Plan to Limit Some Drugs in Medicare Is Criticized
By KATIE THOMAS and ROBERT PEAR
An alliance of drug companies and patient advocates, joined by Democrats and Republicans in Congress, is fiercely opposing an Obama administration proposal that would allow insurers to limit Medicare coverage for certain classes of drugs, including those used to treat depression andschizophrenia.
Opponents warn that the proposal, if enacted, could harm patients. Federal officials say it would lower costs and reduce overuse of the drugs.
The proposed rule, which would lift a requirement that insurers cover “all or substantially all” drugs in certain treatment areas, is just one of a series of changes to the drug program that are being opposed by the unlikely alliance. Even insurers and drug benefit managers, who have previously supported added limits on drug coverage, oppose the rule. They object to provisions including changes to so-called preferred pharmacy networks, where consumers are steered toward a limited network of pharmacies, and to reducing the number of plans that insurers can offer in any one region.
A House subcommittee plans to hold a hearing on the proposal next week, and the rule is open for public comment until March 7.
“We’ve been scratching our heads over this,” said John J. Castellani, the chief executive of the Pharmaceutical Research and Manufacturers of America, the drug-industry trade group. Medicare Part D, he noted, is the rare government program that not only gets high marks from consumers but also has cost taxpayers billions of dollars less than originally expected. “Why is the administration trying to make such extensive changes to a program that isn’t broken?”
Mr. Castellani’s organization was one of more than 200 groups that signed a letter this week asking that the rule be withdrawn. Earlier this month, Republican and Democratic members of the Senate Finance Committee warned that the proposal could “diminish access to needed medication” without saving much money.
The administration’s proposal would remove the protected status from three classes of drugs that has been in place since the program’s inception in 2006: immunosuppressant drugs used in transplant patients, antidepressants and antipsychotic medicines. They include many well-known drugs, such as Wellbutrin, Paxil and Prozac to treatdepression, and Abilify and Seroquel to treat schizophrenia. Three other categories — cancer, H.I.V. and anti-seizuredrugs — would retain their status as protected classes and insurance companies would be required to continue covering nearly all drugs in those treatment areas. Medicare has traditionally required the broad coverage because patients with these conditions must often try several drugs before finding one that works.
Coping With Infectious Disease
The list of infectious diseases that could leap from remote areas of the world to strike countries thousands of miles away is growing. A warning of what can happen occurred a decade ago when an outbreak in China of a mysterious new viral disease, known as SARS, or severe acute respiratory syndrome, was covered up by the Chinese authorities, allowing infected airline passengers to carry the virus to more than two dozen other countries. The disease killed nearly 800 people and caused large economic losses in Asia and Canada.
Now longstanding worries that such deadly viruses as Ebola might be carried from Africa to the United States and elsewhere have been joined by new concerns. These include, among others: potentially dangerous strains of avian flu recently detected in China; a newly discovered and often lethal lung disease, known as Middle East respiratory syndrome, or MERS, which has so far been found mostly in Saudi Arabia; multidrug-resistant strains of tuberculosis that are very difficult to treat; and a painful mosquito-borne viral disease known as Chikungunya fever, which was first detected in Africa, spread to Asia and Europe, and recently invaded the Caribbean.
Beyond these natural threats lurk man-made threats, such as biological weapons that could kill millions and the danger that deadly pathogens being studied in laboratories might escape confinement or be deliberately released to set off a pandemic.
It made good sense, then, when the Obama administration, after meeting with representatives of three United Nations agencies and 26 countries last week, announced an ambitious plan to improve the surveillance and treatment of infectious diseases over the next five years in up to 30 countries.
Should Obesity Be a ‘Disease’?
IN June 2013, millions of Americans contracted a disease. They developed it not because of some pathogen or illness, but thanks to the American Medical Association’s decision to label obesity a “multi-metabolic and hormonal disease state.”
On its surface, this seemed like a good move: Calling obesity a disease provides a clear warning of the significant health risks associated with excessive weight. And the obesity-is-a-disease message sparked attention, funding and research aimed at finding medically driven remedies.
We wondered, however, if there also might be psychological ramifications inherent in that message. Would it reduce or add to the burden of body-image concerns and shame? Would it empower people to fight back, or lead to a fatalistic acceptance of being overweight?
