A Proposal to Import Drugs from Other Countries Creates an Unusual Alliance in the Senate

A Proposal to Import Drugs from Other Countries Creates an Unusual Alliance  in the Senate | Kaiser Health NewsSource: Kaiser Health News, by Victoria Knight

Harmony is not often found between two of the most boisterous senators on Capitol Hill, Bernie Sanders (I-Vt.) and Rand Paul (R-Ky.).

But it was there at Tuesday’s Senate Health, Education, Labor and Pensions Committee markup of legislation to reauthorize the Food and Drug Administration’s user fee program, which is set to expire Sept. 30.

This user fee program, which was first authorized in 1992, allows the FDA to collect fees from companies that submit applications for drug approval. It was designed to speed the approval review process. And it requires reauthorization every five years.

Congress considers this bill a must-pass piece of legislation because it’s used to help fund the FDA, as well as revamp existing policies. As a result, it also functions as a vehicle for other proposals to reach the president’s desk — especially those that couldn’t get there on their own.

And that’s why, on Tuesday, Sanders took advantage of the must-pass moment to propose an amendment to the user fee bill that would allow for the importation of drugs from Canada and the United Kingdom, and, after two years, from other countries.

Prescription medications are often much less expensive in other countries, and surveys show that millions of Americans have bought drugs from overseas — even though doing so is technically illegal.

“We have talked about reimportation for a zillion years,” said a visibly heated Sanders. “This bill actually does it. It doesn’t wait for somebody in the bureaucracy to make it happen. It actually makes it happen.” He then went on for several minutes, his tone escalating, citing statistics about high drug prices, recounting anecdotes of people who traveled for drugs, and ending with outrage about pharmaceutical companies’ campaign contributions and the number of lobbyists the industry has.

“I always wanted to go to a Bernie rally, and now I feel like I’ve been there,” Paul joked after Sanders finished talking. He went on to offer his support for the Vermont senator’s amendment — a rare bipartisan alliance between senators who are on opposite ends of the political spectrum.

“This is a policy that sort of unites many on both sides of the aisle, the outrage over the high prices of medications,” added Paul. He said he didn’t support drug price controls in the U.S. but did support a worldwide competitive free market for drugs, which he believes would lower prices.

Even before Sanders offered his amendment, the user fee bill before the committee included a limited drug importation provision, Sec. 906. It would require the FDA to develop regulations for importing certain prescription drugs from Canada. But how this provision differs from a Trump-era regulation is unclear, said Rachel Sachs, a professor of law at Washington University in St. Louis and an expert on drug pricing.

“FDA has already made importation regulations that were finalized at the end of the Trump administration,” said Sachs. “We haven’t seen anyone try to get an approval” under that directive. She added that whether Sec. 906 is doing anything to improve the existing regulation is unclear.

Sanders’ proposed amendment would have gone further, Sachs explained.

It would have included insulin among the products that could be obtained from other countries. It also would have compelled pharmaceutical companies to comply with the regulation. It has been a concern in drug-pricing circles that even if importation were allowed, there would be resistance to it in other countries, because of how the practice could affect their domestic supply.

A robust discussion between Republican and Democratic senators ensued. Among the most notable moments: Sen. Mitt Romney (R-Utah) asked whether importing drugs from countries with price controls would translate into a form of price control in the U.S. Sen. Tim Kaine (D-Va.) said his father breaks the law by getting his glaucoma medication from Canada.

The committee’s chair, Sen. Patty Murray (D-Wash.), held the line against Sanders’ amendment. Although she agreed with some of its policies, she said, she wanted to stick to the importation framework already in the bill, rather than making changes that could jeopardize its passage. “Many of us want to do more,” she said, but the bill in its current form “is a huge step forward, and it has the Republican support we need to pass legislation.”

“To my knowledge, actually, this is the first time ever that a user fee reauthorization bill has included policy expanding importation of prescription drugs,” Murray said. “I believe it will set us up well to make further progress in the future.”

Sen. Richard Burr (R-N.C.), the committee’s ranking member, was adamant in his opposition to Sanders’ amendment, saying that it spelled doom for the legislation’s overall prospects. “Want to kill this bill? Do importation,” said Burr.

Sanders, though, staying true to his reputation, didn’t quiet down or give up the fight. Instead, he argued for an immediate vote. “This is a real debate. There were differences of opinions. It’s called democracy,” he said. “I would urge those who support what Sen. Paul and I are trying to do here to vote for it.”

In the end, though, committee members didn’t, opting to table the amendment, meaning it was set aside and not included in the legislation.

Later in the afternoon, the Senate panel reconvened after senators attended their weekly party policy lunches and passed the user fee bill out of the committee 13-9. The next step is consideration by the full Senate. A similar bill has already cleared the House.

