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Six Takeaways Of The KAISER HEALTH NEWS-AP Investigation Into The Erosion Of Public Health

Local and state public health departments across the country work to ensure that people in their communities have healthy water to drink, their restaurants don’t serve contaminated food and outbreaks of infectious diseases don’t spread. Those departments now find themselves at the forefront of fighting the coronavirus pandemic.

But years of budget and staffing cuts have left them unprepared to face the worst health crisis in a century.

KHN and The Associated Press sought to understand the scale of the cuts and how the decades-long starvation of public health departments by federal, state and local governments has affected the system meant to protect the nation’s health.

Here are six key takeaways from the KHN-AP investigation:

  • Since 2010, spending for state public health departments has dropped by 16% per capita, and for local health departments by 18%. Local public health spending varies widely by county or town, even within the same state.
  • At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce in what was once viewed as one of the world’s top public health systems.
  • Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health.
  • More than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware.
  • Some public health workers earn so little that they qualify for government assistance. During the pandemic, many have found themselves disrespected, ignored or even vilified. At least 34 state and local public health leaders have announced their resignations, retired or been fired in 17 states since April.
  • States, cities and counties whose tax revenues have declined during the current recession have begun laying off and furloughing public health staffers. At least 14 states have cut health department budgets or positions, or were actively considering such cuts in June, even as coronavirus cases surged in several states.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


Essential Worker Shoulders $1,840 Pandemic Debt Due To COVID Cost Loophole By: Kaiser Health News

Carmen Quintero works an early shift at a distribution warehouse that ships N95 masks and other products to a nation under siege from the coronavirus. On March 23, she developed a severe cough, and her voice, usually quick and enthusiastic, was barely a whisper.

A human resources staff member told Quintero she needed to go home.

“They told me I couldn’t come back until I was tested,” said Quintero, who was also told she would need to document that she didn’t have the virus.

Her primary care doctor directed her to the nearest emergency room for testing because the practice had no coronavirus tests.

The Corona Regional Medical Center is just around the corner from her house in Corona, California, and there a nurse tested her breathing and gave her a chest X-ray. But the hospital didn’t have any tests either, and the nurse told her to go to Riverside County’s public health department. There, a public health worker gave her an 800 number to call to schedule a test. The earliest the county could test her was April 7, more than two weeks later.

At the hospital, Quintero got a doctor’s note saying she should stay home from work for a week, and she was told to behave as if she had COVID-19, isolating herself from vulnerable household members. That was difficult — Quintero lives with her grandmother and her girlfriend’s parents — but she managed. No one else in her home got sick, and by the time April 7 came, she felt better and decided not to get the coronavirus test.

Then the bill came.

The Patient: Carmen Quintero, 35, of Corona, California, who works at a distribution warehouse. She has an Anthem Blue Cross health insurance plan through her job with a $3,500 annual deductible.

Total Bill: Corona Regional Medical Center billed Quintero $1,010, and Corona Regional Emergency Medical Associates billed an additional $830 for physician services. She also paid $50 at Walgreens to fill a prescription for an inhaler.

Service Provider: Corona Regional Medical Center, a for-profit hospital owned by Universal Health Services, a company based in King of Prussia, Pennsylvania, that is one of the largest health care management companies in the nation. The hospital contracts with Corona Regional Emergency Medical Associates, part of Emergent Medical Associates.

Medical Service: Quintero was evaluated in the emergency room for symptoms consistent with COVID-19: a wracking cough and difficulty breathing. She had a chest X-ray and a breathing treatment and was prescribed an inhaler. What Gives: On that day in late March when her body shook from coughing, Quintero’s immediate worry was infecting her family, especially her girlfriend’s parents, both over 65, and her 84-year-old grandmother.

“If something was to happen to them, I don’t know if I would have been able to live with it,” said Quintero.

Quintero wanted to isolate in a hotel, but she could hardly afford to for the week that she stayed home. She had only three paid sick days and was forced to take vacation time until her symptoms subsided and she was allowed back at work. At the time, few places provided publicly funded hotel rooms for sick people to isolate, and Quintero was not offered any help.

For her medical care, Quintero knew she had a high-deductible plan yet felt she had no choice but to follow her doctor’s advice and go to the nearest emergency room to get tested. She assumed she would get the test and not have to pay. Congress had passed the CARES Act just the week before, with its headlines saying coronavirus testing would be free.

That legislation turned out to be riddled with loopholes, especially for people like Quintero who needed and wanted a coronavirus test but couldn’t get one early in the pandemic.

“I just didn’t think it was fair because I went in there to get tested,” she said.

Some insurance companies are voluntarily reducing copayments for COVID-related emergency room visits. Quintero said her insurer, Anthem Blue Cross, would not reduce her bill. Anthem would not discuss the case until Quintero signed its own privacy waiver; it would not accept a signed standard waiver KHN uses. The hospital would not discuss the bill with a reporter unless Quintero could also be on the phone, something that has yet to be arranged around Quintero’s workday, which begins at 4 a.m. and ends at 3:30 p.m.

Three states have gone further than Congress to waive cost sharing for testing and diagnosis of pneumonia and influenza, given these illnesses are often mistaken for COVID-19. California is not one of them, and because Quintero’s employer is self-insured — the company pays for health services directly from its own funds — it is exempt from state directives anyway. The U.S. Department of Labor regulates all self-funded insurance plans. In 2019, nearly 2 in 3 covered workers were in these types of plans.

