Health Care Reform Articles - December 21, 2021

https://www.nytimes.com/2021/12/15/upshot/overall-health-spending-record-2020.html?searchResultPosition=1 

Editor's Note -

This link to an interiew with Kay Tillow about the DCE threat to traditional Medicare  is very informative - and scary.

- SPC 

 https://davidswanson.org/talk-world-radio-theyre-privatizing-medicare-while-your-eyes-are-on-a-democracy-summit/

 Editor's Note -

The following clipping contains a link to an interview with health care journalist Merril Goozner about the new Direct Contract Entity program currently being  rolled out by CMS. 

It's well worth the hour devoted it.

A New Way To Think About Medicare

Introduced during the Trump administration, “direct contracting” is a Medicare payment model that allows private medical practices and insurance companies to arrange set payments from Medicare for the year, rather than bill the administration for services. But critics warn that the system, which has continued under the Biden administration, is being exploited by venture capitalists. Merrill Goozner is a health care reporter who has spent decades covering the slow-moving crisis of American healthcare, and he joins to Ryan Grim to discuss the present and possible future of Medicare.

 

Merril Goozner on DCEs

https://play.acast.com/s/deconstructed/a-new-way-to-think-about-medicare

The biggest threat to Medicare you've never even heard of

By Rep. Pramila Jayapal (D-Wash.) and Dr. Susan Rogers - The Hill - December 9, 2021

 

Every year on July 30, advocates across the nation bake cakes and hold rallies to celebrate the anniversary of Medicare, the popular federal program established in 1965 to provide health care to seniors and Americans living with disabilities. The festivities are for good reason: Seniors love Medicare. It is simple, efficient, and empowers them to manage their own health. 

But starting this year, millions of seniors are quietly being enrolled into a program run by third-party middlemen called Medicare Direct Contracting (DC). This is occurring without their full knowledge or consent. If left unchecked, the DC program could radically transform Medicare within a few years, without input from seniors or even a vote by Congress. 

Developed late in the Trump administration, the Medicare DC program allows commercial insurers and other for-profit companies to “manage” care for seniors enrolled in Traditional (fee-for-service) Medicare. Instead of paying doctors and hospitals directly for seniors’ care, Medicare gives these middlemen (called Direct Contracting Entities, or DCEs) a monthly payment to cover a defined portion of each seniors’ medical expenses. DCEs are then allowed to keep what they don’t pay for in health services, a dangerous financial incentive to restrict and ration seniors’ care.

A majority of seniors choose Traditional Medicare over Medicare Advantage, the version of Medicare run by commercial insurers, because they value having free choice of providers and the power to manage their own care. But under the Medicare Direct Contracting program, older Americans who actively chose the popular Traditional Medicare program are automatically enrolled into a Direct Contracting Entity without their full knowledge or consent. 

Seniors in Traditional Medicare may be “auto-aligned” to a DCE if any primary care physician they’ve visited in the past two years is affiliated with that DCE. That means Medicare automatically searches two years of seniors’ claims history without their full consent to find any visits with a participating DCE provider as the basis for enrollment. It’s no wonder that the current DC pilot phase includes potentially 30 million Traditional Medicare beneficiaries enrolled in 53 DCEs across 38 states. 

It gets worse. Who are we trusting to “manage” our seniors’ care? Virtually any type of company can apply to be a DCE, including commercial insurers, venture capital investors, and even dialysis centers. In fact, applicants are approved without oversight from Congress. Unlike other care management models, there isn’t even a requirement that DCEs be majority owned by health care providers. This opens the door to ownership by for-profit entities with no health care expertise at all. 

Wall Street investors are already tripping over themselves to get into the DC program. This should be a huge red flag for taxpayers and anyone concerned about funding Medicare for future generations. While Traditional Medicare spends an impressive 98 percent of its budget on patient care, Direct Contracting Entities only spends 60 percent of our tax dollars on patient care — keeping up to 40% of revenues for their own profit and overhead. We can’t think of any other industry with numbers like these, let alone one entrusted to care for the health of our nation’s seniors. 

If you’ve never heard of Direct Contracting, you’re not alone. The DC program was created by the Center for Medicare and Medicaid Services’ “Innovation Center”, which was established to pilot health payment models without congressional authorization. The Innovation Center can approve and sign contracts with Direct Contracting Entities. They can even scale up the program to cover all of Medicare, without so much as a vote or hearing in Congress. 

That’s why doctors from across the nation are gathering at the Department of Health and Human Services (HHS) this week to ring the alarm bells about Direct Contracting. They’re calling on HHS Secretary Xavier Becerra to end the DC program immediately. They’re also urging members of Congress to demand a hearing on this attempt to sell our beloved Medicare to Wall Street investors. 

Since Direct Contracting is a pilot program, it can and should be stopped in its tracks by the Biden administration while we have the chance. After our experience with commercial Medicare Advantage plans, we already know that inserting a profit-seeking middleman into Medicare ends up costing taxpayers more, with fewer choices and worse outcomes for seniors. 