Popular State Worker Health Insurance Plan Projected To Go Up In Price 17% Next Year

Popular state worker health insurance plan projected to go up in price 17% next  year

Source: The Sacramento Bee, by Wes Venteicher

Premiums are projected to grow an average of about 7% for CalPERS health insurance policyholders next year, with two popular PPOs spiking by more than 14%, according to preliminary prices posted online Tuesday by the retirement system.

The California Public Employees’ Retirement System provides health insurance for about 1.5 million people, including roughly 750,000 state and local public employees and retirees and about 770,000 dependents.

The system introduced changes two years ago that boosted PPO premiums while lowering costs for two expensive plans with the richest benefits. The changes are aimed at preserving the top-tier plans and stabilizing prices over the long term.

The plans that will go up in price are the PERS Gold and PERS Platinum PPOs. Together they cover about 278,000 people.

PERS Gold, covering about 124,000, is projected to increase in price by 17.8%, reaching $766 per month for an individual starting Jan. 1, according to preliminary figures.

PERS Platinum, covering about 153,000, is projected to go up 14.5%, to $1,084 per month next year, according to the figures.

The most popular plan by far that CalPERS offers is a Kaiser Permanente HMO that covers about 556,000 people. The Kaiser HMO is slated to go up about 6% next year, reaching about $853 per month.

The preliminary rates posted online are subject to further negotiation, and could change slightly before they are approved by the CalPERS Board of Administration next month. California pays about $650 per month toward individual state workers’ plans, and offers an additional $260 health insurance stipend to members of SEIU Local 1000.

Two years ago, the CalPERS board approved a new rate-setting methodology on the recommendation of its health insurance experts, who said the system needed to make changes to save three of its best plans.

Those plans — Anthem Traditional HMO, Blue Shield Access+ and a plan formerly known as PERS Care — attract people who spend the most on medical treatment. Insurers kept raising their premiums to cover large bills, driving healthy people away and prompting more price hikes.

That pattern, known as a “death spiral,” would have made the plans unsustainable, experts told the board two years ago.

So the board adopted a structure that, in oversimplified terms, essentially shifts money from plans with lower health risk to those with higher risk. As a result, the prices for the Anthem and Blue Shield plans are projected to go down by nearly 7% each next year, in a second year of price drops.

Plans formerly known as PERS Select, PERS Choice and PERS Care were combined into two plans, the Gold and Platinum plans, which under the new methodology are supposed to level off in price starting in 2024.

CalPERS also offers Medicare Advantage policies and Medicare supplemental plans for those who qualify.

Included in the offerings are Medicare supplement plans called PERS Gold and PERS Platinum that cover about 150,000 seniors. The Gold plan premiums are going up 4% and the Platinum premiums are going up about 10%.

Other popular Medicare plans will go up by a couple percentage points or be reduced. A Kaiser Permanente Senior Advantage policy covering about 111,000 seniors will drop in price by about 6.4%.

Open enrollment, during which policyholders may switch plans, will run from Sept. 19 to Oct. 14.

Medicare Could Save Billions Buying Generic Drugs At Mark Cuban’s Prices

Medicare drug prices: The U.S. could save billions on generics buying at Mark  Cuban prices, study findsSource: NBC News, by Berkeley Lovelace Jr.

How can the U.S. government lower the high price of prescription drugs? It may need to look to tech entrepreneur Mark Cuban for answers.

Medicare could have saved nearly $4 billion in 2020 by purchasing generic drugs at the same prices offered by Cost Plus Drug Company, Cuban’s online pharmacy that launched this year, according to a study published Monday in the journal Annals of Internal Medicine.

 

Cost Plus Drug offers certain generic drugs, such as the depression drug fluoxetine or blood pressure medication lisinopril, at discounted prices, by selling medications at a fixed markup of 15% plus a $3 flat fee, according to the company’s website. Cost Plus doesn’t offer brand-name drugs or accept insurance, so patients pay for medications out of pocket.

The study “does show that Medicare is overpaying for some of the generic drugs,” said Dr. Hussain Saleem Lalani, a researcher at Brigham and Women’s Hospital in Boston and the study’s lead author. “And this is a conservative estimate, so the actual savings are likely higher.”

Researchers at Brigham and Women’s Hospital compared the price of 89 generic drugs sold by Cost Plus Drug in 2022 to the price paid by Medicare Part D plans in 2020. Medicare Part D provides coverage for a wide range of prescription drugs, including for self-administered drugs, such as for those to control high blood pressure or diabetes.

After adjusting for changes in drug costs between 2020 and 2022, the researchers found that Medicare paid more on 77 generic drugs: $8.1 billion compared with $4.5 billion if Medicare had purchased the drugs at the same prices as Cost Plus.

Only 12 drugs did not appear to offer any savings.

