We have known for many years that people in the five to ten years before they qualify for Medicare have a significant burden of illness. For example, nearly a quarter of cancer cases diagnosed in the U.S. annually occur in people ages 55-64.[1]  In addition, the prevalence of chronic disease increases with age, and multimorbidity (having more than one disease) becomes more common.

It is no surprise, then, that health care costs also increase as we age. People over 55 account for more than 50% of the total health care spending in this country. Those between 55 and 64 are responsible for 20% of the total health spend even though they only make up 13% of the population. That is a step up compared to ages 45 and 54 who account for 13% of the population and 13% of the spend.[2] Our failure to provide universal health insurance coverage in this country means that a chunk of the pre-Medicare population is either uninsured or underinsured and therefore exposed to significant out-of-pocket expenses.

There has been a push to expand Medicare to everyone (“Medicare for All”) but failing some advocate for at least lowering the age of eligibility.[3]This would make coverage available to individuals in their high healthcare cost years. A study in the May 2021 issue of Health Affairs [4] reveals that uninsured older Americans have worse cancer outcomes than their slightly older counterparts who are covered by Medicare. This supports the idea that expanding Medicare eligibility to age 60 (or maybe lower) could have a significant impact on cancer outcomes, an important measure of health and well-being of people at any age.

What did the study hope to achieve?

The research team, led by Gerard Silvestri at the Medical University of South Caroline, wanted to assess differences in cancer survival between uninsured patients younger than age 65 and older Medicare beneficiaries. They used data from more than 1.2 million people in the National Cancer Database from 2004-2016 to answer the following questions:

  • What was the survival for sixteen different cancer types at one, two, and five years?
  • And, were differences in survival associated with differences in insurance coverage?

Patients were divided into 8 groups based on age and type of insurance or lack thereof as shown in Table 1 below.

Table 1. Uninsured cancer outcomes

 

They also did a comparison of the younger patients with either Medicare or private insurance with the older patients with Medicare only or Medicare with private insurance.

Other patient characteristics examined included race/ethnicity, a measure of comorbid illness burden and characteristics of their cancer (type, stage, and place of treatment.

What were the results?

The results showed what many of us would have expected knowing how important it is to have insurance to help pay for the high cost of care in the United States. Nevertheless, this study is important because it clearly showed a “dose-response” effect on survival that varied by the robustness of the coverage, ranging from none to excellent.

The study included survival curves by age and insurance status for three different cancers. Although the details differ, what is strikingly similar is that in each of the three cancers illustrated the best outcomes were for the younger patients (60-64) who had private insurance. The next best were Medicare patients (65-69) who had Medicare plus private insurance (also known as Medicare supplemental insurance. Medicare-only patients (65-69) were the lowest on the survival curves. And bringing up the bottom in every case were younger patients (60-64) who were uninsured.

The major findings can be summarized as follows:

  • Uninsured patients (60-64) were almost twice as likely to have late-stage disease when first diagnosed compared to older Medicare beneficiaries
  • They were also “significantly less likely” to get typical cancer treatments, such as surgery, chemotherapy, or radiotherapy
  • These differences occurred despite the younger patients having lower comorbidity (other conditions) than the Medicare-aged patients.
  • The younger patients also had what the authors called “strikingly lower” 5-year survival across all the cancer types in the study

An example of the last bullet point is that younger uninsured patients with late-stage breast or prostate cancer had a five-year survival that was 5-17 percent shorter than the older patients with Medicare.

The authors concluded that “survival after a diagnosis of cancer is considerably lower in younger uninsured patients than in older Medicare patients.”

Some caveats about the research

The study is what we call an observational study. The researchers examined a database of patients in the US that captures about 72 percent of newly diagnosed cancer patients. They used that data to look for associations between age (pre-Medicare and Medicare age) and insurance status. Because it is retrospective (looking at the past) and there is no control (or reference) group, you can’t be sure that lack of insurance actually was the reason why the uninsured group had the poorest outcomes. The outcomes could have partially or completely due to other things in their life that were not measured in this study. A different type of study is needed to determine a causal relationship – that is to determine if the lack of insurance was what led to (or caused) the unfavorable result.

Nevertheless, studies of this type are valuable as they can much more easily and quickly uncover associations that we might not have recognized. They often provide the impetus for more definitive studies to be carried out.

What are the implications of this study?

This study is important because it suggests that lack of insurance is associated with worse cancer outcomes – something that is devastating for patients and their families. There is also a high societal cost related to prematurely losing the lives of patients during their working years. I believe (as did the authors) that this study can be used by policymakers and advocates to make the case for expanding Medicare eligibility to at least age 60.

You may think that this is too expensive and that we just cannot afford it. Leaving aside the fact that the US is one of the only Western countries that fails to provide universal health coverage, think about this: Our failure to diagnose cancer patients at an early stage means that they will likely need more expensive treatments (e.g., more extensive surgery, more rounds of chemo or radiation). And even if they don’t get it while they are pre-Medicare (as this study suggests), a portion of them will age into Medicare bringing these higher costs of care with them.

The authors point out that insurance alone “would not eliminate the health disparities facing underserved Americans with cancer,” prior studies on health insurance status suggest strongly that it would definitely help low-resource people have better and earlier access to care.

References:

1.  Mallin K, Browner A, Palis B, et al. Incident cases captured in the National Cancer Database compared with those in U.S. population-based central cancer registries in 2012-2014. Ann Surg Oncol 2019:26(6):1604-12

2.Sawyer B, Claxton G. How do health expenditures vary across the population? Peterson KFF Health System Tracker, Jan. 16, 2019. https://www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/#item-start

3. Ghilarducci T. The time is now to lower the Medicare age to 50. Forbes 2020 Apr 10. https://www.forbes.com/sites/teresaghilarducci/2020/04/10/now-more-than-ever-is-time-to-lower-medicares-age-to-50/?sh=5b317bd852be

4. Silvestri G, Jamal A, Yabroff K, et al. Cancer Outcomes Among Medicare Beneficiaries and Their Younger Uninsured Counterparts. Health Affairs 202140(5)754-762

Some years ago, a few months after I had made the decision to leave academic medicine for the greener pastures of private practice anesthesia, I was called in one night to evaluate a young man in his early thirties with a presumptive diagnosis of appendicitis.

He had classic symptoms1, was febrile, and had an elevated white blood cell count. A quick ultrasound followed by a CT scan confirmed the diagnosis. Unfortunately, the scan also demonstrated free air in his abdomen. This signaled that his appendix had ruptured, making his surgery urgent.

We had some time together before the rest of the surgical team arrived at the hospital to get the operating room ready, so I was able to chat with him a little. I learned that he was an accountant with his own small firm. He rented an apartment in the Marina, was married, and was thinking about buying a house in Marin near where I lived. He and his wife were expecting their first child.

Any chance we don’t need to do surgery?

I could tell he was nervous and assumed he was worried about the anesthesia and surgery, so I did my best to calm him.

“Anesthesia is safe”, I told him. “Surgery will go quickly, and you will do just fine! You are young and healthy, and you should recover easily.”

I explained to him that a laparoscopic appendectomy usually takes less than an hour and that he would have very little in the way of post-op pain. He nodded and said,

“I’ve been having bad pain and fever for a few days. It just kept getting worse. I didn’t want to come in at all, but my wife made me. Any chance we don’t need to do surgery?” he asked.