As a physician and a member of Congress, we’ve never heard a senior ask for their health care to be more complicated, or to have their choice of Traditional Medicare taken away. But that’s exactly what Direct Contracting would do. Traditional Medicare has proven its value for more than half a century. Instead of selling it off to the highest bidder, let’s strengthen and improve its benefits while working to expand it to cover every American.  

 

https://thehill.com/blogs/congress-blog/healthcare/585103-the-biggest-threat-to-medicare-youve-never-even-heard-of?

 

 

The Eisenhower Principle

by Kim Bellard -  The Health Care Blog - December 9, 2021

I’ve finally come to understand why the U.S. healthcare system continues to be such a mess, and I have President Dwight Eisenhower to thank.

I’ve been paying close attention to our healthcare system for, I hate to admit, over forty years now. It has been a source of constant frustration and amazement that – year after year, crisis after crisis – our healthcare system doesn’t get “fixed.” Yes, we make some improvements, like ACA, but mostly it continues to muddle along.

Then I learned about President Eisenhower’s approach to problems:

That’s it!  All these smart people, all these years; they didn’t know how to solve the problem that is our healthcare system, so they all took the Eisenhower approach: enlarge the problem.  Let our healthcare system get so bad that not addressing it no longer is possible.

If, indeed, there is such a point.

The actual Eisenhower quote is more nuanced than the above version. It was:

Whenever I run into a problem I can’t solve, I always make it bigger. I can never solve it by trying to make it smaller, but if I make it big enough, I can begin to see the outlines of a solution.

I guess we’re not yet at the point when the outlines of a solution are clear (Bernie Sanders notwithstanding). 

Instead, we’ve been chipping away at the problem, trying to make it smaller. For example:

• Employer-sponsored health insurance tax preference (WWII)
• Hill-Burton Act (1946)
• Medicare/Medicaid (1965)
• Federal HMO Act (1973)
• Stark Physician Self-Referral Law (1989)
• DGRs (1983) & RBRVS (1992)
• CHIP (1997)
• Medicare Modernization Act (2003)
• Affordable Care Act (2010)

I could add a plethora of non-legislative efforts, largely private-sector driven, such as second surgical opinion (1970’s), PPOs (1980’s), centers of excellence (1980’s), disease management (1990’s), value-based purchasing (2000’s), or digital health (2010’s).  Each was well-intentioned, each was expected to make a dent in a problem, and each was subsumed into the maw of our healthcare system.  

But we still pay way more than any developed country for our healthcare system, for health outcomes that put us, at best middle of the pack. Tens of millions of us still lack health insurance, in part because some states refused to expand Medicaid and in part because people still can’t afford/don’t see the value of health insurance, despite subsidies. Health inequities abound, particularly for people of color. 

Yes, some of the best care in the world can be found here, but most people shouldn’t expect to receive it – it takes luck, money, and/or the right location. Our malpractice system penalizes physicians without protecting most victims of malpractice.  “Public health” has at best been ignored (like most other of our infrastructure) and at worse seen as some sort of Communist plot.

One might have thought that a global pandemic would make the problem big enough. We’ve got over 800,000 people dead already, we’ve overwhelmed many of our hospitals, we’ve burned out large numbers of our healthcare workers, we’ve exposed the fragility of our healthcare (and other) supply chains. Yes, we’ve thrown trillions of dollars at the pandemic, yes, our scientists have developed very effective vaccines in record time, but too many people refuse mitigation measures that might finally bring it to an end. 

Yet still the outlines of a solution continue to elude us. It seems there is no health problem so big that we can’t turn into a political issue, not even a pandemic.

Even before the pandemic, we were facing epidemics of chronic diseases, such as diabetes and obesity, as well as gun violence, opioid addiction, and mental health. We know we should address these, we know we could, but mostly we just shake our heads and offer “hopes and prayers.” 

How many Americans will have to go bankrupt from the cost of healthcare they received? How many Americans will have to suffer or die from the care they didn’t receive – or from the care they did receive? How embarrassed are we willing to be about our health disparities? How reluctant do people in other countries have to get about living/visiting here due to the risk of getting caught up in our healthcare system? 

In Gen Z’s lifetimes, much less those of millennials or Baby Boomers, the problems in our healthcare system have grown from huge to unfathomable.  When it comes to healthcare, we’ve let the problem get big enough. It’s been enlarged to the point it is hurting us, our economy, and our futures. 

Yet here we are, still fumbling for solutions.

It’s possible that the pandemic will cause our healthcare system to collapse and force us to take action on fundamental reforms. More likely, due to the valiant efforts of our healthcare professionals, it will survive this too, and the pandemic will just be one more insult added to our injury. 