The researchers did not account for out-of-pocket costs for Medicare enrollees, meaning it was unclear how much lower their cost at the pharmacy counter would have been had Medicare purchased the drugs at a lower price.

The findings illustrate the need for policy reform, the authors wrote.

Medicare “could save a lot more money if it had stricter policies on how it paid for drugs,” Lalani said. “There’s a lot more reforms that could be done to optimize the generic drug pricing system, and we should really consider doing those things to lower costs for patients,” he said.

Price negotiation a ‘black box’

Lalani said the study had limitations: Researchers could only compare prices for drugs that were sold by Cost Plus Drug, which represent 25% of the approximately $38 billion in Medicare Part D generic drug spending in 2020.

Juliette Cubanski, deputy director of the program on Medicare policy at the Kaiser Family Foundation, said the study certainly raised the question of whether Medicare plans are leaving money on the table, and could be getting better deals on drugs. She was not involved in the research.

Right now, price negotiation is “just a completely black box. There’s not a lot of transparency,” she said.

“We’re kind of putting the burden on the patients to chase down lower prescription drug prices as opposed to kind of finding ways to make them widely accessible,” she said.

However, making changes that could tackle the problems of generic drug pricing has not been the primary focus of policymakers, Cubanski said. That’s because the kinds of medications patients usually struggle to pay for are brand-name drugs.

Democrats, in particular, have pushed for laws that allow Medicare to directly negotiate prices of the most expensive drugs, which is currently prohibited.

“Saving $3.6 billion is certainly worth pursuing if there’s an opportunity to get that amount of savings,” she said. But most of the dollars from Medicare “are going to higher-priced, brand name and specialty drugs.”

Lalani, who led the study, said it underscores the need for a closer look at our prescription drug pricing system, which includes wholesalers, pharmacy benefit managers, pharmacies and insurers.

Californians Brace For Increased Healthcare Premiums If Federal Subsidies Expire

Californians brace for increased healthcare premiums if federal subsidies  expire - Los Angeles TimesSource: Los Angeles Times, by Melody Gutierrez and Anabel Sosa

For the last two years, Syd Winlock has had a major burden lifted from his surgically repaired shoulder.

Federal subsidies passed as part of a temporary pandemic relief package have drastically cut how much he pays in healthcare premiums, allowing the Sacramento-area small-business owner to purchase an insurance plan during the last two years that provided better coverage for his shoulder and knee replacements.

Those federal subsidies, however, will expire at the end of this year if Congress does not extend the program. His “very manageable” price — about $700 a month for him and his wife — will increase to $2,300, Winlock said.

“Even if we went to a lesser-type policy, it would still be about $1,800 a month,” Winlock, 63, said. “I mean, that’s more than my mortgage.”

Roughly 150,000 lower- and middle-income Californians would be similarly priced out of coverage by the rising premiums if the federal subsidies are not extended, a Covered California analysis recently estimated.

The federal subsidies were passed in early 2021 as part of the Biden administration’s American Rescue Plan Act, which temporarily provided help to Americans to recover from the economic and health effects of the COVID-19 pandemic.

Under the act, health insurance premiums were capped at 8.5% of a household’s income. That significantly dropped monthly payments and led to more consumers signing up through Covered California, the insurance marketplace created by the 2010 Affordable Care Act for working-age people who aren’t covered by a health plan at their job.

Enrollment in the state’s exchange has hit a record-high 1.8 million, of which Covered California reported that 92% received some form of subsidy.

“These enhanced subsidies have fundamentally delivered affordability and delivered on the promise of the Affordable Care Act in the way that it was intended,” said Jessica Altman, executive director of Covered California.

“There were a lot of people who said things like, ‘Oh, my gosh, you know, for the first time I can afford my health insurance and my child care….’ This is particularly important given the inflationary environment we are in now.”

More than 1 million lower-income earners — individuals making between $17,775 and $32,200 and families of four with income between $36,570 and $66,250 — would see their premiums more than double if Congress doesn’t extend the program, according to the Covered California analysis. Monthly premiums for middle-income earners would increase, on average, by $272 per member next year.

John Baackes, the chief executive of L.A. Care, a health insurance plan serving Los Angeles County’s poorest and most vulnerable residents, said that although the enhanced subsidies don’t expire until the end of the year, the window for Congress to act is growing smaller because of its monthlong August recess. At that point, legislation typically slows down in an election year.

Baackes said health plans will need time to send renewal notices to consumers of anticipated rates for the 2023 coverage year, which are mailed in October.

“So we’re very concerned about it,” Baackes said. “The American Rescue Plan provided increased subsidies that are really a wonderful thing. And many of our members benefited from it.”

