel and unusual punishments.”

Nevada’s cisatracurium supply expired in 2019. About a year later, as part of a legal settlement with the drug manufacturers, the state relinquished its unused cisatracurium and the other two medications.

Flawed systems fail patients

High-alert medications should come preformulated whenever possible, not in a powder or small vial that a hospital pharmacist needs to dilute and mix with saline in an IV bag. This is the recommendation of ECRI, a Plymouth Meeting-based national nonprofit that focuses on patient safety.

Additionally, hospitals should update computerized medication cabinets so practitioners must type in five letters instead of two or three to avoid retrieving medications that look and sound alike.

Vaught, who lost her nurse’s license and job in Tennessee, admitted her mistake. She told state authorities that she got “distracted” by a trainee while operating the automated drug dispenser and had become “complacent” in her job.

But she said the fault was not hers alone. The system failed, too.

During an interview with an investigator, Vaught said, “Ultimately, I can’t change what happened. … The best I can hope for is that something will come of this, so a mistake like that can’t be made again.”

ECRI president and CEO Marcus Schabacker agrees that system failures, not individuals, are at the root of medication errors.

“This is not about catching someone doing something wrong,” Schabacker said. “This is about understanding why a miss or near miss happens and then putting things in place to avoid a similar mistake.”

Schabacker noted that there hasn’t been a deadly accident in commercial air-safety traffic in the United States since 2009. Yet, each year, about 100,000 patients die of preventable medical errors in America. Like commercial aviation, health-care institutions should not only scrutinize errors, but near errors as well, so safety gaps can be closed tight, he said.

An anesthesiologist and intensive care specialist, Schabacker said hospitals must employ additional safeguards for cisatracurium and other high-alert medications, including limiting access and double verification by two qualified practitioners prior to dispensing and administering.

Hospital administrators who want to prevent errors must set the tone and atmosphere for staffers to come forward and report incidents in which a mistake occurred or nearly did, without fear of blame or discipline.

Until that happens, medical errors, particularly those related to medications, will continue, Schabacker said.

“We, as a medical profession, have just become too complacent,” he said.

By Amanda Holpuch, Dec. 29, 2022, The New York Times.

In the next few weeks, tens of thousands of people in Cook County, Ill., will open their mailboxes to find a letter from the county government explaining that their medical debt has been paid off.
Officials in New Orleans and Toledo, Ohio, are finalizing contracts so that tens of thousands of residents can receive a similar letter in the coming year. In Pittsburgh on Dec. 19, the City Council approved a budget that would include $1 million for medical debt relief.

More local governments are likely to follow as county executives and city councils embrace a new strategy to address the high cost of health care. They are partnering with RIP Medical Debt, a nonprofit that aims to abolish medical debt by buying it from hospitals, health systems and collections agencies at a steep discount.

“What we need in this country is universal health care, clearly,” Toni Preckwinkle, the president of the Board of Commissioners in Cook County, said. “But we’re not there as a nation yet, and so those of us who are responsible for local units of government have to do everything we can to make health care available, accessible to people.”

About 18 percent of Americans have medical debt that has been turned over to a third party for collection, according to a report published in July 2021 in the medical journal JAMA. That figure does not account for medical debt that is carried on credit cards or all medical bills owed to providers. Research shows that people with medical debt are less likely to seek needed care and that medical debt can damage people’s credit and make it more difficult for them to secure employment.

Cook County plans to spend $12 million on medical debt relief and expects to erase debt for the first batch of beneficiaries by early January. In Lucas County, Ohio, and its largest city, Toledo, up to $240 million in medical debt could be paid off at a cost of $1.6 million. New Orleans is looking to spend $1.3 million to clear $130 million in medical debt. The $1 million in Pittsburgh’s budget could wipe out $115 million in debt, officials said.

ProMedica Toledo Hospital is one of the largest hospitals in Toledo, where the city, Lucas County and RIP Medical Debt are working out a $1.6 million plan to relieve eligible residents of medical debt.

These initiatives are all being funded by President Biden’s trillion-dollar American Rescue Plan, which infused local governments with cash to spend on infrastructure, public services and economic relief programs. Health policy experts say that while medical debt relief provides an immediate benefit to people, it does not address the root causes of medical debt, which is almost nonexistent outside the United States.

To be eligible for debt relief through RIP Medical Debt, people must have a household income up to 400 percent of the federal poverty level, or about $111,000 for a family of four, or have medical debts that exceed 5 percent of their annual income. People cannot apply to be considered for debt relief, and they do not pay taxes on the purchase of their debt. RIP Medical Debt analyzes debt portfolios to determine who qualifies.

Wendy Pestrue, the chief executive of the United Way of Greater Toledo, said debt relief could remove a source of economic stress for the 43 percent of families who either were living in poverty or were unable to afford housing, child care, food, transportation or health care in Toledo, which has a population of nearly 269,000.

“It puts some of this economic strength back in the hands of those who are having debt exonerated and really helps them plan for their stability,” she said.

Michele Grim, who joined Toledo’s City Council in January 2022, pushed for some of the city’s $180 million in American Rescue Plan funds to be used for medical debt relief after she read about the Cook County initiative.

Michele Grim is one of the leading voices behind Toledo’s use of the American Rescue Plan for medical debt relief.

“Here’s something so simple that local governments can do, maybe even state governments can do, to really help ease that burden on people, because we really need an overhaul in our system, and that’s going to take years,” said Ms. Grim, who is leaving the council at the end of the year because she was elected in November to be a Democratic state representative.

