Wednesday, October 8, 2014

Prepping your wallet for a colonoscopy

Dr. Rig Patel says he can't keep up with all the twists in insurance coverage of colonoscopies,  and he's president of the N.C. Society of Gastroenterologists.

When I called him recently to ask about hidden costs,  he was eager to talk.  The situation is changing rapidly for the better,  he said,  but the situation is still  "very frustrating and very difficult"  for doctors and patients.

As the 50-and-over crowd knows,  the last thing you want to do is add unpleasantness to what's already a humbling reminder that you're getting old. Taking a superlaxitive and getting a probe of your bowels is no fun  --  but the reduction of colon cancer deaths in people over 50 is one of the big success stories in the fight against cancer.  So it's worth talking about a topic that makes us squirm to help people reduce the financial wallop.

A screening colonoscopy for people 50 and older is supposed to be fully covered under the Affordable Care Act.  But depending on your policy,  you could get a bill for sedation,  for a pathologist's service  or even for the whole procedure if precancerous polyps are found.  Patel says private insurance companies are coming around to full coverage,  but there are still exceptions  --  and patients who get bills based on outdated information.  His advice:  Work this out with the insurance company and the billing office before you show up,  rather than trying to wrangle with your doctors and nurses when the time comes.

Don't go to a hospital for the procedure unless there's a medical reason;  it can double or triple your bill,  Patel says.  And ask how you'll be sedated.  Some doctors administer Demerol and/or Versed to induce drowsiness and  reduce pain.  That's not likely to generate a separate bill.  However,  Patel says the trend is toward using propofol,  which puts patients into a deeper sleep and must be done under supervision.  He said his practice in Raleigh has shifted from an anesthesiologist to a certified nurse anesthetist to cut costs.  Ask your doctor about the medical and financial issues beforehand.

Can a patient skip the sedation altogether?  "If they're motivated we will do that,"  Patel said,  but it's far from ideal.  "You need a very quiet,  peaceful patient who's not moving around.  We want to be able to focus on the procedure and not on that uncomfortable patient."

Tuesday, October 7, 2014

Repeal or reform: Next steps aren't simple

A recent conservative poll found that 60 percent of voters want Congress to repeal the Affordable Care Act.

The Kaiser Family Foundation's polling found the opposite, that 63 percent would rather see Congress work to improve it.

So what's up?  According to a piece by Jeffrey Anderson in The National Review Online,  it's a sign that the Kaiser foundation skewed results by casting the issue as a choice between  "work to improve the law"  and  "repeal the law and replace it with something else."  The political research and strategy firm McLaughlin and Associates offered the options of   "it should remain the law of the land,  either in its current form or in amended form,"  "it should be repealed and replaced with a conservative alternative that aims to lower health costs and help people get insurance,"  or "it should be repealed but not replaced with an alternative"  (the last two combined got 60 percent). 

Anderson is executive director of The 2017 Project,  which promotes a conservative agenda. He argues that Kaiser isn't the  "gold standard"  on health care polling that many in both parties believe it to be,  but  "a pro-Obamacare outfit." 

Given the Observer's decision  (and mine)  to work with Kaiser Health News,  which is funded by the foundation,  I thought that was worth checking out.  It didn't take long to find that the McLaughlin questions were focused on conservative alternatives promoted by The 2017 Project  --  or that Anderson's group commissioned that poll,  which he failed to mention in the National Review piece.  As I reported last month,  the Kaiser poll also found plenty of anti-Obamacare sentiment  --  in fact,  the Kaiser poll got a stronger negative reaction to  "a health reform bill signed into law in 2010"  (49 percent unfavorable to 35 percent favorable)  than The 2017 Project poll got to  "the Patient Protection and Affordable Care Act, also known as Obamacare"  (52 percent disapproval to 43 percent approval).

But there's an important kernel of truth in Anderson's piece when he notes that  "improve the law"  and  "replace it with something else"  are vague options.  That's the nature of public polling;  we get people's gut reaction to broad terms,  not an in-depth analysis.   From what I can tell,  most Americans agree that our health care system needs a lot more work and few of us know how to make that happen.