With open enrollment beginning one week before the Nov. 8 midterm elections, Democrats on Capitol Hill are increasingly eager to prevent consumers from receiving notices about huge increases in insurance premiums before voters go to the polls. But the debate about whether to extend the subsidies or — as some have pushed — make them permanent has been hamstrung by wrangling over the price tag and the effect on skyrocketing inflation.

Keeping the subsidies an additional three years would cost $74 billion, while the price tag for making them permanent is $220 billion over the first 10 years, according to the Congressional Budget Office.

Gov. Gavin Newsom and state lawmakers proposed spending $304 million in separate state healthcare subsidies to lessen the burden if the federal program is not extended. That money, which is included in a state budget that is expected to be finalized this month, would offset premium increases for more than 700,000 residents.

However, those state-funded subsidies will cover only a fraction of the federal premium discount currently available under the American Rescue Plan, which provided $1.7 billion to California in each of the last two years to help with healthcare costs.

“Nearly half of the folks in Covered California are paying less than $10 a month,” said Anthony Wright, the executive director of Health Access California, a consumer group that is pushing Congress to make the increased federal subsidies permanent. “We live in a high-cost-of-living state, so people will have to make decisions about how much healthcare they can afford.”

That worries Tuan Nguyen, a caregiver in the Silicon Valley city of Milpitas. Having been diagnosed six years ago with a rare and painful disorder called glossopharyngeal neuropathy, Nguyen said he has to buy more costly insurance coverage that allows him to see particular specialists.

“I need the healthcare plan,” said Nguyen, 44. “I need to see my doctor. I need my treatment. These are things that are a necessary part of my life, and they’re all very expensive and getting much harder to afford.”

Reducing the number of uninsured residents in the state has been a top priority for Newsom and legislative leaders, who in 2019 approved legislation creating a fee for anyone who does not have insurance. The individual mandate was intended to induce younger and healthier individuals to buy coverage through Covered California to widen the pool and lower rates overall as Democratic leaders move California closer to universal coverage.

As part of that effort, California has incrementally expanded eligibility for Medi-Cal, the state’s healthcare program for the poor, to certain age groups of low-income people regardless of immigration status. California’s pending budget would offer Medi-Cal to the final remaining age group in 2024, opening the healthcare program to residents 26 to 49 years old regardless of immigration status. Newsom said the move will make California “the first state in the country to achieve universal access to health coverage.”

Miranda Dietz, a research and policy associate at UC Berkeley Labor Center, said the significant increase in the number of Californians with health insurance over the last two years would be in jeopardy without the federal subsidies. Dietz co-wrote a study in partnership with the UCLA Center for Health Policy Research that projects that as many as 1 million people will forgo insurance in California next year if federal subsidies expire.

“It makes it so it’s very disheartening to take away these extra subsidies that have been really crucial in improving affordability for folks,” Dietz said. “It’s a real blow towards that goal of universal coverage and more affordable coverage.”

The added cost of premiums “will be a real struggle for folks who are deciding between rent and groceries,” Dietz said.

For Winlock, the small-business owner, the added cost if federal subsidies are not extended would be temporary. Next year, Winlock and his wife turn 65 and will qualify for Medicare. In the meantime, he would probably look for the cheapest plan possible and hope for the best.

“We probably would look at some alternative ways to get healthcare,” Winlock said. “We certainly wouldn’t be able to afford mainstream healthcare. It is just out of our budget.”

New Drug Prices Soar To $180,000 A Year On 20% Annual Inflation

New drug prices soar to $180,000 a year on 20% annual inflation |  BenefitsPRO

Source: BenefitsPRO, by Robert Langreth

While gasoline and food prices soar, few products rival the inflation in prices on newly launched prescription drugs, according to a new study.

The median launch price of a new drug in the US soared from $2,115 in 2008 to $180,007 in 2021, a 20% annual inflation rate over the period, researchers at Harvard-affiliated Brigham and Women’s Hospital in Boston found. Even after adjusting for factors such as drugmakers’ focus on expensive disease categories like cancer and estimated discounts that manufacturers give some purchasers, the annual inflation rate in launch prices over the period was still almost 11%.

Drug companies regularly introduce new medicines that aim to improve upon the efficacy or tolerability of existing treatments. While public attention has focused on year-to-year price hikes for existing prescription medicines, the study indicates that soaring launch prices also contribute to rising costs.

Over 47% of new drugs introduced in 2020 and 2021 cost more than $150,000 per year, compared to just 9% of new drugs from 2008 to 2013, the researchers found. The study, published in the JAMA medical journal, is based on an analysis of annual list prices of 548 drugs launched between 2008 and 2021 and uses price data from SSR Health research firm. The analysis of discounted prices was based on a smaller subset of 395 drugs.

“The trend in prices for new drugs outpaces growth in prices for other health care services,” the researchers concluded in the study.