Resolution: As lockdown restrictions ease and coronavirus cases rise around the country, public health officials say quickly isolating sick people before the virus spreads through families is essential.

But isolation efforts have gotten little attention in the U.S. Nearly all local health departments, including that of Riverside County, where Quintero lives, now have these programs, according to the National Association of County and City Health Officials. Many were designed to shelter people experiencing homelessness but can be used to isolate others.

Raymond Niaura, interim chairman of the Department of Epidemiology at New York University, said these programs are used inconsistently and have been poorly promoted to the public.

“No one has done this before and a lot of what’s happening is that people are making it up as they go along,” said Niaura. “We’ve just never been in a circumstance like this.”

Quintero still worries about bringing the virus home to her family and fears being in the same room with her grandmother. Quintero works at a warehouse that distributes 3M products including personal protective equipment and other companies’ products. Quintero returns from work every day now, puts her clothes in a separate hamper and diligently washes her hands before she interacts with anyone.

The bills have been another constant worry. Quintero called the hospital and her insurance company and complained that she should not have to pay since she was seeking a test on her doctor’s orders. Neither budged, and the bills labeled “payment reminders” soon became “final notices.” She reluctantly agreed to pay $100 a month toward her balance — $50 to the hospital and $50 to the doctors.

“None of them wanted to work with me,” Quintero said. “I just have to give the first payment on each bill so they wouldn’t send me to collections.”

The Takeaway: If you suspect you have COVID-19 and need to isolate to protect vulnerable members of your household, call your local public health department. Most counties have isolation and quarantine programs, but these resources are not well known. You may be placed in a hotel, recreational vehicle or other type of housing while you wait out the infection period. You do not need to have a positive COVID test to qualify for these programs and can use these programs while you await your test result. But this is an area in which public health officials repeatedly offer clear guidance — 14 days of isolation — which most people find impossible to follow.

At this point in the pandemic, tests are more widely available and federal law is very clearly on your side: You should not be charged any cost sharing for a coronavirus test.

Be wary, though, if your doctor directs you to the emergency room for a COVID test, because any additional care you get there could come at a high price. Ask if there are any other testing sites available.

If you do find yourself with a big bill related to suspected COVID-19, push beyond a telephone call with your insurance company and file a formal appeal. If you feel comfortable, ask your employer’s human resources staff to argue on your behalf. Then, call the help line for your state insurance commissioner and file a separate appeal. Press insurers — and big companies that offer self-insured plans — to follow the spirit of the law, even if the letter of the law seems to let them off the hook.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it! COPY HTML

1 in 4 doctors say prior authorization has led to a serious adverse event

FEB 5, 2019

Andis Robeznieks

Senior News Writer

American Medical Association

PRIOR AUTHORIZATIONS ARE SIGNIFICANTLY AFFECTING OUR HEALTH!! THE HEALTHCARE CONSUMERS NEEDS TO BE AWARE OF THIS PROBLEM. THE FOLLOWING ARTICLE PUBLISHED BY THE AMA IS EYE OPENING.

It just keeps getting worse. That’s a major finding of an AMA survey of 1,000 practicing physicians who were asked about the impact prior authorization (PA) is having on their ability to help their patients.

More than nine in 10 respondents said PA had a significant or somewhat negative clinical impact, with 28 percent reporting that prior authorization had led to a serious adverse event such as a death, hospitalization, disability or permanent bodily damage, or other life-threatening event for a patient in their care.

PA, a health plan cost-control process, restricts access to treatments, drugs and services. This process requires physicians to obtain approval prior to the delivery of the prescribed treatment, test or medical service in order to qualify for payment.

Traditionally, health plans applied PA to newer, expensive services and medications. However, physicians report an increase in the volume of prior authorizations in recent years, to include requirements for drugs and services that are neither new nor costly.

The vast majority of physicians (86 percent) described the administrative burden associated with prior authorization as “high or extremely high,” and 88 percent said the burden has gone up in the last five years.

“The AMA survey continues to illustrate that poorly designed, opaque prior authorization programs can pose an unreasonable and costly administrative obstacle to patient-centered care,” said AMA Board of Trustees Chair Jack Resneck Jr., MD. “The time is now for insurance companies to work with physicians, not against us, to improve and streamline the prior authorization process so that patients are ensured timely access to the evidence-based, quality health care they need.”

“The AMA is committed to attacking the dysfunction in health care by removing the obstacles and burdens that interfere with patient care,” Dr. Resneck added. “To make the patient-physician relationship more valued than paperwork, the AMA has taken a leading role by creating collaborative solutions to right-size and streamline prior authorization and help patients access safe, timely and affordable care, while reducing administrative burdens that pull physicians away from patient care.”

The AMA offers prior-authorization reform resources that allow physicians to make a difference with effective advocacy tools, including model legislation and an up-to-date list of state laws governing prior authorization.

Share  your story with the AMA about PA’s impact on your practice and your patients to help #FixPriorAuth. Visit FixPriorAuth.org to learn more.

Other highlights of the AMA physician survey include that:

  • 91 percent believe that PA delays patients’ access to care.
  • 75 percent reported that PA can lead to patients abandoning their course of treatment.

The AMA survey was conducted online in December 2018. Participants were physicians who practice in the United States, provide at least 20 hours of direct patient care and complete PAs during a typical week of practice. Forty percent of participants were primary care physicians, and 60 percent were in other specialties.