So here's my suggestion:  If you're trying to think through what needs to happen next year,  check out Politico's recent piece on Obamacare 2.0.  The online magazine asked 15 leaders in the health care scene to describe the next steps.  The authors span the political spectrum.  Some tout the act's successes while others proclaim it a disaster.  But they all talk about follow-up actions,  whether that's creating a single-payer system  (independent Sen.  Bernie Sanders),  rolling out a new system that emphasizes choice and cost control  (GOP Sen. Lamar Alexander) or making adjustments to what's in place.  Reading this piece takes time,  but it's the kind of discussion regular people need to tap into if we want to get beyond sound bites.

Friday, October 3, 2014

Pregnancy prevention: What about vasectomy?

While researching an upcoming story on preventive services,  I came across something perplexing:  Tubal sterilization for women is fully covered by insurance,  per the Affordable Care Act mandate,  while vasectomy for men is not.

The act mandates that specific preventive services be exempt from deductibles and other cost-sharing,  not only for policies bought through the ACA exchange but for employer-provided and other privately purchased health insurance  (grandfathered policies are the exception). The goal is making sure that money doesn't deter anyone from getting care that's likely to head off more serious medical issues and bigger bills.

The medical,  financial and societal benefits of preventing unwanted pregnancies seem clear.  So why not support men who are willing to step up?

"You hear that from everyone who looks at this. It doesn't make sense," says Adam Sonfield of the Guttmacher Institute, which focuses on reproductive issues and pushed for vasectomies to be included.

Early versions of the ACA incorporated preventive standards that were already in place from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention. Eventually it grew to include children's services recommended by the American Academy for Pediatrics.

And the Department of Health and Human Services commissioned the Institute of Medicine to create a separate list of covered preventive services for women. That list includes FDA-approved contraceptive devices and sterilization techniques.  But there's no parallel provision for men.

"This position seems particularly short sighted, and insurers should consider covering these services without cost-sharing anyway,"  Sonfield,  a senior public policy associate with Guttmacher,  wrote in 2012.  "Vasectomy is less expensive and less invasive than female sterilization, so it benefits no one to provide economic incentives for couples to choose female sterilization.  Moreover, contraceptive methods used by men and by women offer the same benefits for women’s health,  stemming from the prevention of unplanned pregnancies and the ability to time and space planned ones."

With a growing number of insurance policies requiring consumers to pay bigger sums out of pocket,  the bill for a vasectomy could be significant.  Planned Parenthood lists the cost as $350 to $1,000.  A Southern California public radio station recently did a price check and found fees ranging from $500 to $1,750.

Sonfield said he thought insurance companies would choose to exempt vasectomies from cost-sharing to encourage a cheaper,  safer alternative to tubal sterilization,  but he hasn't seen that happen. Other avenues for change would be for HHS to add vasectomies to the list of covered women's services or for the USPS Task Force to add it to the overall adult list. 

Wednesday, October 1, 2014

Congressmen want to revive end-of-life support

Thirty-four Democratic members of Congress,  including North Carolina's David Price,  recently wrote to the nation's top Medicare administrator urging her to adopt a plan that would reimburse doctors for time spent counseling patients about end-of-life care.

The letter to Marilyn Tavenner, administrator of the Centers for Medicare & Medicaid Services, notes that working with a doctor to create an advance directive ensures that the elderly will receive the type of care they want and reduces stress and depression among loved ones.

"We find it troubling that Medicare reimburses almost every medical procedure, yet places no value on the time doctors take to provide thoughtful counsel to prepare patients and families for the delicate,  complex and emotionally demanding decisions surrounding the end of life,"  says the letter,  composed by Rep. Earl Blumenauer of Oregon.

2009 Obamacare protest (Talking Points Memo)
Such reimbursements were part of an early version of the Affordable Care Act,  leading Sarah Palin to launch the stubbornly persistent idea that the president wants to create  "death panels" that would rule on whether the elderly are granted medical care.  I've always found that one of the more baffling twists to Obamacare politics; I don't know anyone who doesn't want some control over their final days.