Survey: 13% Of Medicare Advantage Claims, Prior Authorization Requests Denied

Survey shows 13% of Medicare Advantage enrollees had a claim or pre-authorization  request denied | Healthcare Finance NewsSource: Fierce Healthcare, by Robert King

A recent survey of Medicare Advantage enrollees found 13% had a claim or pre-authorization request denied as the program has gotten scrutiny over its prior authorization practices.

 

The survey, released Monday by the online insurance marketplace eHealth, also found that 67% of respondents chose MA over Medigap due to concerns over its affordability. The MA market has become an increasingly lucrative one for insurers, as projections expect enrollment to surpass traditional Medicare in the coming years.

“As demonstrated in this report, we found that a striking majority of Medicare Advantage enrollees are satisfied with their plans,” the survey said.

EHealth’s survey of more than 2,800 MA enrollees last month showed that a large majority (77%) did not have their claims or prior authorization requests denied, while 10% did not know and 13% reported they did have rejections.

Of the 13% who were denied coverage, 3% said they could not get a specific drug and 2% were for coverage visits.

“Those who experienced a self-reported denial of coverage include many who were declined for things like dental and vision care, which aren’t typically covered by Medicare,” the survey report said.

In addition, 43% of respondents who did have a claim or prior authorization request denied say their plan told them the claim was excluded from coverage. Another 15% said coverage was denied because the service wasn’t medically necessary.

But 15% of respondents who had a claim or request denied said that the insurer eventually paid it later.

The findings come amid increased scrutiny of MA insurers’ prior authorization practices. A report from the Department of Health and Human Services’ Office of Inspector General that analyzed 250 prior authorization denials and 250 payment denials from MA plans found the denials were sometimes for services that met Medicare coverage requirements.

For instance, 13% of prior authorization denials and 18% of payment declines were for services Medicare should cover.

 

The report comes as some lawmakers have criticized the MA program for driving up Medicare costs due to tactics to game risk adjustment scores and gain higher bonus payments.

EHealth’s report, however, showed that MA remains a very popular program with seniors. It found that 88% of respondents were satisfied with their coverage, and 63% were very satisfied.

One of the key benefits for the program is lower costs compared with Medigap plans as 67% of seniors said they chose MA because Medigap, which pays for supplement benefits not covered by traditional Medicare, was too expensive. Another 25% signed up with MA because Medigap did not offer drug coverage.

After Months Of Warnings, CMS Hands Out Its First Fines To Hospitals Failing On Price Transparency

CMS issues first price transparency fines to 2 Georgia hospitalsSource: Fierce Healthcare, by Dave Muoio

Eighteen months after its final rule on price transparency went into effect, the Centers for Medicare and Medicaid Services issued its first penalties to a pair of Georgia hospitals that did not update their websites or reply to the agency’s warning letters.

 

Northside Hospital Atlanta and Northside Hospital Cherokee have been issued civil monetary penalties of roughly $880,000 and $214,000, respectively, according to letters published on CMS’ Hospital Price Transparency website. Both hospitals are part of the same health system.

The agency calculated the penalties based on the hospitals’ size and how long their websites were non-compliant (up to $300 per day). The hospitals may submit a request for a hearing to have their penalties appealed.

“CMS expects hospitals to comply with the Hospital Price Transparency regulations that require providing clear, accessible pricing information online about the items and services they provide,” Director of Medicare Meena Seshamani, M.D., said in an email statement provided to Fierce Healthcare. “This enforcement action affirms the Biden-Harris Administration’s commitment to making health care pricing information accessible to people across the country and we are committed to ensuring that consumers have the information they need to make fully informed decisions regarding their healthcare.”

Since Jan. 1, 2021, CMS has required hospitals to post a comprehensive machine-readable list of their services and prices as well as a patient-friendly tool to help shop for 300 common services.

Hospitals that are not compliant with the requirements receive warning letters from CMS requesting they submit a corrective action plan to amend their websites.

 

The agency began delivering those letters in April, saying at the time it was hesitant to issue civil monetary penalties due to the harm that publicly naming noncompliant hospitals could bring to those organizations.

In the warning letters, CMS said it had conducted reviews of their websites, requested corrective action plans and delivered warning notices to both hospitals last fall. CMS issued warning to the hospitals in April and May, according to the letters, which neither hospital responded to.

CMS has issued a total 352 warning letters to hospitals as of this month, according to a CMS spokesperson. Among these, 171 received case closure notices after addressing the agency’s citations while 157 remain non-compliant, the spokesperson said.

Industry-wide compliance with the federal transparency requirements has been spotty to date. Only 14.3% of hospitals were compliant with both major components of the mandate one year after it went into effect, according to a review by PatientRightsAdvocate.org.

 

A study published in JAMA earlier this week corroborated low compliance as of the six to nine months after the rule went into effect, noting that hospitals in low-concentration healthcare markets, urban hospitals and those with lower per patient-day revenue were more likely to be in compliance.

