Opinion | How a Covid-19 Vaccine Could Cost Americans Dearly
By Elisabeth Rosenthal - NYT - July 6, 2020
Yes, of course, Americans’ health is priceless, and reining in a deadly virus that has trashed the economy would be invaluable.
But a Covid-19 vaccine will have an actual price tag. And given the prevailing business-centric model of American drug pricing, it could well be budget breaking, perhaps making it unavailable to many.
The last vaccine to quell a global viral scourge was the polio inoculation, which ended outbreaks that killed thousands and paralyzed tens of thousands each year in the United States. The March of Dimes Foundation covered the drug cost for a free national vaccination program.
It came in the mid-1950s, before health insurance for outpatient care was common, before new drugs were protected by multiple patents, before medical research was regarded as a way to become rich. It was not patented because it was not considered patentable under the standards at the time.
But a Covid-19 vaccine will have an actual price tag. And given the prevailing business-centric model of American drug pricing, it could well be budget breaking, perhaps making it unavailable to many.
The last vaccine to quell a global viral scourge was the polio inoculation, which ended outbreaks that killed thousands and paralyzed tens of thousands each year in the United States. The March of Dimes Foundation covered the drug cost for a free national vaccination program.
It came in the mid-1950s, before health insurance for outpatient care was common, before new drugs were protected by multiple patents, before medical research was regarded as a way to become rich. It was not patented because it was not considered patentable under the standards at the time.
Now we are looking for viral
deliverance when drug development is one of the world’s most lucrative
businesses, ownership of drug patents is disputed in endless court
battles, and monopoly power often lets manufacturers set any price, no
matter how extraordinary. A new cancer treatment can cost a half-million
dollars and old staples like insulin have risen manifold in price to
thousands of dollars annually.
And the American government has no effective way to fight back.
Recent vaccines targeting more limited populations, such as a meningitis B vaccine for college students and the shingles vaccine for older adults, have a retail cost of $300 to $400 for a full course.
If a Covid-19 vaccine yields a price of, say, $500 a course, vaccinating the entire population would bring a company over $150 billion, almost all of it profit.
Kevin Schulman, a physician-economist at the Stanford Graduate School of Business, called that amount “staggering.” But Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, said that from society’s perspective “$150 billion might not be an unreasonable sum” to pay to tame an epidemic that has left millions unemployed and cost the economy trillions.
Every other developed country has evolved schemes to set or negotiate prices, while balancing cost, efficacy and social good. The United States instead has let business calculations drive drug price tags, forcing us to accept and absorb ever higher costs. That feels particularly galling for treatments and vaccines against Covid-19, whose development and production is being subsidized and incentivized with billions in federal investment.
And the American government has no effective way to fight back.
Recent vaccines targeting more limited populations, such as a meningitis B vaccine for college students and the shingles vaccine for older adults, have a retail cost of $300 to $400 for a full course.
If a Covid-19 vaccine yields a price of, say, $500 a course, vaccinating the entire population would bring a company over $150 billion, almost all of it profit.
Kevin Schulman, a physician-economist at the Stanford Graduate School of Business, called that amount “staggering.” But Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, said that from society’s perspective “$150 billion might not be an unreasonable sum” to pay to tame an epidemic that has left millions unemployed and cost the economy trillions.
Every other developed country has evolved schemes to set or negotiate prices, while balancing cost, efficacy and social good. The United States instead has let business calculations drive drug price tags, forcing us to accept and absorb ever higher costs. That feels particularly galling for treatments and vaccines against Covid-19, whose development and production is being subsidized and incentivized with billions in federal investment.
When AZT, the first effective drug for combating the virus that causes AIDS, was introduced in 1992, it was priced at up to $10,000 a year
or about $800 a month. It was the most expensive prescription drug in
history, at that time. The price was widely denounced as “inhuman.” Today that price gets you some drugs for toenail fungus.
Investors already smell big money for a Covid-19 vaccine.
The market cap of Moderna, a small Boston area company that has partnered with the National Institutes of Health in the vaccine race, has tripled since Feb. 20, to $23 billion from $7 billion, turning its chief executive into an overnight billionaire. While Moderna’s vaccine is regarded as a strong contender, the company has never brought a successful drug to market.
Manufacturers have traditionally claimed that only the lure of windfall profits would encourage them to take the necessary risks, since drug development is expensive and there’s no way of knowing whether they’re putting their money on a horse that will finish first, or scratch.
More recently they have justified high prices by comparing them to the costs they would prevent. Expensive hepatitis C drugs, they say, avoid the need for a $1 million liver transplant. No matter that the comparison being made is to the highly inflated costs of treating disease in American hospitals.
Such logic would be disastrous if it were applied to a successful Covid vaccine. Covid-19 has shut down countless businesses, creating record-high unemployment. And the medical consequences of severe Covid-19 mean weeks of highly expensive intensive care.
“Maybe the economic value of the Covid vaccine is a trillion and even if the expense to the company was a billion. That’s 1,000 times return on investment,” said Dr. Schulman. “No economic theory would support that.”
In 2015, the Senate Finance Committee came up with a simpler explanation for high drug prices. After reviewing 20,000 pages of company documents, it found that Gilead had, what the committee’s ranking Democratic member Ron Wyden of Oregon called, “a calculated scheme for pricing and marketing its hepatitis C drug based on one primary goal, maximizing revenue.”
Investors already smell big money for a Covid-19 vaccine.
The market cap of Moderna, a small Boston area company that has partnered with the National Institutes of Health in the vaccine race, has tripled since Feb. 20, to $23 billion from $7 billion, turning its chief executive into an overnight billionaire. While Moderna’s vaccine is regarded as a strong contender, the company has never brought a successful drug to market.
Manufacturers have traditionally claimed that only the lure of windfall profits would encourage them to take the necessary risks, since drug development is expensive and there’s no way of knowing whether they’re putting their money on a horse that will finish first, or scratch.
More recently they have justified high prices by comparing them to the costs they would prevent. Expensive hepatitis C drugs, they say, avoid the need for a $1 million liver transplant. No matter that the comparison being made is to the highly inflated costs of treating disease in American hospitals.
Such logic would be disastrous if it were applied to a successful Covid vaccine. Covid-19 has shut down countless businesses, creating record-high unemployment. And the medical consequences of severe Covid-19 mean weeks of highly expensive intensive care.
“Maybe the economic value of the Covid vaccine is a trillion and even if the expense to the company was a billion. That’s 1,000 times return on investment,” said Dr. Schulman. “No economic theory would support that.”
In 2015, the Senate Finance Committee came up with a simpler explanation for high drug prices. After reviewing 20,000 pages of company documents, it found that Gilead had, what the committee’s ranking Democratic member Ron Wyden of Oregon called, “a calculated scheme for pricing and marketing its hepatitis C drug based on one primary goal, maximizing revenue.”
In
setting prices, drug makers rarely acknowledge the considerable federal
funding and research that has helped develop their products; they have
not offered taxpayer-investors financial payback.
The Biomedical Advanced Research and Development Authority, a federal agency known as Barda, is giving Moderna up to $483 million for late-stage development of its vaccine.
The basic science that has allowed the small company to move so rapidly was developed with a huge prior infusion of federal money to develop a treatment for diseases like Zika.