The reimbursements were cut from the act that won approval,  but Blumenauer,  Price and others keep pushing to revive them.   The  "Personalize Your Care Act"  introduced by Blumenauer to provide Medicare and Medicaid reimbursement for voluntary end-of-life planning got 59 co-sponsors.  Among them are eight Republicans  (none from the Carolinas).  Price,  whose District 4 includes Raleigh, Durham, Chapel Hill and Fayetteville,  is among the sponsors,  as was Congressman Mel Watt of Charlotte,  a Democrat who later resigned to become director of the Federal Housing Finance Agency.  That bill was referred to the Ways and Means Subcommittee on Health,  joining the list of issues Congress hasn't acted on.

Last week's letter didn't include any Republican signers,  and Tavenner's office has not yet responded to a query about whether the letter will prompt any action.

Price said he thinks it's important to keep pushing.

“The American Medical Association, the Institute of Medicine, and a bipartisan group of lawmakers support Medicare coverage of voluntary end-of-life counseling, which is already covered by many private insurers and Medicare Advantage plans," he said Tuesday.  "I strongly agree with Congressman Blumenauer that Medicare should empower seniors to develop and adopt advance directives to protect their dignity in the final stages of life."

Tuesday, September 30, 2014

Asheville hospital: We're cutting ... and growing

Asheville's Mission Health,  which runs six hospitals,  has joined Carolinas HealthCare System in announcing job cuts as part of the 2015 budget.

Michael Tarwater,  CEO of the Charlotte-based system,  announced earlier this month that CHS is cutting 100 management jobs as part of its quest to trim $110 million.

On Monday Ronald Paulus, CEO of Mission, said his organization had to find ways to offset $52 million in federal and state reimbursement cuts.  That included eliminating 130 full- and part-time  "caregiver positions,"  he said.  Fifty-five of those employees are leaving the system,  15 have found new jobs with Mission and 60 hope to do so, he said.

But the overall workforce will grow by 147 people, he added.  For instance,  he cited a primary care network of 275 physicians that didn't exist a year ago,  focused on  "safety outcomes and cost efficiency."  For Paulus'  eight-minute video message to employees,  click here.

Hospitals and medical practices across North Carolina are grappling with cuts to Medicare and Medicaid,  coming partly from the Affordable Care Act and partly from state efforts to reel in spiraling costs.  The state's decision not to accept federal money to expand Medicaid means North Carolinians are paying the costs for other states' expansion without getting the benefit of increased coverage for low-income adults.  Medicaid will be high on the General Assembly's agenda in January,  and some are watching to see whether our state will follow the lead of other GOP-led states that have found ways to put the federal money to use.

Tuesday, September 23, 2014

Some see huge hike for Medicare Advantage

Notices of 2015 rates for Medicare Advantage plans started landing in mailboxes last week,  and at least one local plan is seeing premiums more than triple.

I heard from David Darwin of Charlotte and Gary Ludwick of Huntersville,  both of whom were told that their HMO premium from Blue Cross and Blue Shield of North Carolina is going from just under $19 a month to $64.40,  with their out-of-pocket limit rising from $3,400 to $4,500.  Both wanted to know what's going on.

That runs counter to the trends announced by the federal Centers for Medicare & Medicaid Services. The agency says 2015 premiums are rising an average of $2.94 next year,  to $33.90 a month,  and estimates the actual hike will be more like $1.30 a month on average as  some choose lower-cost plans.

"The vast majority of (Medicare Advantage) enrollees will face little or no premium increase for the next year with 61 percent of beneficiaries not seeing any premium increase at all," the release says.

Ludwick and Darwin,  not surprisingly,  are wondering if their notice foretells bad news for more people in this area.  "Maybe you can get some answers as to what caused such outrageous price hikes across the board,"  Ludwick emailed,  "and I'm also curious if the costs for Obamacare have any bearing on this."

