CMS, Medicare Advantage

Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage

By Susan Jaffe, KFF Health News | March 29, 2024

Bart Klion (Hans Pennink for KFF Health News)

Bart Klion, 95, and his wife, Barbara, faced a tough choice in January: The upstate New York couple learned couple that this year they could keep either their private, Medicare Advantage insurance plan — or their doctors at Saratoga Hospital.

The Albany Medical Center system, which includes their hospital, is leaving the Klions’ Humana plan — or, depending on which side is talking, the other way around. The breakup threatened to cut the couple’s lifeline to cope with serious chronic health conditions.

Klion refused to pick the lesser of two bad options without a fight.

..With rare exceptions, Advantage members are locked into their plans for the rest of the year — while health providers may leave at any time. …But a few years ago, CMS created an escape hatch by expanding special enrollment periods, or SEPs, which allow for “exceptional circumstances.” Beneficiaries who qualify can request SEPs to change plans or return to original Medicare. [Continued on KFF Health News]

Affordable Care Act, Drugs, The Lancet

Biden prioritises health care in State of the Union speech

Volume 403, Issue 10431
16 March 2024 

WORLD REPORT  Plans to protect reproductive rights, further reduce drug prices, and improve women’s health research have been welcomed by some experts. Susan Jaffe reports from Washington, DC.  

The State of the Union address is typically a report to Congress on the nation’s progress and goals entwined with occasional lofty rhetoric, but this one was different…. “This speech signals that health care will be a big part of President Biden’s campaign this year”, said Larry Levitt, Executive Vice President for Health Policy at KFF, formerly the Kaiser Family Foundation. [Continued here]

NIH, The Lancet

Volume 403, Issue 10427  ♦  17 February 2024

 

PROFILE  Dr. Monica Bertagnolli, Director of the National Institutes of Health  

“I imagine a health-care system where clinical decisions are informed in real time by current research data,” the new National Institutes of Health director tells The Lancet. “And one where patients have the opportunity to both contribute their data for research and get back research results so that they can experience the best that science has to offer.” [Susan Jaffe reports here.]

Drugs, FDA, The Lancet

Imported drugs unlikely to lower US prices any time soon

Volume 403, Issue 10423
20 January 2024 

WORLD REPORT  Americans pay some of the highest prices in the world for prescription drugs, but the decision by the US Food and Drug Administration to allow Florida to import cheaper medications from Canada won’t cut prices any time soon. Although the ruling represents a shift in the decades-long fight for drug importation, opposition from the US pharmaceutical industry, Canadian health officials, and others is expected to block implementation at every stage. [Susan Jaffe reports, here]

CMS, Medicare Advantage, Medicare costs

Dodging the Medicare Enrollment Deadline Can Be Costly

By Susan Jaffe, KHN  | December 7, 2023 | This story also ran on  

Angela M. Du Bois, a retired software tester in Durham, North Carolina, wasn’t looking to replace her UnitedHealthcare Medicare Advantage plan. She wasn’t concerned as the Dec. 7 deadline approached for choosing another of the privately run health insurance alternatives to original Medicare.

But then something caught her attention: When she went to her doctor last month, she learned that the doctor and the hospital where she works will not accept her insurance next year.

Faced with either finding a new doctor or finding a new plan, Du Bois said the decision was easy. “I’m sticking with her because she knows everything about me,” she said of her doctor, whom she’s been seeing for more than a decade.

Du Bois isn’t the only one tuning out when commercials about the open enrollment deadline flood the airwaves each year — even though there could be good reasons to shop around. But sifting through the offerings has become such an ordeal that few people want to repeat it. Avoidance is so rampant that only 10% of beneficiaries switched Medicare Advantage plans in 2019.

