Editor's Note -
2021 Shkreli Awards
The following link is to the webinar presentation of the 2021 Shkreli Awards orignally conducted on January 13, 2022. The Shkreli awards are presented each year by the Lown Institute, named after Nobel Prize winner Dr. Bernard Lown, a Maine native who was awarded the Nobel Peace Prize in 1985 together with Soviet cardiologist Yevgeny Chazov for their work in establishing International Physicians for the Prevention of Nuclear War.
A link to a description of the awards is:
https://lowninstitute.org/projects/shkreli-awards/2021-shkreli-awards/
To watch the awards ceremony itself because of the very high level of the discussion about the reason for the selection of each each award winner (very much worth the time!), follow this link:
https://vimeo.com/646641763
I think of this webinar as a very well done combination of a reality show and Saturday Night Live - except that it's really not funny!.
- SPC
Universal health care bill advances in California Assembly
SACRAMENTO, Calif. (AP) — California Democrats on Tuesday took their first step toward abolishing the private health insurance market in the nation’s most populous state and replacing it with a government-run plan that they promised would never deny anyone the care they need.
But the proposal that cleared a legislative committee in the state Assembly is still a long way from becoming law. It faces strong opposition from powerful business interests who say it would cost too much. And even if it does become law, voters would have to approve a massive income tax increase to pay for it — a vote that might not happen until 2024.
Still, Democrats hailed Tuesday’s vote for jumpstarting one of their long-stalled policy goals and signaling they won’t back away from a fight even during an election year. In an hourslong hearing, some lawmakers and advocates assailed a health care industry they say has benefited corporate interests at the expense of consumers.
Ady Barkan, a 38-year-old married father of two, was diagnosed with ALS six years ago and now is mostly paralyzed. He testified at Tuesday’s hearing with the help of a computerized voice that spoke as he typed using technology that followed the movement of his eyes. Barkan said he has battled his private insurance carrier to get treatment he needed, including suing them to get a ventilator that keeps him alive.
“Even good health insurance, which I have, does not cover the cost of the care I need to survive,” he said.
To pay for everything, Democrats have introduced a separate bill that would raise taxes on businesses and individuals by about $163 billion per year, according to an analysis by the California Taxpayers Association, which opposes the bill. Voters would have to approve the tax hikes. Assembly member Ash Kalra, a Democrat from San Jose and the author of the proposal, said Tuesday it could be 2024 before that proposal made it to the ballot.
The bill that advanced on Tuesday would create the universal health care system and set its rules. It cleared the Assembly Health Committee on an 11-3 vote. Republicans voted no, arguing the bill would cost too much and pay doctors and nurses less, potentially worsening a shortage of health care workers.
“If government-run health care becomes law, millions of Californians will flee the state — either to avoid the $163 billion per year in new taxes or to escape the lengthy waits for care that will become the norm,” Assembly Republican Leader Marie Waldron said.
Even some Democrats who voted for the bill had sharp criticism for the proposal. Assembly member Autumn Burke, a Democrat from Inglewood, said advancing the bill without a funding source made a mockery of the process.
“This bill has been sold to my community that it is going to change thigs now and that it is free. And neither one of those things are true,” she said.
Business groups, led by the California Chamber of Commerce, said the government-run health care system would be so expensive that the tax increase still wouldn’t be enough to pay for everything. In 2018, California’s total health care expenditures totaled $399.2 billion, accounting for 13.2% of the state’s gross domestic product, according to an analysis by the Healthy California for All Commission.
“Completely abolishing the current system in face of unrelenting pandemic by annually taxing Californians hundreds of billions of dollars is not the solution,” said Preston Young, a policy advocate for the California Chamber of Commerce.
Kalra, the San Jose Democrat and the author of the proposal, said he knew opponents would focus on how much the plan would cost. But he said that argument distracts from the fact that Californians are already paying “the highest health tax in the world.”
