Health Care Reform Articles - March 31, 2022

 

Health Care Reform Must Return Ownership to the Community Health Justice Monitor - March 31, 2022

Summary: In a landmark article in The Nation, long-time single payer leaders (including four HJM bloggers) review the pervasive and damaging ownership of providers by corporations. They propose that real reform must transfer ownership and control of providers to communities.

Medicare for All Is Not Enough - The Nation - March 31, 2022 By David U. Himmelstein, Steffie Woolhandler, Adam Gaffney, Don McCanne, John Geyman   We have long advocated for single-payer national health insurance. By eliminating private insurers and simplifying how providers are paid, single-payer would free up hundreds of billions of dollars now squandered annually on insurance-related bureaucracy. The savings would make it feasible to cover the uninsured and to eliminate the cost barriers that keep even insured patients from getting the care they need. And it would free patients and doctors from the narrow provider networks and other bureaucratic constraints imposed by insurance middlemen. We still urgently need this reform.   However, the accelerating corporate transformation of US health care delivery complicates this vision. In the past, most doctors were self-employed, free-standing hospitals were the norm, and for-profit ownership of facilities was the exception. Single-payer proposals hence envisioned payment flowing from a universal, tax-funded insurer (like traditional Medicare) to independent clinicians, individual hospitals, and other locally controlled, nonprofit providers. This was usually the state of play when national health insurance (NHI) was achieved in other nations, such as Canada in the 1960s and ’70s—the model for single-payer reform in the United States.   But insurers are now being joined by a new set of corporate middlemen asserting control over American care. Amazon plans to expand Amazon Care from Seattle to 20 other cities this year, and then to all 50 states. Wall Street is buying up doctors, hospitals, and other health care institutions, distorting care to generate profit. Today, most doctors are employees of large organizations, and most hospitals have become subsidiaries of corporate enterprises encompassing many facilities and firms with tenuous ties to the communities they serve. Meanwhile, for-profit control of health care providers—including by private equity firms—has burgeoned, despite strong evidence that profit-seeking siphons off resources and undermines quality.   These sweeping changes require an expansion of the traditional single-payer vision. Reform needs to go beyond changing the way we pay for care: It also needs to change whom we pay for care. Communities, not corporations, should own our nation’s vital health care assets.   Responding to the evidence of for-profits’ misconduct, most Medicare for All bills and proposals have prudently called for either the exclusion or public buy-out of for-profit providers. However, the first option, excluding them, is not a viable solution, because their facilities—like the 5,300 dialysis clinics owned by Fresenius and Davita, the two dialysis giants—are needed for patient care. And while a public buy-out is economically feasible, who would then own and operate such providers? And what of the nonprofits whose boards often run them as private fiefdoms and increasingly behave like for-profit wannabes?   In both instances, a transition to public, community-based ownership—a reform model generally labeled National Health Service (NHS), in contrast to NHI—seems the most appropriate solution, especially since taxpayers have directly or indirectly bankrolled the construction of most hospitals and other health facilities.   Such an NHS should have federal funding and oversight, similar to the Veterans Health Administration—a publicly owned and operated health system that delivers higher quality of care at lower cost than the private sector. However, as Democratic Representative Ron Dellums proposed in the 1970s, the NHS should delegate day-to-day governance to local communities. The system should direct new investments to currently underserved communities, develop the primary care infrastructure that is the bedrock of effective and efficient care, and build the linkages between public health and medical care whose lack has hobbled the US’s pandemic response—and in so doing, turn the tide of faltering health in America.

