Medicare |

Economists Warn Of Costs If Medicare Covers New Obesity Drugs

March 16, 2023 By Jay Baldauf

The cost of expanding U.S. Medicare prescription drug coverage to pay for expensive, new obesity medications could be catastrophic, health economists warned in a report published on Saturday.

Big-selling diabetes drugs have been repurposed as obesity treatments after demonstrating weight loss of more than 20% in clinical trials. While they are far more effective than older drugs, lifetime use might be required to keep lost weight off.

Once-weekly injections of Novo Nordisk’s (NOVOb.CO) Wegovy, for example, cost more than $13,000 per year in the U.S. after rebates and discounts. Mounjaro from Eli Lilly and Co (LLY.N), expected to gain U.S. approval for obesity next year, retails at $1,540 for a one-month supply for diabetes.

Presently, Medicare is forbidden by law from paying for antiobesity prescriptions. But should the bipartisan The Treat and Reduce Obesity Act get reintroduced and passed by Congress, Medicare will be compelled to cover drugs for weight loss.

Health economists writing in The New England Journal of Medicine estimate that if 10% of Medicare recipients with obesity diagnoses used prescription weight loss drugs, annual part D spending would be $26.8 billion for Wegovy compared with $1.32 billion for a generic version older Qysmia from Vivus Inc.

That amounts to nearly 20% of the total 2019 Medicare Part D spending, Khrysta Baig of Vanderbilt University School of Medicine and colleagues said.

“The burden of obesity and obesity-related conditions is unquestionably high, but the value of Medicare coverage of antiobesity medications remains unclear,” they said, adding that more research is needed to know whether weight loss induced by these drugs translates to better long-term health outcomes.

The Medicare health program covers more than 60 million Americans, most over age 65. The authors point out that many people in the program have already incurred the health problems associated with long-term obesity, unlike younger populations typically included in clinical trials.

Obesity prevalence in the United States is 41.5% among adults aged 60 and older, according to the Centers for Disease Control and Prevention.

The influential Institute for Clinical and Economic Review (ICER) has said the annual price of Wegovy would need to decrease to $7,500 to $9,700 for it to be cost effective compared with lifestyle modification alone. Even at that price range, it still would not be cost-effective compared with generic Qysmia, ICER said.

“Given the outstanding questions about the benefits of these drugs for Medicare beneficiaries, it would be prudent for Congress and CMS (the Centers for Medicare & Medicaid Services) to fully consider tradeoffs before passing legislation of this magnitude,” Baig said.

Filed Under: ACA, Doctors, Drugs, Employer Benefits, General Health, Medi-Cal, Medicare, Reform Tagged With: act, bipartisan, Cost, covers, Drugs, economists, injections, Medicare, Mounjaro, New, Nordisks, obesity, Part D, Spending, Warn

White House Budget Leans Into Drug Pricing, Obamacare Expansion

March 16, 2023 By Jay Baldauf

President Biden’s budget proposal focuses heavily on expanding access to health care and lowering the cost of prescription drugs.

In an effort to extend the life of Medicare’s hospital trust fund, the budget proposal would increase the number of drugs that can be negotiated, and allow those negotiations to begin sooner.

The plan builds off the Inflation Reduction Act (IRA), which granted Medicare the power to negotiate the prices of up to 20 drugs each year — though the drugs can only qualify after being on the market for at least nine years.

The IRA passed with only Democratic votes last year, and some in the GOP have already claimed they will try to repeal it.

Another IRA provision that would get a boost in the budget is the requirement that drug companies pay rebates to Medicare when they increase prices faster than inflation. Under the White House proposal, that requirement would extend to the commercial market as well.

The budget also seeks to extend the $35 insulin cap to the private sector. Under the IRA, Medicare beneficiaries won’t pay more than $35 out of pocket for insulin.

A proposal to cap the cost for all Americans was defeated by Senate Republicans.

The White House budget also includes proposals to expand ObamaCare programs.