“You may refer to it as premiums, deductibles, co-pays, denial of care,” Kalra said, saying none of those costs would exist under a universal health care system. “It’s clear as day they are being fleeced and far too many understandably feel helpless about it.”
California’s health care system is paid for by multiple entities — patients, insurance companies, employers and governments. But a universal health care system would be paid for by a single entity — the government, or the “single payer.”
A single payer system has been a staple of California progressive political rhetoric for decades. But it’s not been easy to accomplish in a state where most people pay for private health insurance through their jobs. In 1994, voters overwhelmingly rejected a ballot initiative that would have created a universal health care system. Another attempt passed the state Senate in 2017, but it never got a vote in the state Assembly.
Questions about how to pay for a single payer system have doomed previous plans. In 2011, Vermont enacted the nation’s first universal health care system in the country. But state officials abandoned it three years later because they said they couldn’t afford to pay for it.
Gov. Gavin Newsom promised to do it when he ran for governor in 2018, and voters elected him in a landslide. But in his first three years in office, Newsom has focused more on making sure everyone in California has health insurance — a strategy he said contains “the spirit” of a single payer system.
“When you’re governor, you’ve got to be in the ‘how’ business,” Newsom said. “I believe in a single payer financing model. The ‘how’ at the state level is the question that needs to be answered thoughtfully.”
Perspective: Explaining Near-Record Health Spending Growth during the 2020 Decline in Health Care Utilization
George Miller, Corwin (Corey) Rhyan and Ani Turner - Altarum - December 23, 2021
Recently released data from the Centers for Medicare & Medicaid Services (CMS) summarized in Health Affairs show that spending on health care in the first year of the COVID-19 pandemic increased 9.7% from the prior year, reaching a record total of $4.1 trillion dollars. Surprisingly, this increase in health care spending came during a period of declines in utilization of most health care services, including less hospital care, fewer outpatient visits, declines in nursing home and residential care residents, and fewer dental visits, largely due to the postponement of elective care, delay in treating other health needs, and general avoidance of in-person visits during the pandemic. Compensating for the decline in utilization and revenues from patient care in 2020 were large increases in direct, lump-sum government support for the health care industry, including Paycheck Protection Program (PPP) loans, CARES Act Provider Relief Funds, and other government assistance programs. In this blog, we assess the overall impact of federal health care system support on the 2020 health spending estimates, decompose the total government support across different health sectors using the new CMS data, and estimate the distribution of 2020 health spending by month with and without the federal government assistance.
Methods
Data describing national health expenditures in 2020 were taken from CMS’ detailed “National Health Expenditures by type of service and source of funds” spreadsheet, whose contents are described in the Health Affairs paper. We used our Health Sector Economic Indicators methodology to distribute these expenditures across months with and without the increased lump-sum federal expenditures in response to the COVID-19 pandemic. We estimated the magnitude of these increased federal expenditures to be the amount by which 2020 federal spending on the CMS categories of “Other Federal Programs” and “Public Health Activity” exceeded the amount spent in 2019. (Our numbers therefore disagree slightly with those presented in Health Affairs, which describes the total amounts spent in these categories in 2020.) We assumed that the increase in federal spending began in May (most government spending in response to the pandemic became available in April but ramped up in subsequent months) and was spent uniformly across all months from May through December.
Overall Impact of COVID-Specific Effects
Increases in federal government spending having the most impact on health spending growth in 2020 included funds given to health care providers to assist with COVID-related lost revenue and increased costs, and increased funding for federal public health initiatives for development of COVID-19 vaccines and treatments, stockpiling of vaccines and drugs, and preparedness. These spending increases were not directly related to patient care, helping to explain the apparent paradoxical large increase in expenditures that accompanied the decline in utilization of many health care services.
Exhibit 1 shows the impact of these increases on national health spending and on the spending components that received this government support, which included $179.9 billion dollars allocated to providers and an increase of $114.9 billion for public health activities, for a total contribution of $294.8 billion. As CMS notes, without this federal spending, year-over-year growth in health care costs would have been 1.9% rather than 9.7%. The rightmost columns in Exhibit 1 display the growth with and without the federal spending increase for each spending category. With the additional federal spending, none of these spending categories except dental services experienced a decline in spending in 2020; without them, spending on hospital care, physician and clinical services, and other professional services would have declined. The increase in federal spending on government public health activities caused this spending to be more than double the amount spent without the increase.