Francis Collins, the head of the National Institutes of Health, has said the government has some intellectual property rights. Moderna seems to dispute that view, saying that it is “not aware of any I.P. that would prevent us from commercializing” a Covid-19 vaccine.
Likewise, AstraZeneca, another top competitor, has received a Barda promise of up to $1.2 billion for commercializing a product derived from research at the University of Oxford.
There is no simple, direct mechanism for regulators or legislators to control pricing. Our laws, in fact, favor business: Medicare is not allowed to engage in price negotiations for medicines covered by its part D drug plan. The Food and Drug Administration, which will have to approve the manufacturer’s vaccine for use as ‘safe and effective,’ is not allowed to consider proposed cost. The panels that recommend approval of new drugs generally have no idea how they will be priced.
“The idea that we would allow ourselves to be held hostage in an emergency is mind boggling,” said David Mitchell, head of Patients for Affordable Drugs, an advocacy group.
The Biomedical Advanced Research and Development Authority, a federal agency known as Barda, is giving Moderna up to $483 million for late-stage development of its vaccine.
The basic science that has allowed the small company to move so rapidly was developed with a huge prior infusion of federal money to develop a treatment for diseases like Zika.
Francis Collins, the head of the National Institutes of Health, has said the government has some intellectual property rights. Moderna seems to dispute that view, saying that it is “not aware of any I.P. that would prevent us from commercializing” a Covid-19 vaccine.
Likewise, AstraZeneca, another top competitor, has received a Barda promise of up to $1.2 billion for commercializing a product derived from research at the University of Oxford.
There is no simple, direct mechanism for regulators or legislators to control pricing. Our laws, in fact, favor business: Medicare is not allowed to engage in price negotiations for medicines covered by its part D drug plan. The Food and Drug Administration, which will have to approve the manufacturer’s vaccine for use as ‘safe and effective,’ is not allowed to consider proposed cost. The panels that recommend approval of new drugs generally have no idea how they will be priced.
“The idea that we would allow ourselves to be held hostage in an emergency is mind boggling,” said David Mitchell, head of Patients for Affordable Drugs, an advocacy group.
That’s why a bipartisan coalition in the House recently proposed two new bills to prevent “price gouging” for “taxpayer funded Covid-19 drugs” to ensure affordable pricing.
The exact mechanisms for enacting the provisions therein — such as requiring manufacturers to reveal their actual development costs — remain unclear. The industry has previously protected development data as a trade secret. The bills would also require “reasonable pricing clauses” be included in agreements between drug companies and agencies funding their work. They propose waiving exclusive licenses for Covid-19 drugs, allowing competitors to sell the same products so long as they paid the patent holder royalties.
Other countries, such as Britain, take a more head on approach: a national body does a cost-benefit analysis regarding the price at which a new drug is worth being made available to its citizens. Health authorities then use that information to negotiate with a drug maker on price and to develop a national reimbursement scheme.
We could too, but would need to consider mechanisms outside of our current box — at least for this national emergency.
The federal government could, for example, invoke a never-before-used power called “march-in rights,” through which it can override a patent holder’s rights if it doesn’t make its medicines “available to the public on reasonable terms.” (Unfortunately, in already-signed agreements with Barda, some drug makers have explicitly watered down or eliminated that proviso.)
We could, alternatively, allow Medicare to negotiate drug prices — a proposal that has been raised by politicians and beaten back by industry again and again. We would then need to restrict markup for a Covid-19 vaccine for the private market. Otherwise we’d get the kinds of results emerging from the Covid testing industry, where Medicare pays $100 for the test but some labs charge insurers over $2,000.
There is already reason to worry that our deliverance from coronavirus will cost us plenty. Barda paid AztraZeneca up to $1.2 billion toward development, production and delivery of its candidate vaccine, in order to secure 300 million doses in October. Britain paid the equivalent of $80 million to secure 100 million doses in September — one-fifth of what the United States government agreed to pay per dose.
The exact mechanisms for enacting the provisions therein — such as requiring manufacturers to reveal their actual development costs — remain unclear. The industry has previously protected development data as a trade secret. The bills would also require “reasonable pricing clauses” be included in agreements between drug companies and agencies funding their work. They propose waiving exclusive licenses for Covid-19 drugs, allowing competitors to sell the same products so long as they paid the patent holder royalties.
Other countries, such as Britain, take a more head on approach: a national body does a cost-benefit analysis regarding the price at which a new drug is worth being made available to its citizens. Health authorities then use that information to negotiate with a drug maker on price and to develop a national reimbursement scheme.
We could too, but would need to consider mechanisms outside of our current box — at least for this national emergency.
The federal government could, for example, invoke a never-before-used power called “march-in rights,” through which it can override a patent holder’s rights if it doesn’t make its medicines “available to the public on reasonable terms.” (Unfortunately, in already-signed agreements with Barda, some drug makers have explicitly watered down or eliminated that proviso.)
We could, alternatively, allow Medicare to negotiate drug prices — a proposal that has been raised by politicians and beaten back by industry again and again. We would then need to restrict markup for a Covid-19 vaccine for the private market. Otherwise we’d get the kinds of results emerging from the Covid testing industry, where Medicare pays $100 for the test but some labs charge insurers over $2,000.
There is already reason to worry that our deliverance from coronavirus will cost us plenty. Barda paid AztraZeneca up to $1.2 billion toward development, production and delivery of its candidate vaccine, in order to secure 300 million doses in October. Britain paid the equivalent of $80 million to secure 100 million doses in September — one-fifth of what the United States government agreed to pay per dose.
We’ve heard such offers before. Pharmaceutical companies routinely provide coupons to cover patient co-payments for expensive drugs, so that we don’t squawk when they charge our insurance company tens of thousands for the medicine, driving up premiums year after year. A naloxone injector to reverse heroin overdoses is given free to some clinics, but priced at thousands for the rest.
And it won’t feel like a bargain if we get free or cheap vaccines during a pandemic, but pay dearly for annual Covid-19 shots thereafter.
Drug companies deserve a reasonable profit for taking on this urgent task of creating a Covid-19 vaccine. But we deserve a return, too.
So before these invaluable vaccines hit the market, we should talk about an actual price. Otherwise we will be stuck paying dearly for shots that the rest of the world will get for much less.
https://www.nytimes.com/2020/07/06/opinion/coronavirus-vaccine-cost.html?referringSource=articleShare
U.S. Will Pay $1.6 Billion to Novavax for Coronavirus Vaccine
The
Maryland-based company, which has never brought a product to market
before, just made the biggest deal to date with the Trump
administration’s Operation Warp Speed.
by Katie Thomas - NYT - July 7, 2020
The
federal government will pay the vaccine maker Novavax $1.6 billion to
expedite the development of 100 million doses of a coronavirus vaccine
by the beginning of next year, the company said on Tuesday.
The deal is the largest that the Trump administration has made so far with a company as part of Operation Warp Speed, the sprawling federal effort to make coronavirus vaccines and treatments available to the American public as quickly as possible. In doing so, the government has placed a significant bet on Novavax, a company based in Maryland that has never brought a product to market.
Operation Warp Speed is a multiagency effort that seeks to carry out President Trump’s pledge to make a coronavirus vaccine available by the end of the year, but the full extent of the project is still unclear. Officials have declined to list which vaccines and treatments are part of Operation Warp Speed.