We suspected that, while there might be some benefits, the message that obesity is a disease might also have important psychological costs. In collaboration with our colleague Lisa Auster-Gussman from the University of Minnesota, we tested that hypothesis in three studies of more than 700 people, the results of which recently appeared in the journal Psychological Science.
We randomly assigned some participants to read a newspaper article that detailed the A.M.A.’s recent decision. As a control, we assigned the others to read either a standard public health message about weight-loss goals from Washington Family magazine, or an article specifically stating that obesity is not a disease, which combined news coverage from Forbes and the Fox News website. Finally, they all completed questionnaires related to their attitudes about weight loss and eating behavior.
California's enrollment website for Obamacare goes down
By Chad Terhune
12:07 PM PST, February 20, 2014
| advertisement |
Amid a big marketing push, California's enrollment website for Obamacare coverage has suffered an unexpected outage due to software glitches.
The website problems come at a crucial time as the Covered California exchange tries to persuade more uninsured people to sign up ahead of a March 31 deadline.
The state exchange unveiled new TV commercials and radio ads this week aimed in particular at Latinos, who have been slow to enroll so far. The exchange is also urging more people to visit enrollment counselors, who rely on the state's online system.
Covered California took its enrollment system down for scheduled maintenance and upgrades for 24 hours this past weekend. But problems have persisted and Thursday consumers were greeted by a message saying "the enrollment portion of the site is being worked on."
Covered California said website errors began occurring Wednesday and it said "engineers are working around the clock" to resolve the problem.
"Covered California’s enrollment portal has been temporarily taken offline because of software malfunctions that were affecting the consumer experience," the exchange said in a statement.
The rest of the exchange website, including its shop and compare calculator for different health plans, is still available as well as general information.
Through mid-February, Covered California has enrolled 828,638 people in private health plans as part of the Affordable Care Act.
California's website at coveredca.com has performed better than the federal exchange site, healthcare.gov, which had a disastrous launch in the fall.
Instead, Covered California has experienced problems with hourlong wait times on the phone, faulty notices sent to applicants and an error-ridden physician directory that got pulled this month.
US government seeks to cut Medicare payments to insurers
By Caroline Humer, Reuters
Posted Feb. 22, 2014, at 5:55 a.m.
The U.S. government on Friday proposed a cut in payments to private health insurers for 2015 Medicare Advantage plans, a move Republican lawmakers said would hurt benefits for the elderly and disabled.
The proposal, released in a document by a division of the U.S. Department of Health and Human Services, appeared to cut payments by more than the 6 to 7 percent the insurance industry had expected, one Wall Street analyst said.
“Now the lobbying begins: can the plans get Congress to help make the cut less severe?” CRT Capital analyst Sheryl Skolnick said, adding that her assessment of the hundreds of pages of information was preliminary.
Friday’s notice of proposed rates opens a window for negotiations on the final ruling, due April 7.
Insurers and lawmakers have said cuts will mean smaller networks of doctors and hospitals and higher out-of-pocket costs. Insurers have said they could only maintain benefits if there was no change in payments for 2015 from 2014.
Many factors go into determining the government’s total reimbursement to insurers. These payments are based in part on the assumption that Medicare Advantage spending per person will fall 3.55 percent in 2015. Total reimbursement to insurers, however, is influenced by factors such as payments for patients who are sicker than average.
An executive at one company that manages Medicare Advantage plans said that insurers are facing cuts in the 8 percent to 10 percent range when factoring in the per capita spending decline and other planned reductions. These include a new health insurance tax under President Barack Obama’s health care law as well as other risk adjustments.
Other industry officials said they were still reviewing the Medicare notice to determine its full impact. Republican lawmakers said any additional cuts to the program were unacceptable.
“These Medicare Advantage cuts are misguided, threaten a successful program for seniors, and must be overturned,” Republican Senator Orrin Hatch said in a statement.
“Medicare Advantage is extremely popular for a reason — run through the private market, seniors gain access to high-quality and coordinated care with additional benefits that they otherwise wouldn’t get,” he said.