Exhibit 1. Impacts of Federal Government Spending Increases on National Health Spending in 2020 (millions of dollars)
Other increases in federal spending, not shown in the exhibit, supported patient care more directly. Most notable among them was an 18.8% year-over-year increase in federal Medicaid expenditures― $72.7 billion more than was spent in 2019. This increase was due to both a 5.1 percent increase in Medicaid enrollment in 2020 and the 6.2 percentage point increase in the federal medical assistance percentage (FMAP) that was effective beginning January 1, 2020 and will continue through the quarter in which the COVID-19 public health emergency declaration is terminated.
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A COVID-related contribution to the growth in spending in 2020 that was not directly caused by increased federal spending was a significant increase in the net cost of insurance, which grew by 27.4% to $301.4 billion. There are two main factors contributing to this increase. First, the Affordable Care Act (ACA) Health Insurance Tax (HIT), which was suspended from 2017 through 2019, took effect again in 2020. It was repealed permanently starting in 2021, but the IRS estimated the HIT for 2020 at $15.5 billion, a significant share of the $21.6 billion increase in the net cost of private health insurance between 2019 and 2020. The second factor was a larger than usual gap between premium revenues and health care outlays due to reduced health care utilization under the pandemic. The ACA’s medical loss ratio (MLR) restrictions reduced this gap by requiring rebates from many commercial insurers in 2020, but more plans likely reached the MLR limits and not all plans are subject to the ACA’s rebate requirements. The gap between dollars taken in and health care outlays for 2020 was also larger for private sector managed care plans covering beneficiaries under both the Medicare and Medicaid programs, as net cost of insurance increased under both public programs as well.
Detailed Impacts of Increased Federal Government Spending
We estimated monthly spending growth in 2020 for total national health spending and each of the six categories of spending on health care services with the largest increases in government spending that were summarized in Exhibit 1. The graphs in Exhibit 2 show the cumulative rates of growth in spending from January 2020 through the end of the year with and without the non-patient-care increases in federal spending.
Exhibit 2. Cumulative Spending Growth Since January 2020, by Major Category
The federal government assistance helped ensure positive spending growth for hospital care, physician and clinical services, and nursing home care. Nursing homes in particular benefited from the federal spending and would have sustained a significant decline in revenues without the federal assistance. (The qualitatively different pattern of spending growth for nursing homes compared with the other components was driven by the fact that the large decline in nursing home spending occurred one month later than for the other components, in May rather than April.) Federal assistance also represented a substantive share of 2020 spending on home health care (7.9%), although this sector achieved positive spending growth by mid-2020 even without the additional federal dollars. On the other hand, the federal assistance to the dental sector, while a comparable share of 2020 expenditures (6.1%) to hospitals (6.7%) and physician and clinical services (5.4%), was not enough to offset the dramatic decline in spending on dental services early in the pandemic, making dental services the one major sector with negative spending growth at the end of 2020 even with the additional funding.
Summary
The large year-over-year increase in national health expenditures in 2020 in the face of lower utilization of health care services is largely explained by an increase in federal government spending of $294.8 billion that was not directly tied to the provision of health care services. This increased spending provided essential funds to federal public health activities that led to the development and stockpiling of COVID-19 vaccines and therapeutics. It also provided major support to struggling providers facing declining demand and increasing costs related to the pandemic.
We have incorporated these effects into our Health Sector Economic Indicators methodology and have developed preliminary estimates of health care expenditures through October 2021. These estimates reflect the expectation that elevated spending on public health and federal financial support to health care providers has continued in 2021. While there is significant uncertainty in the 2021 estimates, they provide an initial look at likely spending patterns as we continue to battle the pandemic.
https://altarum.org/news/explaining-near-record-health-spending-growth-during-2020-decline-health-care-utilization
You Know What Would Help Exhausted Doctors and Nurses? More Money.