In an interview on Sunday, Novavax’s president and chief executive, Stanley C. Erck, initially said he was not sure where in the government the $1.6 billion was coming from. A Novavax spokeswoman later said the money was coming from a “collaboration” between the Health and Human Services Department and the Defense Department.
The deal is the largest that the Trump administration has made so far with a company as part of Operation Warp Speed, the sprawling federal effort to make coronavirus vaccines and treatments available to the American public as quickly as possible. In doing so, the government has placed a significant bet on Novavax, a company based in Maryland that has never brought a product to market.
Operation Warp Speed is a multiagency effort that seeks to carry out President Trump’s pledge to make a coronavirus vaccine available by the end of the year, but the full extent of the project is still unclear. Officials have declined to list which vaccines and treatments are part of Operation Warp Speed.
In an interview on Sunday, Novavax’s president and chief executive, Stanley C. Erck, initially said he was not sure where in the government the $1.6 billion was coming from. A Novavax spokeswoman later said the money was coming from a “collaboration” between the Health and Human Services Department and the Defense Department.
In May, the administration announced it was awarding up to $1.2 billion
as part of Operation Warp Speed to the British drugmaker AstraZeneca,
which has said that its vaccine could be available by October. Four
other companies — Moderna Therapeutics, Johnson & Johnson, Merck and
Sanofi — have also received federal assistance for their experimental coronavirus vaccines.
“Adding Novavax’s candidate to Operation Warp Speed’s diverse portfolio of vaccines increases the odds that we will have a safe, effective vaccine as soon as the end of this year,” Alex M. Azar II, the health and human services secretary, said in a statement.
Mr. Erck said Novavax’s coronavirus vaccine uses the same technology as its other experimental vaccines, such as one for the flu, that have been tested in late-stage clinical trials. Novavax has recently brought in senior executives from established manufacturers like AstraZeneca and GlaxoSmithKline, he said.
“The risk they’re taking is that a company like ours — which doesn’t have a pipeline of already commercialized products — can we get to the big leagues and scale up?” he said. “And I think they’re placing the bet that we can.”
The U.S. investment comes after an international group, the Coalition for Epidemic Preparedness Innovations, awarded up to $388 million to Novavax in May to make its coronavirus vaccine available globally.
“Adding Novavax’s candidate to Operation Warp Speed’s diverse portfolio of vaccines increases the odds that we will have a safe, effective vaccine as soon as the end of this year,” Alex M. Azar II, the health and human services secretary, said in a statement.
Mr. Erck said Novavax’s coronavirus vaccine uses the same technology as its other experimental vaccines, such as one for the flu, that have been tested in late-stage clinical trials. Novavax has recently brought in senior executives from established manufacturers like AstraZeneca and GlaxoSmithKline, he said.
“The risk they’re taking is that a company like ours — which doesn’t have a pipeline of already commercialized products — can we get to the big leagues and scale up?” he said. “And I think they’re placing the bet that we can.”
The U.S. investment comes after an international group, the Coalition for Epidemic Preparedness Innovations, awarded up to $388 million to Novavax in May to make its coronavirus vaccine available globally.
Several
vaccine experts said Novavax’s vaccine would help diversify the federal
portfolio by including another candidate that uses a protein-based
vaccine that has worked against other pathogens, like hepatitis B. The
Novavax vaccine uses microscopic particles that carry fragments of the
coronavirus, prompting the body’s immune system to respond. Sanofi,
which has received nearly $31 million in government funding, is also
developing a vaccine that is based on viral proteins.
Other leading candidates are relying on less proven technologies. For example, Moderna is using genetic material from the coronavirus called mRNA to provoke an immune response, and AstraZeneca and Johnson & Johnson are both testing vaccines that use a harmless virus to deliver coronavirus genes into cells.
“This is a sort of diversification from other approaches, which makes a certain amount of sense,” said John P. Moore, a professor of microbiology and immunology at Weill Cornell Medical College in New York City. “You don’t want all of your eggs in one basket.”
Mr. Erck said the deal with the United States would allow Novavax to begin manufacturing the vaccines before the company concludes late-stage clinical trials, expected by the end of the year. The company would ensure that 100 million doses — enough for 50 million people to receive an initial shot and a booster — are delivered by the first quarter of 2021, if its coronavirus vaccine is proved safe and effective. In June, Novavax secured a $60 million contract from the Defense Department to guarantee the delivery of 10 million doses to vaccinate American troops for the coronavirus.
Novavax began early-stage safety trials in Australia in May, and the company has said it expects to make the results available this month. It said it planned to begin so-called Phase 3 efficacy trials by the fall of this year and could release interim data by the end of 2020.
There is no vaccine for the coronavirus, and many clinical trials fail when vaccines turn out to be ineffective or to cause serious side effects. Until now, new vaccines have taken years to develop, and many experts have said the aggressive timelines set by companies and government officials for a coronavirus vaccine are overly optimistic.
Through its deal with the Coalition for Epidemic Preparedness Innovations, Novavax is also setting up manufacturing in other sites around the world, including in Europe and Asia, to serve populations outside the United States. The company is using its own facilities to scale up manufacturing and will also contract with outside companies, Mr. Erck said.
Other leading candidates are relying on less proven technologies. For example, Moderna is using genetic material from the coronavirus called mRNA to provoke an immune response, and AstraZeneca and Johnson & Johnson are both testing vaccines that use a harmless virus to deliver coronavirus genes into cells.
“This is a sort of diversification from other approaches, which makes a certain amount of sense,” said John P. Moore, a professor of microbiology and immunology at Weill Cornell Medical College in New York City. “You don’t want all of your eggs in one basket.”
Mr. Erck said the deal with the United States would allow Novavax to begin manufacturing the vaccines before the company concludes late-stage clinical trials, expected by the end of the year. The company would ensure that 100 million doses — enough for 50 million people to receive an initial shot and a booster — are delivered by the first quarter of 2021, if its coronavirus vaccine is proved safe and effective. In June, Novavax secured a $60 million contract from the Defense Department to guarantee the delivery of 10 million doses to vaccinate American troops for the coronavirus.
Novavax began early-stage safety trials in Australia in May, and the company has said it expects to make the results available this month. It said it planned to begin so-called Phase 3 efficacy trials by the fall of this year and could release interim data by the end of 2020.
There is no vaccine for the coronavirus, and many clinical trials fail when vaccines turn out to be ineffective or to cause serious side effects. Until now, new vaccines have taken years to develop, and many experts have said the aggressive timelines set by companies and government officials for a coronavirus vaccine are overly optimistic.
Through its deal with the Coalition for Epidemic Preparedness Innovations, Novavax is also setting up manufacturing in other sites around the world, including in Europe and Asia, to serve populations outside the United States. The company is using its own facilities to scale up manufacturing and will also contract with outside companies, Mr. Erck said.