Toledo’s City Council voted 7-5 on Nov. 9 to provide $800,000 to pay off the debts. Its contribution was matched by Lucas County, resulting in $1.6 million for medical debt relief. The city, the county and RIP Medical Debt are now working out a contract.

One council member who opposed the plan was George Sarantou, who said that he voted against it because his top funding priority was public safety, including upgrading city fire stations and police vehicles. While Mr. Sarantou said he was not opposed to medical debt relief, he was concerned about state funding for cities and villages, which is expected to be 1.66 percent of Ohio’s 2022-23 budget. “Ohio has the money,” he said. “Toledo does not.”

Medical debt relief appears to be popular. A poll by Tulchin Research found that 71 percent of respondents supported it. Fifty percent supported relieving student loan debt, 65 percent supported “Medicare for all” and 68 percent supported expanding Medicaid. The national poll of 1,500 people was conducted online from Nov. 14 to 20, after the Toledo vote, and had a margin of sampling error of plus or minus three percentage points. (Ms. Grim’s husband works for the polling company.) This debt relief comes as states change how medical debt is treated.

In November, Gov. Kathy Hochul of New York signed legislation that blocked health care providers from using property liens or garnishing wages to collect medical debt. The day before the Toledo City Council vote, 72 percent of Arizona voters chose to lower interest rates for medical debt and to increase protections for people who owe debt, though a judge has since halted part of the measure.

Officials in Toledo and other cities are partnering with a nonprofit organization that aims to abolish medical debt by buying it from hospitals, health systems and collections agencies at a steep discount.

Wesley Yin, an associate professor of economics at the University of California, Los Angeles, said medical debt relief could be a “game changer” for some people, but governments should also be addressing the causes of medical debt, including high costs and limited access to good health insurance.

In partnership with RIP Medical Debt, Professor Yin is studying how the group’s work affects people’s livelihoods. “I believe there are some positive effects economically, but it might be more muted compared to the face value of the debt that is being forgiven,” he said.

Daniel Skinner, a health policy professor at Ohio University in Athens, said that debt relief was “low-hanging fruit,” considering that the mean amount of medical debt people carry is in the hundreds, not tens of thousands, of dollars.

“We need to get the cost of medicine under control, ultimately,” Professor Skinner said. “I’m all for what Toledo is doing, I’m all for what Cook County and now New Orleans are doing, but, ultimately, we can’t come back every couple of years and do this. It’s not good policy, it’s not efficient.”

Supporters of debt relief measures agree that there is more to be done.

RIP Medical Debt’s chief executive, Allison Sesso, said that a key part of the group’s work was to further discussions about changing the health care system.

In the past two years, RIP Medical Debt has placed more of an emphasis on buying debt directly from hospitals and health systems, before it reaches collectors. Ms. Sesso said that this gave the group a direct channel to talk with hospitals about how their own health repayment plans for low-income patients work. Some of the people whose debt RIP Medical Debt buys should have qualified for these programs in the first place, but they were not enrolled, she said.

“I do this job every day, and I appreciate that what we’re doing is really important and helpful for the individuals that we are helping and it’s resolving this problem for them,” Ms. Sesso said. “At the same time, I can’t help but wonder and question why my existence as an institution is needed in the first place.”

Link to article.

APRA has joined a coalition of 75 (and growing) organizations that are advancing the call to expeditiously form a new independent federal agency, the National Patient Safety Board (NPSB), to model aspects of the National Transportation Safety Board and the Commercial Aviation Safety Team within health care. The NPSB would improve and promote public health and welfare by monitoring and anticipating adverse events, creating recommendations and solutions to prevent medical error, and bringing lessons into practice.  The NSPB would model the efforts of the NTSB and CAST within health care and would complement existing agencies in monitoring and anticipating patient safety events with artificial intelligence, provide expertise to study the causes of errors, create recommendations and solutions to prevent future harms, and leverage existing systems to bring key learnings into practice. The NPSB would guarantee a data-driven, scalable approach to preventing and reducing patient safety events in healthcare settings—and will save lives.

On Wednesday, December 8, U.S. Representative Nanette Barragán (D-CA) announced the introduction of H.R.9377 – the National Patient Safety Board Act, legislation.  The text of this bill can be found here.

APRA will keep its members informed regarding coalition activities and the progress of the proposed legislation.

It’s open enrollment season again. From now through Dec. 7, about 65 million Americans are facing the annual question of which Medicare options will give them the best health coverage. An onslaught of television and radio ads, emailed promotions, texts and mailers serve as reminders, though not necessarily clarifying ones.

“It’s a very consequential decision, and the most important thing is to be informed,” said Jeannie Fuglesten Biniek, a senior policy analyst at the Kaiser Family Foundation and a co-author of a recent literature review comparing Medicare Advantage and traditional Medicare.

If you are navigating this decision for yourself or for a loved one, here are some of the important factors to consider.

Why the marketing barrage?

Medicare — the federally funded health care program — has been in place since 1965. Since then, an expanding array of Medicare Advantage plans have become available. For 2023, the typical beneficiary can choose from 43 Advantage plans, the Kaiser Family Foundation has reported.

Medicare Advantage plans, like traditional Medicare, are funded by the federal government, but they are offered though private insurance companies, which receive a set payment for each enrollee. The idea is to help control costs by allowing these insurers, who must cover the same services as traditional Medicare, to keep some of the federal payment as profit if they can provide care less expensively.