Comment by: David Himmelstein & Steffie Woolhandler   Medicare for All would cover the 31 million who are uninsured, relieve the cost burdens faced by the tens of millions more who are under-insured, rein in administrative costs, and ameliorate inequality because providers would receive the same reimbursements for the care of rich and poor patients.   But Medicare for All would not, by itself, address the ill effects of the corporate ownership of physicians' practices, hospitals, and other health care institutions. Avaricious firms -- both for-profit and non-profit – are gobbling up the vital resources needed for care, gaming even traditional Medicare's payment incentives, and prioritizing profitability over patients' and communities' needs. Physicians, like other health care personnel employed by these organizations, must either comply with executives' profit-seeking directives or be shown the exit.   Hence, health care reform must address who owns health care, not only who pays the bill. Taxpayers' and patients' dollars have paid to build the US health care system; the public must reclaim ownership of it. Following Scotland's National Health Service, we should recast patients (in partnership with health care personnel) as owners of the health care system, not its customers.   House of Medicine for Rent by Peter Swenson, Ph. D. - Medscape Internal Medicine - March 29, 2022 Organized medicine has come a long way since the founding of the American Medical Association (AMA) in 1847. For conflicts of interest, the journey has been a downhill slide. At its inception, the AMA declared that it was “reprehensible" for physicians to attest to the efficacy of patent medicines or in any way to promote their use. Holding a patent for any drug or surgical device was "derogatory to professional character" for doctors. Accepting money to shill for industrial patent holders was a breach of ethics. Starting in the 1920s, organized medicine, including hundreds of specialty societies, discarded this staunch defiance of commercialism for wary collaboration and ultimately a full embrace of support from the pharmaceutical and medical device industries. Today, the threadbare remnant of organized medicine's original stance is a weak principle of "transparency" about the flow of money and influence from industry into medical practice. But organized medicine doesn't even hold itself to that flimsy standard. Anyone can now go to the federal government's Open Payments website to see what individual physicians receive from industry. And as of 2022, what physicianassistants and specialty nurses get is also being exposed to sunshine's supposed disinfecting properties. Even money flowing from industry to academic medical centers is reported — but the same isn't true for their professional societies. Why not? The human and economic costs of medicine's commercial entanglements are huge: overdiagnosis, overuse, overmedicalization — and therefore potential doings of harm. Because medical societies actively contribute to the bustling business of continuing medical education, the promulgation of clinical guidelines, and publication of educational material on drug and device therapies, they potentially share responsibility for overpriced and often meretricious drugs, often used for poorly studied off-label indications, contributing to clinical risks and massive waste. The grossest example of economically compromised organized medicine was exposed in the US Senate's 2017 investigation of the opioid epidemic. The public learned how Purdue Pharma and Johnson & Johnson spent close to $9 million between 2012 and 2017 on physician and patient organizations (like the American Pain Society) that together broadcasted the unfounded claim that opiates prescribed for pain rarely led to addiction. The medical-industrial complex's laser focus on expensive medicinal therapies and surgical interventions means neglect of prevention and the social causes of disease in medical organizations' educational and lobbying activities. For example, out of around 300 scientific sessions of the upcoming 2022 meeting of the American College of Cardiology (ACC), only seven concern lifestyle and other nonmedicinal modes of prevention. By contrast, there were at least 38 sessions sponsored by pharmaceutical and medical device corporations on clinical uses of their products are planned. From Arm's Length to Ready Embrace The opioid crisis exposed only the scandalous tip of a deeply rooted problem that was long in the making. Early in the 20th century, AMA executive and JAMA editor George H. Simmons treated drug companies "with suspicion and grave doubt, like diplomats working on an armistice." Simmons told his successor, Morris Fishbein, that negotiating with pharmaceutical manufacturers to clean up their specious advertising was "about the same as Faust trying to make a deal with Mephistopheles." Under Simmons, the AMA succeeded in imposing some ethical standards for industry access to JAMA's advertising pages. It actively lobbied for passage of the Pure Food and Drugs Act of 1906. But after 1924, under Fishbein, the downward slide began. In 1938, the AMA watched passively as lay forces pushed for another major drug law reform, the Federal Food, Drug, and Cosmetic Act, which demanded proof of safety before marketing. In the early 1940s, Fishbein helped raise $1 