He and others have
noted that more than one vaccine will need to succeed in order to
vaccinate the entire world. “Right now, we need and want everybody’s to
work,” he said.
https://www.nytimes.com/2020/07/07/health/novavax-coronavirus-vaccine-warp-speed.html?action=click&module=Top%20Stories&pgtype=Homepage
https://www.nytimes.com/2020/07/07/health/novavax-coronavirus-vaccine-warp-speed.html?action=click&module=Top%20Stories&pgtype=Homepage
In a new hospital ranking, doing good counts nearly as much as doing well
The rankings show that those hospitals with good clinical outcomes tend to score poorly in addressing inequities that affect the health of their communities. And even when hospitals perform many low-value procedures — those that research has shown to be of limited or no benefit — their patients generally have a low risk of dying both in the hospital and after being discharged, as well as a low risk of having to be readmitted.
No previous hospital rankings use “civic leadership,” which includes community-minded policies such as charity care, financial aid, and paying all staffers a living wage, or “value of care,” meaning whether a hospital avoids 13 procedures of questionable or clearly absent clinical benefit. The Lown Institute, a nonprofit think tank in Brookline, Mass., incorporated both measures into its rankings of 3,282 hospitals because “it is time for hospitals to rethink what it means to be great,” said Lown’s president, physician Vikas Saini.
Civic leadership matters because the health of the people in a hospital’s community “reflect things outside the four walls of a hospital,” he said. “If one patient is going back to a community without a lot of resources, where health equity is low, and another is going back to a wealthier community, their [long-term] health will be very different even if the quality of care in the hospital was identical. Hospitals have an obligation to improve the health of the outside community.”
Veterans of hospital rankings generally applauded Lown’s efforts, with caveats.
“I love that they’re measuring civic leadership,” said Sara Singer of Stanford University School of Medicine, an expert in health care management. “I also think they’re right to evaluate overuse of low-value procedures: You want to be sure you aren’t going to receive treatments you shouldn’t be receiving.”
She questioned, however, whether those measures should be bundled into a composite score, as Lown did. Quality of care indicators such as staffing levels and patient outcomes such as surgical mistakes and bedsores account for 50% of a hospital’s composite ranking and associated letter grade, while civic leadership counts for 30% and value of care 20%.
“I’m not sure civic leadership should influence where a patient chooses to get care as much as quality measures should,” Singer said, “though I can see using it to decide where you might make a charitable contribution.”
In contrast, patients would do well to consider a hospital’s overuse of procedures that research has shown to have little clinical benefit, she said, such as knee arthroscopy, spinal fusions, EEG for headache, hysterectomies for benign conditions such as uterine fibroids or pelvic organ prolapse, and putting stents in renal arteries.
Although a patient having, say, a hip replaced might not care whether a hospital performs many vertebroplasties (injecting bone “cement” into vertebrae to treat osteoporosis) or other low-value procedures unrelated to her planned surgery, Singer said, “I can imagine that if a hospital is overtreating patients with these particular procedures, it might overmedicate, oversedate, or overtreat you for what you’re there for, too.” In addition, some low-value care disproportionately affects people of color: Black women are more likely to have unnecessary hysterectomies than white women are.
Many hospitals perform high numbers of low-quality procedures, which tend to be lucrative (and waste an estimated $100 billion per year in health care spending). “The right thing to do financially isn’t necessarily the right thing to do for patients,” said Leah Binder, president and CEO of the Leapfrog Group, a nonprofit backed by large employers that aims to identify and promote high-quality, high-value health care and whose hospital ratings emphasize patient safety.
She called Lown’s decision to downgrade a hospital for performing many low-quality procedures “a breakthrough” in hospital ratings. “We know inappropriate care is an extremely significant problem for the health care system,” Binder said. “It’s also a terrible tragedy for individual patients to go through an unnecessary procedure.”
The American Hospital Association, however, said in a statement that the report offers consumers no “accurate and useful information,” instead offering “a hodgepodge of composite score, ranking, star ratings, and letter grades that will, at best, confuse consumers and likely mislead them.”
In Lown’s composite rankings, which are based on 2017 data from Medicare and other government sources, the top hospitals are JPS Health Network in Fort Worth, Texas; Marshall Medical Center in Placerville, Calif.; UPMC McKeesport in Pennsylvania; Seton Northwest Hospital in Austin, Texas; and Mercy Health-West Hospital in Cincinnati. Each scored A or A+ on all three measures, showing it is possible to do well by the community while also delivering excellent patient care, Saini said.
Of course, hospital rankings reflect the values of the groups that produce them. For instance, JPS gets an underwhelming C from Leapfrog, due to safety failures (patient bedsores and falls), unresponsive doctors and nurses, and surgical problems (wounds splitting open and dangerous blood clots).
Of the top 100 in the Lown ranking, 91 are nonprofits. Only nine are safety-net hospitals, even though they account for 21% of the total. That’s probably because these hospitals tend to serve poorer communities, and even if they provide excellent care, patients might not receive the high-quality follow-up care that can keep them alive and healthy. Quality of care includes the percentage of patients who die one month, three months, and one year after their hospital stay.
“Life expectancy,” said Saini, often “depends more on your ZIP code than your genetic code” — an argument for hospitals to contribute to community groups that make a ZIP code healthier.
The top 100 also includes 53 teaching hospitals, which make up only one-third of all hospitals. Their overrepresentation reflects generally excellent patient outcomes and a culture of avoiding procedures that lack scientific evidence of efficacy.
The starkest disparity is between many hospitals’ excellent patient outcomes and their poor civic leadership, as measured by Lown. (It used Internal Revenue Service and other government data for CEO pay and spending on charity care and community organizations.) The leaders for civic leadership were Harris Health System in Houston and five New York City public hospitals.
On average, 2.8% of hospital expenses went to charity care. But while the most charitable spent 15% or more, about 150 spent less than 0.1%. And although some nonprofit hospitals, whose tax-exempt status requires them to provide “community benefits,” spent 20% or more on their community, some spent less than 1%.
A number of hospitals renowned for their quality of care got A+ or A for patient outcomes but a D for civic leadership, including Massachusetts General Hospital, the Cleveland Clinic, the Mayo Clinic, and the University of Washington in Seattle. Teaching hospitals such as these do pretty well on supporting their communities, but pay equity — multimillion-dollar salaries for top executives — sinks them in Lown’s calculation of civic leadership. Not a single hospital in the top 100 for patient outcomes was in the top 100 for civic leadership, and vice versa.
Few patients are likely to reject a hospital based on how much it pays its CEO relative to its custodians. But Binder called civic leadership an important metric. “If there is anything you want out of a hospital, it’s ethics,” she said. Charity care, community support, and pay equity “are informative about a hospital’s culture.”
https://www.statnews.com/2020/07/07/new-hospital-ranking-counts-doing-good-nearly-as-much-as-doing-well/
Voters in deep-red Oklahoma approve Medicaid expansion
by Amy Goldstein - The Washington Post - July 1, 2020
The expansion’s approval, by a slender margin, means that an estimated 250,000 additional Oklahoma residents will be eligible for the public insurance, including nearly 50,000 who have lost coverage as unemployment has soared this year.
The 50.5 percent vote in favor of Oklahoma’s ballot question, announced late Tuesday night, shows that, even in red states, voters are significantly less hostile to the Affordable Care than President Trump, whose administration is trying to invalidate the law in a case before the Supreme Court. The ACA is the law that gives states the ability to expand Medicaid, a program run jointly by states and the federal government that originated out of the 1960s’ War on Poverty. With Tuesday’s vote, all but 13 states have decided to allow adults without children at home and those with slightly higher incomes into the program.