It calls for permanently expanding enhanced subsidies for health plans on the exchanges, which currently expire at the end of 2025. The enhanced subsidies make insurance premiums free for most Americans with incomes just above the poverty line, and they lower the cost of premiums for Americans with higher incomes.

The budget also proposes “Medicaid-like” coverage for eligible people in states that haven’t expanded Medicaid coverage yet, paired with financial incentives to ensure states maintain their existing expansions.

Republicans began blasting elements of the budget before it was formally released, and are not likely to support the proposals.

The White House called the budget a “blueprint” to build on progress from the first two years of the administration. It claims that Republicans “have taken a very different approach” and want to add to the nation’s debt.

Filed Under: ACA, Doctors, Drugs, Employer Benefits, General Health, Medi-Cal, Medicare, Reform Tagged With: Budget, democrat, Drug pricing, GOP, Inflation reduction act, leans, Medicare, obamacare expansion, White House

Senators Urge CMS To Close ‘Loopholes’ In Payer Price Transparency Rule

March 16, 2023 By Jay Baldauf

Two top senators are urging the Biden administration to address “loopholes” that they said allow insurers to skirt price transparency requirements.

Sens. Maggie Hassan, D-New Hampshire, and Mike Braun, R-Indiana, wrote in a letter (PDF) to Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure that the agency should update its regulations to “ensure that there is true health plan transparency and compliance.”

The senators said some insurers have posted the required data in “an indecipherable structure” or made the files so large that they can only be processed by a supercomputer. This technically meets the requirement of posting the data but makes the information extremely difficult to use.

“As a result, employers and researchers have been unable to use the data to assess the drivers of high health care costs and target solutions,” they wrote.

The letter noted that public policy experts have suggested multiple avenues CMS could take to mitigate these loopholes, including setting file size limits, creating a standardized template for reporting, requiring a clear organization system with labels and reducing reporting frequency.

The senators said these changes would make the data more readily usable but would also streamline reporting requirements for insurers.

In addition, the agency should pair these reforms with stepped-up enforcement of requirements, holding plans that post low-quality data—or no data at all—more accountable.

“Randomly auditing the quality of plan data would result in better usability, and additional enforcement would help ensure that remaining noncompliant plans follow the law,” the senators wrote. “We urge CMS to consider these and other expert recommendations so we may continue improving price transparency for Americans and ultimately bring down health care costs.”

Filed Under: ACA, Doctors, Drugs, Employer Benefits, General Health, Medi-Cal, Medicare, Reform Tagged With: Biden administration, braun, close, CMS, hassan, loopholes, payer, Price, rules, senators, Transparency, urge

CMS Proposes Prior Authorization Rule Changes For Health Plans

March 16, 2023 By Jay Baldauf

When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.

As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.

But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.

“On at least four or five occasions, she called me up, hysterical,” Roux said.

Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.

Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.

Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.

Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.

So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.

“The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”

In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed Centers for Medicare & Medicaid Services rule was scheduled to be open for public comment through March 13.

Although groups like AHIP, an industry trade group formerly called America’s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don’t go far enough.

“Seven days is still way too long,” said Dr. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “We need to move very quickly. We have to make decisions.”

Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days. In Michigan, insurers must report annual prior authorization data, including the number of requests denied and appeals received. Other states have adopted or are considering similar legislation, while in many places insurers regularly take four to six weeks for non-urgent appeals.

Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to delays in cancer care in Pennsylvania, meant sick children in Colorado were more likely to be hospitalized, and blocked low-income patients across the country from getting treatment for opioid addiction.

In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.

Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.

Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.

Conlisk thought her mom’s case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn’t show on the day Conlisk was told it would. No one notified them the ride hadn’t been pre-authorized.

The time it takes to juggle a prior authorization request can also perpetuate racial disparities and disproportionately affect those with lower-paying, hourly jobs, said Dr. Kathleen McManus, a physician-scientist at the University of Virginia.

“When people ask for an example of structural racism in medicine, this is one that I give them,” McManus said. “It’s baked into the system.”

Research that McManus and her colleagues published in 2020 found that federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown. But she said that because more than half the nation’s Black population lives in the South, they’d be the patients more likely to face this barrier.