It’s possible that when health spending reaches 20% of GDP – as it is projected to do by the end of the decade – we’ll decide we’d had enough, but I remember when we thought 10% was the limit. 

It’s possible that we’ll suddenly recognize that, hey, our declining mortality – which is not all due to COVID — is a real problem, but that’s probably too slow and subtle an indicator for us to act.

By now, we shouldn’t just have shadows of solutions. By now, the problem is so big that solutions should be crystal clear to everyone. But they’re not.

We shouldn’t be surprised. We’re very good at kicking the can down the road. We should be very concerned about the national debt, but we add to it blithely. We should be terrified of the impact that climate change is already having and how much worse it will soon be, but addressing it would require us to make too many changes. 

Our infrastructure is aging, brittle, and outdated, but even the recent Infrastructure and Investment Jobs Act is much smaller than it really needed to be. The racial wealth gap is a consequence of shameful historical patterns, yet continues to widen; it is not survivable for a democracy.

We’ve learned only half of Eisenhower’s adage: we’ve got the letting the problem get bigger part down, but we’ve forgotten the part about how/when to come up with solutions.

Where’s Eisenhower when we need him?

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

https://thehealthcareblog.com/blog/2021/12/14/the-eisenhower-principle/?

 

 

Mississippi’s miserly healthcare system

The poorest and blackest state in the US declined to expand Medicaid, leaving many citizens without coverage

by April Simpson - The Guardian - December 16, 20211

This story was published in partnership with the Center for Public Integrity, a non-profit news organization that investigates inequality.

Jabriel Muhammad pays up to $40 when he sees a doctor at the community health center in Jefferson county in rural south-western Mississippi. And he goes to the center only when he is really ill. But there’s another price to pay for not having health insurance. In October, he was hit with a $1,394 hospital bill for an MRI scan to diagnose why he wasn’t breathing properly.

“We’re poor folks trying to make it as best we can,” said Muhammad, a 40-year-old self-employed carpenter and plumber. “If I make $10,000 with the work that I do in a year, that’s a nice feeling to me.”

In Mississippi, the poorest and blackest state in the US, single adults without children like Muhammad are not eligible for public health insurance, regardless of how little they earn each year. If he lived 30 miles west in Louisiana, across the Mississippi river, he could afford to see a doctor more often.

Louisiana is the only deep south state that expanded Medicaid under the 2010 Affordable Care Act, which extended healthcare access for people who work but don’t have medical coverage. Most of the 2 million people in the US without expanded coverage live in eight states in the south, where the legacy of slavery continues to shape healthcare policies, efforts to alleviate poverty and the life circumstances of thousands of Black people.

In Mississippi, 78% of the people who would become eligible for health insurance if the state expanded Medicaid are poor adults without children, like Muhammad.

“The denial of Medicaid coverage is scandalous,” said Don Simonton, a retired professor from Alcorn State University, a historically Black college in Mississippi. “It is so typical of the power structure of the south from slave days forward: ‘If you’re poor, you better make some money if you don’t want to die.’”

The Center on Budget and Policy Priorities, a thinktank that supports policies to reduce poverty and inequality, says, “Many of the states that have refused expansion have a long history of policy decisions based on racist views of who deserves to get healthcare services.”

The pandemic and the racial justice uprising last year focused the nation’s attention on healthcare disparities that states have allowed to fester, even as the pandemic punctuated how those disparities can be deadly. That’s especially true in rural Black communities that lack adequate access to basic preventive healthcare services to treat chronic diseases.

Medicaid expansion was designed to reduce racial and geographic inequities in health insurance coverage. The expansion also sought to create a national standard; however, that didn’t happen because, as in the past, some states refused to participate.

Jefferson county sits just downstream and across the Mississippi River from Madison parish, Louisiana. Both places, named for former presidents and slave owners, are among the poorest and blackest in the country. But in Madison access to health insurance has cut the amount of unpaid care costs from insurers and patients, demonstrating how access to healthcare can reduce longstanding racial disparities.

Before the Affordable Care Act, more than 20% of adults younger than 65 in both counties were uninsured. But then their paths diverged. Since 2015, a year before Louisiana expanded Medicaid under the ACA, the percentage of uninsured adults in Madison parish has plunged eight percentage points, while it has remained the same in Jefferson county.

Medicaid expansion has also extended a lifeline to some rural hospitals across the country that were threatened with closure because of charity care and bad debt. Since Louisiana expanded Medicaid in 2016, uncompensated care costs dropped 55% among the state’s rural hospitals, according to a study in the March 2021 issue of Health Affairs. And the hospitals are much better off than those in non-expansion states.

In Madison parish, local and hospital leaders are building a new facility that they hope will mean people won’t have to travel 20 or 30 miles to specialty clinics that treat conditions like diabetes or cancer.

Meanwhile, the Jefferson County Hospital & Behavioral Health unit in Mississippi has been limping along for years, in part because it’s being reimbursed at a rate that is too low to cover its costs.