The criticism from Hatch and other leading Republicans adds to pressure from the party over Obama’s signature domestic policy achievement. The Patient Protection and Affordable Care Act, which aims to extend health coverage to millions of uninsured Americans, includes provisions to cut Medicare spending.
UnitedHealth Group Inc., Humana Inc. and Aetna Inc. are among the insurers who manage private Medicare plans for about 15 million of the 50 million Americans eligible for Medicare.
The shares of insurers fell in after-hours trading. Humana posted the biggest loss with a 4 percent decline.
PLANNING FOR 2015
The proposed payment rates are a key factor in how insurance companies plan their business for the coming year, including in which markets they will offer health plans, what their medical and administrative costs will be and at what level to set premiums and doctor visit co-payments.
Insurers have said that 2014 was a difficult year for Medicare Advantage because of cuts to payments estimated at about 6 percent overall by the industry group, called America’s Health Insurance Plans.
“As 2015 payment rates are finalized, we urge the Medicare agency to protect seniors from facing higher costs and fewer benefits by keeping Medicare Advantage payment rates flat,” AHIP Chief Executive Karen Ignagni said in a statement.
Letter to the editor: Facts, 'unfacts' of single-payer health care system
The Feb. 18 Press Herald included a letter to the editor penned by Bryan Dench, “Doctors should reject expansion of Medicaid.”
I value differences of opinion but do not like publicly expressed opinions that are short on facts. I am a group insurance broker who is a staunch supporter of a single-payer system being implemented in Maine.
First, let me separate the “unfacts” in the letter from the facts:
• $4 to $10 per week for a policy purchased on the exchange is way too low, even with a generous federally paid-for stipend.
• I personally know of many able-bodied adults in our state who are unemployed and want to work. They are without insurance while unemployed, and even when employed are often not offered coverage. They need to remain healthy to get and keep a job.
Other facts:
• The Affordable Care Act, or Obamacare, does not go far enough. At 17 percent of gross domestic product, the cost of health care in this country is the highest of any developed country by at least 6 percent.
• Our outcomes are the worst as measured by infant mortality, longevity of life, repeated hospitalizations and general health.
• Our administrative costs for doctors and hospitals are ludicrous, and are pretty much unknown in other developed countries.
• Those other developed countries with single-payer systems are unfamiliar with the idea of a denied medical claim.
• Doctors and hospitals are paid more quickly by single-payer systems than here in the U.S.
• Citizens of those countries love their medical single-payer systems.
More healthy citizens, less cost, fewer administrative headaches – no wonder many, many doctors and hospitals support a single-payer system!
Marilyn McWilliams
Gorham
How Obamacare Could Unlock Job Opportunities
During college, Lauren Braun worked at a health clinic in Peru, where she spent an inordinate amount of time tracking down mothers in an effort to get them to bring their children in for vaccinations. The experience was frustrating, but through it Braun came up with a business plan: Make silicone bracelets that function as punch cards, to remind mothers about upcoming appointments. Back in the United States, she consulted with mentors and perfected the idea, but then, she set it aside after graduation, going to work for a large health-insurance company, taking a salary and benefits over the uncertain life of an entrepreneur.
A year and a half later, she got word that her bracelet company, Alma Sana, might have a life after all: The Bill and Melinda Gates Foundation had awarded her $100,000 to test the idea. Braun was O.K. with the 60 percent pay cut she would take by quitting her day job. But she did not want to lose her health insurance.
Were it not for Obamacare, Braun, 25, would be confronting a phenomenon that economists call “job lock”: when people stay in jobs they dislike, or don’t want, solely to keep their health coverage. A Harvard Business School study in 2008 estimated that 11 million workers are affected by this dilemma. Other studies show that when people don’t have to worry about health insurance, they are up to 25 percent more likely to change jobs. Obamacare was designed, in part, to fix this inefficiency in the labor market, and thanks to that association, job lock has become a political lightning rod.
A Hot Debate Over E-Cigarettes as a Path to Tobacco, or From It
Dr. Michael Siegel, a hard-charging public health researcher at Boston University, argues that e-cigarettes could be the beginning of the end of smoking in America. He sees them as a disruptive innovation that could make cigarettes obsolete, like the computer did to the typewriter.