Many of the denied claims are reversed if a patient appeals, according to the federal government. New data specific to Medicare Advantage plans found 82% of appeals resulted in fully or partially overturning the initial prior authorization denial, according to KFF.

It’s not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.

“I lose hours of time that I really don’t have to argue … with someone who doesn’t even really know what I’m talking about,” said Kanter, the hematologist in Birmingham. “The people who are making these decisions are rarely in your field of medicine.”

Occasionally, she said, it’s more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and the patient more.

“It’s a terrible system,” she said.

A KFF analysis of 2021 claims data found that 9% of all in-network denials by Affordable Care Act plans on the federal exchange, healthcare.gov, were attributed to lack of prior authorization or referrals, but some companies are more likely to deny a claim for these reasons than others. In Texas, for example, the analysis found 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.

Facing scrutiny, some insurers are revising their prior authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years by eliminating the need for patients to obtain permission for some diagnostic procedures, like MRIs and CT scans, said company spokesperson Heather Soules. Health insurers have also adopted artificial intelligence technology to speed up prior authorization decisions.

Meanwhile, most patients have no means of avoiding the burdensome process that has become a defining feature of American health care. But even those who have the time and energy to fight back may not get the outcome they hoped for.

When the ambulance never showed in July, Conlisk and her mother’s caregiver decided to drive the patient to the clinic in the caregiver’s car.

“She almost fell outside the office,” said Conlisk, who needed the assistance of five bystanders to move her mother safely into the clinic.

When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day, for two weeks leading up to the clinic visit, working to get prior authorization. Her efforts were unsuccessful. Once again, her mother’s caregiver drove her to the clinic himself.

Filed Under: ACA, Doctors, Drugs, Employer Benefits, General Health, Medi-Cal, Medicare, Reform Tagged With: ACA, AMA, CMS, health plans, KHN, New, pre certification, prior authorization, proposes, rule change

Virtual or In Person: Which Kind of Doctor’s Visit Is Better, And When It Matters

March 8, 2023 By Jay Baldauf

When the covid-19 pandemic swept the country in early 2020 and emptied doctors’ offices nationwide, telemedicine was suddenly thrust into the spotlight. Patients and their physicians turned to virtual visits by video or phone rather than risk meeting face-to-face.

During the early months of the pandemic, telehealth visits for care exploded.

“It was a dramatic shift in one or two weeks that we would expect to happen in a decade,” said Dr. Ateev Mehrotra, a professor at Harvard Medical School whose research focuses on telemedicine and other health care delivery innovations. “It’s great that we served patients, but we did not accumulate the norms and [research] papers that we would normally accumulate so that we can know what works and what doesn’t work.”

Now, three years after the start of the pandemic, we’re still figuring that out. Although telehealth use has moderated, it has found a role in many physician practices, and it is popular with patients.

More than any other field, behavioral health has embraced telehealth. Mental health conditions accounted for just under two-thirds of telehealth claims in November 2022, according to FairHealth, a nonprofit that manages a large database of private and Medicare insurance claims.

Telehealth appeals to a variety of patients because it allows them to simply log on to their computer and avoid the time and expense of driving, parking, and arranging child care that an in-person visit often requires.

But how do you gauge when to opt for a telehealth visit versus seeing your doctor in person? There are no hard-and-fast rules, but here’s some guidance about when it may make more sense to choose one or the other.

If It’s Your First Visit

“As a patient, you’re trying to evaluate the physician, to see if you can talk to them and trust them,” said Dr. Russell Kohl, a family physician and board member of the American Academy of Family Physicians. “It’s hard to do that on a telemedicine visit.”

Maybe your insurance has changed and you need a new primary care doctor or OB-GYN. Or perhaps you have a chronic condition and your doctor has suggested adding a specialist to the team. A face-to-face visit can help you feel comfortable and confident with their participation.

Sometimes an in-person first visit can help doctors evaluate their patients in nontangible ways, too. After a cancer diagnosis, for example, an oncologist might want to examine the site of a biopsy. But just as important, he might want to assess a patient’s emotional state.