Hospitals and health systems say their adherence struggles are the result of the high cost and complexity of implementation. They’ve also pointed to the final rule’s language, which they say is vague and difficult to interpret.

“Many organizations are not investing beyond the bare minimum requirements, and they don’t plan to do more until there is further clarity around the regulations and the expectations going forward,” KLAS Research wrote in an April report polling 66 hospital revenue cycle leaders on price transparency compliance.

American Hospital Association Urges CMS To Extend Enforcement Discretion For No Surprises Act

3.2% payment increase is not enough, American Hospital Association says |  Healthcare Finance NewsSource: Healthcare Finance, by Jeff Lagasse

The American Hospital Association has urged the Centers for Medicare and Medicaid Services to extend enforcement discretion for the No Surprises Act regulatory requirement that healthcare providers exchange certain information to create a good faith estimate for uninsured and self-pay patients – until the agency identifies, and providers can implement, a standard, automated way to exchange the information.

“In the interim final rule implementing this policy, CMS notes that it is exercising enforcement discretion until Jan. 1, 2023, as it may take time for providers and facilities to ‘develop systems and processes for receiving and providing the required information,’” AHA wrote. “We agree that developing and implementing the solution will take time and cannot be achieved efficiently without additional guidance from CMS that identifies a standard technical solution that can be implemented by all providers.”

One of the main concerns from the AHA is that there are currently no methods for unaffiliated providers to share or receive good faith estimates with a convening provider or facility in an automated manner. To share this information, billing systems would need to be able to request and transmit billing rates, discounts and other necessary information for the good faith estimates between providers/facilities.

This is not something that practice management systems can generally do, said the AHA, since billing information is traditionally sent to health insurers and clearinghouses, not other providers.

“Due to the lack of currently available automated solutions, this process would require a significant manual effort by providers, which would undoubtedly result in the convening provider being unable to meet the short statutory timeframes for delivering good faith estimates to the patients and could also lead to inadvertent errors,” the AHA wrote.

AHA requested an extension in enforcement discretion until a technical solution has been found and implemented.

WHAT’S THE IMPACT

Without an automated standard, the AHA said, providers would need to determine individually how to transmit the information. That in turn could lead to variance throughout the industry, especially considering differences in size and technical sophistication among co-providers and facilities. Navigating a non-standardized process, the AHA contended, would increase administrative burden on providers.

To help work toward a standard solution, The AHA said it’s partnering with the American Medical Association, the Medical Group Management Association and HL7 to create a workgroup to discuss potential technical solutions for sharing and receiving critical information among providers. The group will consist of providers and vendors with knowledge of provider systems.

THE LARGER TREND

In December 2021, the American Hospital Association, American Medical Association and other provider organizations sued the Department of Health and Human Services and other federal agencies over implementation of the No Surprise Act. The groups are not against the legislation, they said in the lawsuit filed in federal court but take issue with how HHS implemented a dispute resolution process in the bill.

The No Surprises Act prevented 2 million surprise bills for the commercially insured, according to a survey by AHIP and the Blue Cross Blue Shield Association released in May. The analysis further showed that, if the trend continues, more than 12 million surprise bills would be avoided in 2022.

Can California Keep Offering Cheap Health Care? Here’s What State Network’s New CEO Says

Can California keep offering cheap health care? Here's what state network's  new CEO says | Nation | fltimes.com

Source: The Sacramento Bee, by Cathie Anderson

Jessica Altman took over in March as chief executive officer of Covered California, and even as she was settling into a new home in Sacramento she also was making the rounds with congressional leaders to drive home just how much Californians want access to health insurance.

The greatest barrier to getting it is all too often the cost, Altman said in her first interview with The Sacramento Bee, and nothing underscored that more than the record enrollment Covered California saw last year when new federal assistance in the American Rescue Plan slashed premiums for California enrollees by an average of 20%.

Enrollment in plans offered on California’s state-based marketplace surged to 1.8 million, according to Covered California records, an increase of more than 150,000 people.

Altman said she has to keep sharing the story that the financial help put in place under the American Rescue Plan is having an astounding impact for all Americans who rely on state and federal marketplaces to provide them with a lifeline when they or their family members are unexpectedly struck by illness and to get the preventative care that is so crucial to staying in good health. The federal subsidies were approved for only 2022 policies.

“Health care is core,” she said, “and being healthy is core to our ability to live happy and healthy lives and pursue the things that we want to pursue. It is also, within our society, a great equalizer if it’s used effectively and equitably in supporting people across our nation and in California.”

In other words, Altman said, Covered California’s work is not done when a consumer pays a premium.