million for a massive "National Physicians Committee" campaign to fight national health insurance and therefore preserve the "American system of medicine." But the committee was mislabeled —about 90% of its funding came from Hoffman-Laroche and other huge drug companies. "Captive and Beholden" In the 1950s, the AMA and the drug industry became fully enmeshed. JAMA relaxed its control on advertising to increase its revenue. A revolving door opened between the two. The Pharmaceutical Association of America (PMA) rewarded Austin Smith, who had succeeded Fishbein in 1949, with its presidency. In 1963, after Smith moved on to a more lucrative job as president of Parke-Davis, the PMA replaced him with C. Joseph Stetler, the AMA's executive vice president. Money circled back. In the early 1960s, 17 of the largest drug firms gave nearly $1 million to the AMA's lobbying arm to help it fight Medicare, in part out of fear of federal controls on drug pricing. In 1962, the AMA testified along with the PMA against a proposed amendment to the 1906 Food and Drug Act that demanded that new drugs show efficacy, not just safety, in controlled clinical studies. The AMA argued that individual clinicians didn't need government advice on what worked or didn't. It also backed the drug industry's successful objections to provisions breaking its monopoly pricing power. The unholy alliance was cemented in the early 1970s. In 1971, the AMA dropped from its ethical code its historic disapproval of medicine patents held by physicians. The next year, it shut down its semi-independent Council on Drugs that had issued advice on hundreds of products on the market to help bewildered clinicians separate good from useless — or worse — medications. The council had damned many profitable drugs as "not recommended" or even "irrational." In 1973, John Adriani, the chair of the now-disbanded council, indignantly explained to Congress that the AMA was "captive of, and beholden to, the pharmaceutical industry." Rental Payments The ties have only grown tighter. Over the last 40 years, medical specialty societies have eclipsed the AMA in overall importance and political muscle. Much of their growth in revenues and activities was funded by industry. In a 2008 Medscape article, Lawrence Grouse, a disaffected insider in the ranks of organized medicine, estimated that many specialty societies received almost 80% of their revenue from industry for grants-in-aid, project grants, educational enterprises, donations to their spin-off foundations, and in-kind contributions. He had to estimate because of the organizations' secrecy. Since then, nothing has changed. In 2019, for example, membership dues accounted for only about 13% of the almost $150 million that the ACC and its foundation took in. That most of the remaining revenue came from industry can be inferred from the fact that in 2018, 22 of the ACC's 26 leaders had financial ties with industry totaling almost $23 million. In fact, around 80% of specialty society leaders in the 10 costliest areas of medicine, including cardiology, had financial ties with industry. For those with ties, the median reward was about $30,000. For leaders of the American Society of Clinical Oncology with such ties, the median was a little over $500,000. What remains today of the 19th century AMA ethics against entanglement with medical industries? Nothing but a lukewarm endorsement of the need for transparency about which medical practitioners get what from whom. Tellingly, the forceful implementation of that principle had to be pushed for by a coalition of outsiders to organized medicine, including powerful politicians, in the form of the Physician Payments Sunshine Act, which was passed in 2010 as part of the Affordable Care Act. Of course, keeping money out of medicine is impossible and probably not even desirable, given the relative scarcity of federal funding for medical research, continuing medical education, and clinical guideline formulation. But we must do something to restore balance to the system. Medical reformers have offered various solutions to organized medicine's pervasive conflicts of interest, including a total divorce from industry. Those will be slow in coming. An intermediate fix, albeit an insufficient one, would be for the law to subject the entanglements to critical scrutiny by the public and the medical profession at large. But considering the likely opposition to forced reporting and public disclosure, even new federal regulations or congressional action will be hard to achieve. Between 1998 and 2021, the AMA was the fourth largest spender on federal lobbying among trade associations and major corporations — doling out more than $462 million during that period. Without a countervailing alliance of lay forces and reform-minded physicians to force disclosure, the armada of specialty societies and industry powerhouses will continue to have unchecked power and political clout. And that's a prescription for bad medicine. Peter A. Swenson, PhD, is the C.M. Saden Professor of Political Science at Yale University, New Haven, Connecticut, and a prize-winning author on the political history of healthcare and the welfare state. His latest book is Disorder: A History of Reform, Reaction, and Money in American Medicine (Yale University Press, 2021). https://www.medscape.com/viewarticle/970974#vp_3