But his former teacher and mentor, Stanton A. Glantz, a professor of medicine at the University of California, San Francisco, is convinced that e-cigarettes may erase the hard-won progress achieved over the last half-century in reducing smoking. He predicts that the modern gadgetry will be a glittering gateway to the deadly, old-fashioned habit for children, and that adult smokers will stay hooked longer now that they can get a nicotine fix at their desks.
These experts represent the two camps now at war over the public health implications of e-cigarettes. The devices, intended to feed nicotine addiction without the toxic tar of conventional cigarettes, have divided a normally sedate public health community that had long been united in the fight against smoking and Big Tobacco.
The Dream of Moving Abroad in Later Life, With Good Health Care
By TIM GRAY
FOR the well-traveled, the idea of retirement abroad can seem an idyll. You pick a place you’ve loved visiting, whether it’s the thrumming avenues of Paris or the sunny strands of Panama, and jet off for the perfect permanent vacation.
But the fantasy can become less carefree if you haven’t figured out in advance what to do about health insurance. The best policies, those offering the broadest coverage and giving access to the best hospitals, can be jarringly costly. More affordable alternatives can come with exceptions that may surprise people accustomed to the comprehensive coverage offered through many United States employers. Many countries offer high-quality care — France is a prominent example — but retirees won’t be able to access it without insurance or paying out of pocket. And in almost all cases, Medicare doesn’t pay for health care provided outside of the United States.
“Health insurance really is a primary consideration when retiring overseas,” said Brendan Sharkey, director of individual products for HTH, which sells and administersGeoBlue international health insurance. “People may want sunshine and affordable living, but they’ll also want to make sure they’ll be covered adequately.” That means not just buying a policy, but also assessing the quality of health care in the country where they plan to settle.
“If you’ve had two heart attacks, you have to ask yourself if it makes sense to retire in Nicaragua, where the underlying quality of care just isn’t there,” Mr. Sharkey said. More practical alternatives might be Panama or Thailand — warm, affordable countries known for better-quality care, he said.
For health insurers, age equals risk — senescence brings sickness. So older people can expect to pay up for international health insurance, especially as they reach their middle to late 70s. “It’s the same everywhere in the world — the older you get, the more expensive the premiums,” saidSteve Nelson, product development manager at Medibroker, an insurance brokerage in North Shields, England.
EMMC expands plans for medical office building, seeks more land from city of Bangor
By Nick McCrea, BDN Staff
Posted Feb. 22, 2014, at 11:15 a.m.
BANGOR, Maine — Eastern Maine Medical Center was worried its 30,000-square-foot medical office building planned for just off Maine Avenue wouldn’t have enough space for all the practitioners it wants to add, so the hospital is going bigger.
Last summer, Eastern Maine Healthcare Systems purchased 2.4 acres of land in the Maine Business Enterprise Park from the city for $183,000. The plot is located between Northeast Cardiology Associates and Bangor Family Medicine.
The original plan was to build a two-story, $5.25 million office hub for new doctors and specialists. However, concerns arose in recent months that the facility would be too cramped, so officials reconsidered the scale of the project.
Joel Farley, facilities administrator for EMMC, said the new building will still be two stories, but it could be up to 20,000 square feet larger than first planned, ensuring that the building provides enough space for the hospital to be flexible in how it is divided up and used.
To move forward with the project, EMHS is coming back to the city with hopes of purchasing more land — six acres at a cost of $13,333 per acre, according to Tanya Emery, Bangor’s director of economic and community development. The City Council will decide whether to authorize that purchase during its meeting Monday night.
Farley said the extra acreage will provide more room for employee parking spots and will cut down the distance patients have to walk to get from their cars to the building.
EMMC expects to break ground on the project in the spring or early summer, and that construction should take about 18 months, according to Farley. He said the projected cost of the project has increased as the size of the building increased, but he didn’t have the new estimate immediately available.
EMHS, a nonprofit, has agreed to make an annual payment in lieu of taxes equal to 30 percent of the property value it’s built and assessed, according to Emery.
Farley said EMMC has identified a need for about 50 medical practitioners in Bangor, ranging from primary care providers and specialists to nutritionists and behavioral health professionals. Exactly how many and which doctors will set up shop in the new facility is still being worked out, according to Farley.