The biggest providers of Advantage plans are Humana and United Healthcare, and they and others market aggressively to persuade seniors to sign up or switch plans. A new U.S. Senate report found that some of these Advantage plan practices are deceptive; for example, some marketing firms sent Medicare beneficiaries mailers made to look like government websites or letters. This has confused many seniors, and Medicare officials have promised to increased policing.

But the marketing has paid off for insurers. The proportion of eligible Medicare beneficiaries enrolled in Medicare Advantage plans has hit 48 percent. By next year, most beneficiaries will likely be Advantage enrollees.

Which is better: Medicare or Medicare Advantage?

The two plans operate quite differently, and the health and financial consequences can be dramatic. Each has, well, advantages — and disadvantages.

Jeannie Fuglesten Biniek, a senior policy analyst at the Kaiser Family Foundation, is a co-author of a recent literature review comparing Medicare Advantage and traditional Medicare. One important finding, Dr. Biniek said: “Both Medicare Advantage and traditional Medicare beneficiaries reported that they were satisfied with their care — a large majority in both groups.”

Advantage plans offer simplicity. “It’s one-stop shopping,” she added. “You get your drug plan included, and you don’t need a separate supplemental policy,” the kind that traditional Medicare beneficiaries often buy, frequently called Medigap policies.

Medicare Advantage may appear cheaper, because many plans charge low or no monthly premiums. Unlike traditional Medicare, Advantage plans also cap out-of-pocket expenses. Next year, you’ll pay no more than $8,300 in in-network expenses, excluding drugs — or $12,450 with the kind of plan that permits you to also use out-of-network providers at higher costs.

Only about one-third of Advantage plans (called P.P.O.s, or preferred provider organizations) allow that choice, however. “Most plans operate like an H.M.O. — you can only go to contracted providers,” said David Lipschutz, the associate director of the Center for Medicare Advocacy.

Advantage enrollees may also be drawn to the plan by benefits that traditional Medicare can’t offer. “Vision, dental and hearing are the most popular,” Mr. Lipschutz said, but plans may also include gym memberships or transportation.

“We caution people to look at what the scope of the benefits actually are,” he added. “They can be limited, or not available, to everyone in the plan. Dental care might cover one cleaning and that’s it, or it may be broader.” Most Advantage enrollees who use these benefits still wind up paying most dental, vision or hearing costs out of pocket.

What are the downsides to Medicare Advantage?

One big downside is that these insurers require “prior authorization,” or approval in advance, for many procedures, drugs or facilities.

“Your doctor or the facility says that you need more care” — in a hospital or nursing home, say — “but the plan says, ‘No, five days, or a week, two weeks, is fine,’” said David Lipschutz, the associate director of the Center for Medicare Advocacy. Then you must either forgo care or pay out of pocket.

Advantage participants who are denied care can appeal, and those who do so see the denials reversed 75 percent of the time, according to a 2018 report by the Department of Health and Human Services’s Office of Inspector General. But only about 1 percent of beneficiaries or providers file appeals, “which means there’s a lot of necessary care that enrollees are going without,” Mr. Lipschutz said.

Another report this spring by the inspector general’s office determined that 13 percent of services denied by Advantage plans met Medicare coverage rules and would have been approved under traditional Medicare.

Advantage plans can also be problematic if you are traveling or spending part of each year away from home. If you live in Philadelphia but get sick on vacation in Florida, all local providers may be out of network. Check to see how the plan you’re using or considering treats such situations.

So maybe I should just go with traditional Medicare?

“The big pro is that there are no networks,” Jeannie Fuglesten Biniek, a senior policy analyst at the Kaiser Family Foundation, said of traditional Medicare. “You can see any doctor that accepts Medicare,” as most do, and use any hospital or clinic. Traditional Medicare beneficiaries also largely avoid the delays and frustrations of prior authorization.

But traditional Medicare sets no cap on out-of-pocket expenses, and its 20 percent co-pay can add up quickly for hospitalizations or expensive tests and procedures. So most beneficiaries rely on supplemental insurance to cover those costs; either they buy a Medigap policy or they have supplementary coverage through an employer or Medicaid. Medigap policies are not inexpensive; a Kaiser Family Foundation survey found that they average $150 to $200 a month.

The Kaiser literature review found that traditional Medicare beneficiaries experienced fewer cost problems than Advantage beneficiaries if they had supplementary Medigap policies — but if they didn’t, they were more likely to report problems like delaying care for cost reasons or having trouble paying medical bills.

Traditional Medicare also provides somewhat better access to high-quality hospitals and nursing homes. David Meyers, a health services researcher at Brown University, and his colleagues have been tracking differences between original Medicare and Medicare Advantage for years, using data from millions of people.

The team has found that Advantage beneficiaries are 10 percent less likely to use the highest quality hospitals, four to eight percent less likely to be admitted to the highest quality nursing homes and half as likely to use the highest-rated cancer centers for complex cancer surgeries, compared to similar patients in the same counties or ZIP codes.

In general, patients with high needs — people who were frail, limited in activities of daily living or had chronic conditions — were more apt to switch to traditional Medicare than those who were not high-need.

“When you’re healthier, you may run into fewer of the limitations of networks and prior authorization,” Dr. Meyers said. “When you have more complex needs, you come up against those more frequently.”

Another downside to traditional Medicare, though, is that it does not include drug coverage. For that, you need to buy a separate Part D plan.