“No,” I told him. “That’s pretty unlikely.” Despite my attempt at a friendly reassuring pep talk he still seemed doubtful and was obviously anxious and hesitant to proceed.

So, I tried again. I explained that a ruptured appendix was a true surgical emergency and that he was lucky he sought help before he became really sick. I told him that he should thank his wife profusely for convincing him to come in.

So, how much is it going to cost?

I laughed and made some dumb comments about how men are pretty bad at figuring out when they need help. I had just gone through some health issues of my own and told him that even doctors are often subject to self-denial.

He became quiet, seemed to think about this a bit. Then in a low voice, as if he was afraid someone else would hear him, he said,

“How much do you think this is going to cost me doc?”

Aha – I thought, this was what he was worried about, not so much the surgery, but his co-pay or deductible. I explained that depending on his insurance, this could run from nothing to a few hundred dollars to at most a few thousand.

“Don’t worry,” I said, “Your insurance will cover almost all of it. This is emergency surgery.”

And then I went to his chart and found his hospital face sheet to see what kind of insurance he had. In the box where the form lists patient insurance were the words “self-pay package” – the space that usually shows a photocopy of the insurance card was blank.

The high price of feeling low

“Did you forget your insurance card?” I stupidly asked.

“No…I don’t have health insurance.” He hesitantly said. “That’s why I’m worried. I can’t afford more than a few thousand dollars?”

I considered the best way to allay these concerns without alarming him too much. I didn’t want to panic him, but I also didn’t want to lie. So, I started doing some rough calculations in my head. The emergency room fee, the ER doctor’s bill, CT scan, radiologist’s pro-fee, stat labs, IV set up and fluids, pain medications, antibiotics…

The mental list grew and grew. I could visualize every line item and its ridiculously inflated price. The bill before he even went into the operating room was easily going to be over ten thousand dollars2.

Now add to this the operating room costs at several thousand dollars per hour, professional fees (mine and the surgeons), pathology, surgical and anesthetic supplies, recovery room fees and medications, and on and on.

All of the itemized lines have prices that are designed for a system in which the cost and what is paid are disconnected by contract pricing from the twilight zone of insurance reimbursement.

In this alternate bizarro world, a single Tylenol tablet can be priced at twenty dollars, a bag of IV saline solution, over a hundred. Nobody actually pays those prices…unless you are paying cash. Then all bets are off.

The real world of price versus cost does not apply

As my accountant patient was undoubtedly good at math himself, I am sure he was capable of adding numbers more quickly than I was. What he probably didn’t know was that the real world of price versus cost does not apply to American healthcare. It is far more similar to government military contract spending3, where a hammer or a single bolt can be billed out at many times the actual cost.

Unfortunately for my young accountant, his ruptured appendix was a truly life-threatening event and surgery could not be delayed. However, this was also only the beginning of his treatment.

He would end up needing several days of inpatient hospitalization, intravenous fluids, and antibiotics to ensure an adequate cure and recovery from his ruptured purulent appendix and subsequent peritonitis. Had he come in just a day or two earlier, he could have saved himself an incredible amount of money. More importantly, he would have reduced his risk of further medical complications.

By the end of his stay with us, his bill easily exceeded a hundred thousand dollars. On my post-op visit the day after surgery, we talked more about his money concerns than his medical ones.

Could have, should have

I explained to him that he did have some financial options. For instance, he could try to negotiate with the hospital4 for a cash discount. Or he could set up a payment plan. I heavily discounted my professional fee, and I discussed his situation with the surgeon as well, who also agreed to a steep discount.

The hospital, I thought, would be a harder sell. I suspected it would be difficult to convince the finance people of a large “not-for-profit” institution that a college-educated accountant with his own business didn’t know better than to go uninsured and not carry any kind of health insurance at all. And I also knew there were many other young people5 in his position.

By the end of his stay, my new accountant friend was deeply in debt. This was before “Obamacare” and the provisions of what would become the Affordable Care Act.6  Had he simply enrolled in a reasonably priced Kaiser plan, or at least bought a catastrophic insurance policy at a few hundred dollars a month, he would have been protected from the threat of bankruptcy over this one episode.

More content on Healthcare Coverage:  Why You Need to Prioritize Getting the Right Healthcare Coverage

But like many young, healthy Americans who are either self-employed, or unemployed, or who work at firms that don’t provide insurance, he hadn’t. This incident left me deeply affected and made me wonder like David Byrne in The Talking Heads’ song “Once in a Lifetime”7 – well, how did we get here?

The good old days

In the good old days of medical practice, the relationship between the price of a service provided and the amount paid for it was more or less the same thing and bore some passing resemblance to the reality of cost.

A hundred years ago, health insurance as we now know it simply did not exist. Actuaries declined to provide medical insurance to individuals owing to their inability to assess and quantify this particular type of risk.

In-depth medical knowledge was an oxymoron and many popular therapies were unproven quackery8. Statistics was a nascent science. An excerpt from an article in an insurance industry publication stated,

“The opportunities for fraud [in health insurance] upset all statistical calculations….Health and sickness are vague terms open to endless construction. Death is clearly defined, but to say what shall constitute such loss of health as will justify insurance compensation is no easy task” (The Insurance Monitor: July 1919, vol. 67 (7), p. 38).

Insurers lacked the ability to determine whether doctors or patients were less than honest in their claims. As always, death, taxes, and cheating were seen as the only sure thing.

Health care was relatively inexpensive

Instead, insurers offered “sickness insurance”, an early form of disability insurance. Lost income rather than the cost of treatment was the justification for compensating those who missed work as a result of illness. Poor people, alas, were out of luck and depended entirely on charity or the church.

Fortunately, health care was relatively inexpensive, and hospitalizations were rare. Most people were born, treated, and died at home. Doctors made house calls, and cash or barter were the only methods of payment and compensation.

Although physicians were respected members of society and did quite well financially compared to many others, they weren’t exactly rolling in cash. Perhaps the same was true of insurers. They collected premiums and paid restitution in the case of major catastrophes like fires, ship loss, or crop failure.

But unlike doctors, insurance brokers were businessmen and sought to profit from their ventures. Some insurance executives became wealthy as a result of their enterprise.

However, I suspect few individuals were lighting cigars with hundred-dollar bills. And maybe some Park Avenue doctors did better than others due to the wealth of their clientele, but for the most part, they were not multi-millionaires unless they were very good investors or made it the old-fashioned way, through inheritance.

This was all about to change, however. Prior to the late eighteen-hundreds, the cause of sickness was poorly understood, and remedies were not that far removed from blood-letting and leeches. The Gilded Age ushered in the twin promises of science and technology.

The Golden Age of Medicine

In rapid succession progress in medicine included advancements such as reliable and effective general and local anesthetics, and in turn safer and more effective surgery. Antibiotics were discovered and improved upon, which followed the understanding of the germ theory of diseaseand anti-sepsis. Vaccines became common, and polio and smallpox were largely eradicated. Insulin was discovered.

Later, imaging technology such as computed tomography, nuclear medicine, ultrasound, and magnetic resonance enabled diagnostic “vision” unimaginable only a generation before.