PACE helps older adults stay in their community

by Dr. Peter DeGolia - Just Care - March 14, 2022

The Program of All-inclusive Care for the Elderly (PACE) is a home and community-based program designed to keep older adults who are at risk for nursing home placement living in their community.  PACE is a partnership between a local sponsoring organization, and Medicare and Medicaid health insurance programs. To become a PACE “participant,” a person must be nursing home eligible. While a person can pay privately for services, most participants have Medicare, Medicaid, or both insurance programs.

The PACE philosophy: PACE members are called “participants” because they are encouraged to participate in their care–decision making and active care–whenever possible.  The overarching goal of the PACE Model of Care is to keep people living in the community and out of institutional care.  While an individual does not need to visit the PACE Center, which offers adult day programs with wrap around health services, it promotes socialization and addresses common problems of isolation, loneliness, and boredom.

Who can get PACE? Programs of All-Inclusive Care for the Elderly (PACE®) serve individuals who are age 55 or older, certified by their state to need nursing home care, able to live safely in the community at the time of enrollment and live in a PACE service area.

How does PACE work? PACE works by providing care and services in the home, the community, and at the PACE center. It is team-based care that provides everything covered by Medicare and Medicaid if authorized by your health care team.  If your health care team decided you need care and services that Medicare and Medicaid doesn’t cover, PACE may still cover them.  The team provides comprehensive coordinated care and includes the PACE participant, physician, nurse, social worker, recreational specialist, rehabilitation specialists, and transportation specialists.

Services: Delivering all needed medical and supportive services, a PACE program is able to provide the entire continuum of care and services to older adults with chronic care needs while maintaining their independence in their home for as long as possible. Services include the following:

• adult day health care that offers nursing; physical, occupational and speech/language therapies; recreational therapies; meals; nutritional counseling; social work and personal care;
• medical care provided by a PACE physician familiar with the history, needs and preferences of each participant;
• home health care and personal care;
• all necessary prescription and over-the-counter medications;
• medical specialties, such as audiology, dentistry, optometry, and podiatry and speech therapy;
• respite care; and
• hospital and nursing home care when necessary.

See more at: http://www.npaonline.org/policy-advocacy/value-pace#services

Find a PACE program near you: Currently, there are 144 PACE organizations in 30 states serving 58,000 people. To find out if you or a loved one is eligible, and if there is a PACE program near you, visit www.pace4you.org or www.Medicaid.gov, or call your Medicaid office.

Beware of for-profit PACE programs: Government audits find for-profit PACE program neglects patients, delays needed care and cancels critical care.

Learn what to do to ensure safety at home for people aging in their communities. And, see how one new program is helping older adults remain at home with assistance from a handyman, occupational therapist and nurse. For those who like technology solutions, check out how sensors can offer peace of mind to caregivers.

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https://justcareusa.org/pace-helps-older-adults-stay-in-their-community/?

 

Albert Lea seniors caught in insurance quagmire, with limited access to new clinic

Residents are asking the Minnesota attorney general to help resolve the issue. 

by Christopher Snowbeck - Star Tribune - March 19, 2022

Albert Lea residents scrambled a few years ago to recruit a new health care provider after Mayo Clinic announced it would start closing many hospital services in the southern Minnesota town.

The effort culminated last summer with the opening of MercyOne Albert Lea Family Medicine & Specialty Care, a new facility that's competing for patients against the clinic and hospital operations that Mayo still runs in the community.

But some patients say their access to the new clinic is being sharply limited by insurance rules that make visits to MercyOne much more expensive. It's a problem for seniors enrolled in Medicare health plans from Blue Cross and Blue Shield of Minnesota, the dominant carrier in the market.

The dust-up is the latest example of how rules governing insurance networks — the subset of clinics and hospitals where subscribers pay less out of pocket to see a doctor — can limit choices for seniors as more elect to receive their government benefits through private Medicare Advantage health plans.

At least some of the affected seniors are asking Blue Cross to work with Mayo to remove the barrier, and recently turned to the state attorney general for help.

"Why would we have a clinic in Albert Lea that we can't use?" asked Jan Mattson, 79, of Albert Lea. "It seems to me like Blue Cross Blue Shield could add Mercy to in-network, and then I would be very happy."

Blue Cross says that it has no plans to add MercyOne to its regional Medicare Advantage network. Mayo has a say in any such change, the insurer says, because contract terms give the Rochester-based clinic "a financial responsibility to improve health outcomes and lower health care costs in southern Minnesota," Blue Cross said in a statement.

Specific contract terms that would illustrate exactly how this all works are confidential. But agreements like the one between Blue Cross and Mayo are described in the insurance industry as "narrow" or "focused" network arrangements.

In these deals, health care providers give insurers a better price for services so they are in the health plan's network and have the chance to treat a greater volume of patients. Patients pay significantly more out-of-pocket when they go out-of-network, so the incentives are strong to get most care in-network.

The agreement between Blue Cross and Mayo is a "total cost of care" contract, an increasingly common type of payment relationship where providers take a degree of financial risk for the overall health costs and outcomes for health plan enrollees.

In such agreements, providers want to control as much of the care given in a population as possible to boost quality while keeping overall expenses down.