What should I know about drug plans?

Unlike most Medicare Advantage plans, traditional Medicare does not include drug coverage. For that, you must buy a separate Part D plan.

For 2023, beneficiaries can typically choose between 24 stand-alone Part D plans, at premiums that range from $6 to $111 a month and average $43 for policies available nationwide, said Juliette Cubanski, the deputy director of the program on Medicare policy at the Kaiser Family Foundation.

“If you’re the person who doesn’t take many medications or only uses generics, the best strategy might be to sign up for the plan with the lowest premium,” Dr. Cubanski said. “But if you take a lot of medications, the most important thing is whether the drugs you take, especially the most expensive ones, are covered by the plan.”

Different plans cover different drugs (which can change from year to year) and place them in different pricing tiers, so how much you pay for them varies. And, to make comparisons more dizzying, certain pharmacy chains are “preferred” by certain plans, so you could pay more at CVS than at Walmart for the same drug, or vice versa.

How does Part D work? First, most stand-alone plans have a deductible: $505 in 2023. You pay that amount out of pocket before coverage kicks in.

Then, a Part D plan, either stand-alone or as part of a Medicare Advantage plan, usually establishes five tiers for drugs. The cheapest two tiers, for generic drugs, could be free or run up to about $20 per prescription. Next comes a tier for preferred brand-name drugs, probably $30 to $45 per prescription in 2023.

Drugs on the next highest tier, for nonpreferred brand-name drugs, usually involve coinsurance — paying a percentage of the drug’s list price — rather than a flat co-pay. For national stand-alone plans, that ranges from 34 to 50 percent, Dr. Cubanski said.

Drugs that cost more than $830 a month are considered specialty drugs, the highest-priced tier. You only pay 25 percent of the price, but because these are so expensive, your costs rise.

Once your total drug costs reach $4,660 (for 2023), including out of pocket costs and what your plan paid, you have entered the so-called coverage gap phase and will pay 25 percent of the cost, regardless of tier.

Finally, when your costs reach $7,400 — including what you’ve paid, plus the value of manufacturer discounts — you have hit the threshold for catastrophic coverage. After that, you pay just 5 percent.

After I pick a plan, can I switch if I don’t like it?

You can, but be careful.

Switching between Medicare Advantage plans is fairly easy. But switching from traditional Medicare to an Advantage plan can cause a major problem: You relinquish your Medigap policy, if you had one. Then, if you later grow dissatisfied and want to switch back from Advantage to traditional Medicare, you may not be able to replace that policy. Medigap insurers can deny your application or charge high prices based on factors like pre-existing conditions.

(There are some exceptions. For instance, people who drop a Medigap policy to enroll in an Advantage plan for the first time can repurchase it, or buy another Medigap policy, if they switch back to traditional Medicare within a year.)

“Many people think they can try out Medicare Advantage for a while, but it’s not a two-way street,” said David Lipschutz, the associate director of the Center for Medicare Advocacy. Except in four states that guarantee Medigap coverage at set prices — New York, Massachusetts, Connecticut and Maine — “it’s one type of insurance that can discriminate against you based on your health,” he said.

The fact is, few consumers do any real comparison shopping, or shift their coverage in either direction. Dozens of lawsuits charging Medicare Advantage insurers with fraudulently inflating their profits apparently haven’t made much difference to consumers, either.

In 2020, only 3 in 10 Medicare beneficiaries compared their current plans with others, a recent Kaiser Family Foundation survey reported. Even fewer beneficiaries changed plans, which might reflect consumer satisfaction — or the daunting task of trying to evaluate the pluses and minuses.

Where can I find help with these decisions?

You will find plenty of information on the Medicare.gov website, including the Part D plan finder, where you can input the drugs you take and see which plan gives you the best and most economical coverage. The toll-free 1-800-MEDICARE number can also assist you.

Perhaps the best resources, however, are the federally funded State Health Insurance Assistance Programs, where trained volunteers can help consumers assess both Medicare and drug plans.

These programs “are unbiased and don’t have a pecuniary interest in your decision making,” said David Lipschutz, the associate director of the Center for Medicare Advocacy. But their appointments tend to fill up quickly at this time of year, and the annual open enrollment period ends on Dec. 7. Don’t delay.

By Susan Jaffe, KHN, May 03, 2022.

Something strange happened between the time Linda Griffith signed up for a new Medicare prescription drug plan during last fall’s enrollment period and when she tried to fill her first prescription in January.

She picked a Humana drug plan for its low prices, with help from her longtime insurance agent and Medicare’s Plan Finder, an online pricing tool for comparing a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention-deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.

“I didn’t pick it up because I thought something was wrong,” said Griffith, 73, a retired construction company accountant who lives in the Northern California town of Weaverville.

“To me, when you purchase a plan, you have an implied contract,” she said. “I say I will pay the premium on time for this plan. And they’re going to make sure I get the drug for a certain amount.”

But it often doesn’t work that way. As early as three weeks after Medicare’s drug plan enrollment period ends on Dec. 7, insurance plans can change what they charge members for drugs — and they can do it repeatedly. Griffith’s prescription out-of-pocket cost has varied each month, and through March, she has already paid $433 more than she expected to.

A recent analysis by AARP, which is lobbying Congress to pass legislation to control drug prices, compared drugmakers’ list prices between the end of December 2021 — shortly after the Dec. 7 sign-up deadline — and the end of January 2022, just a month after new Medicare drug plans began. Researchers found that the list prices for the 75 brand-name drugs most frequently prescribed to Medicare beneficiaries had risen as much as 8%.