As health care workers prepare to enter the third year of the pandemic, we are experiencing disillusionment and burnout on an extraordinary scale. Many of us have confronted more death and sickness than ever before in our careers.
As a physician at a teaching hospital that was one of the hardest hit in New York, I have witnessed firsthand the mayhem that this pandemic has brought on. Some of my colleagues harbor frustration and even anger at patients who have chosen to remain unvaccinated or not wear masks and now are hospitalized with Covid-19, imposing additional risks to us and our families.
In this environment, attrition is inevitable. A survey of health care workers in the second half of 2020 found that 1 in 5 doctors and even more nurses were considering leaving their practice within two years. Today, hospitals are dealing with staffing shortages even as we work amid another viral surge.
Federal and state governments can and should do something to help. They should start by providing hazard pay to health care workers who continue to serve on the front lines of the pandemic.
Hazard pay is defined by the U.S. Labor Department as “additional pay for performing hazardous duty or work involving physical hardship.” Federal employees who work directly with “virulent biologicals” like the coronavirus may already qualify for such pay. A 25 percent hazard bonus is authorized for federal employees working directly with or close to substances “of micro-organic nature which when introduced into the body are likely to cause serious disease or fatality and for which protective devices do not afford complete protection.”
This definition certainly reflects the situation of health care workers in emergency rooms, intensive care units and medical wards today. The World Health Organization estimates that more than 100,000 health care workers may have died of Covid-19 between January 2020 and May 2021.
Though hazard pay won’t eliminate our professional risk, it will serve as a concrete and much-needed demonstration of appreciation to the doctors, nurses, respiratory technicians and other workers who continue to put their lives — and the health of their families — on the line for the public good.
In Congress, Democrats as well as Republicans have proposed legislation for federally funded hazard pay for health workers, but no bill has been passed into law. In May 2020, the House of Representatives passed a relief package called the Heroes Act that authorized $200 billion in hazard pay for essential workers — but it fizzled out in the Senate in the absence of sufficient Republican support. That same month, Senator Mitt Romney, Republican of Utah, proposed a “Patriot Pay” bonus for essential workers up to $12 an hour for three months. His proposal was also not approved.
Some states, such as Pennsylvania, have provided limited hazard pay using federal money from the $2.2 trillion pandemic relief bill that Congress passed in March 2020. Other states, including Massachusetts and Maine, have negotiated with unions to offer hazard pay to health workers in state facilities. Yet any bonuses offered have been modest, sporadic and temporary.
I am not under the illusion that hazard pay will cure the burnout and disaffection that is widespread in health care. Some of it undoubtedly predates the pandemic. However, hazard pay would recognize the outsize burdens that have been placed on health care providers working in once-in-a-century circumstances and acknowledge that society has an obligation to compensate us for our sacrifices.
Moreover, much of the essential work in hospitals is performed by low-wage workers — medical trainees, nursing assistants, custodians and orderlies — who often scarcely earn a living wage to support a family. The custodian who cleans the exam rooms in our clinic earns less than $20 an hour. Hazard pay for such workers could make a real financial difference.
How should such pay be provided? First, Congress must make federal funds available for this purpose. Then, states should determine eligibility criteria and wage thresholds. The most straightforward policy would be to include all health workers (medical and nonmedical) in facilities in Covid-19 hot spots.
To keep things simple and not penalize low-wage workers, the bonuses should be a fixed amount of money, rather than a percentage of pay, and should be authorized on a monthly or quarterly basis to discourage attrition. They should continue to be paid until there is a sustained reduction in hospitalizations. If funds are scarce, eligibility could be limited for those at the highest end of the pay scale — typically attending physicians like me.
Whatever the specific plan, for many health care workers the exact amount will not be as important as the gratitude and acknowledgment that it represents. Medicine is a humanitarian profession, and health care workers have a duty to care for the sick. But social order also relies on reciprocity and fairness.