Physicians’ views on the impact of care delays comes into focus when one considers the typical turnaround times they see from health plans.

In the AMA survey:

  • 65 percent of physicians said they wait an average of at least one business day for a prior-authorization decision from a health plan.
  • 26 percent reported waiting at least three days.
  • 7 percent reported waiting an average of more than five days.

Physicians in the survey reported processing an average 31 PAs per week, with this PA workload consuming 14.9 hours—nearly two business days—of physician and staff time.

Additionally, 36 percent reported that their practice has staff who work exclusively on PA.

In January 2017, the AMA with 16 other associations urged industry-wide improvements in prior authorization programs to align with a newly created set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. More than 100 other health care organizations have supported those principles.

In January 2018, the AMA joined the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association in a consensus statement outlining a shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.

From Prisoner to Customer to Sophisticated Consumer

The coronavirus is providing us with a great opportunity to understand why it is so important for each person to have a healthcare plan. We have all been exposed to a rare opportunity to view how healthcare providers run the “business of healthcare.” We are also witnessing the oftentimes recalcitrant behavior of healthcare patients and the potential hazards of these actions.

Since 1983, the federal government changed the reimbursement formula for how healthcare providers were paid by Medicare from a reimbursement model to a prospective payment model. The most dramatic and observable impact of this new legislation was dropping hospital occupancy from around 80% to 63% in just 3 years. This change set in motion numerous responses and reactions by the healthcare system that continue to evolve today and more importantly have been exposed by the pandemic. On the downside, this over capacity has led to the closure of many hospitals, the consolidation of many more and the creation of mega-multi-hospital systems. There would also be a physician glut of specialists and simultaneously a shortage of primary care physicians. A nursing shortage was also becoming a concern and the emergence of what would be called a “healthcare customer” vs. a healthcare patient. This all created a massive change in healthcare terminology. Customer satisfaction became a thing, patients would become guests, guest relationship training became in vogue,  amenities like valet parking, escort services, hotel quality bed linen and towels, concierge level floors were all part of a hospital’s  marketing approach to the new healthcare customer.

Here’s the shocking surprise to this story. The implementation of the new Medicare payment methodology was a cost-control initiative. In 1986, the US spent $458 billion or 10.9% of the gross national product (GNP) on healthcare. By 2019, this number escalated to an estimated $3.6 trillion and with the pandemic $4.0 trillion is certainly within range for 2020. To put this in personal terms, according to the Milliman Medical Index the average cost for a family of four covered by an employer-sponsored, preferred provider organization plan was $28,166 in 2018. Using some over-simplistic ratio analysis a comparative number in 1986 would be approximately $3,600. This is an inflation factor of 782%. This unintended consequence resulted in the passage of what has become known as Obamacare in March 2010. The official name, The Patient Protection and Affordable Care Act, was the most extensive healthcare legislation since the aforementioned change in the Medicare payment methodology. The focus of the legislation was on the uninsured, improving quality and again the holy grail of controlling healthcare costs. This has continued to be a very challenging political issue and we will not discuss all of the continuing issues this has created.

Ironically, healthcare in the US is still broken as evidenced by the current chaos being caused by the pandemic. It’s become evident that $3.6 trillion isn’t enough to handle a crisis. Healthcare will be a major issue in the 2020 presidential race. As an industry, the focus continues to largely be internal with massive doses of superficial rhetoric surrounding quality, patient safety and customer satisfaction.

A little discussed factor underlying the healthcare system is that it’s the most financially driven industry in America. As of now, Congress has allocated $175 billion in aid to hospital and healthcare providers as a result of the pandemic. A further example of how “economics” drive healthcare was included in the Affordable Care Act. In a little publicized program initiated in 2014 and called, The Hospital-Acquired Condition Reduction Program, CMS began reducing Medicare payments based on the performance on 6 quality measures. This is one of the few public data bases reflecting a hospital’s quality performance and was created by a financial incentive program. Buyer beware!

With this background, we are introducing an initiative to create a class of sophisticated healthcare consumers. As is being illustrated everyday during the current medical crisis, decisions people make about medical care can have life and death consequences.

Let’s get started.

Our first recommendation is “Document Your Family’s Health History.”

Find an App, get a three-ring binder or start a journal. Anytime a person goes to a physician’s office for the the first time they will be asked to complete a medical history template. This information is the critical first step to any physician’s diagnostic process. Go on-line and there are numerous examples and tools to assist in this process. With chronic conditions being important mortality factors in the current coronavirus environment, knowing what family members have what conditions are critical. Decisions regarding genetic testing also are a consideration in today’s environment. If you’re quarantined, it’s a great opportunity to complete this project.

Next, we’ll focus on primary care physician selection.

UnitedHealth commits $1.5 billion for premium rebates and new cost-sharing waivers

UnitedHealth Group announced Thursday it will provide $1.5 billion in direct financial relief for its customers in the form of premium rebates for consumers on individual and small group employer plans, and cost-sharing waivers for seniors on its Medicare Advantage plans.

The nation’s largest health insurer says employers and individual members enrolled in its UnitedHealthcare fully insured health plans will receive a 5% to 20% premium credit on their June billing statements. As of March 31, the company had 8.2 million members enrolled in those plans.