Medicare officials acknowledge that manufacturers’ prices and the out-of-pocket costs charged by an insurer can fluctuate. “Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug,” the Medicare website warns.

But no matter how high the prices go, most plan members can’t switch to cheaper plans after Jan. 1, said Fred Riccardi, president of the Medicare Rights Center, which helps seniors access Medicare benefits.

Drug manufacturers usually change the list price for drugs in January and occasionally again in July, “but they can increase prices more often,” said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University and a member of the Medicare Payment Advisory Commission. That’s true for any health insurance policy, not just Medicare drug plans.

Like a car’s sticker price, a drug’s list price is the starting point for negotiating discounts — in this case, between insurers or their pharmacy benefit managers and drug manufacturers. If the list price goes up, the amount the plan member pays may go up, too, she said.

The discounts that insurers or their pharmacy benefit managers receive “don’t typically translate into lower prices at the pharmacy counter,” she said. “Instead, these savings are used to reduce premiums or slow premium growth for all beneficiaries.”

Medicare’s prescription drug benefit, which began in 2006, was supposed to take the surprise out of filling a prescription. But even when seniors have insurance coverage for drugs, advocates said, many still can’t afford them.

“We hear consistently from people who just have absolute sticker shock when they see not only the full cost of the drug, but their cost sharing,” said Riccardi.

The potential for surprises is growing. More insurers have eliminated copayments — a set dollar amount for a prescription — and instead charge members a percentage of the drug price, or coinsurance, Chiquita Brooks-LaSure, the top official at the Centers for Medicare & Medicaid Services, said in a recent interview with KHN. The drug benefit is designed to give insurers the “flexibility” to make such changes. “And that is one of the reasons why we’re asking Congress to give us authority to negotiate drug prices,” she said.

CMS also is looking at ways to make drugs more affordable without waiting for Congress to act. “We are always trying to consider where it makes sense to be able to allow people to change plans,” said Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, who joined Brooks-LaSure during the interview.

On April 22, CMS unveiled a proposal to streamline access to the Medicare Savings Program, which helps 10 million low-income enrollees pay Medicare premiums and reduce cost sharing. Enrollees also receive drug coverage with reduced premiums and out-of-pocket costs.

The subsidies make a difference. Low-income beneficiaries who have separate drug coverage plans and receive subsidies are nearly twice as likely to take their medications as those without financial assistance, according to a study Dusetzina co-authored for Health Affairs in April.

When CMS approves plans to be sold to beneficiaries, the only part of drug pricing it approves is the cost-sharing amount — or tier — applied to each drug. Some plans have as many as six drug tiers.

In addition to the drug tier, what patients pay can also depend on the pharmacy, their deductible, their copayment or coinsurance — and whether they opt to abandon their insurance and pay cash.

After Linda Griffith left the pharmacy without her medication, she spent a week making phone calls to her drug plan, pharmacy, Social Security, and Medicare but still couldn’t find out why the cost was so high. “I finally just had to give in and pay it because I need the meds — I can’t function without them,” she said.

But she didn’t give up. She appealed to her insurance company for a tier reduction, which was denied. The plan denied two more requests for price adjustments, despite assistance from Pam Smith, program manager for five California counties served by the Health Insurance Counseling and Advocacy Program. They are now appealing directly to CMS.

“It’s important to us to work with our members who have questions about any out-of-pocket costs that are higher than the member would expect,” said Lisa Dimond, a Humana spokesperson. She could not comment about Griffith’s situation because of privacy rules.

However, Griffith said she received a call from a Humana executive who said the company had received an inquiry from the media. After they discussed the problem, Griffith said, the woman told her, “The [Medicare] Plan Finder is an outside source and therefore not reliable information,” but assured Griffith that she would find out where the Plan Finder information had come from.

She won’t have to look far: CMS requires insurers to update their prices every two weeks.

“I want my money back, and I want to be charged the amount I agreed to pay for the drug,” said Griffith. “I think this needs to be fixed because other people are going to be cheated.”

Article link: https://khn.org/news/article/medicare-drug-plan-prices-open-enrollment-rise/

By Michelle Andrews, KHN, May 17, 2022.

Andrew Bade, who was diagnosed with Type 1 diabetes nearly two decades ago, is accustomed to all the medical gear he needs to keep his blood sugar under control. His insulin pump contains a disposable insulin cartridge, and a plastic tubing system with an adhesive patch keeps in place the cannula that delivers insulin under his skin. He wears a continuous glucose monitor on his arm.

Bade, 24, has used the same equipment for years, but every three months when he needs new supplies, his health insurance plan requires him to go through an approval process called prior authorization.

Getting that approval can take as many as three weeks, and Bade sometimes runs out of insulin before it comes through. When that happens, the resident of Fenton, Michigan, makes do with leftover preloaded insulin pens. They’re less precise than the pump, and he feels tired when he uses them. But they get him through.

“I don’t understand why they’re taking all this time to make these decisions and then they always say ‘yes’ anyway,” Bade said.

Michigan legislators in April sought to help patients like Bade by approving a law that sets standards meant to hasten that process. Beginning in June 2023, health plans will have to act on non-urgent prior authorization requests in nine calendar days and on urgent requests in 72 hours. In 2024, the time frame for non-urgent requests will shrink to seven days.