By the late twentieth century with advances in genetic engineering and molecular biology, diseases such as cancer, strokes, and heart failure, while still prevalent, had a chance of control if not outright cure. The major consequence of this rapid change has been a longer and more productive life. In 1900, the mean life expectancy of a man10 in America was forty-seven years, now it is approaching eighty. We also expect to live these longer lives in a healthy and active state.

Of course, the cost of this progress is immense11, consuming an enormous amount of our gross domestic product. By the early 1960’s the explosion in medical technology and cost became increasingly expensive for the average citizen, and inordinate numbers of people, particularly the elderly, simply could not afford medical care.

Related Content:  Did Medieval Medicine Pave the Way for Value-Based Payment?

The Great Society

Fearing a society in which many of its citizens could potentially be driven to the poorhouse, President Johnson initiated sweeping changes to medical reimbursement in his “Great Society” programs12, and Medicare and Medicaid were born.

Private insurers such as Blue Shield and Blue Cross expanded coverage to include “comprehensive” services,  And Health Maintenance Organizations like Kaiser became increasingly popular as a way to contain rising costs while still providing good medical care.

In these early days of health insurance, reimbursement became much better for doctors. Older, mostly retired physicians I know, still pine for the “golden age” of medicine in the nineteen-sixties and seventies.

Middle-aged, still working doctors like myself become greatly annoyed at this talk. The same generation that enjoyed relatively generous reimbursements from Medicare and other insurers, set by the doctors themselves, also enjoyed ridiculously inexpensive real estate, low college and medical school tuition, and other perks completely unavailable to the current crop of medical practitioners. I know… cue the tiny violins.

Doctors do well but insurance executives do obscenely well

We still make quite a good living relative to many others. However, if we do well, insurance executives do obscenely well.13  I remember when I was an anesthesia resident in Seattle, reading an article in the local paper about a public opinion poll on medical reimbursement.

Participants were asked to guess and then opine on the salaries of a primary care doctor, a general surgeon, the CEO of one of the local private hospitals, and the CEO of a regional HMO. The guesses people made weren’t even close.


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Most people assumed that doctors made a bigger salary than they actually did, but not by too much. They were off by a factor of ten in the hospital CEO salary, and a factor of nearly ten times that in the insurance CEO’s compensation. The latter was actually in the tens of millions of dollars with stock options included.

More on Doctor’s Compensation: Physician Compensation 2020: How Much Money Do U.S. Doctors Make Per Year? 

What really bugged me, however, was the follow-up opinions of those surveyed that it was the doctors as opposed to the business executives who made too much. Ouch! I remember thinking to myself Gordon Gekko was right. Greed is good.14

Medical school is expensive and out of reach for many

These days much has changed. Unfortunately for the worse. Income disparity is greater than ever. Great wealth is measured in billions, not millions. To be simply “rich” we are told your net worth should exceed 2.3 million dollars!15

All the while, more and more middle-class individuals like my accountant patient of twenty-some years ago cannot afford even basic health insurance. This is occurring in a backdrop where healthcare costs are taking up an ever-increasing percentage of our GDP16, exceeding seventeen percent in 2020.

For those aspiring physicians out there, medical education costs upwards of one-hundred-thousand dollars per year for four years of medical school. And that is after four years of incredibly expensive college.

It is so pricey and out of reach for most people now, that many medical schools are offering++ low or no tuition for individuals who qualify financially, or who promise to spend several years of their early career in primary care in underserved areas. As generous as this is, it doesn’t cover everyone who wants to be a doctor or people like me who want to become an anesthesiologist or some other kind of specialist.

Far more important, however, is what we must do to protect and preserve our health. If the pandemic has taught us anything, it is that we need to figure out how we are going to provide affordable, basic, and even intensive medical care to our aging and vulnerable population.

As our technology improves, so do our costs. We live in a world where we are only one novel virus away from another pandemic, thus we have some reckoning to do. The miracle of rapid PCR tests for coronavirus, and the even more miraculous mRNA vaccines cost serious money. It was money well-spent, but we will need much, much more.

What about the future?

It would be nice to have a crystal ball, but we don’t, and speculation is a poor substitute for action. I often think of one of my favorite Yogi Berra phrases17 – “it’s tough to make predictions, especially about the future.”

I do know that we have made great strides as a society in the past to help address the problem of affordable health care. The Social Security, Medicare, and Medicaid programs were a start and Obamacare was also a giant step in the right direction.

Whether or not we will see single-payer insurance or universal basic health coverage is a mystery. What is clear to me and my medical colleagues, however, is that the system we have is broken and needs repair.

No great society can last long while its citizens suffer, and no humane person can stand back and impassively watch. I know I can’t.

References


  1. Appendicitis, Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543
  2. Lindsey Tanner, AP Medical Writer.  Appendix removal: Huge sticker shock in study.  Yahoo News, Apr 2012
  3. Jack Smith.  $37 screws, a $7,622 coffee maker, $640 toilet seats: suppliers to our military just won’t be oversold. Los Angeles Times, Jul 1986. https://www.latimes.com/archives/la-xpm-1986-07-30-vw-18804-story.html
  4. Hal Levy. 6 Things to Remember As You Negotiate Medical Bills, HealthCare Insider, Updated Jan 2021. https://healthcareinsider.com/negotiate-medical-bills-68526
  5. Kevin Quinn, Cathy Schoem, Lousia Buatti.  On Their Own:  Young Adults Living Wintour Health Insurance.  The Commonwealth Fund, May 2020.
  6. The Affordable Care Act, Healthcare.gov. https://www.healthcare.gov/
  7. Talking Heads, Once in a Lifetime.  YouTube by Rhino/Warner Records.  https://www.youtube.com/watch?v=CHatn3_UxEU
  8. Quackery, Wikipedia. https://en.wikipedia.org/wiki/Quackery

  9. Germ Theory,  Encyclopaedia Britannica. https://www.britannica.com/science/germ-theory
  10. Life Expectancy, Mortality in The United States, 2018. NCHS, Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/life-expectancy.htm
  11. National Health Expenditure Data, Trends.  Centers for Medicare and Medicaid Services. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata?redirect=/nationalhealthexpenddata/
  12. Great Society, Wikipedia.  https://en.wikipedia.org/wiki/Great_Society
  13. Morgan Haefner.  Pay for each of these 6 health insurance CEOs surpasses $15M.  Becker’s Payer Issues, Aug 2020
  14. Gordon Gekko, Wall Street character.  Wikipedia https://en.wikipedia.org/wiki/Gordon_Gekko#.22Greed_is_Good.22_quotation

  15. Maryalene LaPonsie.  Are You Rich? How the Wealthy Are Defined, U.S. News, Jul 2020. https://money.usnews.com/money/personal-finance/family-finance/articles/are-you-rich-how-the-wealthy-are-defined
  16. National Health Expenditure Data, Historial.  Centers for Medicare and Medicaid Services.  https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
  17. Yogi Berra, American baseball player. Wikiquote.  https://en.wikiquote.org/wiki/Yogi_Berra

Health insurance coverage for infertility treatments varies widely. Some plans cover advanced assisted reproductive technologies (ART). Others only pay for basic evaluations. This article will explore why infertility treatments should be covered by insurance. 

According to the WHO’s 2020 Infertility Fact Sheet, infertility affects millions of people of reproductive age worldwide.[1] It impacts not only individuals but also families and communities. Estimates suggest that “between 48 million couples and 186 million individuals live with infertility globally.” Inequities and disparities in access to fertility care services adversely affect the poor, unmarried, uneducated, unemployed, and other marginalized populations.