“Our hospital had been for a long time one of the biggest concerns in the community,” said Anthony “Bruce” Walton, president of the Jefferson county board of supervisors. “Because if we lost our hospital, then it’s like a trickle-down effect. We can’t have our prison, our schools. Everything that we have in our small community pretty much revolves around the hospital.”

---

Jefferson county, where Muhammad was born and raised, was one of Mississippi’s wealthiest counties, controlled by a few white families until the end of slavery and the civil war set it on a path to becoming among the nation’s poorest today. About 37% of its residents live below the poverty line, or $26,500 for a family of four. Nearly 70% receive some form of government assistance.

In September, Mississippi’s state economist released a report stating that Medicaid expansion would add 11,300 jobs between 2022 and 2027, significantly reduce hospital costs for unpaid care and pay for itself for at least a decade. Yet governor Tate Reeves insists that expanding Medicaid would be bad medicine.

“I firmly believe that it is not good public policy to place 300,000 additional Mississippians on government-funded healthcare,” Reeves, a Republican, wrote last year in his budget recommendation.

Jefferson county could benefit from jobs. Last year, the county had the fourth-highest unemployment rate in the country at 18.4%.

Highway 61, known as the “Blues Highway”, runs through Jefferson but bypasses the county seat of Fayette. Without the highway traffic, Fayette, like much of the county, feels isolated. Main Street is a mix of empty storefronts, low-income housing, single-family homes, a bank and government buildings. There’s a sprinkling of notable businesses, like a Muslim theatre and bakery.

Muhammad, a member of the New Nation of Islam, a Black nationalist group that supports reparations and advocates for self-determination, is like many residents here who create work for themselves because there aren’t enough good-paying jobs outside the school system, healthcare and government. The state has graded the school district an F. And people with four-year college degrees have trouble finding a job.

“I call it the modern-day slavery,” Alford Perryman, a local health insurance salesman said on a recent morning. He sat at a tall table at 61 One Stop, a Black-owned gas station and community gathering space in Fayette owned by Janell Edwards and her husband. “It’s the new way to keep us from progressively moving forward at a faster pace than they are,” he said, referring to white people with power.

Edwards chimed in: “It is a big conundrum of obstacles that really comes from the same source.”

“Four hundred years,” Perryman said. “Four hundred years,” Edwards replied, “of how we came to this country and then the mentalities that were birthed out of that.”

Medicaid was launched in 1965, a critical year for civil rights. The seeds of the safety net program were in legislation aimed to advance the economic, legal and political rights of Black people and President Lyndon B Johnson’s Great Society, a massive social reform initiative that sought to end poverty, among other goals.

Access to healthcare was a critical part of combating poverty. Initially, the government had considered a federally run national healthcare program to serve vulnerable populations. But southern politicians, who opposed civil rights legislation, shaped federal health policy. Administering Medicaid as a state-run program promised to temper their resistance to what they considered federal overreach. Medicaid has been hamstrung ever since.

“Even while recognizing the path-breaking value of Medicaid, we must concede that it has taken constant political struggle to keep the program alive,” Jamila Michener, co-director of the Cornell Center for Health Equity at Cornell University, writes in her book, Fragmented Democracy: Medicaid, Federalism and Unequal Politics. “The political compromises spawned by that struggle have paved the way for geographic inequities.”

The Medicaid program, which matches federal dollars to state money to provide healthcare to the most vulnerable, is of special benefit to Mississippi. For many states, the match is roughly dollar for dollar. But in Mississippi, for every $1 the state spends on Medicaid, the federal government spends $5.46, more than in any other state.

Federal law mandates that states cover certain qualified, low-income groups such as families, people with disabilities, seniors, pregnant women and children. But the state ultimately decides who else is eligible.

A 2012 US supreme court decision gave states the option to decline to expand eligibility. Their decisions fell largely along partisan lines. That left a coverage gap where some people were too poor to qualify for the health insurance subsidies made available under the Affordable Care Act, but not poor enough to meet state guidelines to receive Medicaid.

The American Rescue Plan Act signed by President Joe Biden in March 2021 also temporarily expands the ACA subsidies, extending them through next year to people with incomes above 400% of the poverty level, or $106,000 for a family of four.

Twelve states nationwide, including Mississippi and seven others in the south, have declined to expand healthcare coverage since the supreme court ruling.

Louisiana’s Democratic governor, John Bel Edwards, opted in by executive order, and since then Medicaid coverage of adults in the state has increased by nearly 40%. In Mississippi and the southern states that stayed out of the plan, the proportion of the adult Medicaid population has stayed the same.

“There’s nothing inherently more deserving about the people in Louisiana,” said Michener. “We can say, ‘Well, it’s Mississippi’s choice.’ I think we always have to balance that logic, which is historically grounded in racism, frankly, and white supremacy. I think we always have to challenge that logic and hold it up to the other things we value.”