“A diagnosis of cancer is an emotional event; it’s a life-changing moment, and a doctor wants to respond to that,” said Dr. Arif Kamal, an oncologist and the chief patient officer at the American Cancer Society. “There are things you can miss unless you’re sitting a foot or two away from the person.”

Once it’s clearer how the patient is coping and responding to treatment, that’s a good time to discuss incorporating telemedicine visits.

If a Physical Exam Seems Necessary

This may seem like a no-brainer, but there are nuances. Increasingly, monitoring equipment that people can keep at home — a blood pressure cuff, a digital glucometer or stethoscope, a pulse oximeter to measure blood oxygen, or a Doppler monitor that checks a fetus’s heartbeat — may give doctors the information they need, reducing the number of in-person visits required.

Someone’s overall physical health may help tip the scales on whether an in-person exam is needed. A 25-year-old in generally good health is usually a better candidate for telehealth than a 75-year-old with multiple chronic conditions.

But some health complaints typically require an in-person examination, doctors said, such as abdominal pain, severe musculoskeletal pain, or problems related to the eyes and ears.

Abdominal pain could signal trouble with the gallbladder, liver, or appendix, among many other things.

“We wouldn’t know how to evaluate it without an exam,” said Dr. Ryan Mire, an internist who is president of the American College of Physicians.

Unless a doctor does a physical exam, too often children with ear infections receive prescriptions for antibiotics, said Mehrotra, pointing to a study he co-authored comparing prescribing differences between telemedicine visits, urgent care, and primary care visits.

In obstetrics, the pandemic accelerated a gradual shift to fewer in-person prenatal visits. Typically, pregnancy involves 14 in-person visits. Some models now recommend eight or fewer, said Dr. Nathaniel DeNicola, chair of telehealth for the American College of Obstetricians and Gynecologists. A study found no significant differences in rates of cesarean deliveries, preterm birth, birth weight, or admissions to the neonatal intensive care unit between women who received up to a dozen prenatal visits in person and those who received a mix of in-person and virtual visits.

Contraception is another area where less may be more, DeNicola said. Patients can discuss the pros and cons of different options virtually and may need to schedule a visit only if they want an IUD inserted.

If Something Is New, or Changes

When a new symptom crops up, patients should generally schedule an in-person visit. Even if the patient has a chronic condition like diabetes or heart disease that is under control and care is managed by a familiar physician, sometimes things change. That usually calls for a face-to-face meeting too.

“I tell my patients, ‘If it’s new symptoms or a worsening of existing symptoms, that probably warrants an in-person visit,’” said Dr. David Cho, a cardiologist who chairs the American College of Cardiology’s Health Care Innovation Council. Changes could include chest pain, losing consciousness, shortness of breath, or swollen legs.

When patients are sitting in front of him in the exam room, Cho can listen to their hearts and lungs and do an EKG if someone has chest pain or palpitations. He’ll check their blood pressure, examine their feet to see if they’re retaining fluid, and look at their neck veins to see if they are bulging.

But all that may not be necessary for a patient with heart failure, for example, whose condition is stable, he said. They can check their own weight and blood pressure at home, and a periodic video visit to check in may suffice.

Video check-ins are effective for many people whose chronic conditions are under control, experts said.

When someone is undergoing treatment for cancer, certain pivotal moments will require a face-to-face meeting, said Kamal, of the American Cancer Society.

“The cancer has changed or the treatment has changed,” he said. “If they’re going to stop chemotherapy, they need to be there in person.”

And one clear recommendation holds for almost all situations: Even if a physician or office scheduler suggests a virtual visit, you don’t have to agree to it.

“As a consumer, you should do what you feel comfortable doing,” said Dr. Joe Kvedar, a professor at Harvard Medical School and immediate past board chairman of the American Telemedicine Association. “And if you really want to be seen in the office, you should make that case.”