A wide variety of people, including heterosexual couples, same-sex partners, older persons, individuals who are not in sexual relationships may required infertility services. Some circumstances, such as HIV serodiscordant couples and cancer survivors, may require highly personalized approaches to care.

 Although both women and men can experience infertility, women in a relationship with a man are often perceived to suffer from infertility, regardless of whether they are infertile or not. Further, infertility has significant negative social impacts on the lives of infertile couples. Women are more often suffer negative consequences of infertility such as partner violence, divorce, social stigma, emotional stress, depression, anxiety, and low self-esteem. Addressing infertility can mitigate gender inequality.

The evolving definition of infertility (we’ve come a long way, baby) 

–The landmark 1993 ASRM definition

As far back as 1993, the American Society for Reproductive Medicine (ASRM) – the professional society for reproductive medicine physicians and providers – declared: 

“Infertility is a disease of the reproductive system that impairs the body’s ability to perform the basic function of reproduction.”

Despite this statement by professional experts, it took many more years for other major health groups to formally agree. 

–The 2009 WHO and ICMART definition

In 2009, long after ASRM’s initial declaration, the World Health Organization (WHO) and the International Committee for Monitoring Assisted Reproductive Technology (ICMART) decided to define infertility as:

“a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”

These organizations are important because they influence the perspectives and practices in the international health community. This definition became a part of the WHO-ICMART glossary that was published in 2009.

–International Glossary on Infertility and Fertility Care 

The 2009 International Glossary on Infertility and Fertility Care was updated in 2017 [2] This effort was led by ICMART in partnership with all the major international fertility societies. An important change in the definition of infertility occurred at that time:

“A disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce either as an individual or with his/her partner. …”

This definition acknowledges the rights of individuals with a desire to parent in a non-traditional manner, including having access to fertility care.

–The AMA joins in

In the same year, the American Medical Association (AMA) joined WHO/ICMART in declaring that infertility is a disease. Persuaded by the ASRM, the AMA House of Delegates adopted a resolution during their 2017 annual meeting that described infertility

“as a disease state with multiple etiologies requiring a range of interventions to advance fertility treatment and prevention.”

In a summary of their decision, the AMA stated their hope that the new designation would remove some of the stigmas and importantly, “promote insurance coverage and payment.”

Lobbying the AMA and others has been part of a strategic effort by ASRM to ensure that more Americans have access to reproductive medicine. According to past president Richard Paulson, MD,

“We all feel this way and realized it was time to put our efforts behind it,” adding infertility doctors have become “increasingly sensitive to the fact that much of the American population simply can’t afford infertility treatment.”

–A major advance in billing codes

The presence or absence of a specific code to bill for a service is a key factor in payment for those services. A notable advance in this area occurred when the International Classification of Diseases (ICD) which governs billing codes added “infertility” to the list of ICD-9 codes. It is now a part of the ICD-10 codes currently being used in the US.

Being “covered” is not enough, the coverage must be robust

Financial constraints are an important determinant of whether or not infertility treatments are covered. They also influence the extent of the coverage. In other words, which procedures and drugs are covered as well as the magnitude of the patient’s cost-sharing.

The benefit’s design has significant clinical implications. Infertility professionals express concern that some patients make suboptimal decisions about treatment. For example, they may choose to transfer multiple embryos to the uterus at once, instead of the now-recommended single embryo transfer. The driver of this decision is to avoid paying for more procedures. This leads to a higher risk of complications for mother and child and higher long-term health care costs for insurance companies.

Despite several major health groups declaring that infertility is a disease, complex and varied factors, including those just described, determine what is covered and how much is paid for as part of healthcare coverage. Employers purchase health insurance for their employees and have a say in the type of infertility coverage they want to be included in their plans. Insurance companies must respond to their wishes as well as comply with state and federal regulations as well as a factor in their own financial considerations.

Perceptions of infertility care play a role in coverage 

Major factors that determine coverage include cost, prevalence, and politics/external pressures (including state advocacy and internal pressure from employees on employers). In writing about the politics and culture of parenthood for CNN Health, Elissa Strauss has her own perspective as to why insurance companies still do not sufficiently cover treatments such as in vitro fertilization (IVF)[3]. She sums it up as follows:

“economics, ignorance and sexism.”

There’s widespread agreement on the role of economics and the influence it has on covering infertility treatment.  For years the label “experimental” was problematic. However, now – forty years after the successful birth of Louise Brown, the awarding of the Nobel prize to Sir Bob Edwards for its creation, and the birth of almost 10 million babies worldwide – it’s impossible to continue to call the procedures experimental.

Two other factors have led to low coverage rates for infertility treatment according to Strauss: sexism and the perception of who needs IVF. She points to insurers’ treatment of women’s issues as a “niche” health issue, starting with the fact that 30 years ago childbirth was not covered by insurance and had to be paid out-of-pocket. This attitude, she says, continues to play a role in the denial of coverage. She also notes the irony of treating infertility as a “female” issue when half of the infertility cases are associated with male factor infertility.

The other issue Strauss believes has interfered with gaining wider insurance coverage is the perception that procedures like IVF are only needed/used by wealthy women who require the procedure because they delayed having children until too late while they pursued careers. The demographics of who is affected by infertility and needs treatment definitively show otherwise.

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The trend for coverage of infertility is improving

The trend for coverage of infertility is definitely improving but the most active sectors embracing this change are technology firms, banking, and other highly compensated industry sectors as described in this New York Times article [4]. There is also wide variation in what is covered, how much is paid, and even whether pre-authorization is required before receiving treatment.

The article cites an analysis of infertility coverage by broad industry sectors and the top 250 employers for the 2017/2018 benefit year. A survey of a subset of 10,000 verified IVF patients who had complete IVF coverage in 2017 found that employees who had their IVF covered reported the following:

      • Those with coverage were more likely to remain in their job for a longer period (62%),
      • They were more willing to overlook shortcomings of their employer (53%)
      • Covered individuals were more likely to work harder (22%)
      • And, the vast majority (88%) of women who had their IVF fully paid by their employer decided to return back to that employer after maternity leave

–Employee satisfaction

There is also a higher rate of employee satisfaction with their employer if fertility benefits are offered compared to employers that do not offer a benefit:

      • 4 times more believe their employer is meeting the needs of today’s families
      • 5 times more believe their employer listens to their needs
      • 5 times more believe their employer cares about their well-being

–Comments from the survey

Comments from survey respondents also revealed stark differences in how employees felt about their employers based on whether or not they offered a fertility benefit. One woman stated that because her employer offered such coverage “I’m loyal – it’s the reason I stay.”

Those employers who did not offer coverage earned negative comments from employees including: “behind the times in health coverage,” “makes me feel undervalued,” “discriminated against this disease,” and “must be a better place to work, I’m looking for a better job with better benefits, better understanding.”

Related content by the author:
Sorting Out the Complicated Relationship between Infertility and Depression
IVF or IUI: Which is the Right Fertility Treatment for You?

There is still room for improvement

Coverage of infertility has improved over the years, largely from competitive pressures among companies looking to attract and retain the best employees. However, there is definite room for improvement since only about a quarter of current IVF costs are covered nationally. The current need for infertility services is not being met largely because of a lack of affordability.