---

In Madison parish, 46-year-old Alvin Brown risked crushing medical debt earlier this year when he found himself in the emergency room. The Medicaid program saved him from paying a whopping $9,000 hospital bill.

Brown’s ordeal began in late May. “All of a sudden, I just felt bad,” Brown said. His back hurt and it was painful to urinate. The next day, he visited the emergency room at Madison Parish hospital. A doctor told Brown he was passing a kidney stone and prescribed him medication.

Two days later, Brown was still feeling lousy. Ultimately, he was admitted to a hospital nearly an hour from where he lives.

“That was my first time ever being in the hospital,” he said about the week-long stay. “I never had no [health] issues or nothing.”

It turns out that Brown was dehydrated. As a result, his kidneys began to malfunction. “It was kind of scary,” said Brown, a father of a 15-year-old boy.

He didn’t know he was qualified to receive Medicaid until a hospital employee asked him if he was interested in enrolling in the program. Brown stocks liquor and wine for retail outlets and has an annual household income of $28,000 for a family of three, just under the threshold to qualify for Medicaid coverage.

The coverage kicked in just in time to pay $7,000 toward his $9,000 hospital bill.

---

There’s a deep bent toward self-reliance in Jefferson county that has helped the community withstand its economic challenges.

In 1969, Charles Evers, the brother of slain civil rights leader Medgar Evers, became mayor of Fayette. Despite white flight during his tenure, locals say, he managed to attract some industry to the area and helped launch the local community health center, a pioneer in the movement to provide free and low-cost healthcare.

“We’re not successful because we don’t have the tenacity or the determination,” Perryman said. “We’re not successful because we don’t have people in place that are vouching for us.”

Blocks away on Main Street in Fayette, the New Nation of Islam operates several small businesses with a vision of building a “beautiful, thriving Black community that will be a model for our people, all over the earth,” said the community’s spiritual leader, whose followers call him Son of Man.

A barber by trade, he does carpentry work to support the community’s efforts.

The members of the group support projects like a K-12 school, tucked away in an unincorporated area known as Red Lick. Muhammad is working on his biggest carpentry project to date – a furniture store in an old cleaners building.

The tight-knit community lives and works cooperatively. Son of Man is helping Muhammad pay off his hospital bill, filling the healthcare gap left by the state of Mississippi.

Muhammad is grateful, but he adds: “It hurts my pocket a little because that’s a good little piece of change for somebody who doesn’t make money every day.”

https://www.theguardian.com/society/2021/dec/16/mississippi-miserly-healthcare-system 

 

The Upshot

Overall health spending in the U.S. reached record levels in 2020.

A new report says the amount spent jumped to 19.7 percent of the economy in 2020 from 9.7 percent in 2019, while direct spending on medical care declined.

By Margot Sanger-Katz - NYT - December 15, 2021

The Covid-19 pandemic brought unprecedented trends in health spending last year — with overall health spending reaching its largest share of the U.S. economy ever at 19.7 percent, or $12,530 per person. But direct spending on medical care was lower than it was in 2019.

A new report from the actuaries at the Centers for Medicare and Medicaid Services, published Wednesday in the journal Health Affairs, found that total health spending in the economy grew to $4.1 trillion in 2020, a leap that represented the highest rate of increase since 2002. But nearly all of that growth came from emergency government spending on the pandemic — the effort to rapidly develop Covid vaccinations, infusions of dollars into public health, and economic stimulus spending to states, hospitals and medical providers, meant to insulate them from the shock of shutdowns in the early days of the pandemic.

“Obviously, 2020 was like no other year we’ve estimated in the history of the accounts,” said Aaron Catlin, a deputy director in the Medicare actuary’s national health statistics group.

Spending in most normal categories of health care actually went down. Health spending by businesses, individuals and state and local governments all fell. Direct spending by individuals and health insurers on medical services at hospitals, doctors and dentists also declined.

But federal programs authorized by Congress pumped unusual amounts of money into the health care system, by offering hospitals and medical practices forgivable loans, increasing the federal share of Medicaid spending, and investing billions in public health and vaccine development prograll. Overall spending on health care that did not include public health spending or special pandemic programs grew by 1.2 percent.

 https://www.nytimes.com/2021/12/15/upshot/overall-health-spending-record-2020.html?

 

A hospital asked these parents to pay $45,843 a month for their baby's NICU stay

  By Victoria Knight - Kaiser Health News - December 23, 2021|

 

Baby Dorian Bennett arrived two months early and needed neonatal intensive care. Despite having insurance, mom Bisi Bennett and her husband faced a bill of more than $550,000 and were offered an installment payment plan of $45,843 per month for 12 months.

Close to midnight on Nov. 12, 2020, Bisi Bennett was sitting on the couch in her pajamas and feeling uncomfortable. She was about seven months pregnant with her first child, Dorian, and the thought that she could be in labor didn't even cross her mind.