“We are ecstatic that it passed,” said Dr. Nita Kulkarni, an obstetrician-gynecologist in Flint and a member of the board of directors for the Michigan State Medical Society, which has pushed for the law for years. “It’s a step in the right direction in decreasing the wait time for therapy.”

Michigan’s law is the most recent example of efforts by states, insurers, and doctors to un-gum a process that is notoriously sticky. Yet most of the initiatives have had limited success.

At least a dozen states have passed broad reforms, according to tracking by the American Medical Association. Others have passed narrower laws that target the process or certain types of medical care or drugs. However, state laws don’t protect most patients because they are in so-called self-funded plans, in which the employer pays claims directly rather than buying insurance for that purpose. Self-funded plans are generally regulated by the federal government, not states. There’s no broad protection at the federal level for people with commercial coverage.

A 2018 consensus statement issued by key health plan and medical provider groups to improve the process has been slow to make inroads.

Prior authorization requirements are intended to reduce wasteful and inappropriate health care spending. Few would disagree with that goal. Studies have found that about a quarter of health care spending is wasteful, whether because of overtreatment, overpricing, fraud and abuse, or problems with health care coordination and delivery.

Health plans say that prior authorization requirements help them protect patients’ safety and improve the quality of care, in addition to rooting out waste and error. Doctors disagree. They say that the process too often leads to delays in patient care and that those delays can sometimes cause consumers to abandon treatment.

The complaints aren’t confined to regular commercial coverage. A report released in April by the U.S. Department of Health and Human Services’ inspector general examined a random sample of 250 prior authorization denials at 15 large Medicare Advantage plans in June 2019. It found that 13% of prior authorization denials by Medicare Advantage plans were for services that met Medicare coverage rules.

Health plans’ use of such requirements continues to rise, according to medical groups. In a March poll, 79% of medical practices said that prior authorization requirements had increased in the previous year, according to the Medical Group Management Association.

Even though insurers and providers may fundamentally disagree on the usefulness of prior authorization, many agree that the process needs to be improved. The consensus statement listed several areas that the groups agreed need fixing. For example, they said doctors and other health care providers who follow evidence-based treatment guidelines and have historically had high prior authorization approval rates may sidestep the process.

The groups also agreed that regular review of these requirements is a good idea, with an eye toward eliminating therapies from the list that no longer warrant it. Improved transparency and automation also made the list.

But doctors say that insurers have made little progress in the four years since the document was released.

“It’s been abysmal,” said Dr. Jack Resneck Jr., a dermatologist who is president-elect of the American Medical Association. “We see the problem getting worse, and we don’t see health plans taking any action to honor the commitments they made.”

Insurers say they’re working through the items on the list.

“We believe that a number of the concerns can be solved by innovations in technology,” said Kris Haltmeyer, vice president of policy analysis at the Blue Cross Blue Shield Association, one of the six organizations that partnered on the statement. He pointed to an electronic prior authorization pilot project undertaken by the insurers’ trade group, AHIP, that resulted in a 69% reduction in the decision time on requests, to just under six hours.

That sort of speedy turnaround would have made a big difference to Jodi Burk, 63, who has rheumatoid arthritis. Burk, who lives in Bellaire, Michigan, takes pricey biologic medications to control her pain and other symptoms. A few years ago, her medication stopped working, and the pain became so bad that she could no longer even take her dog for walks.

Her doctor prescribed a different biologic that she thought would treat her symptoms. But the insurer wouldn’t approve the prescribed drug until she had tried — and failed — four other medications, a prior authorization process called step therapy.

It was five months before Burk was approved and began taking a drug that effectively treated her symptoms. “With these time frames, you’re not getting any better,” Burk said. “You hurt more, and your life is put on hold. There were lots of things that I used to be able to do and couldn’t during those times.”

In addition to establishing time frames for acting on prior authorization requests, the new Michigan law sets standards for notifying doctors and other health care providers about changes or additions to existing requirements. And it requires insurers to implement standardized electronic transaction processes for prior authorization requests.

That standard web-based process was a key element of the law for insurers, said Dominick Pallone, executive director of the Michigan Association of Health Plans.

“Many times [providers] submit incomplete or incorrect information,” Pallone said. “We’re trying to make it easier for the provider to go through and complete it quickly.”

“At the end of the day, we do feel we reached a good compromise,” he said.

Article link: https://khn.org/news/article/prior-authorization-treatment-insurers-doctors-faster/

By Lauren Sausser, KHN, Aug 23, 2022.

When Dani Yuengling felt a lump in her right breast last summer, she tried to ignore it.

She was 35, the same age her mother had been when she received a breast cancer diagnosis in 1997. The disease eventually killed Yuengling’s mom in 2017.

“It was the hardest experience, seeing her suffer,” said Yuengling, who lives in Conway, South Carolina.

After a mammogram confirmed the lump needed further investigation, Yuengling scheduled a breast biopsy for Valentine’s Day this year at Grand Strand Medical Center in Myrtle Beach.

Among many concerns she had ahead of that appointment — the first being a potential cancer diagnosis — Yuengling needed to know how much the biopsy would cost. She has a $6,000 annual deductible — the amount her health plan requires she pay before its contribution kicks in — and she wasn’t close to hitting that. Whatever the procedure cost, Yuengling knew she’d be on the hook for most of it.

But the hospital wouldn’t give her a price. She was told her providers wouldn’t know what type of biopsy needle they needed until the procedure was underway and that would impact the price.