So, how does a disease like infertility garner inclusion as a covered benefit? External pressure can drive decision-making by employers who determine benefit coverage with insurers and with state and federal legislators to enact mandates to ensure appropriate coverage for needed treatment. RESOLVE: The National Infertility Association serves as a valuable resource and advocates on both counts.

RESOLVE resources:

  1.  The RESOLVE Coverage at Work Initiative has materials to help individuals advocate on their own behalf with their employer to add fertility coverage to benefit packages. This includes talking points to use with your Human Resources department and/or benefits manager and a template letter you can customize. The letter provides the type of information employers need including studies that show there actually are minimal net costs involved in adding coverage because improved health outcomes result in lower employer maternity expenses. You can download the template “Insurance Coverage Request Letter” by clicking here.
  2. RESOLVE plays an active advocacy role working to secure state legislative mandates requiring insurance coverage for infertility treatment. To learn more about what your state does – or doesn’t do – when it comes to requiring insurance coverage of infertility treatment, you can click on the RESOLVE list.
  3.  The organization also produces a Fertility Scorecard that ranks each state on how well they’re doing on the issue. You can learn more about RESOLVE’s current state advocacy issues here and find out how to become involved.

Some really big questions remain

Whatever varied factors you believe may influence whether infertility is considered a disease with coverage for needed treatment, CNN Health’s Strauss notes there are “thornier” issues to consider: is having a baby a privilege or a right?

Such questions parallel the discussion of whether or not access to health care is a right. While most countries consider it to be so, this position is not universally held in the US. Kara N. Goldman, MD, assistant professor of reproductive endocrinology and infertility at New York University has advocated for comprehensive infertility coverage. She states

“I think of reproduction as a basic human right. Patients should be able to have families, and we have the medical care to make that possible.” [3]

The view that reproductive rights include the right to diagnosis and treatment of infertility is increasingly becoming the international norm. [5]

The bottom line

This article has reviewed why it is important to provide access to infertility and fertility care for all who want a family. Since the major barrier to access is affordability, it is imperative that health insurers, particularly employer-sponsored health plans, include this care as a covered benefit. 

With a healthy economy and a desire for healthy babies, employees facing infertility have every reason to expect that employers can and should offer a fertility benefit. Surveys and studies show it makes companies more competitive, increases their ability to attract and retain the best employees, enhances employee morale and productivity, and improves health outcomes.

References:

  1. WHO. Infertility. 2020 Sept 14, https://www.who.int/news-room/fact-sheets/detail/infertility (Accessed 2/27/21)
  2. Zegers-Hochschild F, Adamson D, Dyer S, et al. The International Glossary on Infertility and Fertility Care, 2017 July 28, ASRM FertStert, DOI:https://doi.org/10.1016/j.fertnstert.2017.06.005
  3. Strauss E. 40 years later, why is IVF still not covered by insurance? Economics, ignorance and sexism. CNN Health, 2018 July 25, https://www.cnn.com/2018/07/25/health/ivf-insurance-parenting-strauss/index.html (Accessed 2/27/21)
  4. Carrns A. Tech Companies Get High Marks for Covering Infertility Treatments. New York Times. 2017 Nov 15. https://www.nytimes.com/2017/11/15/your-money/infertility-treatment-coverage.html. (Accessed 2/27/21)
  5. Starrs A, Ezeh A, Barker G, et al. Accelerate progress: Sexual and Reproductive Health and Rights for All. Report of the Guttmacher-Lancet Commission. 2018 May 9. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30293-9/fulltext

Published 10/29/18. Updated and republished 2/27/21.

Financial disclosure: Dr. Adamson is a part of ARC Fertility. TDWI, however, did not receive any compensation to publish this story. Rather, it was published because of the important nature of its content.

The Medicare Part D coverage gap, also known as the “donut hole”, is present in nearly every Medicare prescription drug plan. It places limitations on coverage for drug expenses between specified values.

In 2021, the gap starts when a beneficiary exceeds $4,130 in covered expenses. It ends after the beneficiary pays $6,550 for drugs out of pocket. At that point, catastrophic coverage kicks in. It covers 95% of the remaining prescription costs for the year. Not everyone who has Part D will face this gap in coverage, but many people do.

The good news is that the coverage gap has slowly shrunk since 2010 thanks to the Affordable Care Act. Currently, beneficiaries only need to pay 25% of the cost of brand-name and generic drugs while in the donut hole period.

Why the Medicare coverage gap closed

Prior to 2006, Medicare beneficiaries did not receive any sort of prescription drug coverage. Part D was introduced in 2006 to solve this problem and provide coverage for prescriptions. However, Part D has always had gaps in coverage that could leave beneficiaries struggling to cover their expenses.

When Part D was first introduced, beneficiaries were responsible for the full cost of their prescriptions once the donut hole gap was reached. That figure has slowly gone down each year under the Affordable Care Act.


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The original purpose of the donut hole was to keep program costs for Medicare low. It was also supposed to encourage beneficiaries to use cheaper generic drugs rather than costly brand-name prescriptions.

However, the hardship caused by the coverage gap has outweighed the benefits for many people. This is especially true. for those who rely on drugs that do not have affordable generic alternatives.

Who pays for drugs in the coverage gap?

The big difference for consumers is who is expected to pick up the costs. Since the passing of the Bipartisan Budget Act of 2018, pharmaceutical companies are required to offer discounts to Medicare beneficiaries. They must mirror what they offer to other insurance providers.

In effect, this means that pharmaceutical companies themselves are expected to cover more of the costs for prescription and generic medications for individuals who fall within the coverage gap.

Is the coverage gap going away entirely?

Some say that the donut hole “closed” in 2020, however, recipients need to be aware that there continues to be prescription drug coverage gaps.

When in the coverage gap phase, brand-name and generic drugs are discounted 75%. This is significantly more than in previous years when the donut hole was larger.

Still, you will have out-of-pocket expenses before catastrophic coverage kicks in and covers all but 5%. It is not likely that discounts will reach 100%, which would close the donut hole completely.

What’s changing in 2021?

The changes to Medicare Part D in 2021 include the following:

  • The standard yearly deductible limit will rise from $435 to $445 (deductibles are based on the plan you have chosen)
  • The initial coverage limit will rise from $4,020 to $4,130
  • Catastrophic coverage will kick in after $6,550 has been spent

As a Medicare recipient, you will receive an Explanation of Benefits (EOB) that will detail how your coverage has been allotted to pay for generic and brand name prescription drugs.

When it comes to reaching the $6,550 threshold for catastrophic coverage, several expenses are applied. Your deductible, coinsurance, and copayments all count toward the out-of-pocket expenses.

The drug company’s manufacturer discount also applies. However, your Part D premiums and any prescription costs that fall outside of the plan do not count toward the out-of-pocket expenses necessary to reach the threshold.

Medicare Related Articles:
Why Premium Support for Medicare is a Bad Idea
 New Long-Term Care Benefits Added to Medicare Advantage Plans

What if you want to change your plan?

Medicare beneficiaries are able to make changes on an annual basis during the Medicare Annual Election Period. This enrollment period is open between October 15 and December 7. Changes made to a plan at that time will reflect on your policy beginning January 1.