Once open enrollment ends, there are limited options for a do-over….  [Continued on Kaiser Health News and NPR]

The Lancet

New US initiative to prevent gun violence welcomed

Volume 402, Issue 10418
9 December 2023 

WORLD REPORT  Thwarted by Congress, President Joe Biden has created the first White House Office of Gun Violence Prevention. Susan Jaffe reports from Washington, DC.  

With Congress unable to ban even the most dangerous firearms made for war zones, US President Joe Biden announced a new strategy to deal with gun violence afflicting the nation: creating the first White House Office of Gun Violence Prevention. Frustrated by the congressional impasse, Biden essentially conceded that the new Office was not the best solution for reducing the unrelenting toll of gun violence in the USA.

“I’ll continue to urge Congress to take common sense actions that the majority of Americans support, like enacting universal background checks and banning assault weapons and high-capacity magazines”, Biden said in his announcement. “But in the absence of that sorely needed action, the Office of Gun Violence Prevention along with the rest of my Administration will continue to do everything it can to combat the epidemic of gun violence that is tearing our families, our communities, and our country apart.” [Continued here]

CMS, Medicare Advantage

Uncle Sam Wants You … to Help Stop Insurers’ Bogus Medicare Advantage Sales Tactics

By Susan Jaffe, KHN  | November 30, 2023 | This story also ran on  

People gathered at the U.S. Capitol in Washington, D.C. in July protested denials and delays in private Medicare Advantage plans. (Alex Wong/Getty Image)

After an unprecedented crackdown on misleading advertising claims by insurers selling private Medicare Advantage and drug plans, the Biden administration hopes to unleash a special weapon to make sure companies follow the new rules: you.

Officials at the Centers for Medicare & Medicaid Services are encouraging seniors and other members of the public to become fraud detectives by reporting misleading or deceptive sales tactics to 800-MEDICARE, the agency’s 24-hour information hotline. Suspects include postcards designed to look like they’re from the government and TV ads with celebrities promising benefits and low fees that are available only to some people in certain counties.

The new rules, which took effect Sept. 30, close some loopholes in existing requirements by describing what insurers can say in ads and other promotional materials as well as during the enrollment process. [Continued on Kaiser Health News and NPR]

Appeals, CMS, Medicare Advantage

Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients

By Susan Jaffe, KFF Health News | October 5, 2023

This article also ran in The Washington Post.

Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from h when she got surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to go home.

At the time, she could not walk more than a few feet, even with assistance — let alone manage the stairs to her front door, she said. She still needed help using a colostomy bag following major surgery.

“How could they make a decision like that without ever coming and seeing me?” said Sullivan, 76. “I still couldn’t walk without one physical therapist behind me and another next to me. Were they all coming home with me?”

UnitedHealthcare — the nation’s largest health insurance company, which provides Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. It does have naviHealth, a care management company bought by UHC’s sister company, Optum, in 2020. NaviHealth’s proprietary “nH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions, and other factors. Based on these comparisons, an algorithm anticipates what kind of care a specific patient will need and for how long. 

 

…Next year, the Centers for Medicare & Medicaid Services will begin restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.[Continued on Kaiser Health News and The Washington Post.]

Uncategorized

More US states ban teenagers’ gender-affirming care

Volume 402, Issue 10405
9 September 2023 

WORLD REPORT  Most health-care provider organisations oppose the bans, calling them harmful. Susan Jaffe reports from Washington, DC.  

With the last-minute approval of the Texas Supreme Court earlier this month, Texas became the latest and largest US state among 22 to ban gender-affirming care for people younger than 18 years. The prohibition applies to medically necessary surgery, hormone therapy, and puberty blockers. Similar efforts are underway across the country, despite numerous healthcare provider groups saying that adolescents should be able to access these safe and effective treatments, with the exception of surgery, which is rarely provided to minors.  [Continued here.]

The Lancet

Abortion foes threaten PEPFAR

Volume 402, Issue 10402
19 August 2023 

 

WORLD REPORT  Republicans question funding for the President’s Emergency Plan for AIDS Relief, one of the USA’s most effective global health programmes. Susan Jaffe reports from Washington, DC.