“As you know, people are hurting right now. Employers are hurting, individual consumers are hurting, and we felt it appropriate to get as much of this back in the hands of people as quickly as possible,” said UnitedHealth Group CEO David Wichmann, adding the company aims to help “small businesses, many of which have been out of work for a while.”

While insurers have pledged to cover coronavirus testing and medical costs, the pandemic has resulted in a sharp drop in medical spending due to delayed elective surgery and diagnostic procedures since the Trump administration issued a national stay-at-home directive in mid-March.

Some insurers and hospital operators have reported surgical volumes and non-Covid-19 emergency room visits in April down 40% or more from a year ago, which is more than offsetting increased costs on coronavirus care and expenses.

Nearly half of primary care doctors are struggling to stay open: Survey

Under the Affordable Care Act, insurers are required to provide a rebate at the end of the year if they spend less than 80% of premiums on medical costs for fully insured employer plans and 85% on individual health plans. Large, self-insured employer plans are not covered by the rebate provision.

UnitedHealth said “the vast majority” of the new financial relief initiatives are not tied the ACA minimum medical spending mandate.

“A small fraction of the amount that consumers and the groups will be receiving relates to that rebate,” Wichmann said. “The rest is based upon what we would characterize as an economic imbalance that we think will persist.”

Record 2020 rebates

Last month, auto insurers announced refunds to customers due to lower driving and accident rates during the pandemic. UnitedHealth is the first health insurer to announce a rebate on premiums due to overall lower medical costs.

But analysts and researchers anticipate that the industry could be on the hook for record refunds on 2020 premiums under the ACA.

An analysis by the Kaiser Family Foundation estimated insurers collectively might have to pay out more than $2.7 billion in rebates for premiums collected this year; an average of $420 per member on individual plans and $1,850 per member on small group plans. That’s more than double the current record of $1.4 billion in rebates insurers are refunding individual consumers and employers for 2019 premiums.

Medicare and Medicaid support

UnitedHealth is waiving co-pays for all doctor visits through September, for the nearly 5.6 million seniors on its privately insured Medicare Advantage plans.

With states now beginning to lift Covid-19 moratoriums on elective surgery and other nonemergency care, the ramp up of rescheduled procedures is expected to be slow until the second half of the year.

“Some of the care that’s being deferred is this care that we would characterize as necessary … and we are strongly encouraging people to access,” Wichmann said.

The company is also providing state Medicaid plans with funding for doctors, as well as support programs that include providing food and baby formula to families.

To date, the company has committed $75 million in funding for community outreach programs, including providing protection equipment for health-care workers, and meals for students on school lunch programs.

UnitedHealth did not provide a breakdown on how the $1.5 billion in new funding will be split between the premium revenues, co-pay waivers and the Medicaid support.

COVID Tests Are Free, Except When They’re Not By Carmen Heredia Rodriguez APRIL 29, 2020

CONSUMER BEWARE………..MAKE SURE YOU CHALLENGE YOUR INSURE COMPANY IF YOU  GET A BILL RELATING TO THE CORONAVIRUS!!!!

 

Even before a novel virus swept around the world, Anna Davis Abel wore a mask to protect herself from getting sick.

The 25-year-old writer lives with lupus, a chronic autoimmune disease that makes her more susceptible to catching a virus or an infection. Davis Abel’s doctor cleared her to travel to a literary conference in San Antonio in early March. Then she developed a sore throat and low-grade fever several days after arriving home in Morgantown, West Virginia.

Consulting a nurse on the phone, Davis Abel was told to manage her symptoms at home. But her symptoms only worsened, so she secured an appointment with her primary care doctor.

“At that point, I was, like, taking shot glasses of Sudafed,” she said.

Given the spread of the coronavirus and a chronic condition that left her vulnerable to a more serious case of COVID-19, she was concerned she’d been infected. To find out, her doctor first ordered tests to evaluate whether Davis Abel’s symptoms were caused by some other respiratory disease. According to the doctor’s notes in her medical record, “we needed to rule out all other viral possibilities before being eligible for the COVID-19 test.”

“Unfortunately at this time, COVID-19 testing is very limited and is not widely available to most patients,” the record noted.

Davis Abel tested positive for influenza Type B.

Then the bill came.

The Patient: Anna Davis Abel is a 25-year-old graduate student studying creative writing at West Virginia University in Morgantown. She is insured through an Aetna plan the university offers.

Total Amount Billed: WVU Medicine charged Davis Abel $2,121 for the visit and testing, according to records. Aetna initially paid $1,584.54 for these services. Abel was responsible for the copay, the remaining amount of her deductible and a coinsurance cost of 20%. In total, she owed $536.46.

The Providers: Davis Abel visited the WVU Healthcare University Town Centre clinic for her primary care appointment. A laboratory within the WVU health system processed her testing for respiratory disease. Both sites were in-network for her plan.

Medical Services: A BioFire Respiratory Panel was used to test a specimen collected from the back of Davis Abel’s nose and throat for more than a dozen respiratory diseases.

What Gives: Congress has taken action to make COVID-19 testing more affordable for consumers with health insurance.

The Families First Coronavirus Response Act requires private insurers to pay for certain services and items related to testing at no cost to the patient. A second piece of legislation, known as the CARES Act, expanded the number of tests and services insurers must cover at no cost. The latter law also requires health plans to reimburse out-of-network providers for their services. However, experts said, there are gaps in these federal protections that may expose patients to unexpected medical bills.