Then, she felt a contraction so strong it knocked her off the couch. She shouted to her husband, Chris, and they ran to the car to start the 15-minute drive to AdventHealth hospital in Orlando, Florida. About halfway through the trip, Bennett gave birth to Dorian in her family's Mitsubishi Outlander. Her husband kept one hand on his newborn son's back and one hand on the wheel.

Born breech, meaning his head emerged last, Dorian wasn't crying at first, and the terrified new parents feared something was wrong. Chris Bennett turned on the SUV's flashers and flagged down a passing emergency vehicle. The EMS team escorted the family to the hospital.

"He was still connected to me with the umbilical cord when they rolled the two of us together into the hospital," Bisi says. "They cut the cord, and the last thing I heard was, 'He has a pulse,' before they wheeled me away."

"I just cried tears of relief," she says.

Dorian stayed in the neonatal intensive care unit until Jan. 7, 2021, for almost two full months. While Dorian was in the hospital, Bisi wasn't worried about the cost. She works in the insurance industry and had carefully chosen AdventHealth Orlando because the hospital was close to her house and in her insurance network.

Then the bills came.

The Patient: Dorian Bennett, an infant born two months premature. He has health insurance through his mother's employer, AssuredPartners, where she works as a licensed property insurance agent.

Medical Service: A neonatal intensive care unit stay of 56 days. Dorian needed highly technical, lifesaving respiratory and nutritional care until his organs matured. He also received laboratory, radiology, surgery, cardiology and audiology services and treatments.

Service Provider: AdventHealth Orlando in Orlando, Florida. It is a part of the AdventHealth system, a large nonprofit and faith-based group of health care providers with locations across Florida and several other states.

Total Bill: AdventHealth Orlando billed $660,553 for Dorian's NICU care. Because of an insurance snafu, the "patient responsibility" portion of the bill sent to the Bennetts was $550,124. They were offered an installment payment plan of $45,843 a month for 12 months.

What Gives: Under the 2010 health law, nonprofit hospitals are required to provide financial assistance to help patients pay their bills, and payment plans can be part of that assistance. But the Bennett family's experience shows the system is still far from friendly to patients.

The installment amount offered to the Bennetts — $45,843 — resembles an annual salary more than a reasonable monthly payment. The laughably unrealistic plan was apparently automatically generated by the hospital's billing system. A spokesperson for the hospital, David Breen of AdventHealth, did not answer KHN's questions about its billing software or why a five-digit monthly payment was not flagged by the hospital as a problem that might need extra attention.

The size of the Bennetts' bill stems from two overlapping issues: Baby Dorian was born in 2020 and needed hospital care into 2021, and Bisi Bennett's employer shifted its health plan to a different company in January 2021. She informed AdventHealth about the change.

As someone who works in the insurance industry, Bennett was pretty sure that she understood the mix-up and that the charge of more than half a million dollars was unjustified. 

AdventHealth Orlando billed $660,553 for Dorian Bennett's time in the neonatal intensive care unit. The Bennetts' portion of the bill was $550,124, and they were offered an installment payment plan of $45,843 a month for 12 months.

But as Dorian turned a year old last month, the family still had bills pending and a tangle of red tape to fight.

AdventHealth bundled the 2020 and 2021 dates of Dorian's NICU stay and then billed both insurance plans for the whole stay. Both insurance plans said the bill contained dates of care when Dorian was not covered, so neither paid the hospital. The shift from one year to the next flummoxed three large business entities, which seemed unmotivated to resolve the problem quickly.

"A bill this large is a huge crisis for the family, but it's not a huge crisis for the insurance company or for the hospital," says Erin Fuse Brown, an associate professor of law at Georgia State University who studies health care policy.

In 2020, Dorian was covered under a UnitedHealthcare plan, which for in-network providers had a $6,000 deductible and $6,000 out-of-pocket maximum for the family.

In 2021, Bisi Bennett's employer switched its third-party administrator of its self-funded plan from UnitedHealthcare to UMR. The deductible and out-of-pocket maximum did not change.

Although UMR is owned by UnitedHealthcare, the two companies did not communicate well about the case.

"It's indicative of all the ways the system fails the patient," Fuse Brown says. "Even the one who does everything right."

Through the nearly yearlong fight over the bill, the Bennetts were also caring for Dorian, who left the hospital with lingering gastrointestinal issues, and managing Chris' treatment for stage 4 neuroendocrine cancer, which was diagnosed in April. At one point, Bisi says, she felt she was going crazy.

"They're in charge of billing, and I shouldn't be the one having to tell them, 'Bill my one insurance for dates in 2020 and bill my other insurance for dates in 2021,' but I did," she says. "I kept having the same conversation over and over."

Resolution: Bisi Bennett immediately noticed and understood the calendar issue when she received the billing statements in spring 2021. She started by calling the hospital and was told the problem would be corrected in March. Yet, in September, she got the same half-a-million-dollar bill.