Hazard pay would publicly acknowledge health care workers’ sacrifices and provide a tangible token of thanks beyond the clapping of hands or the public banging of pots and pans. This is about showing support, just as we do for our troops during war.
https://www.nytimes.com/2022/01/08/opinion/hazard-pay-covid-nurse-doctor.html?
Finding a Surprising Story in a Stack of Medical Bills
The Times journalists Sarah Kliff and Aatish Bhatia joined forces and expertise to investigate the limitations of prenatal testing.
by Sarah Kliff and Aatish Bhatia - NYT - January 13, 2022
As a reporter who covers medical billing for The New York Times, I’m used to readers sending me surprising bills for all sorts of care — from a $3,358 coronavirus test to an $18,357 injection to prevent rabies.
So when I started a new call-out for bills and received a handful for prenatal blood tests that cost as much as $8,000, I saw potential for a similar story.
But when I brought the idea to my editor, Adam Playford, he suggested that I look into a more basic question: What do patients get when they buy these tests?
His instinct was right. It turned out that the most surprising thing about prenatal tests wasn’t the price. It was that, when these tests looked for rare disorders, their positive results were usually wrong.
That information, I later learned, rarely makes its way into the brochures that advertise these products to patients and doctors. This type of prenatal testing is supposed to be for screening, not to render a diagnosis. Nevertheless, companies sometimes advertised the tests, which scan DNA to look for abnormalities, as “reliable” and “highly accurate.”
To understand how well these tests really worked, I teamed up with another New York Times reporter, Aatish Bhatia, who has a Ph.D. in physics and has published academic research analyzing genetic data. Together, we began interviewing experts and reading academic studies. The resulting article “When They Warn of Rare Disorders, These Prenatal Tests Are Usually Wrong” was published online and in print this month.
We learned that this type of blood test, which is known as a noninvasive prenatal test (NIPT), was introduced a decade ago as a screening for Down syndrome, and it works remarkably well at detecting the disorder.
But since then, testing companies have added more screenings for rarer and rarer disorders caused by microdeletions, or missing snippets of chromosomes. Those disorders are associated with mental delays and developmental disorders.
A vast majority of patients receive negative results on these tests. But for the small minority who get a positive result, we started seeing studies showing those findings were more likely to be wrong than right.
But how likely? One issue we confronted early on during the reporting process is that some companies released very little clinical data on the performance of their tests. Some had not provided any such data for certain screenings, and they declined The Times’s requests to do so.
To work around this limitation, we read every relevant clinical study we could find that assessed these microdeletion screenings, and Aatish pooled together data from the seven most rigorous studies to estimate their overall performance. He’d seen this approach used on a similar topic by a National Institutes of Health researcher. And when we ran the idea by experts in this area and they agreed it would be a good approach for us as well.
That’s how we got the estimates that were featured in our story, which showed that the positive results for five microdeletion screenings were, on average, wrong 85 percent of the time.
For These Five Tests, Positive Results Are Often Wrong
As prenatal tests have expanded to more rare conditions, a larger share of their positive results are incorrect. Some of the worst-performing tests look for microdeletions, which are small missing snippets of chromosomes.
results are wrong
DiGeorge syndrome
Affects 1 in 4,000 births
Can cause heart defects and delayed language acquisition. (May appear on lab reports as “22q.”)
1p36 deletion
1 in 5,000 births
Can cause seizures, low muscle tone and intellectual disability.
Cri-du-chat syndrome
1 in 15,000 births
Can cause difficulty walking and delayed speech development.
Wolf-Hirschhorn syndrome
1 in 20,000 births
Can cause seizures, growth delays and intellectual disability.
Prader-Willi and Angelman syndromes
1 in 20,000 births
Can cause seizures and an inability to control food consumption.
Why these five tests?