The guidelines state that insurers are required to cover the cost of an appointment without cost sharing only if the doctor orders or administers a COVID-19 test. Even if the patient shows symptoms and receives other care related to the novel virus, without a test the patient may be on the hook for the cost of the visit, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

“They’re getting a battery of other tests,” said Corlette. “But because there’s not enough [COVID-19] tests, they can’t get this protection.”

A national shortage of COVID-19 tests complicates a patient’s ability to qualify for the federal safeguard. Despite efforts by the federal government and the private sector, some resources needed to increase testing remain scarce, said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.

This reality means some medical providers, like Davis Abel’s doctor, must rule out other respiratory diseases before ordering a COVID-19 test, leaving some patients with a difficult choice. Do they seek medical attention and risk a high medical bill? Or do they forgo care altogether?

A second hole in these federal protections may leave patients holding the bill for their COVID-19 test, experts said. The law prohibits insurers from charging patients for testing, but it does not block medical providers from doing so. If an insurer does not cover the total amount charged by a provider, the patient may get balance-billed, or slapped with a surprise charge.

Guidance from the federal Department of Health and Human Services says that that should not happen because almost any patient can be considered at risk for COVID-19 right now, but it’s unclear if or how that will be enforced.

If any of you are interested in the whole #COVID19 video @NBCNews used, here you go. I can guess why they edited it 🤪 pic.twitter.com/cawpAMfOkS

— Anna Davis Abel (@AnnaDavisAbel) April 15, 2020

Davis Abel’s appointment was on March 11, making her ineligible for the protections offered by the federal laws. By then, however, Aetna had pledged to cover COVID-19 testing without cost sharing. The hospital system then sent Davis Abel a bill for the remaining amount.

WVU Medicine declined to comment on the case.

It’s unlikely Davis Abel is the only patient getting charged for care, according to Karen Pollitz, a senior fellow at the Kaiser Family Foundation. Pollitz said insured consumers may get dinged with a bill if they get care from an out-of-network provider even though the federal protections also require insurers to cover that cost.

Consumers may find protection from these bills through a requirement attached to federal relief funding for medical providers. Health care facilities that receive any of the $100 billion from the CARES Act Provider Relief Fund are not allowed to balance-bill patients for COVID-19 treatment. (Kaiser Health News is an editorially independent program of the foundation.)

Resolution: Aetna retroactively covered Davis Abel’s bill from the hospital after reporters made inquiries. In a statement, the insurer said it is waiving claims after receiving information from her provider that the services were related to COVID-19 testing.

It also said Davis Abel represents a “unique” case and is not aware of whether other members have submitted claims for services they needed to obtain a COVID-19 test. The insurer said it would waive additional testing related to the novel virus if the provider deemed those services necessary.

Before Aetna took action, two strangers read Davis Abel’s story on Twitter and sent her the full amount for the bill. She used the donations to help pay for a medical bill from a previous procedure.

Nearly 10 days after her appointment, Davis Abel received a drive-thru COVID-19 test offered by the same clinic. Her primary care doctor, who ordered the test, said in an email to Davis Abel that new data suggested patients could fall ill with the coronavirus and the flu at the same time.

Davis Abel’s fever and coughing had not subsided. Eight days after the test, she received her result. Negative for COVID-19. She did not pay for the test.

The Takeaway: Experts recommend that insured patients educate themselves about their health care plan. Seek care at an in-network provider whenever possible. Call the insurer to find out exactly what COVID-19 care it covers. Several insurance companies have pledged to waive cost sharing for treatment.

Uninsured consumers may be able to get a free COVID-19 test several ways, Pollitz said. One way is to visit an outpatient testing area at a facility that received relief funding — the law bars the provider from balance-billing patients for care related to the coronavirus.

Another option is through Medicaid. States may now use the government health insurance program for the poor and disabled to cover the cost of testing uninsured residents who qualify.

A third way consumers could receive a free COVID-19 test is through the National Disaster Medical System. That network of health care providers — generally activated in response to an emergency — treats patients and then charges the federal government for their services, said Pollitz. However, she acknowledged, it may be difficult to find a provider who participates in the program.

“The problem right now is the supply of them,” Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, said about COVID-19 tests. “But once that changes, people need to be confident that they’re not going to be stuck with a big bill.”

Dan Weissmann, host of the podcast “An Arm and a Leg,” reported the audio version of this story. You can hear more about Davis Abel’s story on this week’s episode of the podcast. 

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Some

Telehealth Will Be Free, No Copays, They Said. But Angry Patients Are Getting Billed.

Karen Taylor had been coughing for weeks when she decided to see a doctor in early April. COVID-19 cases had just exceeded 5,000 in Texas, where she lives.

Cigna, her health insurer, said it would waive out-of-pocket costs for “telehealth” patients seeking coronavirus screening through video conferences. So Taylor, a sales manager, talked with her physician on an internet video call.

The doctor’s office charged her $70. She protested. But “they said, ‘No, it goes toward your deductible and you’ve got to pay the whole $70,’” she said.

Policymakers and insurers across the country say they are eliminating copayments, deductibles and other barriers to telemedicine for patients confined at home who need a doctor for any reason.

“We are encouraging people to use telemedicine,” New York Gov. Andrew Cuomo said last month after ordering insurers to eliminate copays, typically collected at the time of a doctor visit, for telehealth visits.