As Congress considers next month whether to renew funding for the President’s Emergency Plan for AIDS Relief (PEPFAR), global health advocates fear its two decades of bipartisan support might fracture. Created by President George W Bush in 2003, the programme is often cited as proof that adversaries across the political spectrum can agree on healthcare policy. …But this time is looking different.  [Continued here.]

CMS, Drugs, Medicare, Medicare costs, The Lancet

US pharmaceutical companies sue to halt cuts in drug prices

Volume 402, Issue 10399
29 July 2023 

 

WORLD REPORT  Medicare will soon be able to negotiate some drug prices to reduce costs for patients and taxpayers. Susan Jaffe reports from Washington, DC.

The first set of ten drugs subject to price negotiations by the US Medicare programme will be unveiled on Sept 1, 2023, but some pharmaceutical companies and their allies are not waiting to find out which products will be on the list. So far, four manufacturers and two trade associations are suing to stop the process before it begins. [Continued here.] 

 

The Lancet

US affirmative action ruling may harm health equity

 8 July 2023
Volume 402, Issue 10396 

WORLD REPORT  Health and science groups warn the Supreme Court ‘s decision threatens workforce diversity and patient care. Susan Jaffe reports from Washington, DC.

Leading medical and scientific organisations have criticised the June 29 US Supreme Court decision severely limiting how colleges and universities consider an applicant’s race in the admissions process. A 6 to 3 majority abandoned 45 years of legal precedent protecting affirmative action, which is widely expected not only to reduce the number of Black and Latinx college students but also roll back their representation in medicine, law, science, and other postgraduate programmes, diversity advocates say.  [Continued here.] 

The Lancet

Sackler money to go towards reducing overdose deaths

Volume 401, Issue 10392  ||  10 June 2023  

WORLD REPORT  A US $6 billion settlement must help to expand treatment access, harm reduction programmes, and recovery services. Susan Jaffe reports.

Federal, state and local governments along with community organisations may soon receive an infusion of US$6 billion to fight the opioid epidemic, including at least $775 million for victims and their families, after a federal appeals court approved a bankruptcy settlement for Purdue Pharma and its founders, the multi-billionaire Sackler family. However, in a controversial move last month, the court also restored protections for the Sacklers from civil lawsuits, despite accusations that their illegal schemes to boost sales of the company’s strongly addictive pain killer, OxyContin (oxycodone), vastly increased their wealth. But without this shield, the agreement would have remained mired in court challenges. [Continued here.] 

HHS, The Lancet

US health experts divided on social media age restrictions

27 May 2023
Volume 401, Issue 10390 

WORLD REPORT  Some medical associations support restrictions on social media use to protect adolescent’s health, while others focus on making companies provide safer platforms. 

Laws intended to protect adolescents from the harms of social media are spreading across the USA but, among some of the nation’s leading medical and public health associations, there is not yet a consensus on limiting social media access for young people. Nearly two dozen states are considering legislation. Several have already enacted a patchwork of age restrictions and partial bans. [Continued here.]
CMS, Medicare

A Covid Test Medicare Scam May Be a Trial Run for Further Fraud

By Susan Jaffe, KHN  | May 18, 2023 | This story also ran on  

Medicare coverage for at-home covid-19 tests ended last week, but the scams spawned by the temporary pandemic benefit could have lingering consequences for seniors.

Medicare advocates around the country who track fraud noticed an eleventh-hour rise in complaints from beneficiaries who received tests — sometimes by the dozen — that they never requested. It’s a signal that someone may have been using, and could continue to use, seniors’ Medicare information to improperly bill the federal government. …One beneficiary in Indiana suspected something was amiss after receiving 32 unrequested tests over a 10-day period. [Continued on Kaiser Health News, NPR, Yahoo News, and St. Louis Post-Dispatch]