“Our role as a marketplace does not end simply when people get covered,” she said. “It goes to what happens next. Is that health insurance providing the access that people need. Do they have the providers that they need? Are the providers providing high quality care that is actually delivering them better health outcomes? So this next phase of responsibility (is) not just access to coverage but access to quality, equitable care.”

A native Californian, Altman was the insurance commissioner for the state of Pennsylvania before she took the top job at Covered California. Altman takes the reins from Peter V. Lee, the founding leader of the marketplace since 2012.

She offered a glimpse into her key priorities during a question-and-answer session with The Bee. We asked what her three key priorities were as she started her tenure.

The top priority is always going to be consumer-centric? How can Covered California, better serve customers that we have today, better reach the customers that we can have tomorrow, and better serve them in navigating our health care system, that can be all too complex.

One example: How can we better assist Californians as they transition between types of coverage — whether that’s from Medi-Cal to private insurers, from COBRA to a Covered California insurer, or between plans within Covered California or other types of transitions.

What are the outreach tools and the infrastructure that we have to identify these people at the time when they need us and to help them through those processes?

GO DEEPER WITH DIVERSITY, EQUITY AND INCLUSION

Equity is built into our mission. It is something Covered California has always done. Are the providers providing high quality care that is actually delivering better health outcomes for all enrollees?

This next phase of responsibility is not just about access to coverage but access to quality, equitable care.

There are many things that we are doing through the equity lens, for example, our outreach to community-based organizations, our efforts to be embedded in different communities across California to provide customer service, our push to be known and understood across languages and across cultures, and our work to make sure that the providers that are in the network of the health plans that we contract with are diverse are culturally competent and are meeting the health care needs of all of our population.

‘OUR JOB DOESN’T STOP WITH COVERAGE’

Our job doesn’t stop with coverage. It goes to quality.

Over the next coming years, we will be monitoring our health plans’ performance for six key measures of quality. We will have our health plans putting financial accountability on the table (paying penalties) if they do not meet the goals of those quality measures.

We are talking about things like: How many children that they cover are getting immunizations? How many adults are getting colorectal screenings that save lives at the appropriate age? How are they doing in monitoring blood sugar levels and hypertension among their population and improving it? These are the things that we know are the drivers of morbidity and mortality.

We will, by the way, be collecting and reviewing those measures not just holistically but also stratified by demographic factors like race and ethnicity to really make sure we are understanding any disparities.

Our equity work and our quality work are both the same and much more than one another. So what I mean by that is, health care quality is equity. Delivering on health care quality will help us deliver equitable outcomes.

WHAT MAKES YOU WANT TO DO THIS WORK?

I come from a family who has worked in health care and is steeped in health care. My father’s father was a primary care physician who I remember well, doing house calls even into his 80s with his black leather doctor’s bag and his stethoscope. My mother’s father was an obstetrician-gynecologist who provided women’s health services in a very different era.

And both my parents have worked in health care and had long careers in health care.

The issues hit close to home for me both because of watching my family members and loved ones give their lives and commitment to improving the health care of others and also (because) I have seen too many people I love experiencing health challenges. I have always been driven to public service, I have never worked anywhere other than in public service.

Preventive Care May Be Free, but Follow-Up Diagnostic Tests Can Bring Big Bills

From access to care coordination, U.S. primary care lags far behind other  wealthy countries: report | Fierce Healthcare

Source: Kaiser Health News, by Michelle Andrews

When Cynthia Johnson learned she would owe $200 out-of-pocket for a diagnostic mammogram in Houston, she almost put off getting the test that told her she had breast cancer.

“I thought, ‘I really don’t have this to spend, and it’s probably nothing,’” said Johnson, who works in educational assessment at a university. But she decided to go forward with the test because she could put the copay on a credit card.

Johnson was 39 in 2018 when that mammogram confirmed that the lump she’d noticed in her left breast was cancer. Today, after a lumpectomy, chemotherapy, and radiation, she is disease-free.

Having to choose between paying rent and getting the testing they need can be a serious dilemma for some patients. Under the Affordable Care Act, many preventive services — such as breast and colorectal cancer screening — are covered at no cost. That means patients don’t have to pay the normal copayments, coinsurance, or deductible costs their plan requires. But if a screening returns an abnormal result and a health care provider orders more testing to figure out what’s wrong, patients may be on the hook for hundreds or even thousands of dollars for diagnostic services.

Many patient advocates and medical experts say no-cost coverage should be extended beyond an initial preventive test to imaging, biopsies, or other services necessary for diagnosing a problem.

“The billing distinction between screening and diagnostic testing is a technical one,” said Dr. A. Mark Fendrick, director of the University of Michigan’s Center for Value-Based Insurance Design. “The federal government should clarify that commercial plans and Medicare should fully cover all the required steps to diagnose cancer or another problem, not just the first screening test.”