But in a fragmented health system — which encompasses dozens of insurers, 50 state regulators and thousands of independent doctor practices ― the shift to cost-free telemedicine for patients is going far less smoothly than the speeches and press releases suggest. In some cases, doctors are billing for telephone calls that used to be free.

Patients say doctors and insurers are charging them upfront for video appointments and phone calls, not just copays but sometimes the entire cost of the visit, even if it’s covered by insurance.

Despite what politicians have promised, insurers said they were not able to immediately eliminate telehealth copays for millions of members who carry their cards but receive coverage through self-insured employers. Executives at telehealth organizations say insurers have been slow to update their software and policies.

“A lot of the insurers who said that they’re not going to charge copayments for telemedicine ― they haven’t implemented that,” said George Favvas, CEO of Circle Medical, a San Francisco company that delivers family medicine and other primary care via livestream. “That’s starting to hit us right now.”

One problem is that insurers have waived copays and other telehealth cost sharing for in-network doctors only. Another is that Blue Cross Blue Shield, Aetna, Cigna, UnitedHealthcare and other carriers promoting telehealth have little power to change telemedicine benefits for self-insured employers whose claims they process.

Such plans cover more than 100 million Americans — more than the number of beneficiaries covered by the Medicare program for seniors or by Medicaid for low-income families. All four insurance giants say improved telehealth benefits don’t necessarily apply to such coverage. Nor can governors or state insurance regulators force those plans, which are regulated federally, to upgrade telehealth coverage.

“Many employer plans are eliminating cost sharing” now that federal regulators have eased the rules for certain kinds of plans to improve telehealth benefits, said Brian Marcotte, CEO of the Business Group on Health, a coalition of very large, mostly self-insured employers.

For many doctors, business and billings have plunged because of the coronavirus shutdown. New rules notwithstanding, many practices may be eager to collect telehealth revenue immediately from patients rather than wait for insurance companies to pay, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

“A lot of providers may not have agreements in place with the plans that they work with to deliver services via telemedicine,” she said. “So these providers are protecting themselves upfront by either asking for full payment or by getting the copayment.”

David DeKeyser, a marketing strategist in Brooklyn, New York, sought a physician’s advice via video after coming in contact with someone who attended an event where coronavirus was detected. The office charged the whole visit — $280, not just the copay ― to his debit card without notifying him.

“It happened to be payday for me,” he said. A week earlier and the charge could have caused a bank overdraft, he said. An email exchange got the bill reversed, he said.

With wider acceptance, telehealth calls have suddenly become an important and lucrative potential source of physician revenue. Medicare and some commercial insurers have said they will pay the same rate for video calls as for office visits.

Some doctors are charging for phone calls once considered an incidental and non-billable part of a previous office visit. Blue Cross plans in Massachusetts, Wyoming, Alabama and North Carolina are paying for phoned-in patient visits, according to America’s Health Insurance Plans, a lobbying group.

“A lot of carriers wouldn’t reimburse telephonic encounters” in the past, Corlette said.

Catherine Parisian, a professor in North Carolina, said what seemed like a routine follow-up call with her specialist last month became a telehealth consultation with an $80 copay.

“What would have been treated as a phone call, they now bill as telemedicine,” she said. “The physician would not call me without billing me.” She protested the charge and said she has not been billed yet.

By many accounts, the number of doctor encounters via video has soared since the Department of Health and Human Services said in mid-March that it would take “unprecedented steps to expand Americans’ access to telehealth services.”

Medicare expanded benefits to pay for most telemedicine nationwide instead of just for patients in rural areas and other limited circumstances, HHS said. The program has also temporarily dropped a ban on doctors waiving copays and other patient cost sharing. Such waivers might have been considered violations of federal anti-kickback laws.

At the same time, the CARES Act, passed by Congress last month to address the COVID-19 emergency, allows private, high-deductible health insurance to make an exception for telehealth in patient cost sharing. Such plans can now pay for video doctor visits even if patients haven’t met the deductible.

Dozens of private health insurers listed by AHIP say they have eliminated copays and other cost sharing for telemedicine. Cigna, however, has waived out-of-pocket costs only for telehealth associated with COVID-19 screening. Cigna did not respond to requests for comment.

Teladoc Health, a large, publicly traded telemedicine company, said its volume has doubled to 20,000 medical visits a day since early March. Its stock price has nearly doubled, too, since Jan. 1.

With such a sharp increase, it’s not surprising that insurers and physicians are struggling to keep up, said Circle Medical CEO Favvas.

“It’s going to be an imperfect process for a while,” he said. “It’s understandable given that things are moving so quickly.”

Abbie VanSickle, a California journalist, wanted her baby’s scheduled wellness visit done remotely because she worried about visiting a medical office during a pandemic. Her insurer, UnitedHealthcare, would not pay for it, the pediatrician told her. Mom and baby had to come in.

“It seems like such an unnecessary risk to take,” VanSickle said. “If we can’t do wellness visits, we’re surely not alone.”

A UnitedHealthcare spokesperson said that there was a misunderstanding and that the baby’s remote visit would be covered without a copay.

Jacklyn Grace Lacey, a New York City medical anthropologist, had a similar problem. She had to renew a prescription a few weeks after Cuomo ordered insurers to waive patient cost sharing for telehealth appointments.

The doctor’s office told her she needed to come in for a visit or book a telemedicine appointment. The video visit came with an “administrative fee” of $50 that she would have had to pay upfront, she said — five times what the copay would have been for an in-person session.