During the Annual Election Period, you can make several types of policy changes:

      • swap between Original Medicare Parts A and B to Medicare Advantage, also known as Part C.
      • change from one Medicare Advantage plan to a different one.
      • sign up for a prescription drug plan under Medicare Part D if you do not already have one.
      • modify your existing Medicare Part D plan or change to a different one.
      • cancel your Part D plan.
  • Adding drug coverage

If you do not currently have prescription drug coverage and wish to add it during the Annual Election Period, you may need to pay a late enrollment penalty. This penalty is assessed any time you have gone without prescription drug coverage for 63 consecutive days and you did not enroll immediately upon becoming eligible.

In other words, if you have declined Medicare Part D in the past but would like to add it in now that the coverage gap has closed, you will be responsible for a one-time late enrollment penalty.

  • Swap between Medicare Advantage and Original Medicare

If the only change you wish to make is to swap between a Medicare Advantage plan and an Original Medicare plan, you have an additional opportunity to do so. The Open Enrollment Period for Medicare Advantage begins on January 1 and lasts until March 31.

If you change from Medicare Advantage to Medicare Parts A and B during this time period, you have until March 31 to enroll in a Part D prescription drug plan.

When making this change, remember that your coverage goes into effect on the first day of the month after enrollment. Therefore, if you enroll on February 14, your coverage will begin on March 1.

Is Medicare Part D right for me?

If you are eligible for Medicare, prescription drug coverage is an optional form of coverage. It’s up to you to decide whether it’s worth signing up for Medicare Part D or an all-inclusive Medicare Advantage Plan. If you have drug coverage from another group health plan, you probably do not need to enroll in Medicare Part D.

You may want to add Part D or change to a Medicare Advantage Plan or Medicare Cost Plan that will cover your medical expenses and the price of your prescriptions. Ultimately, it’s your decision which type of coverage will be best for your individual situation and medical needs.

Recent changes to the Medicare coverage gap make it more affordable than ever to obtain the prescription coverage you need. Talk to your insurer for more information so you can make the best choice for your needs.


Published Aug. 10, 2018. Revised by the author for republication 1/19/2021.

This article examines the future of healthcare in a post-COVID-19 world as gleaned from the HLTH VRTL 2020 online mega-conference. It also explores the impact of the future state on the care of chronic inflammatory diseases, my area of focus. As I engaged in virtual sessions and networking, I viewed them through my lenses as a financial analyst, business consultant, and patient.

In keeping with my mission at Your Autoimmunity Connection, I constantly kept one question in mind. How could these post-COVID changes help patients with autoimmune and autoinflammatory conditions?

How did HLTH VRTL work out?

I love going to conferences, from the anticipation of adventure with my well-worn suitcase and beloved travel clothes. Plus the excitement of meeting new people in the most unlikely locations: bathrooms, hallways, and elevators. For me, conferences have been intermittent opportunities to take the pulse of digital health.

In the past, HLTH has been one of the best such adventures. In 2019, I shared a room with Mette Dyhrberg, founder of Mymee, a great way to collaborate on our joint missions to improve research, diagnosis, and care for autoimmune patients.

This year, 2020, the Year of the COVID-19 pandemic, is different. With safe travel options limited, we are all adjusting to virtual conferences.

I am happy to report that the HLTH VRTL platform execution was superb. During an entire week of online presentations and one-on-one virtual meetings, the platform never crashed. In fact, that dreaded circular buffering icon never once appeared. Kudos to the HLTH VRTL tech team for creating a seamless virtual conference experience.

First impressions of HLTH VRTL 2020

First impressions are key. HLTH did a great job setting the stage. They started with an inspirational video and followed with an informative statistics video.

Among the myriad of tracks, I found the daily recaps with Andy Slavitt, Leona Wen, and John Brownstein to be useful and informative. These helped me to quickly identify the healthcare delivery trends that I think might be important to chronic autoimmune and autoinflammatory patients.

Below are highlights of selected sessions, framed by my analysis and commentary on how disruptive post-COVID drivers of change might help create a new normal that will better meet the current and future needs of autoimmune patients.

The disruptor: COVID-19 forced rapid growth in telemedicine and remote patient monitoring.

In the “Future of Telehealth,” section of the HLTH Counterpoint Series, Tina Reed, Executive Editor of Fierce Healthcare, moderated contrasting perspectives on the future of telehealth from Roy Schoenberg, President, and CEO of Amwell (NYSE: AMWL), and Mario Schlosser, CEO of Oscar Health.

graphic speakers at HLTH discussing health care in post-covid-19 world

Graphic provided by the author

  • Amwell – telehealth platform for all

Amwell is a leading telehealth platform provider in the United States and globally. It connects and enables stakeholders to deliver greater access to more affordable, higher quality care. These include:

      • providers,
      • insurers,
      • patients,
      • innovators.

With over a decade of experience, Amwell powers telehealth solutions for over 2,000 hospitals and 55 health plan partners with over 36,000 employers, covering over 80 million lives.

Roy Schoenberg, CEO of Amwell, said,

“The coronavirus has shown people that delivering healthcare with technology has a role to play. We have a strong voice for the payer and provider, maybe we are beginning to see the arrival of the patient voice…If we can create a gratifying experience for the people that we serve over the long term that is a winning strategy.”

He continued,

“There is an important question as to whether these technologies are part of the delivery or the payer side of care.”

He sees a future where group practices are enabled by technology to be more easily accessible to patients while providing great customer service and communication. Rather than viewing telehealth as just another “tool”, he believes that a “home run” would be when:

”Telehealth is a care setting in which traditional medicine is delivered and the home front will be the most coveted care setting.”

How does this apply to autoimmune care?

Chronic disease patients, especially autoimmune and autoinflammatory disorders patients, need ongoing support between regularly scheduled appointments. The expanding use of telehealth may benefit them.

Telehealth can enable more frequent, convenient, yet less costly encounters from patients’ homes. This is even more true if telehealth is not just replacing PCP encounters but augmenting them with coaching and other staff. Coordinating with specialists is another important feature for chronic and autoimmune disease patients, but that doesn’t seem to be as far advanced.

  • Oscar Health – Beyond insurance

Oscar Health is a hybrid insurance company, telemedicine platform, and primary care provider, based in the Pacific Northwest. Founded in 2012, Oscar Health was the first direct-to-consumer (DTC) health insurer. It facilitates member engagement with their own full-stack technology platform that handles both the insurance side and the care delivery side of the business. This includes:

      • claims processing workflows,
      • benefits adjudication,
      • prior authorizations,
      • features to support telemedicine, remote patient monitoring, and care collaboration and coordination.

Oscar is one of many companies building variations on care teams to improve coordination, delivery, and customer service while controlling costs. These teams, which Oscar calls concierge care guides, can help patients do the following:

      • find a physician or specialist,
      • coordinate their care,
      • navigate billing and benefits.

This approach: digitally supported personalized care teams led by nurses, coordinated by guides (aka coaches), and physicians. The personalized care teams provide a range of care, including chronic disease plans, which is similar to ideas we’ve proposed from 2014 on to help CID patients navigate their complex ongoing care.

Mario Schlosser, CEO of Oscar Health, told HLTH that the COVID boost to telehealth is a

“huge opportunity to bend the cost curve and increase the number of touchpoints (visits) and therefore reduce the variation in care.”

For autoimmune and autoinflammatory disorders patients, more telehealth visits and remote monitoring of symptoms, medications, etc. between appointments could help them reduce flares, better manage side effects, and avoid costly emergency care and hospitalizations.