Filed Under: ACA, Doctors, Drugs, Employer Benefits, General Health, Medi-Cal, Medicare, Reform Tagged With: chronic condition, doctor visit, first visit, in person, physical exam, specialist, virtual, when it matters, which is better

Can’t Take Statins? New Pill Cuts Cholesterol, Heart Attacks

March 8, 2023 By Jay Baldauf

Drugs known as statins are the first-choice treatment for high cholesterol but millions of people who can’t or won’t take those pills because of side effects may have another option.

In a major study, a different kind of cholesterol-lowering drug named Nexletol reduced the risk of heart attacks and some other cardiovascular problems in people who can’t tolerate statins, researchers reported Saturday.

Doctors already prescribe the drug, known chemically as bempedoic acid, to be used together with a statin to help certain high-risk patients further lower their cholesterol. The new study tested Nexletol without the statin combination — and offers the first evidence that it also reduces the risk of cholesterol-caused health problems.

Statins remain “the cornerstone of cholesterol-lowering therapies,” stressed Dr. Steven Nissen of the Cleveland Clinic, who led the study.

But people who can’t take those proven pills “are very needy patients, they’re extremely difficult to treat,” he said. This option “will have a huge impact on public health.”

Too much so-called LDL or “bad” cholesterol can clog arteries and lead to heart attacks and strokes. Statin pills like Lipitor and Crestor – or their cheap generic equivalents – are the mainstay for lowering LDL cholesterol and preventing heart disease or treating those who already have it. They work by blocking some of the liver’s cholesterol production.

But some people suffer serious muscle pain from statins. While it’s not clear exactly how often that occurs, by some estimates 10% of people who’d otherwise qualify for the pills can’t or won’t take them. They have limited options, including pricey cholesterol-lowering shots and another kind of pill sold as Zetia.

Nexletol also blocks cholesterol production in the liver but in a different way than statins and without that muscle side effect.

The new five-year study tracked nearly 14,000 people who were unable to tolerate more than a very low dose of a statin. Half got daily Nexletol and half a dummy pill.

The main finding: Nexletol-treated patients had a 13% lower risk of a group of major cardiac problems. Then researchers teased apart those different conditions and found a 23% reduced risk of a heart attack, the biggest impact. The drug also cut by 19% procedures to unclog arteries. There wasn’t a difference in deaths, which researchers couldn’t explain but said might require longer to detect.

The data was published in the New England Journal of Medicine and presented Saturday at a meeting of the American College of Cardiology. The study was funded by Nexletol maker Esperion Therapeutics.

The results are “compelling,” Dr. John H. Alexander of Duke University, who wasn’t involved with the study, wrote in the journal. They “will and should” spur use of the drug by patients unwilling or unable to take statins.

“It is premature, however, to consider bempedoic acid as an alternative to statins,” he cautioned. “Given the overwhelming evidence of the vascular benefits,” statins remain the top choice for most patients.

Filed Under: ACA, Chronic Conditions, Critical Illness, Doctors, Drugs, Employer Benefits, General Health, Medi-Cal, Medicare, Reform Tagged With: bempedoic acid, cholesterol, cleveland clinic, heart attacks, New, nexletol, pills, Statins

CMS: US Health Care Spending Reached $4.3 Trillion In 2021 During COVID

March 8, 2023 By Jay Baldauf

During the peak COVID timeframe in 2021, the U.S. spent nearly $4.3 trillion on health care. Government insurance programs, such as Medicare and Medicaid, made up 42% (or a whopping $1.8 trillion of national health care spending) in 2021. That’s according to the Centers for Medicare and Medicaid Services (CMS), which says private insurance programs, including employer-sponsored plans and plans purchased through the Affordable Care Act, made up 28% of spending, or about $1.2 trillion.

Also, out-of-pocket spending, such as premiums paid by individuals and other out-of-pocket costs, spending by third-party payers, investment in research and equipment, and public health activity accounted for the remaining 29%, or $1.2 trillion, of national health spending.

Breaking it down even further, in 2021, about 64 million Americans received health insurance through Medicare. The largest component of Medicare spending is on hospital care services, which accounted for nearly 40%, or $351 billion, of spending in 2021. Hospital care has been declining, however, as a share of Medicare spending since a prescription drug benefit became part of the program in 2006. Over the last two decades, spending on prescription drugs grew from less than $2 billion in 2000 to $120 billion in 2021.