“I was not going to go into a doctor’s office and potentially expose people just to get a refill on my monthly medication,” she said.

Are You a Healthcare Prisoner in the Big Pharma Prison? “Follow the Money” and Find Out.

As we further explore the healthcare consumer in a healthcare prison, Big Pharma is an area we need to review and explore because companies are profiting hugely by raising prices to dizzying heights. Drugs that cost less than $400 a year in some countries cost $300,000 a year in the United States.

Eighty percent of the growth of profits in the 20 largest drug companies has resulted from price increases — not new drugs. Just raising prices.  The brunt of that pain is felt by the healthcare consumer because the drugs that we buy here are much more expensive than the prices elsewhere.

A few points need to be clarified regarding Your Doctor, Big Pharma and the Consumer before we can answer the question.

Your doctor contributes to the problem.  The following study is mind boggling:

In 2013, 1,122 (39.1%) of 2,873 Medicare Part D prescribers received gifts from pharmaceutical companies totaling $3.9 million in 2013. Compared to non-gift recipients, gift recipients prescribed 2.3 more claims per patient, prescribed medications costing $50 more per claim, and prescribed 7.8% more branded drugs. 

Physicians who received small gifts (less than $500 annually) had more expensive claims ($114 vs. $85) and more branded claims (30.3% vs. 25.7%) than physicians who received no gifts. Those receiving large gifts (greater than $500 annually) had the highest average costs per claim ($189) and branded claims (39.9%) than other groups.

Big Pharma by the Numbers:

First, most large drug companies spend more on sales and marketing than on research and development.  Anyone who watches television can attest to the growth and dominance of marketing to the consumer.

Second, since 1980 and the Bayh-Dole Act, drug companies can feed off research funded by the National Institutes of Health, which they acquire at late stages of development. The big companies can either license the drugs or buy out small biotech companies carrying out NIH-funded research. In short, much of the research going into these products is funded by taxpayers, not pharmaceutical revenues. Many companies have operating profits ranging from 15% to 30%.  The average S & P company had an operating profit of 10.4%

Third, the pharmaceutical industry has a massive lobbying presence, consistently spending over $200 million a year, according to the Center for Responsive Politics. It has more than two lobbyists for every member of Congress and spends tens of thousands of dollars per election cycle. That type of investment is only undertaken when there is a significant return expected. For example, Congress placed a provision in the 2003 Medicare Prescription Drug Benefit that prohibits Medicare from negotiating with drug companies on pricing. Now that’s a return on lobbying costs!

Fourth, Nielson estimated that $5.2 billion was spent on prescription drug advertising in 2015. The largest chunk of that amount was for television advertising.

And lastly, in 2013, biopharmaceutical companies led all other industries in corporate giving by donating 19.4% of pre-tax profits to charitable organizations. You probably won’t be surprised, though, that 90% of the contributions came in the form of in-kind product donations. High list prices for certain drugs can add up to some major bucks quickly. Still, it’s nice to know that the frequently vilified Big Pharma companies aren’t as heartless as they’re sometimes portrayed.

Now from a healthcare consumer prospective:

  • It is estimated that there are 110 million regular prescription drug users across the US.
  • 49% of us take at least one drug
  • 19% of us have skipped taking a drug or cut it in half
  • 14% of us chose not to fill prescriptions at all

Additionally, Big Pharma and insurance companies have developed relationships that have forced healthcare consumers to buy brand name versus generic drugs.  Insurance companies tell consumers the generics are not covered only brand names.  Unbelievable!!!!!

The above ‘costs of doing business’ result in the cost of healthcare for every healthcare consumer increasing at all levels. Furthermore, the practice of “gifting” medical professionals should be considered a crime—similar to rebating in the insurance industry.

Big Pharma gifts influence MDs script writing, which affects Medicare, Medicaid, and all healthcare insurance policies, coverages and, ultimately, premiums insureds pay.

If the above hasn’t convinced you are a healthcare prisoner in a healthcare prison I’m not sure what will.  Big Pharma locks us up and throws away the key. We clearly are prisoners. I rest my case!!!!!!

We have spoken with many healthcare consumers and they’ve shared scores of unbelievable stories. Talk to any of your friends, relatives or colleagues and I am sure they will have a Big Pharma story to tell.

Tells us what you think.

 

Escaping the Healthcare Prison; Are You a Healthcare Prisoner?

If one would judge by the rhetoric and lip-service coming from the healthcare industry, all is fine and getting better. The reality, however, is the healthcare landscape has changed significantly in a very short period of time and not for the betterment of the patient or consumer. Healthcare consumers and patients are finding themselves virtually captive.   Healthcare consumers are asked to do more, pay more and receive less value for each dollar spent. While healthcare consumerism receives much media attention, the reality is healthcare providers and payers are very content with the status quo.

 

In market based businesses, consumers require pricing information and a means to determine the quality of goods or service they’re receiving. In other complicated industries involving high consumer volume, like financial services, travel, retailing or automobiles, the government regulates the quality aspect and commercial enterprises provide pricing transparency. Healthcare is void of both. Providers nor payers have any intention of relinquishing the control.   Making it easy for the consumer to navigate the maze is counter productive to the current business model The lack of transparency isn’t unintentional, therefore, creating transparency must be intentional.