Testing companies currently offer seven microdeletion screenings. But two syndromes — Langer-Giedion and Jacobsen — are so rare that there is not enough data to understand how well the tests work. A few other tests for conditions that are not caused by microdeletions are also widely offered, with varying degrees of reliability. The screenings for Patau syndrome (which often appears on lab reports as “trisomy 13”) and Turner syndrome (“monosomy X”) also generate a large percentage of incorrect positives, while the screenings for Down syndrome (“trisomy 21”) and Edwards syndrome (“trisomy 18”) work well, according to experts.
Once we had that data, there was still the other an important question to answer: What was the experience of getting a false positive result like for expecting parents? I discovered a Reddit forum where dozens of people were sharing their stories. I began messaging them, asking for interviews.
In our phone calls, many described not having all of the information about the screening test when their doctor ordered it. They understood it would screen for Down syndrome, but they didn’t know it would also screen for the rarer conditions.
When they did get a positive result, some said their doctors had not provided helpful context on what it meant. A few women didn’t know about the possibility of false positives until they came across the same Reddit forum I did, and said their doctors treated the screening test as a definitive diagnosis.
The phrase “worst time of my life” came up repeatedly in my interviews, as expectant mothers described the anguish of receiving a positive screening test and then waiting weeks or even months to learn it was wrong. Some spent thousands on follow-up testing; others took time off work, finding themselves unable to concentrate as they weighed the possibility of terminating a pregnancy.
A few were initially apprehensive to share their experiences with a national news outlet, but decided to go forward with the interviews so that other patients in similar situations would know they were not alone.
In our article, we were able to combine Aatish’s data analysis with my interviews to show readers how well these screening tests perform and what that could mean for patients. The reporting took about four months from start to finish.
Neither part could have stood on its own, but together they gave us a compelling picture of a nascent testing industry that is growing larger by the year — and the type of information that more pregnant women are likely to confront.
Editor's Note -
The following clipping is a good example of how health insurance companies actually impede access to health care rather than facilitating access to care, even in a health care emergency such as the Covid-19 pandemic. How long is it going to take the American public to understand this empirical fact?
- SPC
Insurers Say Saturday Is Too Soon to Meet White House Goals on Rapid Tests
Not all health plans will be ready for the Covid tests to be free upfront at stores, relying at first on receipts and reimbursement.
by Sarah Kliff - NYT - January 14, 2022
Starting Saturday, new federal rules will require private insurers to cover the at-home coronavirus tests that Americans buy in pharmacies and other stores. The new system could, in theory, allow millions of consumers to pick up tests at thousands of locations without spending any money.
The reality, at least in the short term, is likely to be messier: Some insurers say it will probably take weeks to fully set up the system the White House envisions.
The new process will be hard, the insurers say, because over-the-counter coronavirus tests are different from the doctor’s visits and hospital stays they typically cover.
The tests do not currently have the type of billing codes that insurers use to process claims. Health plans rarely process retail receipts; instead they’ve built systems for digital claims with preset formats and long-established billing codes.
Because of this, some insurers plan to manage the rapid test claims manually at the start.
“This is taking things back to the olden days, where you’ll have a person throwing all these paper slips in a shoe box, and eventually stuffing it into an envelope and sending it off to a health insurer to decipher,” said Ceci Connolly, president and C.E.O. of the Alliance of Community Health Plans, which represents smaller, nonprofit insurers.
Ms. Connolly also criticized the implementation timeline as too rushed, with the government issuing rules on a Monday that are to take effect on a Saturday.
“It is going to be exceedingly difficult for most health plans to implement this in four days,” she said.
The challenges of insurers may soon trickle down to consumers, who will be responsible at first for navigating their health plans’ reimbursement rules to get their tests covered.
“There will be some people who buy them, and then have a six-month nightmare trying to get reimbursed,” said Jenny Chumbley Hogue, a Texas-based insurance broker. She has not yet seen a plan she works with that has sent out member guidance on how coverage will be handled.
Uncertain of what the rules will be, Ms. Hogue is advising her clients to save not just receipts but also the boxes that the tests come in, because some plans may require the boxes as proof of purchase.