Adding too many other clinics and hospitals could introduce more costs, or worsen patient outcomes, in ways that would limit payments for the health system. So, Blue Cross says, it's not unusual in these arrangements for the primary health care system to have a say in creating the network and subsequent changes to it.

Mayo is the "focus" of the current network in the region, but it does include "many other non-Mayo specialty providers, at a competitive price," Blue Cross said.

For its part, Mayo said it "does not oppose the addition of other facilities or providers if they would best serve the community."

Following a meeting with Albert Lea residents this month, Attorney General Keith Ellison "is exploring what tools his office may have to help in this matter," a spokesman said in an e-mail.

Other Medicare Advantage plans available in Albert Lea provide in-network access to the new clinic.

Eagan-based Blue Cross runs by far the biggest Medicare Advantage heath plan in and around Albert Lea with about 2,000 enrollees in Freeborn County.

Because MercyOne is out-of-network, subscribers in that part of the state who want to use the new clinic must pay 45% of the allowed amount for treatments. This "co-insurance" fee typically is much larger than the fixed-dollar copays patients pay at in-network clinics.

Seniors in Albert Lea say they're irritated that the new clinic is actually in-network for people in the Twin Cities and western Minnesota who enroll in Medicare Advantage plans from Blue Cross; it's only out-of-network for those in Freeborn and 14 other counties across southern Minnesota.

"Our Medicare Advantage network in southern Minnesota was built from the ground up in partnership with Mayo to ensure our members have access to high-quality local care at a competitive price," Blue Cross said.

MercyOne didn't know the Medicare Advantage plan from Blue Cross in southern Minnesota had a limited network "until we tried to sign up for it," said Rod Schlader, the president of MercyOne Northern Iowa Medical Center in Mason City.

"We finally got to the bottom of it, and they said: We're sorry, this is a narrow network product that they've come to an agreement with, with Mayo," Schlader said. "And right now, they're not allowing any other providers to join that narrow network product."

The barrier is unique to Medicare Advantage plans from Blue Cross, he added, so people in Albert Lea with other types of coverage from the health insurer have in-network access to the new clinic.

MercyOne, which is based in suburban Des Moines, is not a small player. It's a joint venture between two large, national nonprofit health care systems that operates a number of hospitals and clinics in Iowa. The health system's clinic in Albert Lea was created with some financial support from the Albert Lea Healthcare Coalition, a nonprofit group that recruited MercyOne.

"When you really think about it, shouldn't Blue Cross and Mayo be sitting down and saying: What is in the best interest of the citizens of southern Minnesota?" asked Brad Arends, a benefits consultant and leader with the community group. "The best interest of the people ... is to get MercyOne in that network."

For Annie Mattson, the network snag led her to drive 25 minutes from Albert Lea last summer to get painful symptoms diagnosed at a clinic in a neighboring town.

Mayo's Albert Lea clinic couldn't see her that day and the symptoms didn't seem to require a visit to Mayo's emergency room in town. She could have been seen promptly at the new MercyOne clinic, but doing so would have been more expensive.

Mattson is happy for the care she received for what turned out to be a kidney stone at Mayo's clinic in New Richland. What's upsetting though, she said, was having to drive 20 miles from her home when the MercyOne clinic was just 5 minutes away.

"After all the time and effort of starting this clinic, we certainly want to be a part of it," said Mattson, 70, who collected signatures back in 2017 to protest Mayo's announcement that it would scale back hospital operations in Albert Lea.

"The inflexibility has caused me to change my health care from the Blue Cross Medicare Advantage to UnitedHealthcare," she said.

Mattson and her partner, Paul Stieler, were on a call this month urging the attorney general to intervene. Stieler's health insurance lets him visit MercyOne, but he's concerned the network limit at Blue Cross could hurt the new clinic.

That's a problem, he said, because MercyOne helps the local economy while giving seniors in the region a better shot at accessible and affordable health care.

"I feel that Mayo has created a monopoly down here in this area, and because they have a monopoly they can charge more," said Stieler, 74. "This block that we have on being able to use the Mercy clinic is not good."

Albert Lea residents have long been among the most vocal in criticizing the cost of care at Mayo while feeling captive to the health system.

They cite reports from a Minneapolis-based nonprofit group showing patient care costs in Minnesota are highest at Mayo — a finding that clinic officials over the years have argued stems from flaws in the group's methodology.