“It’s important for the country to know what happened in Oklahoma last night,” Amber England, campaign manager for Yes on 802, the grass-roots group leading the effort to pass the measure, said Wednesday. “In the middle of the pandemic, Oklahomans stood up to deliver health care to our friends, families and neighbors.”
Question 802 was the number of the initiative on the state’s primary ballot. She said volunteers collected 313,000 signatures — a state record — to get the question before voters, and hosted Zoom happy hours instead of house parties in this pandemic spring. Both proponents and opponents ran ads.
The vote results do not expand Medicaid in the Sooner State immediately or automatically. Under the wording change to the state constitution, the expansion will start in one year. The state is required within 90 days to submit to federal health officials a request to make the change to its Medicaid program. And the state legislature would need to agree to pay for the state’s portion of funding for the expansion, at least 90 percent of which is covered by federal money under ACA rules.
Approving the change “is huge, but it’s also just the start,” said Carly Putnam, policy director of the Oklahoma Policy Institute, which favors the expansion. “We are finally at the point where we can do the hard work to get this implemented.”
Oklahoma Gov. Kevin Stitt (R) immediately made his opposition clear.
“Our Oklahoma legislators now have the difficult job of deciding where we will find an estimated $200 million in funding to support this constitutional mandate,” Stitt said in a statement Wednesday.
With states’ finances eroded from shutting down large parts of their economy to help protect people from the coronavirus, Stitt said, “we are currently looking at a $1 billion deficit for this upcoming year, and the options on the table are raise taxes on hard working Oklahomans or cut finding to core services, such as education, roads and bridges or public safety.”
In Oklahoma, the Medicaid vote occurred against a complicated backdrop. The state is the only one so far that had taken the Trump administration up on an offer to abandon the program’s traditional status as a federal entitlement, in which each state is paid a fixed amount for each person who qualifies. Instead, the administration has said it is willing to free states from a lot of federal rules if they switch to a per-person cap — or a block grant, in which a state’s federal money would be fixed in times of economic crisis, such as a pandemic, when more people would qualify. Oklahoma applied for such a switch this spring, and it is unclear how the expansion vote will affect that.
According to the federal Bureau of Labor Statistics, Oklahoma’s unemployment rate for the civilian labor force shot up from 3.2 percent in February to 14.7 percent in April.
Stitt cited the sharp rise in unemployment — and a bigger pool of residents who now qualify for Medicaid — in May when he vetoed a bill that would have provided money for the first phase of the Medicaid transition to a block grant the governor has asked federal officials to approve.
In embracing a more expansive version of Medicaid, residents of Oklahoma — a state in which about two-thirds of voters supported Trump in the 2016 election — fit within a broad political shift. A May poll by the Kaiser Family Foundation, a nonpartisan health research organization, showed that two-thirds of people in states that had not expanded Medicaid thought their state should do so. That preference was even more common (72 percent) among adults in those states who said they or someone in their home had lost pay or a job during the pandemic.
Oklahoma’s Medicaid ballot initiative was different from the four others, because it called for a change to a state constitution rather than state laws. Others have hit snags after the vote. Maine passed a ballot initiative in late 2017, but Medicaid did not expand there until a Republican governor was succeeded by a Democrat in early 2019. Political wrangling ensued in Utah and Idaho before the expansions began there. Like those two states, Nebraska approved an expansion in November 2018, but it is not scheduled to take effect until this fall.
Striking BIW workers will lose health insurance in midst of pandemic
Workers continue picketing and gathering after the shipyard announced Monday Two more workers have tested positive for coronavirus.
Staff Reports - Maine Times Record - July 1, 2020
BATH — Members of the Bath Iron Works union on strike since last week are losing their health insurance in the midst of a pandemic Wednesday unless they opt to pay for a plan out of pocket.Machinist Union Local S6, which represents 4,300 of the shipyard’s 6,700 employees, went on strike June 22 after rejecting the 3-year contract proposal over disagreements about the company’s plans to continue hiring subcontractors and proposed changes to worker seniority privileges.
“The choice is very simple. I had to strike. There was no other option,” said Brad Farrell, who’s married and has four children, and fears subcontracting and seniority changes could force him out of his job in the tin shop.
Workers are preparing for a lengthy strike, looking at other job and health care options. Keeping health insurance through the COBRA program can cost up to a couple of thousand dollars a month. Others said they will simply go without insurance.
Kelley Ammons, a 58-year-old marine electrician, opted not to purchase insurance. She filled a blood pressure prescription Tuesday, before the expiration of the company’s insurance, and will have to make it last.
“Hopefully that’ll get me through until the team can get back to the negotiating table and work out a deal,” Ammons said.
Gordon Campbell, a 55-year-old sandblaster, has money set aside, and he’s paying more to be on his wife’s insurance. “I just hope that both sides will get together and try to resolve this,” he said.
Bath Iron Works, a subsidiary of Virginia-based General Dynamics, provided a good insurance plan for workers because the union negotiated for it, and that underscores the necessity of fighting for a good contract, said union spokesman Tim Suitter.
Suitter said workers knew they would lose their Cigna health insurance starting in July, and while there are extension coverage plans workers can purchase, “the premiums are outrageous,” with a lot of out-of-pocket costs.
BIW is one of the Navy’s five largest shipbuilders and one of only two that make destroyers, the workhorse of the fleet. The shipyard is already about six months behind schedule, and it will need subcontractors to help get back on schedule, Bath Iron Works President Dirk Lesko has said.
The union has characterized some of the shipyard’s proposals as an attempt to break the union, while the company contends it needs to streamline operations to lower prices to remain competitive.
The company hired 1,800 workers last year and is hiring another 1,000 this year, so there’s no effort to shrink the workforce, the company said.
PICKETING, GATHERINGS CONTINUE DESPITE PANDEMIC
Monday, BIW announced two more workers tested positive for COVID-19. These two new positive cases were tied to the shipyard’s fourth positive case, announced last week. The company said the workers had been carpooling together. There have now been six total cases at the shipyard since the pandemic reached Maine in March.
“It’s just one more thing that you have to worry about being on strike right now, as we are in the middle of that pandemic and it does raise the stakes for everyone involved, and certainly why we want to get back to the table and work through an agreement,” Suitter said.
The COVID-19 pandemic has claimed the lives of 105 in Maine as of Tuesday, according to the latest figures from the Maine CDC. To date, the Maine CDC has reported 3,219 total cases of COVID-19. That figure includes 2,863 cases that were confirmed through molecular tests and 356 “probable” cases in which a person with symptoms either tested positive on an antibody test or had close contacted with a known infected person. There were 491 active cases in Maine as of Monday, according to the Portland Press Herald.
The Maine CDC planned to offer testing to 53 people who were determined to have been potentially exposed to three workers who have tested positive for COVID-19 at Bath Iron Works. If necessary, the Maine CDC will offer department-by-department testing at the shipyard, which is one of Maine’s largest employers.
Suitter said the union is making masks available and encouraging union members to wear them. However, the union is still not requiring workers to wear masks while picketing or attending union events.
“Unfortunately it’s hard to make that mandatory, especially when a lot of people are practicing the social distancing,” he said Tuesday.