Schlosser sees a future where there will be more remotely enabled physician practices that take on the financial risk themselves so that

“the number of physician visits go up, but the price goes down.”

Implications for autoimmune patients

In conclusion, telemedicine and remote patient monitoring are enabling technologies, much needed. However, they have not yet directly focused on autoimmune or autoinflammatory disease care.

Using telehealth to expand access, speed, and the number of encounters, along with the expanded use of care-based team models that include specialists, could potentially benefit autoimmune patients.

Likewise, remote patient monitoring can enable better chronic autoimmune disease care. However, this will only occur if payers, providers, and platform companies finally focus on this invisible opportunity, as costly and complex as cancer.

The driver: faster migration from FFS to VBC enables new payment & reimbursement models

Value-based care (VBC) offers a new financial foundation for healthcare delivery business model experiments. From the perspective of autoimmune patients, I wonder if the VBC payment models better support the long-term, multiple-modality care coordination that such patients need, but have generally not received from FFS delivery models?

graphic of speakers at HLTH talking about healthcare in a post-COVID-19 world

Graphic provided by the author

Bryony Winn did a great job setting the stage, asking why this is a good time to discuss “A Push Into Value-Based Care”, as she asserted that:

    1. The COVID pandemic shows that perverse incentives make FFS unsustainable for providers. However, VBC’s steady revenue models may better align payers, providers, and patients.
    2. We now have evidence from programs that were launched and tested mainly by the government over a decade ago, that VBC can work to reduce costs and improve outcomes.
    3. An open question: what kind of provider networks work best under VBC?

From my perspective, FFS has not been a good model for chronic disease management, let alone, chronic antiinflammatory, and autoimmune diseases. The key question is, will VBC payment models support providers and practices to provide better care for lifelong chronic inflammatory patients?

  • Hospital-led ACO – Mass General Physicians Organization

The Massachusetts General Physicians Organization (MGPO) is the largest multi-specialty medical group in New England and one of the largest in the U.S.

Dr. Timothy Ferris- CEO of Mass General Physician Organization, said,

“I do not see [hospital-led ACOs vs independent physician practice-led ACOs]as an either-or? [Hospital-led ACOs] have capital that can be redeployed in ways that generate benefits for the system and patients…The key thing is investing in the infrastructure and services that the FFS model does not pay for.”

These include:

      • high-risk care managers,
      • tracking hypertension patients,
      • embedded mental health services.
      • other proactive preventive strategies.

How can big ACOs compete with new, inexpensive retail FFS offerings? For example, DTC apps such as HIMS, HERS, Keeps, etc. offer one-stop, doc-in-a-box shopping for popular prescription drugs. Other competitors include big point-of-care retailers, like CVS and Walgreens, for acute care, vaccinations, prescriptions, etc.

Ferris continued,

“I think that integrated delivery systems of the future will have to find a model to deliver low-end services.” (flu shots, etc.) as cheaply as their new competitors. “But most of our spend is not on low-value care, but rather on folks who are very sick.”

In part because many very sick patients present with multiple comorbidities, any provider’s ability to reduce the spending on these sick folks is limited.

“We can show that large integrated delivery systems were able to reduce overall system costs by 2%”.

How could big hospital systems apply this to autoimmune patients?

Dedicated care managers (similar to those tracking hypertension patients) could help autoimmune patients with treatment support needs between regular appointments. They could also help foster more proactive flare-prevention strategies.

Autoimmune and autoinflammatory conditions are costly to manage and not just because of specialty medications. However, avoiding flares and thus even more expensive episodes of emergency care and hospitalization strike me as low-hanging fruit, high-return investments for big hospital systems.

Yet this unmet need is an opportunity that seems generally to have been overlooked. Maybe the emergence of post-COVID syndromes, which look very much like autoimmune reactions, will force big provider systems to come to grips with the unseen epidemic of immunological and inflammatory diseases.

More Content by the author: 
HLTH: Uncovering Innovations to Help Patients with Immune-Mediated Diseases

  • Physician-led ACO – Aledade

Aledade is a platform company that partners with primary care physicians to help them build and lead their own Accountable Care Organizations (ACOs).

Farzad Mostashari, the co-founder and CEO of Aledade, told us that 6 years ago they bet that independent PCP ACOs would win over hospital-led ACOs. The independents were not burdened with the large financial overhead of hospital systems. Therefore, Aledade saw an opportunity to

“Go with those with the most to gain and the least to lose from VBC.”

As of 2020, Aledade serves 550 practices and 7000 clinicians with $10 billion under management.

“It is working and it’s growing.”

Aledade provides regulatory expertise, technology, data analytics, business transformation services, and upfront capital. In addition to all the other elements, independent practitioners need to succeed in value-based care.

Patients are not seeing reduced care. Mostashari said we can offer “more screening, more immunizations, better blood pressure control.”  Patients are getting primary care that is “more accessible, more informed, and more engaged.”

Overall, they claim an 8-13% reduction in the total cost of care. Savings vary by state.

Will this improve autoimmune care?

Providing affordable, easy to integrate, off-the-shelf IT infrastructure and other business process support tools as well as data management for primary care docs could enable them to better compete with large hospital systems. This might also enable them to offer more timely, accessible care to chronic disease patients, including autoimmune patients.

This leaves open the question of how specialists, much utilized by autoimmune and chronic inflammatory patients, fit in. Specialist practices have thrived under supply-restricted, high-demand FFS models.  And so far have not been eager to participate in digitally-enabled care team practices.

Once more, maybe the pandemic disruption to cash cows like colonoscopy will accelerate the previously sluggish migration of specialists to VBC models.

Conclusion of Part 1 of Healthcare in a Post-COVID-19 World

Telemedicine and remote patient monitoring are two necessary but not sufficient enabling technologies for better autoimmune care delivery. Making care more accessible from patients’ homes through telemedicine, apps and the expanded use of care-based team models could potentially benefit those with chronic immune conditions, who need more frequent touchpoints on their care journeys.

The changing reimbursement landscape, from fragmented, uncoordinated FFS to patient-centered (or at least capitation or episode-of-care coverage) VBC may also better financially support care delivery for autoimmune patients. Especially those patients on specialty meds who need monitoring, management, and support between regular physician and specialist visits.

Such care should also include non-pharmacological modes like physical therapy, exercise coaching, diet management, sleep, and mental health support. Some of these pieces are being incorporated into some of the new care delivery models. However, the chronic disease focus has been on cancer, diabetes, and cardiopulmonary disease, not inflammatory, immunological, autoimmune or autoinflammatory conditions.

The conference focused on bringing virtual primary care into the home or at least to the smartphone. However, I have unanswered questions concerning the role of specialists in these new models. How will team-based care coordination integrate the multiple specialists (e.g. rheumatologist, gastroenterologist, dermatologist, neurologist) many autoimmune patients need to guide chronic care?

Part 2 focuses on new delivery models and the competition for the digital front door from inside and outside traditional healthcare. 

We all need to keep an eye on the weather in our state capitals. That’s because a public health storm is forecasted. It is caused by the opposing forces of the pandemic-related economic downturn and related diminished tax income versus an increased demand by many unemployed Americans newly eligible for Medicaid. The Medicaid tsunami is here!