About 77 million Americans, including children below the poverty level, nursing home residents, and non-elderly adults with disabilities used Medicaid in 2020. Medicaid spending for hospital care has been the largest portion of total payments for the program, making up roughly 35% of total spending on average, and is projected to stay relatively stable. Overall, spending for dental and other health, residential, and personal care expenditures are driving the growth in Medicaid payments. In the past 20 years, such spending has more than tripled from about $41 billion to $154 billion.

In 2020, private insurance programs covered 217 million people. Spending on hospital care services is the largest source of payment by private insurance programs. Such spending has tripled in the past two decades, from $150 billion to $449 billion. Another driver of overall growth in spending by private insurance is prescription drugs. Such spending has grown from $70 billion in 2000 to $152 billion in 2021.

CMS predicts federal spending for Medicare and Medicaid will increase faster than private spending. For example, according to their projections from March 2022, Medicare spending will climb from about $1.0 trillion in 2022 to $1.7 trillion in 2030, an increase of 68%. Medicaid spending would grow from $0.8 trillion to $1.2 trillion, an increase of 48%. Meanwhile, spending by private insurance programs would increase from $1.3 trillion to about $2.0 trillion, an increase of 50%.

According to the Peterson Center on Healthcare, some solutions to the continuing rise in health care spending could lie in tracking health care spending at the state level and addressing shortages and the high prices for medications, to name a few.

Filed Under: ACA, Covid19, Doctors, Drugs, Employer Benefits, General Health, Medi-Cal, Medicare, Reform Tagged With: $4.3trillion, 2021, CMS, Covid19, Healthcare, hospital, Medicaid, Medicare, Private insurance, reached, Spending, US

After A Pandemic Pause, The State Will Restart Checking Medi-Cal Eligibility

March 8, 2023 By Jay Baldauf

California will soon restart its annual eligibility review for people enrolled in Medi-Cal, a process that has been suspended since the onset of the COVID-19 pandemic.

This means that starting in mid-April, residents enrolled in Medi-Cal, the state’s insurance program for low-income people, will start to receive renewal notices in the mail. The process will be spread over 14 months. Some people may be automatically re-enrolled, but most people will have to fill out a renewal packet with information about their income and household size. People who no longer qualify or who fail to fill out the paperwork will lose their free or low-cost coverage.

State officials estimate that between 2 million and 3 million people could lose their Medi-Cal coverage. Ideally, people who no longer qualify for Medi-Cal will transition to a plan in the state’s insurance marketplace, Covered California, or to a job-sponsored health plan. Still, health advocates worry that many people could fall through the cracks or get caught in administrative hurdles and become uninsured, leaving them more likely to delay or forgo care altogether.

Currently, 15.4 million people — more than a third of the state’s population — are enrolled in Medi-Cal, the most ever, according to the California Department of Health Care Services. That’s partly a result of the increased need during the pandemic: As people lost jobs and wages, many also lost their medical insurance. From March 2020 to February 2023, Medi-Cal enrollment increased 16%, according to the department.

And as thousands of people became newly eligible for Medi-Cal, far fewer were coming off. Federal rules prohibited states from dropping people from government-sponsored insurance during the pandemic as a way to protect access to care. Now those federal rules are lapsing.

California’s renewal process will restart on April 1 and should be completed around June 2024, meaning people can receive their renewal notices and paperwork anytime during this time period. Those who in the past have renewed in the month of June will get their paperwork first, said Yingjia Huang, assistant deputy director for health care benefits and eligibility at the Department of Health Care Services. This phased-in approach will help spread the caseload for county offices in charge of the review, Huang said, and also allow enrollees who have renewed in the past to keep a similar timeline.

To qualify for Medi-Cal, people can earn up to 138% of the federal poverty level — that’s $20,121 a year for an individual or $41,400 for a family of four. Some Californians, such as pregnant women and people with disabilities, may qualify with slightly higher incomes.