Bath Deputy Police Chief Andrew Booth said there were reportedly about 200 people at a small barbeque at the union hall on Washington Street in Bath at around 9 p.m. last Friday night. Booth said it drew more people than police were comfortable with.
The Local S6 plans to host a pig roast at the union hall on Washington Street on Friday. Booth said he is worried the event would draw more than 50 people, which is the limit for social gatherings set by Gov. Janet Mills. If there are too many people, the police will ask them to disperse, Booth said.
“We’ve got confirmed cases in the yard and it’s involving picketers,” Booth said Tuesday. “Now that there’s an outbreak, they’ve got to start taking things a little bit more seriously.”
Suitter said the pig roast is part of the union’s work to keep workers’ spirits up during the strike.
“It’s certainly one of those things that nobody wants to do,” he said. “They’re faced with not having a paycheck, faced with losing their insurance. It’s a trying time for everybody. The company doesn’t seem to have any interest in working through anything or getting back to the table soon, so anything we can do fo tour embers to last try to keep up their spirits is what we’re going to continue to do.”
https://www.pressherald.com/2020/06/30/striking-biw-workers-will-lose-health-insurance-in-midst-of-pandemic/
Letter to the editor: BIW strike exposes issues with employer-sponsored insurance
by Dan Bryant, M.D. - Portland Press Herald - June 28, 2020
Neither the shipyard nor workers should have to deal with details of
health care coverage when key workplace issues remain unaddressed.
When health care coverage is tied to employment, labor negotiations
can suffer. The stalled contract negotiations between Bath Iron Works
and Machinists Union Local S6 and the resulting strike are a good example of this.The health care section of BIW’s June 13 “last, best and final offer” included an increase in deductibles, prescription drug co-pays and out-of-pocket maximums in 2022, as well as a 5 percent annual increase in employee contributions in the years 2021-2023. According to Local S6 District Lodge 4’s June 11 negotiation update to members, “Depending on your medical plan and specific medical conditions that you or your family may have, the changes in health care could eat up the proposed wage increase.”
Deciding the pros and cons of these details is far beyond me, but what seems obvious is that neither BIW nor the union should have to be mired down in them when so many other important workplace issues need to be negotiated. A strike is the last thing either side, or the Maine economy, needs right now, but one is well underway. This makes clear that health care cost concerns have taken time away from addressing the key disagreements: subcontractors, work rules and seniority.
It’s time to free both employers and employees from the albatross of employment-based health care coverage.
Daniel Bryant, M.D.
Cape Elizabeth
June 28, 2020
https://www.pressherald.com/2020/06/28/letter-to-the-editor-biw-strike-exposes-issues-with-employer-sponsored-insurance/
Move to repeal Affordable Care Act ‘just inviting chaos,’ Maine leaders say
Should the U.S. Supreme Court uphold the Trump administration's effort
to overturn the law, they say, the consequences would reverberate
throughout the health care system.
by Glen Jordan - Portland Press Herald - July 4, 2020
Jeff Austin, vice president of government relations for the Maine
Hospital Association, considered what the state’s health care landscape
would look like if the Trump administration is successful in repealing
the Affordable Care Act, also known as “Obamacare.”
“It would cause a lot of problems,” Austin said, “for a lot of people.”Austin was forced to reflect on such a possibility because of a brief filed June 25 to the U.S. Supreme Court in a case brought by 18 Republican state attorneys general (and initially joined by two governors, including Paul LePage of Maine). They, with support from the president, seek to overturn the 2010 health care law on the grounds that its now-hobbled individual mandate is unconstitutional.
Four days after the filing, the Democratic-led U.S. House of Representatives passed a bill that would strengthen and expand the ACA, allow the federal government to negotiate lower prescription drug prices and put pressure on the 14 states that have opted against expanding Medicaid. The Republican-led Senate is unlikely to consider the measure, but it does offer a stark contrast between the two parties in advance of the November elections and no doubt will be the subject of countless campaign ads.
“When you have somebody like President Trump, or states who are saying, ‘Let’s just get rid of the ACA and figure out where we can go from here,’ that is just inviting chaos,” said Aaron Frey, Maine’s attorney general. “And chaos is exactly the opposite of what we need.”
Frey, a Democrat who served three terms in the Maine House before joining the administration of Gov. Janet Mills as attorney general, extracted Maine from what he called “the wrong side” of the ACA litigation and joined a bipartisan amicus brief that supports the landmark health care law.
In Maine, Austin and other health experts described the chaos they believe would follow a successful ACA repeal. The rate of Mainers without health insurance would more than double, from about 51,000 citizens to 134,000, according to a recent estimate from the Urban Institute.
Maine’s uninsured rate had dropped from about 10 percent in 2014 to 8 percent four years later. That was still the highest in New England until last year’s figure dropped to 4.9 percent after Maine voters approved a Medicaid expansion in a 2017 referendum and Mills took over from LePage, who had refused to implement the change.
“Immediately, we’d be looking at 83,000 Mainers who would stand to lose their health coverage because of an ACA invalidation,” Frey said. “That’s just at the front end. That doesn’t explain the different repercussions that might happen when you see the problems of how people are going to access health care and what it’s going to mean for their families.”
Through the end of June, 57,665 Mainers had health insurance through the expansion of Medicaid, known in the state as MaineCare. An additional 62,031 signed up for insurance through the ACA marketplace during the Nov. 1 through Dec. 15 regular enrollment period, although that number may be higher because pandemic-related layoffs trigger a special enrollment period of 60 days following loss of coverage.
“I would say that it’s higher,” said Carol Zechman, senior director of access to care at MaineHealth. “We’re definitely doing special enrollments and seeing people come in that way.”
Ann Woloson, executive director of Augusta-based Consumers for Affordable Health Care, said people can apply for MaineCare anytime. She urged anyone who recently lost employer-provided health insurance coverage to call the state’s Health Insurance Consumer Assistance Program (800-965-7476) for help sorting through options or applying for ACA marketplace coverage.
A repeal of the entire ACA also could mean a reversion to 2010 conditions, when insurance plans could offer fewer benefits and deny coverage to those with pre-existing medical conditions. Whether the Supreme Court could simply strike the individual mandate portion of the law and leave its consumer protections in place remains to be seen.
U.S. Sen. Susan Collins, a Republican, voted in 2017 to zero out the tax penalty for the individual mandate, which says citizens must have health insurance or pay a penalty. Critics say that vote helped set the stage for the current lawsuit.
However, Collins also was one of three Republicans who voted that year against a so-called skinny repeal of the ACA, along with Sens. Lisa Murkowski of Alaska and the late John McCain of Arizona.
In a statement to the Portland Press Herald, Collins called the Trump administration’s decision to submit the new brief “the wrong policy at the worst possible time as our nation is in the midst of a pandemic. The Affordable Care Act remains the law of the land, and it is the Department of Justice’s duty to defend it.”
Collins also argued that had Congress wanted to repeal the entire act, it could have done so.
“Instead, it took a targeted approach by eliminating the penalty on families making just barely more than 400 percent of the poverty level who simply could not afford to purchase insurance,” she said. “Congress maintained important consumer protections in the ACA for people with preexisting conditions such as asthma, arthritis, cancer, diabetes and heart disease.”