The hospital’s online “Patient Payment Estimator” showed Yuengling an uninsured patient would owe about $1,400 for the procedure.

“That’s fine. No big deal,” she thought to herself, confident it would be cheaper for her because she did have insurance. A Google search indicated it could be closer to $3,000, but Yuengling thought that price seemed reasonable, too. She wasn’t fretting too much about money as she underwent the procedure.

It soon brought the good news that she didn’t have cancer.

Then the bill came.

The Patient: Dani Yuengling, now 36, who is covered by Cigna through her employer, a human resources contractor for the Mayo Clinic.

Medical Service: An ultrasound-guided breast biopsy.

Service Provider: Grand Strand Medical Center, a 403-bed, for-profit hospital in Myrtle Beach, South Carolina. It is one of 182 hospitals owned by Nashville-based HCA Healthcare, which generated $58.7 billion in revenue last year.

Total Bill: $17,979 for the procedure, including lab work, pharmacy charges, and sterile supplies. Cigna’s in-network negotiated rate was $8,424.14, of which the insurance company paid the hospital $3,254.47. Yuengling was billed $5,169.67, the balance of her deductible.

What Gives: It’s not uncommon for uninsured patients — or any patient willing to pay a cash price — to be charged far less for a procedure than patients with health insurance. For the nearly 30% of American workers with high-deductible plans, like Yuengling, that means using insurance can lead to a far bigger expense than if they had been uninsured or just pulled out a credit card to pay in advance.

Ge Bai, an associate professor at Johns Hopkins Bloomberg School of Public Health, recently published research on this topic and said hospitals in the U.S. often set their cash prices lower than the prices they charge to treat commercially insured patients.

“We can very confidently say this is very common,” said Bai, who advised that all patients, regardless of their insurance status, inquire about the cash price before undergoing a procedure. “It should be a norm.”

Grand Strand charged Yuengling’s insurance an extraordinarily high price for her procedure. By comparison, according to the federal government’s website, Medicare patients who need an ultrasound-guided biopsy similar to the one Yuengling received would pay only about $300 — their required 20% coinsurance for outpatient care. Medicare would pay the hospital the remainder of the bill, about $1,200. The hospital expected more than five times the Medicare price from Yuengling and her insurer.

Patients in Conway with private health insurance who are treated at other hospitals also typically are charged less than what Yuengling paid for the same procedure — on average about $3,500, according to Fair Health Consumer, an organization that analyzes health insurance claims.

And uninsured patients who pay cash prices and need an ultrasound-guided breast biopsy at the nearby Conway Medical Center are likely to owe even less — about $2,100, according to Allyson Floyd, a spokesperson for the hospital.

Meanwhile, Grand Strand Medical Center spokesperson Caroline Preusser blamed “a glitch” involving the hospital’s online calculator for the inaccurate information Yuengling received and said the correct estimate for the cash price for a breast biopsy at the hospital is between $8,000 and $11,500 “depending on the exact procedure and equipment used.”

The hospital removed certain procedures from the payment estimator until they can be corrected, Preusser wrote. She did not say how long that would take.

Resolution: Yuengling tried disputing the charges with the hospital. She called the billing department and was offered a 36% discount, lowering the amount she needed to pay to $3,306.29. Grand Strand Medical Center allows patients to set up payment plans, but Yuengling decided to charge the full amount to a credit card because she wanted the whole thing to go away.

“I could not sleep. It was driving me crazy. I was having migraines. I was sick to my stomach,” she said. “I hate having debt. I didn’t want to think about it. Obviously, that didn’t work because I’m still thinking about it.”

She said she requested on multiple occasions to speak to the hospital’s patient advocate and was eventually connected with an outside company, Parallon, which conducted an audit of her bill. She eventually received a letter dated May 26 from the hospital’s Revenue Integrity Department. It stated: “After a review of the charges in question and your medical record, the following was identified; The charges on your account were appropriate.”

“I don’t know why I actually expected a different outcome,” she said.

The hospital has requested that Yuengling return for a follow-up appointment related to the biopsy. She has refused.

Harlow Sumerford, a spokesperson for HCA Healthcare, told KHN in an email that the hospital system apologizes for any confusion caused by the payment estimator “and we are working to fix the issue.”

The Takeaway: With a family history of breast cancer, Yuengling was right to follow up with her doctor after feeling a lump. After failing to get a clear answer on her costs from Grand Strand Medical Center, she could have taken an additional step to explore what other hospitals in the area charge. Although her physician referred her to Grand Strand, she was not obligated to use that hospital. She could have saved a significant amount of money by opting to undergo the procedure elsewhere.

Furthermore, patients like Yuengling who have a high-deductible insurance plan should consider paying cash prices for certain procedures and not involving their insurance company at all.

Jacqueline Fox, a health care attorney and a professor at the University of South Carolina School of Law, said she isn’t aware of any law that would prohibit a patient from doing that. After all, she pointed out, patients with health insurance pay cash prices for prescription medications all the time. It stands to reason they could do the same for medical procedures.

But some facilities make this difficult. Grand Strand Medical Center, for example, offers “self-pay” patients an “uninsured discount,” but that discount is limited to people who have “no third party payer source of payment or do not qualify for Medicaid, Charity or any other discount program the facility offers,” according to the hospital’s website. Only patients confirmed to have no health insurance are offered information about the discount.