 

What’s the big secret? Why does pricing need to be so convuloted?  Pricing transparency is a hot topic. Industry insiders will argue against pricing transparency because they claim it’s to complicated for consumers to understand. Payers guard pricing like Coke protects the soda formulas. Compare trying to find a price for a healthcare service to any other consumer good or service!!!  Take a look at a hospital bill to really see the insanity. There will be a laundry list of incomprehensible items followed by individual pricing that will sum to a very large total followed by a relatively large discount resulting in what someone is expected to pay. This is an artifact of the Byzantine health insurance world when patients had little to no financial exposure to paying for healthcare services. Even though the marketplace has dramatically changed, incumbents have chosen not to.    States and the Federal government have done very little to help the healthcare consumer.  It’s laughable compared to other industries.

 

I believe we are healthcare prisoners in a virtual prison.  The following will explain what I mean.

 

Let’s define a healthcare consumer/patient, healthcare prisoner, and a virtual healthcare prison.

 

First a healthcare Consumer/Patient: Simple……Any person wanting to protect themselves from a catastrophic healthcare event or anyone who requires medical care.

 

Second, let’s define a Healthcare Prisoner
A Healthcare prisoner is a person buying health insurance or obtaining medical care.
 

 Third, let’s define the Virtual Healthcare Economic Prison.

With the passage of the Patient Protection and Affordable Act, effectively all Americans have been granted access to the healthcare economic prison. It’s now only a question of what degree. A Virtual Healthcare Economic Prison is any organization that extracts financial resources from patients/consumers or provides healthcare services to patients/consumers. These Virtual Prisons are…. the government (social security tax/Medicare/Medicaid), employers (health benefit premiums/workers compensation), insurance companies (protection depositories), hospitals, big pharma or other allied healthcare providers just to name a few.  They are prisons because our healthcare choices are dictated by these entities through unknowable contractual terms. These relationships are almost entirely based upon financial arrangements.   They protect us as long as we are cooperative and meet our financial commitments and follow the rules.

 

Studies show in 2017, Preferred Provider Organization (PPO) health insurance coverage for a family of four cost an employer approximately $27,000. The employees share was approximately $12,000. On the health exchanges the average cost for a family of four without subsidies was approximately $21,000. (No telling how comparative the policies might be.) Several studies have shown consumers over-purchase health insurance by 24%. The value of services received for this payment is highly dependent upon a well-informed consumer/patient. Transparency will arrive when it is an expectation of the consumer/patient.

 

WE ARE ALL EXPEREINCING BEING A HEALTHCARE PRISONER OR IN A HEALTHCARE PRISON 

 

I realize some will disagree.  Some will agree.  I know for sure the healthcare consumer will agree.  We have spoken to many of them.  The consumer is the only one that counts.

 

Let us know what you think….

 

THE HEALTHCARE PATIENT VERSUS THE HEALTHCARE CONSUMER

Today, we define a healthcare patient as receiving healthcare services; we define a healthcare consumer as making healthcare choices.  Undoubtedly a very big difference that requires a shift in focus.  The healthcare consumer is responsible for the overall management of their health needs and out of pocket costs. Out of pockets costs are defined as deductibles, co-pays, co-insurance, premiums, and other related costs. The typical consumer does not plan for healthcare.  Consumers, annually, select a health insurance plan based on premium cost and hope they are healthy enough to avoid large out of pocket costs.  A Personal/Family Health Plan should be the first step to proactively managing healthcare options and costs. The Plan should be all inclusive from selecting a health insurance plan to creating a budget.  Radical? Yes…but by not planning for healthcare the result could be disastrous with health and financial consequences.

The average healthcare consumer has limited experience navigating the healthcare system, including those who work in the healthcare industry.  Many of us have heard friends and relatives express their frustration managing options, care, and costs, resulting in incorrect billing, high costs, out of network charges and denied services. One example is a recent survey that shows the consumer lacks understanding of basic health care terms. The following are the results:

  • 45.3% Co-Insurance
  • 35.2% Max out of pocket
  • 30.8% Covered Services
  • 27.2% Premium
  • 25.6% Deductible
  • 23.5% Co-pay

The degree of misunderstanding is astonishing.

The healthcare system is a maze that healthcare consumers cannot navigate easily. Healthcare consumers are afraid, frustrated, confused and angry.  All healthcare sectors, including Doctors, Hospitals and Insurance Companies, have contributed to the growing confusion.

Many talk about consumerism in healthcare but don’t understand healthcare consumer needs and wants. Clearly, the healthcare consumer has not been prepared to manage their healthcare finances as the above survey demonstrates.  The healthcare system has failed the healthcare consumer.

Our responsibility is to educate and guide the healthcare consumer through the maze.  With that said, the following company and web site has been established:

HEALTHCARE CONSUMER NAVIGATOR CENTER, LLC

Our Vision…The Need….The Mission Statement

Our company has a vision that all healthcare consumers have easy access to reliable and timely healthcare information, education, and tools required to plan and manage their healthcare needs.

Consumers need understandable healthcare information to make informed decisions regarding their medical and financial future.

Healthcare Consumer Navigator Center is a national company with a business mission to guide consumers through the complex healthcare system.  Healthcare Consumers will be provided tools, guides, information and education to navigate the complexities of the healthcare systems.

WEB SITE:   www.healthcareconsumernavigatorcenter.com

Take a look and lets us know your comments and thoughts.

 

 

 


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