UnitedHealthcare spokesperson Maria Gordon Shydlo, who also fielded KHN's questions for UMR, says the insurance company told AdventHealth to revise the bill with correct dates in the spring.

Breen, the spokesperson for AdventHealth Orlando, confirmed to KHN that the billing error stemmed from the change in insurers from 2020 to 2021. In a statement, Breen says medical billing can be a complex process and the hospital "understand[s] this has been a confusing and challenging experience for Ms. Bennett, and we apologize for the frustration this has caused."

AdventHealth Orlando did not submit a revised bill with corrected dates until KHN contacted the hospital in October 2021.

After UHC and UMR reprocessed the 2020 and 2021 claims, the original bill of more than $550,000 was knocked down to $300. 

Dorian Bennett was born in late 2020 and needed hospital care into 2021. Bisi Bennett's employer shifted its administrator for health insurance in the new year. The hospital then billed both insurance plans for the whole stay. Both insurance plans said the bill contained dates of care when the baby was not covered, so neither paid.

In his statement, Breen says that the Bennetts' case sparked AdventHealth to identify and address issues in its system and that the hospital plans to improve the billing and communications process for future patients, particularly when there is a change in insurance.

The Takeaway: Much of our fragmented health care system is on autopilot, with billing software that generates confusing or, in this case, absurd bills and payment plans.

Bisi Bennett did everything right: She chose an in-network hospital and informed it of the changes to her health insurance. She followed up when she saw there was an error. But her case didn't reach a resolution until a reporter called on her behalf.

If you are fighting a bill that you believe contains an error, call all the entities involved — the hospital, insurers, other providers — and don't forget about your company's human resources department. It may be able to pressure insurers to resolve an error faster than you can.

Most states have a department of consumer services that can help you file a complaint with the appropriate oversight entity. Staff members at state agencies can help you figure out what is going on. Tell the medical providers you are reporting them to the state.

Still, it is a frustrating, uphill battle, especially when patients have improper bills hanging over their heads for many months and are at risk of having the bills sent to a collection agency or having their credit score dinged. There should be far more transparency in billing and a set time limit for dispute resolution, experts say.

"This shows how little leverage or power a patient has in this situation," Fuse Brown says. "You almost have to go outside the system and put external pressure." 

https://www.mainepublic.org/npr-news/2021-12-21/a-hospital-asked-these-parents-to-pay-45-843-a-month-for-their-babys-nicu-stay 

 

Biogen Slashes Price of Alzheimer’s Drug Aduhelm, as It Faces Obstacles

A group of Alzheimer’s experts and health advocates called on the F.D.A. to withdraw its approval of the drug, the latest of several setbacks for the treatment.

by Pam Belluck - NYT - December 20, 2021

Biogen slashed the price of its controversial new Alzheimer’s drug Aduhelm on Monday as the drug faces weak sales and mounting criticism.

The price was reduced to $28,200 a year from $56,000 on the same day that a group of Alzheimer’s experts and health advocates called on the Food and Drug Administration to pull the drug off the market and said they were supporting an effort to file a formal petition with the agency to withdraw it.

“The F.D.A.’s decision to approve Aduhelm is indefensible in both scientific and clinical terms,” said a statement signed by 18 scientists, most of them doctors. “This drug should be withdrawn from the market immediately.”

The agency approved Aduhelm in June, even though a council of senior F.D.A. officials, an advisory committee of outside experts and many Alzheimer’s specialists said the scientific evidence showed that the drug did not provide a clear benefit to patients and that it carried risks of dangerous side effects.

Major health systems, including Cleveland Clinic, Mount Sinai Health System, Mass General Brigham and the Department of Veterans Affairs have declined to offer Aduhelm, citing questions about its benefits and risks. In October, Biogen reported that Aduhelm had brought in just $1.9 million in revenue through September, a strikingly small amount given that about 1.5 million Americans have the mild Alzheimer’s-related dementia that makes them eligible for the drug.

In a statement about the price-cutting on Monday, Michel Vounatsos, Biogen’s chief executive officer, said the company had “listened to the feedback of our stakeholders” and believed that “too many patients are not being offered the choice of Aduhelm due to financial considerations.”

But Brian Skorney, an analyst at Robert W. Baird & Company, said after the price announcement: “For the broad majority of people who are critical of Aduhelm, $56,000 and $28,000 are both exceptionally high prices for a drug that a lot of people perceive doesn’t work at all.”

The statement from Alzheimer’s experts and health advocates calling on the F.D.A. to withdraw Aduhelm grew out of a three-hour video meeting among the scientists last week.

“We’re not just saying the approval was probably the worst decision the F.D.A. ever made,” Dr. Peter Whitehouse, a neurologist and Alzheimer’s expert at Case Western Reserve University who led the Dec. 15 meeting, told attendees during the session. “It’s so bad that we should advocate for withdrawal.”