Rep. Thom Harnett, a Democrat who represents Gardiner and Farmingdale, said access to adequate and affordable health care should never be a partisan political issue.
“It strikes me as surreal to even be having this discussion,” he said. “We are in the midst of a global pandemic and the worst public health crisis in our country in over 100 years … and seeing our poorer populations suffering terrible health outcomes. Yet despite all that, there are efforts underway to strip 20 million people of the health care they currently receive under the Affordable Care Act.”
Austin, whose association represents Maine’s 36 hospitals, said all of them are nonprofit entities, and that in any given year about half will end up losing money. He said eight of the hospitals have been in the red for five consecutive years and two are restructuring debt in Chapter 11 bankruptcy proceedings.
The COVID-19 pandemic resulted in significant revenue declines from postponed elective surgeries as well as fewer emergency room visits. Austin estimated losses of roughly $600 million from mid-March to July, with federal money providing relief of about $350 million.
“That still leaves a hole,” he said. “And if the ACA goes away and another 150,000 or 175,000 people go uninsured, that’s a massive revenue loss for our guys, because that emergency room door remains open regardless of your ability to pay.”
Frey, the attorney general, said he plans to add his voice “at every opportunity to support the Affordable Care Act and the important access it provides to meaningful insurance for hundreds of thousands of Mainers.”
https://www.pressherald.com/2020/07/04/defeat-of-obamacare-would-be-catastrophic-for-many-in-maine-state-leaders-say/
Early Coronavirus Testing Restrictions Led To Some Big ER Bills
By Julie Appleby - Kaiser Health News - July 6, 2020
Fresh off a Caribbean cruise in early March, John Campbell developed a
cough and fever of 104 degrees. He went to his primary care physician
and got a flu test, which came up negative.
Then things got strange. Campbell says the doctor then turned to him and said, "I've called the ER next door, and you need to go there. This is a matter of public health. They're expecting you."
It was March 3, and no one had an inkling yet of just how bad the COVID-19 pandemic would become in the U.S.
At the JFK Medical Center near his home in Boynton Beach, Fla., staffers met him in protective gear, then ran a battery of tests — including bloodwork, a chest X-ray and an electrocardiogram — before sending him home. But because he had not traveled to China — a leading criterion at the time for coronavirus testing — Campbell was not swabbed for the virus.
A $2,777 bill for the emergency room visit came the next month.
Now Campbell, 52, is among those who say they were wrongly billed for the costs associated with seeking a COVID-19 diagnosis.
Why insurers aren't paying
While most insurers have promised to cover the costs of testing and related services — and Congress passed legislation in mid-March enshrining that requirement — there's a catch. The law requires the waiver of patient cost-sharing only when a coronavirus test is ordered or administered.
And therein lies the problem. In the early weeks of the pandemic and through mid-April in many places, testing was often limited to those with specific symptoms or situations, likely excluding thousands of people who had milder cases of the virus or had not traveled overseas.
"They do pay for the test, but I didn't have the test," says Campbell, who appealed the bill to his insurer, Florida Blue. More on how that turned out later.
"These loopholes exist," says Wendell Potter, a former insurance industry executive who is now an industry critic. "We're just relying on these companies to act in good faith."
Exacerbating the problem: Many of these patients were directed to go to hospital emergency departments — the most expensive place to get care — which can result in huge bills for patients.
Insurers say they fully cover costs when patients are tested for the coronavirus, but what happens with enrollees who sought a test — but were not given one — is less clear.
KHN asked nine national and regional insurers for specifics about how they are handling these situations.
Responses to those queries have been mixed. Three — UnitedHealthcare, Kaiser Permanente and Anthem — say they do some level of automatic review of potential COVID-19-related claims from earlier in the pandemic, while a fourth, Quartz, says it will investigate and waive cost sharing for suspected COVID-19 patients if the member asks for a review. Humana says it is reviewing claims made in early March, but only those showing confirmed or suspected COVID-19. Florida Blue, similarly, says it is manually reviewing claims, but only those involving COVID tests or diagnoses. The remaining insurers point to other efforts, such as routine audits that look for all sorts of errors, along with efforts to train hospitals and doctors in the proper COVID billing codes the providers should use to ensure their patients aren't incorrectly hit with a bill. Those were Blue Cross Blue Shield of Michigan, CIGNA and the Health Care Services Corp., which operates Blues plans in Illinois, Montana, New Mexico, Oklahoma and Texas.
All nine insurers say patients should reach out to them or appeal a claim if they suspect an error.
To be sure, it would be a complex effort for insurers to go back over claims from March and April, looking for patients who might qualify for a more generous interpretation of the cost waiver because they were unable to get a coronavirus test. And there's nothing in the CARES Act passed by Congress — or subsequent guidance from regulatory agencies — about what to do in such situations.
Still, insurers could review claims, for example, by looking for patients who received chest X-rays, and diagnoses of pneumonia or high fever and cough, checking to see if any might qualify as suspected COVID-19 cases, even if they were not given a diagnostic test, Potter says.
One thing is clear from the responses from insurers to our questions: Much of the burden falls on patients who think they've been wrongly billed – it's left to them to call that to the attention of the insurer and the hospital, urgent care center or doctor's office where they were treated.
Some states have broader mandates that could be read to require the waiver of cost sharing even if a COVID test was not ordered or administered, says Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
But no matter where you live, she says, patients who get bills they think are incorrect should contest them.
"I've heard a lot of comments that claims are not coded properly," says Corlette. "Insurers and providers are on a learning curve. If you get a bill, ask for a review."
Scarce tests, rampant virus
In some places, including the state of Indiana, the city of Los Angeles and St. Louis County, Mo., a test is now offered to anyone who seeks one. Until recently, tests were scarce and essentially rationed, even though more comprehensive testing could have helped health officials battle the epidemic.
But even in the early weeks, when Campbell and many others sought a diagnosis, insurers nationwide were promising to cover the cost of testing and related services. That was good public relations and good public health: Removing cost barriers to testing means more people will seek care and thus could prevent others from being infected. Currently, the majority of insurers offering job-based or Affordable Care Act insurance say they are fully waiving copays, deductibles and other fees for testing, as long as the claims are coded correctly. (The law does not require short-term insurance plans to waive cost sharing.) Some insurers have even promised to fully cover the cost of treatment for COVID-19, including hospital care.
But getting stuck with a sizable bill has become commonplace.
"I only went in because I was really sick and I thought I had it," says Rayone Moyer, 63, of La Crosse, Wis., who was extra concerned because she has diabetes. "I had a hard time breathing when I was doing stuff."
On March 27, she went to Gundersen Lutheran Medical Center, which is in her Quartz insurance network, complaining of body aches and shortness of breath. Those symptoms could be COVID-19-related, but could also signal other conditions. While there, she was given an array of tests, including bloodwork, a chest X-ray and a CT scan.
She was billed in May: $2,421 by the hospital, plus more than $350 in doctor bills.
"My insurance applied the whole thing to my deductible," Moyer says. "Because they refused to test me, I've got to pay the bill. No one said, 'Hey, we'll give you $3,000 worth of tests instead of the $100 COVID test,'" she says.
Quartz spokesperson Christina Ott says patients with concerns like Moyer's should call the insurance company's customer service number and ask for an appeals specialist. The insurer, she says, will waive cost sharing for some members who sought a diagnosis.