“It’s not OK for folks to have wait times to get in and see their doctor,” Farley said.
Have Medicaid and private plan — who pays what
Children, Employer-sponsored planschildren under age 19,comparing health plans, Medicaid, small business
When a child has health insurance (from Dad’s work) and also Medicaid, which one pays for what? Last month, my daughter’s dad showed up with an ID card for her. She still has Medicaid. What do I do?
Double Insured Daughter
Dear Double Insured Daughter,
You only need to give both ID cards to the doctor’s office, hospital, or drug store. They know who should get billed first, second, etc. You will pay the lower co-pay of the two plans. This is most likely the Medicaid co-pay.
Just so you know, Medicaid always pays after any other insurance has paid its benefits. “Any other insurance” includes private insurance (like from Dad’s work), car insurance or even property insurance. If your daughter fell in a store because their floor was wet, their insurance would pay her medical bills. These are rare cases, but they do happen. Again, don’t worry about it. The plans will work together, or track down the other payer (the store, the other driver, etc.) to pay the bills.
Maine patients urged to compare test, treatment price tags
A Gardiner couple was shocked by the difference between doctor’s office and hospital medical test prices.
By Betty Adams badams@centralmaine.com
Staff Writer
Staff Writer
When Michael Gove had an echocardiogram 14 months ago at a doctor’s office in the Northpark Professional Building in Augusta, the bill was $658. His insurance policy paid it all.
Some 14 months later, another echocardiogram done at MaineGeneral Medical Center after the doctor’s office moved there cost $2,319 and carried a $220.35 coinsurance bill for the Goves.
The Goves, who live in Gardiner, were astonished at the difference in cost.
“I started asking questions,” Susan Gove said. “It was the exact same procedure that was done in the office.” In fact, she said, it was the same technician. “I was extremely upset.”
Gove works in a doctor’s office and understands medical billing and expected a hospital-based procedure to cost more, but not that much more.
Now she’s a poorer but wiser consumer. If another echocardiogram is ordered, the Goves will talk to their doctor and office staff and see if it can be performed at a nonhospital site where the cost will be less, likely only a $40 copay. “We will go to either Lewiston or Portland. Then I won’t get hit with a large bill,” Susan Gove said.
That practice of shopping around and comparing costs, convenience, etc., which is second nature to most people when buying big-ticket items, is being encouraged by consumer and professional groups, medical professionals among them.
“The issue of cost can’t be ignored any more,” said Dr. Lisa Letourneau, executive director of Maine Quality Counts, an independent healthcare collaborative that encompasses hospitals, physicians, outpatient care and hospice providers, nursing organizations, insurers, governmental groups, consumers, and the like. The mission is to improve “health and healthcare for the people of Maine,” according to its website.
“We are trying to get involved in a way that’s helpful to driving quality,” Letourneau said. Her organization and others promote a “Choosing Wisely” initiative that offers a list of “5 Questions to Ask Your Doctor Before You Get any Test, Treatment, or Procedure.” The list, developed by Consumer Reports Health and the Advancing Medical Professionalism to Improve Health Care Foundation, asks:
• Do I really need this test or procedure?
• What are the risks?
• Are there simpler, safer options?
• What happens if I don’t do anything?
• How much does it cost?
The final question also says, “Ask if there are less expensive tests, treatments or procedures, what your insurance may cover, and about generic drugs instead of brand-name drugs.”
Letourneau said asking those questions can help bring about a culture change among health care consumers accustomed to having insurance that offered first-dollar coverage. “People didn’t have a reason to pay attention,” she said. Now they are becoming more aware of it because of increased out-of-pocket costs.
She also said patients should not be surprised if a physician’s office can’t answer the cost questions. “Billing has been somebody’s job somewhere,” Letourneau said. “It’s entirely conceivable nobody in the office knows about the cost.
Progress Against Hepatitis C, a Sneaky Virus
By JANE E. BRODY
Forty years ago, a beloved neighbor was bedridden for weeks at a time with a mysterious ailment. She knew only that it involved her liver and that she must never drink alcohol, which would make things worse.
It was decades before the cause of these debilitating flare-ups was discovered: a viral infection at first called non-A, non-B hepatitis, then properly identified in 1989 as hepatitis C. The apparent source of her infection was a blood transfusion she had received decades earlier.