The Medicare Advantage plan for southern Minnesota was launched as part of a broader contract agreement struck in 2018 between Mayo and Blue Cross.

Since then, premiums for the primary two Medicare Advantage plans from Blue Cross in the region have increased by more than $12 and $36 per month, while monthly rates for comparable plans in the Twin Cities and western Minnesota have declined.

Blue Cross said premiums are based on a variety of factors including payment rates to health care providers as well as differences in the medical needs of enrollees.

Mayo says it controls costs by coordinating care within its health system including a single electronic health record spanning regional clinics and hospitals as well as its large medical center in Rochester.

"As patients need testing, lab work, radiologic exams, and other diagnostic procedures, they do not need to duplicate those tests as they move through the Mayo Clinic system, thereby saving costs for patients and payers," the clinic said in a statement.

https://www.startribune.com/albert-lea-seniors-caught-in-insurance-quagmire-unable-to-access-new-clinic-mercyone-mayo/600157524/?

 

The case of the $489,000 air ambulance ride

by Julie Applebye - Kaiser Health News - March 25, 2022

 

Sean Deines and his wife, Rebekah, were road-tripping after he lost his job as a bartender when the pandemic hit. But while visiting his grandfather in a remote part of Wyoming, Sean started to feel very ill.

Rebekah insisted he go to an urgent care center in Laramie.

"Your white blood count is through the roof. You need to get to an ER right now," Deines, 32, recalls a staffer saying. The North Carolina couple initially drove to a hospital in Casper but were quickly airlifted to the University of Colorado Hospital near Denver, where he was admitted on Nov. 28, 2020.

There, specialists confirmed his diagnosis: acute lymphoblastic leukemia, a fast-growing blood cancer.

"Literally within 12 hours, I needed to figure out what to do with the next step of my life," said Deines.

So, after he was started on intravenous treatments, including steroids and antibiotics, to stabilize him, the couple decided it was prudent to return to North Carolina, where they could get help from his mother and mother-in-law. They selected Duke University Medical Center in Durham, which was in his insurance network.

His family called Angel MedFlight, part of Aviation West Charters of Scottsdale, Ariz., which told Rebekah Deines that it would accept whatever the couple's insurer would pay and that they would not be held responsible for any remaining balance.

Sean Deines was flown to North Carolina on Dec. 1, 2020, and taken by ground ambulance to Duke, where he spent the next 28 days as an inpatient.

By his discharge, he felt better and things were looking up.

Then the bills came.

The patient: Sean Deines, 32, who purchased coverage through the Affordable Care Act marketplace with Blue Cross Blue Shield of North Carolina.

Medical service: A 1,468-mile air ambulance flight from Colorado to North Carolina, along with ground transportation between the hospitals and airports.

Service provider: Aviation West Charters, doing business as Angel MedFlight, a medical transport company.

Total bill: $489,000, most of which was for the flight from Denver, with approximately $70,000 for the ground ambulance service to and from the Denver and Raleigh-Durham airports.

What gives: Insurers generally get to decide what care is "medically necessary" and therefore covered. And that is often in the eye of the beholder. In this case, the debate revolved first around whether Deines would have been stable enough to safely take a three-plus-hour commercial flight to North Carolina during a pandemic or did he require the intensive care the air ambulance provided. Second, there was the question of whether Deines should have stayed in Denver for his 28-day treatment to get him into remission. Insurers tend not to consider patient stress or family convenience in their decisions.

Also, both air and ground ambulance services have been center stage in the national fight over huge surprise bills, since the for-profit companies that run them frequently do not participate in insurance networks.

Angel MedFlight, which was not in Deines' insurance network, sought prior authorization from Blue Cross Blue Shield of North Carolina. The request was dated Nov. 30, but the insurer said the fax arrived in the predawn hours the same day as the flight, Dec. 1, 2020.

On that day, Angel MedFlight flew Deines to North Carolina in an airplane, along with a nurse to oversee his IV medications and oxygen levels.

Angel MedFlight spokesperson Kimberly Halloran did not answer a specific written question from Kaiser Health News about why the flight went ahead without prior approval; often medical interventions are postponed until it has been obtained. But in an emailed statement to KHN, she said the company "satisfied each step in the health insurance process and transported Sean to his long-term health care providers in good faith."