In some cases, paying a cash price for a procedure might not make financial sense in the long run because none of it would be applied toward the deductible. Patients might save money on one procedure but end up paying their full deductible if unexpected medical expenses mount later during the calendar year.

Insured patients should reach out to their health plan for a good-faith estimate before a procedure. Under the No Surprises Act, health plans are supposed to give members an idea of their total out-of-pocket costs upon request. Ask for an “Advanced Explanation of Benefits,” said Sabrina Corlette, a research professor at the Georgetown University McCourt School of Public Policy, though she points out this part of the law isn’t being enforced yet.

The No Surprises Act also allows patients to file complaints with the federal government regarding their medical bills — whether or not they carry health insurance.

Yuengling filed her complaint in June.

Article link: https://khn.org/news/article/bill-of-the-month-breast-biopsy-with-insurance/

By Fred Schulte, KHN.

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel Tuesday.

Witnesses sharply criticized the fast-growing health plans at a hearing held by the Energy and Commerce subcommittee on oversight and investigations. They cited a slew of critical audits and other reports that described plans denying access to health care, particularly those with high rates of patients who were disenrolled in their last year of life while likely in poor health and in need of more services.

Rep. Diana DeGette (D-Colo.), chair of the subcommittee, said seniors should not be “required to jump through numerous hoops” to gain access to health care.

The watchdogs also recommended imposing limits on home-based “health assessments,” arguing these visits can artificially inflate payments to plans without offering patients appropriate care. They also called for the Centers for Medicare & Medicaid Services, or CMS, to revive a foundering audit program that is more than a decade behind in recouping billions in suspected overpayments to the health plans, which are run mostly by private insurance companies.

Related to denying treatment, Erin Bliss, a Department of Health and Human Services assistant inspector general, said one Medicare Advantage plan had refused a request for a computed tomography, or CT, scan that “was medically necessary to exclude a life-threatening diagnosis (aneurysm).”

The health plan required patients to have an X-ray first to prove a CT scan was needed.

Bliss said seniors “may not be aware that they may face greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare.”

Leslie Gordon, of the Government Accountability Office, the watchdog arm of Congress, said seniors in their last year of life had dropped out of Medicare Advantage plans at twice the rate of other patients leaving the plans.

Rep. Frank Pallone Jr. (D-N.J.), who chairs the influential Energy and Commerce Committee, said he was “deeply concerned” to hear that some patients are facing “unwarranted barriers” to getting care.

Under original Medicare, patients can see any doctor they want, though they may need to buy a supplemental policy to cover gaps in coverage.

Medicare Advantage plans accept a set fee from the government for covering a person’s health care. The plans may provide extra benefits, such as dental care, and cost patients less out-of-pocket, though they limit the choice of medical providers as a trade-off.

Those trade-offs aside, Medicare Advantage is clearly proving attractive to consumers. Enrollment more than doubled over the past decade, reaching nearly 27 million people in 2021. That’s nearly half of all people on Medicare, a trend many experts predict will accelerate as legions of baby boomers retire.

James Mathews, who directs the Medicare Payment Advisory Commission, which advises Congress on Medicare policy, said Medicare Advantage could lower costs and improve medical care but “is not meeting this potential” despite its wide acceptance among seniors.

Notably absent from the hearing witness list was anyone from CMS, which runs the $350 billion-a-year program. The agency took a pass even though committee Republicans invited CMS Administrator Chiquita Brooks-LaSure to testify. Rep. Cathy Rodgers (R-Wash.) said she was “disappointed” CMS had punted, calling it a “missed opportunity.”

CMS did not respond to a request for comment in time for publication.

AHIP, which represents the health insurance industry, released a statement that said Medicare Advantage plans “deliver better service, access to care, and value for nearly 30 million seniors and people with disabilities and for American taxpayers.”

At Tuesday’s hearing, both Republicans and Democrats stressed a need for improvements to the program while staunchly supporting it. Still, the detail and degree of criticism were unusual.

More typically, hundreds of members of Congress argue against making cuts to Medicare Advantage and cite its growing popularity.

At the hearing, the watchdogs sharply criticized home visits, which have been controversial for years. Because Medicare Advantage pays higher rates for sicker patients, health plans can profit from making patients look sicker on paper than they are. Bliss said Medicare paid $2.6 billion in 2017 for diagnoses backed up only by the health assessments; she said 3.5 million members didn’t have any records of getting care for medical conditions diagnosed during those health assessment visits.

Although CMS chose not to appear at the hearing, officials clearly knew years ago that some health plans were abusing the payment system to boost profits yet for years ran the program as what one CMS official called an “honor system.”

CMS aimed to change things starting in 2007, when it rolled out an audit plan called “Risk Adjustment Data Validation,” or RADV. Health plans were directed to send CMS medical records that documented the health status of each patient and return payments when they couldn’t.

The results were disastrous, showing that 35 of 37 plans picked for audit had been overpaid, sometimes by thousands of dollars per patient. Common conditions that were overstated or unable to be verified ranged from diabetes with chronic complications to major depression.

Yet CMS still has not completed audits dating as far back as 2011, through which officials had expected to recoup more than $600 million in overpayments caused by unverified diagnoses.

In September 2019, KHN sued CMS under the Freedom of Information Act to compel the agency to release audits from 2011, 2012, and 2013 — audits the agency contends still aren’t finished. CMS is scheduled to release the audits later this year.

Article link: https://khn.org/news/article/medicare-advantage-congress-hearing-care-overcharging/