"I just think people need to understand what they're about to be hit with,"  said Darwin,  a textile retiree who also blames the spike on the Affordable Care Act.

Source: Kaiser Family Foundation

Some background:  Medicare Advantage is an alternative to traditional Medicare,  which provides health coverage for the elderly and disabled.  About 30 percent of the total Medicare population chooses this approach,  which involves buying a policy through a private insurance company.  This is separate from the ACA marketplace that has gotten so much attention in the past year,  but it works in a similar way:  Customers have a choice of various plans based on where they live.  In 2014, Mecklenburg residents had 22 plans to choose from.

Medicare Advantage also costs the government more than traditional Medicare.  The ACA cut Medicare Advantage payments,  but instead of the expected decline in participation,  record numbers are choosing that route,  according to a Kaiser Family Foundation report.

"When Congress debated the payment reductions in 2010,  forecasters and analysts also projected that reductions would drive insurers to raise premiums, cut extra benefits and even pull out of the Medicare Advantage market as they did after the Balanced Budget Act of 1997.   Thus far, however, the response by insurers to the ACA cuts has been more muted,"  says the report by Tricia Neuman and Gretchen Jacobson.

So what's going on with Darwin's and Ludwick's policy? 

I asked Neuman,  the foundation's Medicare expert,  what to make of the big bump in this local plan.  The 2015 national data just came out Thursday,  so she hadn't had time to analyze it in detail when we spoke.  There are always wide variations among plans,  she noted,  and the averages indicate these folks are seeing a hike that's an outlier on the high side.  Market conditions seem more likely to be the source than the ACA, she said.

"If it was really attributable to the law you'd be seeing it more across the board,"  Neuman said.  "It would be more the norm than the exception."

Starting Oct. 15,  Medicare Advantage customers will have a chance to shop around and see if they can get a better plan for less money.  It will be interesting to see what the Mecklenburg market offers.

Friday, September 19, 2014

N.C. Obamacare numbers remain elusive

Participation in the health insurance marketplace created by the Affordable Care Act has dropped by about 700,000 people,  from 8 million when enrollment closed March 31 to 7.3 million as of Aug. 15, the nation's top Medicare/Medicaid administrator said Thursday.

That partially answers questions many have posed this summer about developments on the insurance exchange,  which includes subsidies for low- and moderate-income people buying individual policies.

Medicare/Medicaid administrator Marilyn Tavenner (AP photo)

It still doesn't offer details on how many have failed to pay premiums,  how many have left the marketplace for other reasons  and how many have been added during special enrollment.  Nor have the state tallies posted in May been updated.

Update: The feds did post a zip code map of enrollments as of April 19; read a report from John Murawski of the News & Observer here.

North Carolina had the nation's fifth-highest enrollment after open enrollment,  with 357,584 enrollments as of March 31.  If the state's numbers reflect the 8.75 percent drop the nation has seen,  we'd have lost about 31,300.

As the Department of Health and Human Services notes,  enrollment changes on a daily basis.  People may sign up,  then lose coverage if they fail to pay premiums.  They move from one state to another.  They gain or lose jobs and go through family changes that affect their health insurance.

Earlier this week,  DHHS announced that 115,000 people nationwide will lose their coverage because they failed to provide immigration documents required to verify their citizenship or immigration status.  The department initially flagged 966,000 people whose applications didn't match data on file.  In July,  after repeated attempts to reach those people,  they sent warning letters to 310,000 saying they'd lose coverage if they didn't verify their status by Sept. 5.  That included 12,300 in North Carolina.

The update on people who will lose coverage because of immigration status didn't include state breakdowns;  a DHHS official said that would come later.

In a conference call with reporters,  Andy Slavitt of the Centers for Medicare and Medicaid Services proudly noted that the overwhelming majority the immigration cases that were initially flagged had been resolved.  But he didn't have answers when a reporter asked whether "resolved" included people who kept their coverage and people who lost it,  and if so,  what the mix was.