A screening test was soon developed, making it possible to check all blood products for the hepatitis C virus. But that by no means put an end to the infection. Transmission persists today, commonly the result of intravenous drug abuse with shared needles, sexual and especially anal intercourse, and, among health care workers, accidental needlesticks or other contact with infected blood.
“An estimated 3.2 million people in the United States are infected, but the vast majority of them don’t know it,” Dr. Mark S. Sulkowski, a liver specialist at Johns Hopkins University School of Medicine, said in an interview.
For several decades, only people at high risk for the infection were advised to be screened for it. That meant anyone who had ever injected illegal drugs; recipients of blood transfusions or organ transplants before 1992, or of clotting factor concentrates made before 1987; children born to infected mothers; patients who underwent long-term kidney dialysis; anyone infected with H.I.V.or with symptoms of liver disease or an abnormal liver enzyme test; organ transplant recipients whose donors were later found to have the virus; and health care workers possibly exposed to infected blood.
Health Care Horror Hooey
Remember the “death tax”? The estate tax is quite literally a millionaire’s tax — a tax that affects only a tiny minority of the population, and is mostly paid by a handful of very wealthy heirs. Nonetheless, right-wingers have successfully convinced many voters that the tax is a cruel burden on ordinary Americans — that all across the nation small businesses and family farms are being broken up to pay crushing estate tax liabilities.
You might think that such heart-wrenching cases are actually quite rare, but you’d be wrong: they aren’t rare; they’re nonexistent. In particular, nobody has ever come up with a real modern example of a family farm sold to meet estate taxes. The whole “death tax” campaign has rested on eliciting human sympathy for purely imaginary victims.
And now they’re trying a similar campaign against health reform.
I’m not sure whether conservatives realize yet that their Plan A on health reform — wait for Obamacare’s inevitable collapse, and reap the political rewards — isn’t working. But it isn’t. Enrollments have recovered strongly from the law’s disastrous start-up; in California, which had a working website from the beginning, enrollment has alreadyexceeded first-year projections. The mix of people signed up so far is older than planners had hoped, but not enough so to cause big premium hikes, let alone the often-predicted “death spiral.”
And conservatives don’t really have a Plan B — in their world, nobody even dares mention the possibility that health reform might actually prove workable. Still, you can already see some on the right groping toward a new strategy, one that relies on highlighting examples of the terrible harm Obamacare does. There’s only one problem: they haven’t managed to come up with any real examples. Consider several recent ventures on the right:
Maine bill calls for giving limited dental coverage to adults getting MaineCare
The goal is to reduce costly emergency room visits to treat dental pain.
Lawmakers are considering a bill that for the first time would provide limited access to dental care for adults who receive MaineCare benefits, a proposal designed to reduce uncompensated emergency room treatment for dental pain.
Maine currently does not provide an adult dental benefit to MaineCare recipients, although children are covered. About 25 states provide at least some dental coverage for adults on Medicaid, the federally funded program that operates in Maine as MaineCare.
Under a proposal by Rep. Drew Gattine, D-Westbrook, if a medical doctor signs off on the need for dental care, an adult MaineCare recipient could visit a dentist and have the work paid for by MaineCare, rather than waiting for the problem to become so acute that it results in a visit to a hospital emergency room.
“This is not intended to provide a full array of MaineCare dental services for adults,” Gattine said. “It’s not just for people who haven’t had a cleaning in a while and want to have a cleaning.”
Rather, Gattine said, if a medical doctor sees obvious signs of tooth decay or an abscess, the MaineCare patient can be sent to a dentist rather than having to go to the emergency room.
In many states, more than 35 percent of all emergency room visits are due to dental problems, according to a 2010 study by the Pew Center on the States.
In 2006, about 8,500 emergency room visits by MaineCare patients ages 15 to 44 were triggered by dental pain, according to a 2010 study by the Muskie School of Public Service at the University of Southern Maine. The study did not specify what percent of total emergency room visits this represents.
The Maine Dental Association supports Gattine’s bill. Dr. Jonathan Shenkin, an association representative, said anything that helps adults get needed dental care is a plus for Maine.
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