The doctors and scientists who signed the statement also agreed to provide their expertise to support the filing of a citizen petition, a formal process to seek reversal of the F.D.A.’s decision. The petition will be filed by the Right Care Alliance, a coalition of clinicians, patients and community members, which is also circulating a pledge for physicians who promise not to prescribe Aduhelm and for patients and family members who say they will not request it.

Dr. Vikas Saini, chairman of the Right Care Alliance and president of the Lown Institute, a health care think tank, said that while the citizen petition process can take months or years, it can prompt F.D.A. action.

Dr. Saini, who helped organize last week’s meeting, said that out of 45 citizen petitions filed since 1971 by the group Public Citizen, in 27 cases the F.D.A. withdrew drugs from the market and in seven other cases the agency sharply restricted a drug’s use.

In response to the call to withdraw approval of Aduhelm, also known by its scientific name, aducanumab, an F.D.A. spokeswoman said that “the data set for Aduhelm was very complex, and our review has been thorough.”

The spokeswoman also said that “careful analyses of the Phase 2 and Phase 3 clinical trials support the conclusion that it is likely that Aduhelm provides clinical benefit — although the data currently available do not provide substantial evidence of effectiveness on clinical benefit.”

Aduhelm has also been encountering resistance in other countries. On Friday, reviewers at the European Union’s drug regulator, the European Medicines Agency, recommended against approving Aduhelm, a decision that Biogen said it would ask to be re-examined.

Several months ago, leading Canadian Alzheimer’s research organizations said that approving the drug in Canada “cannot be justified.”

Dr. Howard Chertkow, scientific director of the Canadian Consortium on Neurodegeneration in Aging, was one of three Alzheimer’s experts from outside the United States who signed the statement calling on the F.D.A. to withdraw the drug. “We feel it’s an abrogation of our responsibility as physicians to allow a marginal medication with a very high cost associated with it to come into the country, so we’re quite active in trying to block what has happened in the states from occurring in Canada,” he said at last week’s meeting.

Two nearly identical clinical trials of Aduhelm, a monoclonal antibody given as a monthly infusion, were stopped early because an independent data monitoring committee concluded that the drug didn’t appear to be beneficial. A later analysis by Biogen found that participants receiving the high dose of the drug in one trial had experienced a very slight slowing of cognitive decline but that participants in the other trial had not benefited at all.

About 41 percent of patients receiving the high dose — the dose the F.D.A. approved — experienced brain swelling or brain bleeding, side effects that were often mild or asymptomatic, but were sometimes serious.

Monday’s statement also objects to the F.D.A.’s justification for its approval. Acknowledging there was insufficient evidence that Aduhelm would help patients, the agency greenlighted it under a program called “accelerated approval,” which allows authorization of drugs without proof of benefit for serious diseases that have few treatment options if the drug affects part of the disease’s biology (known as a surrogate endpoint) in a way that is “reasonably likely to predict clinical benefit.”

The F.D.A. based its approval on Aduhelm’s ability to reduce a protein called amyloid that forms plaques in the brains of people with Alzheimer’s. But experts say years of studies have not shown that reducing amyloid helps memory or thinking problems.

Approving the drug because of amyloid reduction “will have huge and wide-ranging negative implications for patients, families” and dementia research, Dr. Kenneth Langa, a professor of medicine at the University of Michigan, said in last week’s meeting.

The group’s statement, which includes a section for others to sign their names in support, plays on the F.D.A.’s language by calling for “accelerated withdrawal.”

“Reading the justification of the F.D.A. was like watching a ‘Saturday Night Live’ skit for data nerds,” Dr. Saini said. “I mean, I had trouble believing it.”

The agency’s approval requires that Biogen conduct another trial to see if Aduhelm works. In its response Monday, the F.D.A. spokeswoman said “we believe that the data support accelerated approval while holding the company accountable for conducting an additional study.” Last week, Biogen said that it had developed a protocol to get that trial completed in 2026, several years before the F.D.A.-imposed deadline.

Before he signed Monday’s statement, Dr. Sam Gandy, director of Mount Sinai’s Center for Cognitive Health, who helped organize the meeting, said that with advocacy groups like the Alzheimer’s Association still supporting the drug’s approval, he had a “concern that calling for something may trigger a backlash that undoes where we really want to go.”

But Dr. Jerry Avorn, a professor of medicine at Harvard Medical School who also signed the statement, said that while it was unlikely that calling for withdrawal would make F.D.A. officials say, “‘Yeah, they’re right, we goofed, we better undo this decision,’” the action was nonetheless important. “We’re taking a stand and saying the process was terrible and the outcome was terrible, and even if they don’t listen to it, it’ll be kind of a shot across the bow.”

https://www.nytimes.com/2021/12/20/health/alzheimers-aduhelm-price.html?