Some public health experts have criticized the plan as unnecessarily complex, saying they would have preferred the Biden administration to provide free kits directly to patients.
“The direct provision of inexpensive tests for the American public would be the simplest from a consumer standpoint,” Lindsey Dawson, an associate director at the Kaiser Family Foundation, previously told The New York Times. “Someone will need to know it’s reimbursable, navigate the reimbursement process, and front the cost to begin with.”
Other countries have spent more heavily on rapid testing. In Britain, citizens can use a government website to order free rapid tests for home use. Germany invested hundreds of millions of dollars to create a network of 15,000 rapid testing sites. The United States has instead focused public purchasing on vaccines, and efforts to encourage their uptake.
Some local governments in the United States have invested heavily in rapid testing to counter the latest wave of cases. Washington, which has experienced a substantial surge in virus cases, now allows residents to pick up four free rapid tests daily at libraries across the city.
The Biden administration has instead relied more heavily on tests delivered in doctor’s offices. Federal laws have required insurers to cover those at no cost to the patient since the early months of the pandemic.
The new rules require private insurers to cover eight at-home coronavirus tests for each person, every month. The rules will not apply retroactively to at-home tests that Americans have already purchased, and do not cover patients with public insurance such as Medicare and Medicaid.
Under the new rules, consumers who get tests at their health plan’s “preferred” location will have the costs covered upfront, meaning the patient will pay nothing out of pocket. What counts as a “preferred” location will vary from one plan to another, although many expect those facilities to be ones that are already in-network with a given insurer.
Consumers that go to an out-of-network store will need to submit receipts for reimbursement, and the plan will only have to pay $12 per test (or $24 for a kit with two tests). If the sticker price is higher, the patient will be responsible for the additional charges.
Health plans that do not designate a set of “preferred” locations will have to cover the full costs of test receipts that their members submit.
Test prices currently range from $17.98 for a pack of two to $49.99 for an individual test, according to research Ms. Dawson conducted last week.
Highmark Health, a nonprofit plan in Pennsylvania with around six million members, plans to create a network of “preferred” locations but will not have it ready by this Saturday.
“The guidance came out Monday, and we started working on it immediately, but I don’t have a mechanism ready to go, Day 1, where you don’t have to pay upfront,” said Bob Wanovich, a Highmark vice president who works on provider contracting.
One challenge Mr. Wanovich and others described was that insurers typically do not cover over-the-counter items at the pharmacy, like a pregnancy test or a nonprescription medication.
“Retailers need to have a process to capture the right codes, and submit it, and we need to be able to accept it on our end,” he said. “These are the pieces that aren’t there yet.”
Until they set up that infrastructure — a process that could take weeks — Highmark Health will be advising patients to submit receipts along with a photograph of their test kit’s bar code for reimbursement.
Capital District Physicians’ Health Plan, a small insurer in upstate New York, plans to instruct members to hold on to their test receipts as it sorts out a system for processing them.
“We’re getting a ton of calls from consumers asking about it, so we’re trying to arm our member service staff with the right information,” said Ali Skinner, the plan’s vice president for communications.
Ms. Skinner said the insurer was still working to have “preferred” locations designated by Saturday, so patients could pick up tests without the reimbursement process, but she was uncertain about whether it would meet the deadline.
“We’re up against the clock right now,” she said. “It’s a big lift for us. We found out at the same time as consumers did on Monday.”
Even as insurers sort out systems for processing claims, they noted one major factor will remain out of their control: testing supply, and the shortages that consumers have confronted in recent weeks.
“The bigger frustration our members have is over finding a test, and I don’t have any control over the supply,” said Mr. Wanovich of Highmark Health. “We’re working with our providers to figure out who has them, but we know it’s in short supply.”
Sarah Kliff is an investigative reporter for The New York Times. Her reporting focuses on the American health care system and how it works for patients.
https://www.nytimes.com/2022/01/14/upshot/free-rapid-covid-tests.html
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