"During the public health emergency, if the member presented with similar symptoms as COVID, but didn't receive a COVID-19 test and received testing for other illnesses on an outpatient basis, then cost sharing would be waived," she says.
Moyer says she has filed an appeal and was notified by the insurer of a review expected in mid-July. Back in Florida, Campbell filed an appeal of his bill with Florida Blue on April 22, but didn't hear anything until the day after a KHN reporter called the insurer in June to ask about his case.
Then, Campbell received phone calls from Florida Blue representatives. A supervisor apologized, saying the insurer should not have billed him and that 100% of his costs would be covered.
"Basically they said, 'We've changed our minds,'" Campbell says. "Because I was there so early on, and the bill was coded incorrectly."
https://www.mainepublic.org/post/early-coronavirus-testing-restrictions-led-some-big-er-bills
Then things got strange. Campbell says the doctor then turned to him and said, "I've called the ER next door, and you need to go there. This is a matter of public health. They're expecting you."
It was March 3, and no one had an inkling yet of just how bad the COVID-19 pandemic would become in the U.S.
At the JFK Medical Center near his home in Boynton Beach, Fla., staffers met him in protective gear, then ran a battery of tests — including bloodwork, a chest X-ray and an electrocardiogram — before sending him home. But because he had not traveled to China — a leading criterion at the time for coronavirus testing — Campbell was not swabbed for the virus.
A $2,777 bill for the emergency room visit came the next month.
Now Campbell, 52, is among those who say they were wrongly billed for the costs associated with seeking a COVID-19 diagnosis.
Why insurers aren't paying
While most insurers have promised to cover the costs of testing and related services — and Congress passed legislation in mid-March enshrining that requirement — there's a catch. The law requires the waiver of patient cost-sharing only when a coronavirus test is ordered or administered.
And therein lies the problem. In the early weeks of the pandemic and through mid-April in many places, testing was often limited to those with specific symptoms or situations, likely excluding thousands of people who had milder cases of the virus or had not traveled overseas.
"They do pay for the test, but I didn't have the test," says Campbell, who appealed the bill to his insurer, Florida Blue. More on how that turned out later.
"These loopholes exist," says Wendell Potter, a former insurance industry executive who is now an industry critic. "We're just relying on these companies to act in good faith."
Exacerbating the problem: Many of these patients were directed to go to hospital emergency departments — the most expensive place to get care — which can result in huge bills for patients.
Insurers say they fully cover costs when patients are tested for the coronavirus, but what happens with enrollees who sought a test — but were not given one — is less clear.
KHN asked nine national and regional insurers for specifics about how they are handling these situations.
Responses to those queries have been mixed. Three — UnitedHealthcare, Kaiser Permanente and Anthem — say they do some level of automatic review of potential COVID-19-related claims from earlier in the pandemic, while a fourth, Quartz, says it will investigate and waive cost sharing for suspected COVID-19 patients if the member asks for a review. Humana says it is reviewing claims made in early March, but only those showing confirmed or suspected COVID-19. Florida Blue, similarly, says it is manually reviewing claims, but only those involving COVID tests or diagnoses. The remaining insurers point to other efforts, such as routine audits that look for all sorts of errors, along with efforts to train hospitals and doctors in the proper COVID billing codes the providers should use to ensure their patients aren't incorrectly hit with a bill. Those were Blue Cross Blue Shield of Michigan, CIGNA and the Health Care Services Corp., which operates Blues plans in Illinois, Montana, New Mexico, Oklahoma and Texas.
All nine insurers say patients should reach out to them or appeal a claim if they suspect an error.
To be sure, it would be a complex effort for insurers to go back over claims from March and April, looking for patients who might qualify for a more generous interpretation of the cost waiver because they were unable to get a coronavirus test. And there's nothing in the CARES Act passed by Congress — or subsequent guidance from regulatory agencies — about what to do in such situations.
Still, insurers could review claims, for example, by looking for patients who received chest X-rays, and diagnoses of pneumonia or high fever and cough, checking to see if any might qualify as suspected COVID-19 cases, even if they were not given a diagnostic test, Potter says.
One thing is clear from the responses from insurers to our questions: Much of the burden falls on patients who think they've been wrongly billed – it's left to them to call that to the attention of the insurer and the hospital, urgent care center or doctor's office where they were treated.
Some states have broader mandates that could be read to require the waiver of cost sharing even if a COVID test was not ordered or administered, says Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
But no matter where you live, she says, patients who get bills they think are incorrect should contest them.
"I've heard a lot of comments that claims are not coded properly," says Corlette. "Insurers and providers are on a learning curve. If you get a bill, ask for a review."
Scarce tests, rampant virus
In some places, including the state of Indiana, the city of Los Angeles and St. Louis County, Mo., a test is now offered to anyone who seeks one. Until recently, tests were scarce and essentially rationed, even though more comprehensive testing could have helped health officials battle the epidemic.
But even in the early weeks, when Campbell and many others sought a diagnosis, insurers nationwide were promising to cover the cost of testing and related services. That was good public relations and good public health: Removing cost barriers to testing means more people will seek care and thus could prevent others from being infected. Currently, the majority of insurers offering job-based or Affordable Care Act insurance say they are fully waiving copays, deductibles and other fees for testing, as long as the claims are coded correctly. (The law does not require short-term insurance plans to waive cost sharing.) Some insurers have even promised to fully cover the cost of treatment for COVID-19, including hospital care.
But getting stuck with a sizable bill has become commonplace.
"I only went in because I was really sick and I thought I had it," says Rayone Moyer, 63, of La Crosse, Wis., who was extra concerned because she has diabetes. "I had a hard time breathing when I was doing stuff."
On March 27, she went to Gundersen Lutheran Medical Center, which is in her Quartz insurance network, complaining of body aches and shortness of breath. Those symptoms could be COVID-19-related, but could also signal other conditions. While there, she was given an array of tests, including bloodwork, a chest X-ray and a CT scan.
She was billed in May: $2,421 by the hospital, plus more than $350 in doctor bills.
"My insurance applied the whole thing to my deductible," Moyer says. "Because they refused to test me, I've got to pay the bill. No one said, 'Hey, we'll give you $3,000 worth of tests instead of the $100 COVID test,'" she says.
Quartz spokesperson Christina Ott says patients with concerns like Moyer's should call the insurance company's customer service number and ask for an appeals specialist. The insurer, she says, will waive cost sharing for some members who sought a diagnosis.
"During the public health emergency, if the member presented with similar symptoms as COVID, but didn't receive a COVID-19 test and received testing for other illnesses on an outpatient basis, then cost sharing would be waived," she says.
Moyer says she has filed an appeal and was notified by the insurer of a review expected in mid-July. Back in Florida, Campbell filed an appeal of his bill with Florida Blue on April 22, but didn't hear anything until the day after a KHN reporter called the insurer in June to ask about his case.
Then, Campbell received phone calls from Florida Blue representatives. A supervisor apologized, saying the insurer should not have billed him and that 100% of his costs would be covered.
"Basically they said, 'We've changed our minds,'" Campbell says. "Because I was there so early on, and the bill was coded incorrectly."
https://www.mainepublic.org/post/early-coronavirus-testing-restrictions-led-some-big-er-bills
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