A study that examined more than 6 million commercial insurance claims for screening mammograms from 2010 to 2017 found that 16% required additional imaging or other procedures. Half the women who got further imaging and a biopsy paid $152 or more in out-of-pocket costs for follow-up tests in 2017, according to the study by Fendrick and several colleagues and published by JAMA Network Open.

People who needed testing after other preventive cancer screenings also racked up charges: half paid $155 or more for a biopsy after a suspicious result on a cervical cancer test; $100 was the average bill for a colonoscopy after a stool-based colorectal cancer test; and $424, on average, was charged for follow-up tests after a CT scan to check for lung cancer, according to additional research by Fendrick and others.

Van Vorhis of Apple Valley, Minnesota, did an at-home stool test to screen for colorectal cancer two years ago. When the test came back positive, the 65-year-old retired lawyer needed a follow-up colonoscopy to determine whether anything serious was wrong.

The colonoscopy was unremarkable: It found a few benign polyps, or clusters of cells, that the physician snipped out during the procedure. But Vorhis was floored by the $7,000 he owed under his individual health plan. His first colonoscopy several years earlier hadn’t cost him a cent.

He contacted his doctor to complain that he hadn’t been warned about the potential financial consequences of choosing a stool-based test to screen for cancer. If Vorhis had chosen to have a screening colonoscopy in the first place, he wouldn’t have owed anything because the test would have been considered preventive. But after a positive stool test, “to them it was clearly diagnostic, and there’s no freebie for a diagnostic test,” Vorhis said.

He filed an appeal with his insurer but lost.

In a breakthrough for patients and their advocates, people who are commercially insured and, like Vorhis, need a colonoscopy after a positive stool test or a so-called direct visualization test like a CT colonography will no longer face out-of-pocket costs. According to federal rules for health plan years starting after May 31, the follow-up test is considered an integral part of the preventive screening, and patients can’t be charged anything for it by their health plan.

The new rule may encourage more people to get colorectal cancer screenings, cancer experts said, since people can do a stool-based test at home.

Nine states already required similar coverage in the plans they regulate. Arkansas, California, Illinois, Indiana, Kentucky, Maine, Oregon, Rhode Island, and Texas don’t allow patients to be charged for follow-up colonoscopies after a positive stool-based test, according to Fight Colorectal Cancer, an advocacy group. New York recently passed a bill that is expected to be signed into law soon, said Molly McDonnell, the organization’s director of advocacy.

In recent years, advocates have also pushed to eliminate cost sharing for breast cancer diagnostic services. A federal bill that would require health plans to cover diagnostic imaging for breast cancer without patient cost sharing — just as they do for preventive screening for the disease — has bipartisan support but hasn’t made headway.

In the meantime, a handful of states — Arkansas, Colorado, Illinois, Louisiana, New York, and Texas — have moved ahead on this issue, according to tracking by Susan G. Komen, an advocacy organization for breast cancer patients that works to get these laws passed.

This year, an additional 10 states introduced legislation similar to the federal bill, according to Komen. In two of them — Georgia and Oklahoma — the measures passed.

These state laws apply only to state-regulated health plans, however. Most people are covered by employer-sponsored, self-funded plans that are regulated by the federal government.

“The primary pushback we get comes from insurers,” said Molly Guthrie, vice president of policy and advocacy at Komen. “Their argument is cost.” But, she said, there are significant cost savings if breast cancer is identified and treated in its early stages.

study that analyzed claims data after a breast cancer diagnosis in 2010 found that the average overall costs for people diagnosed at stage 1 or 2 were just more than $82,000 in the year after diagnosis. When breast cancer was diagnosed at stage 3, the average costs jumped to nearly $130,000. For people with a stage 4 diagnosis, costs in the year afterward exceeded $134,000. Disease stages are determined based on tumor size and spread, among other factors.

When asked to provide health plans’ perspective on eliminating cost sharing for follow-up testing after an abnormal result, a spokesperson for a health insurance trade group declined to elaborate.

“Health plans design their benefits to optimize affordability and access to quality care,” David Allen, a spokesperson for AHIP, said in a statement. “When patients are diagnosed with medical conditions, their treatment is covered based on the plan they choose.”

In addition to cancer screenings, dozens of preventive services are recommended by the U.S. Preventive Services Task Force and must be covered without charging patients under the Affordable Care Act if they meet age or other screening criteria.

But if health plans are required to cover diagnostic cancer testing without charging patients, will eliminating cost sharing for follow-up testing after other types of preventive screenings — for abdominal aortic aneurysms, for example — be far behind?

Bring it on, said Fendrick. The health system could absorb those costs, he said, if some low-value preventive care that isn’t recommended, such as cervical cancer screening in most women older than 65, were discontinued.

“That is a slippery slope that I really want to ski down,” he said.

Last Updated 06/29/2022

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