People who were eligible for Medi-Cal at some point during the pandemic, but who may no longer qualify because their income has increased, will be automatically transitioned into a similar plan through Covered California, Huang said.

“The system automatically will review their eligibility for Covered California and Covered California will send out the enrollment notice to the member, informing them of their options and to pay the plan premium. So there’s no administrative burden on a member,” Huang said. “We’re trying to make sure that process is seamless and streamlined.”

Whether people successfully make the switch will largely depend on their ability to pay their new monthly premium.

Most people who buy from the marketplace receive generous subsidies, and some people don’t have a premium cost at all. Nearly half of the people enrolled in coverage through Covered California pay less than $50 a month, according to the agency. Still, even a $5 premium, along with the accompanying deductibles and copays, can discourage people from buying a health plan, said John Baackes, CEO of L.A Care, which offers Medi-Cal and Covered California plans to Los Angeles residents.

This auto-transition into Covered California will be a new test for the state. In the past, when people disenrolled from Medi-Cal, they were likely to go without coverage at least temporarily. Between 2016 and 2019, roughly 65% of people who dropped off Medi-Cal (Medicaid in other states) had a period of uninsurance, according to national research from the Kaiser Family Foundation.

To help avoid unnecessary loss in coverage, state officials are asking enrollees to verify their contact information. The Department of Health Care Services estimates that about 12% of enrollees may have moved during the pandemic and are at risk of not receiving their renewal packets. People who have moved during the pandemic should update their address via the state’s KeepMediCalCoverage.org website or by contacting their local county office.

Health advocates are concerned that people won’t be able to access timely help, given the influx of calls and visits county offices may receive. The increased volumes compounded by workforce shortages can prove to be a barrier, said Tiffany Huyenh-Cho, a senior staff attorney with Justice in Aging, a legal aid organization that advocates on behalf of seniors.

“We need these county offices to be appropriately staffed because that is the first place people go with a question about eligibility,” Huyenh-Cho said. “We already hear reports of long wait times in general.”

Awareness that the renewal process is restarting is also key, advocates say. State and county officials have known that the Medi-Cal renewal process would restart at some point, even though the timeline was pushed back multiple times. The general public may be less aware. One national survey found that as of December, 64% of enrollees had not heard of the return to regular eligibility checks, though education efforts have been ramping up as the April 1 date gets closer.

“I wonder how many of these 15 million people even know they still have Medi-Cal coverage?” said Shannon McConville, a research fellow at the Public Policy Institute of California, noting that many people, especially if healthy, distanced themselves from routine care during the pandemic.

Baackes at L.A. Care said the onus of spreading the word about the renewal period also falls on the health insurance plans. L.A. Care, he said, has been beefing up its staff to prepare for the anticipated volume of calls and requests. It will also have 14 locations where people can go and get help filling out the hefty packet.

“The packet is 20 pages. It should be one page: ‘Where do you live? How much do you make? Thank you,’ but it’s 20 pages. So one of the things we’ll be doing is we’ll have these community resource centers spread across the county,” Baackes said.

Among his concerns is that the Medi-Cal renewal process will be taking place at a time when California is preparing for some key expansions and changes. Starting in 2024, more people will qualify for full-scope Medi-Cal benefits as the state opens enrollment to income-eligible undocumented people ages 26 to 49, the last remaining age group. About 700,000 people are expected to gain benefits through that expansion.

At the same time, the state will also commence new Medi-Cal contracts with insurers, which could result in health plan changes for some enrollees. That’s a separate process, Huang at the state department said, and will not require any action from enrollees.

But these different moving parts happening at the same time will create more traffic in county social services offices, Baackes said.

“It’s just unfathomable to me,” he said, “that the state thinks that this is all going to happen without huge confusion on the part of the people we’re trying to serve.”

Filed Under: ACA, Doctors, Drugs, Employer Benefits, General Health, Medi-Cal, Medicare, Reform Tagged With: after, California, checking, Covid 19, DHCS, eligibilty, Medi-cal, pandemic pause, start up, state