According to the review of the case done months later by an independent evaluator, Blue Cross on Dec. 3 denied coverage for the air ambulance services because medical records did not support that it was an emergency and Deines was already in an appropriate medical facility.

At the end of December, Angel MedFlight filed an appeal of that decision on Deines' behalf.

Then, in March 2021, Blue Cross sent Deines a check for $72,000 to cover part of the $489,000 bill, which he forwarded to the air ambulance company. The explanation of benefits showed the majority of the charges were ruled "not medically necessary."

Angel MedFlight, through a revenue management firm it hires called MedHealth Partners, continued to appeal to Blue Cross to overturn the denial of the flight portion of the bill.

Then, three months after Blue Cross demanded Deines pay back the $72,000 that he had already sent to Angel MedFlight.

"The initial thought was, 'I can't believe this is happening,' " said Deines.

Medical necessity criteria are set by insurers, with North Carolina Blue Cross covering air ambulances in "exceptional circumstances," such as when needed treatment isn't available locally. 

Sean and Rebekah Deines review his medical bills at their home in Hendersonville, N.C. Eventually, the insurance company dropped its attempt to get repayment.

When Deines, who was still unemployed and undergoing treatment, couldn't pay, the debt was sent to collections.

In late June, Deines' representatives at Angel MedFlight took the next step allowed under the Affordable Care Act, appealing the insurer's internal determination that the flight wasn't medically necessary to an independent third party through the state.

On July 29, the evaluator ruled in favor of Blue Cross.

Normally, such a flight would be appropriate because the patient was "medically unfit to travel via commercial airflight," the review noted. But, it went on to say, there was actually no need to travel, as the University of Colorado Hospital — a member of the National Comprehensive Cancer Network — could have managed Deines' treatment.

His health plan "clearly stipulates their indications for medical flight coverage and unfortunately this case does not meet that criteria," the review concluded.

Resolution: The bill disappeared only after the press got involved. Shortly after a KHN reporter contacted the communications representatives for both the insurer and Angel MedFlight, Deines heard from both of them.

The $72,000 payment was made in error, said Blue Cross spokesperson Jami Sowers.

"We apologize for putting the member in the middle of this complicated situation," she said in an email that also noted "the air ambulance company billed more than $70,000 just for ground transportation to and from the airport — more than 30 times the average cost of medical ground transport."

Such a situation would "typically" be flagged by internal systems, but for some reason, it was not, Sowers said.

"I have never heard of a ground transport that costs that much. That's shocking," said Erin Fuse Brown, director of the Center for Law, Health & Society at Georgia State University College of Law, who studies patient billing and air ambulance costs.

Still, there's good news for Deines: Both the insurer and the air ambulance company told KHN he will not be held responsible for any of the charges. (None of the charges stemmed from his first air ambulance flight from Casper to Denver, which was covered by the insurer.)

"Once North Carolina Blue engages in our formal inquiries about its refund request, the status of the funds will be resolved," the ambulance spokesperson wrote in her email. "One thing is certain, Sean will not have to pay for North Carolina's wavering coverage decision."

In an email, Blue Cross' Sowers said it had "ceased all recoupment efforts" related to Sean Deine's case.

The takeaway: If the flight had happened this year, the couple might have received more price information before they took the flight.

A law called the No Surprises Act took effect Jan. 1. Its main thrust is to protect insured patients from "balance bills" for the difference between what their insurance pays and what an out-of-network provider charges in emergencies.

It also covers nonemergency situations in which an insured patient is treated in an in-network facility by an out-of-network provider. In those cases, the patient would pay only what they would owe had the service been fully in-network.

Another part of the law, called a good faith estimate, might have provided Deines with more transparency into the costs.

That portion says medical providers, including air ambulances, must give upfront cost estimates in nonemergency situations to patients. Had the law been in effect, Deines might have learned before the flight that it could be billed at $489,000.

Insured patients in similar situations today should always check first with their insurer, if they are able, to see whether an air transport would be covered, experts said.

Even if the law had been in effect, it likely would not have helped with the big hang-up in Deines' case: the disagreement over "medical necessity." Insurers still have leeway to define it.

For his part, Deines said he's glad he took the flight to be closer to home and family, despite the later financial shock.

"I would not change it, because it provided support for myself and my wife, who needed to take care of me; she was keeping my sanity," he said. 

https://www.mainepublic.org/npr-news/2022-03-25/the-case-of-the-489-000-air-ambulance-ride