As explained by the Kaiser Family Foundation (KFF), to support Medicaid and provide fiscal relief, generally, the Families First Coronavirus Response Act (FFCRA) authorized a relief package to help Medicaid meet the demands of new enrollment.

It will remain in effect until the end of the last quarter.  The relief package was designated by the government as a Public Health Emergency (PHE). This is currently the end of March 2021 (unless it is renewed).

Most states made specific efforts to help people obtain and maintain coverage. And ten states reported expanding enrollment assistance or member call center capacity.

ADD_THIS_TEXT
 

But regardless of efforts, states may have to make hard decisions about how to cover their enrollees during times of economic shortfalls.

Medicaid adaptations prop up the public health

As we head towards colder weather, our nation is experiencing a massive surge in Covid-19 cases. Unlike the earlier waves of infection that were more localized, this time the infections are widespread.  Covid-19 is impacting rural areas that were largely spared before.

It is clear that the most vulnerable individuals among us need a functioning Medicaid program. This is because it allows all Americans to fight the pandemic in the most equitable way possible. 

Cuts to Medicaid might seem prudent when state budgets are facing a shortfall. But the short-term savings will pale in comparison to the long-term fiscal – not to mention emotional – pain of not providing health coverage for our most vulnerable populations. More than ever, states need to dedicate themselves to keeping their residents healthy. 

States have worked hard since March to use Medicaid as a tool to help patients suffering from COVID-19. These programs are laudable, but now it is time for states to think more long-term.

At-risk populations have long-term health needs that need to be addressed by Medicaid. Protecting public health includes providing important medical services, such as flu shots or even telemedicine for people living with chronic conditions.

When people get regular healthcare, both preventive, and therapeutic, there are better health outcomes and fewer healthcare expenditures.

Telehealth is more than a fad, it’s a vital service in Medicaid

As state Medicaid programs make plans for eligibility changes, expansions, provider rates, and taxes, perhaps one of the most important changes to implement is expanded telehealth access.

Medicaid can stand alongside Medicare as a leader in providing telehealth services. Especially at a time when private health plans are fighting to cut telehealth use.

Related Content: Telehealth Update from ATA President, Joe Kvedar.

Unfortunately, there have been news reports that major private insurers, like United Healthcare, who offered telehealth during the PHE, are now pulling back on those benefits. Similarly, STAT reported that Anthem will stop waiving the cost of copays, coinsurance, and deductibles for virtual visits not related to Covid-19.

Even as we reopen and in-person office visits rebound, telehealth is a lifeline for patients with chronic illness. Patients that the Global Healthy Living Foundation (GHLF) represents live with chronic illnesses including the following:

  • all forms of arthritis,
  • Crohn’s disease,
  • ulcerative colitis,
  • psoriasis,
  • HIV,
  • migraine,
  • cardiovascular disease,
  • and many others.

Many of these patients continue to isolate strictly to remain safe from the coronavirus. Telehealth helps our community to have continued access to care, which is vital for people living with one or more chronic diseases that require ongoing management.

According to a poll we conducted this summer, 72 percent of respondents (n=379) had a telehealth appointment since the pandemic started. The mean rating of those visits where 0 was the WORST health care provider visit and 10 was the BEST was 8, suggesting most people were happy with their appointment.

Telehealth expansion in Medicaid and CHIP

On October 14, 2020, the Centers for Medicare & Medicaid Services (CMS) expanded the list of telehealth services that Medicare will reimburse during the public health emergency. CMS also announced providing extra support to state Medicaid and Children’s Health Insurance Program to expand telehealth access.

CMS Administrator Seema Verma said:

“Medicaid patients should not be forgotten, and today’s announcement promotes telehealth for them as well. This revolutionary method of improving access to care is transforming healthcare delivery in America.”

According to the KFF data, many state Medicaid programs plan to extend the telehealth expansion put in place at the beginning of the pandemic by:

  • Continuing to allow a patient’s home to be a reimbursable site, an expansion critical to GHLF’s patient community.
  • Extending fee-for-service telehealth coverage beyond the public health emergency, meaning it would cover pre-existing chronic conditions.

Right now, many expansions are timebound and tied to the duration of the PHE. This is a problem because we are still studying the impact of Covid-19 on individuals and the community. It is possible that more permanent relief will be required.

We believe that all states should be considering such permanent expansions of telehealth for a wide range of services to ensure all have access to care for their unique conditions.

Telehealth has been embraced by Medicaid

As we call on states to work to keep their residents healthy, telehealth is an instrumental part of achieving that goal. Preliminary Medicaid and Children’s Health Insurance Program (CHIP) data of telehealth utilization during the pandemic revealed that between March and June of 2020 there were more than 34.5 million services delivered via telehealth. This accounts for a more than 2,600 percent increase compared to the same period in 2019.

We cannot defeat a virus when a sizable portion of a state population is unable to seek medical care.  That is because private insurance isn’t offered or is unaffordable. We cannot defeat a virus when essential workers who ride our public transit systems, who act as our “gig workers,” who deliver our food potentially are unable to seek out healthcare for themselves. The investment in Medicaid is needed to curb the spread of disease. 

States need to squint a bit to see the long-term effect if viruses such as COVID-19, the flu, and others, have free reign over our low-income populations. The effects will be devasting.

Simple care that is not provided now will mean more expensive care later. Worse: it will mean a greater viral spread that will strain our system just as we are experiencing the Third Wave of the epidemic.

By continuing to provide access to telehealth, patients will be able to receive their regular care. This is essential to avoid potential deterioration of their health conditions that would have more impact and distress on our health care system.

A call to action

To our state leaders please, for the sake of your residents, for the sake of our country, and yes, for the long-term sake of your state budgets, please be sure to fully fund Medicaid in your upcoming budgets. To learn more about this issue and others related to access to healthcare, visit the Global Healthy Living Foundation’s 50-State Network.


Disclosure: Steven Newmark has no personal conflicts of interest to disclose. He is an employee of the Global Healthy Living Foundation (GHLF). GHLF receives grants, sponsorships, and contracts from pharmaceutical manufacturers and private foundations. A full list of GHLF funders is publicly available here: https://www.ghlf.org/our-partners/.

There is no doubt that the United States is in the midst of a maternal health crisis. In fact, a new study found that the U.S. has the highest maternal mortality rate amongst 11 high-income countries.[1] Further, we are one of the few developed countries where deaths related to pregnancy or childbirth are actually on the rise.

In fact, American women today are 50% more likely to die in childbirth than their mothers were. Moreover, there is a significant racial disparity in outcomes. According to the CDC, black women have a maternal mortality rate that is nearly three times higher than white women.

Despite these devastating statistics, providers are in a unique position to have lifesaving impacts on our pregnant patients, especially women of color, through more thoughtful education and support.

ADD_THIS_TEXT
 

As an OB/GYN, I am acutely aware of the health care gaps that contribute to maternal morbidity and mortality in the U.S. A report from nine maternal mortality review committees estimated that over 60% of pregnancy-related deaths were preventable. Further, it cites better patient/provider engagement and empowerment as one of the main opportunities for improvement.

But how do we do this, especially in the midst of the COVID-19 pandemic that has added many outside stressors and barriers to consistent care?

Impact of COVID-19 on the maternal health crisis

Moms-to-be these days have a lot to deal with. They must manage their risks related to the novel coronavirus as well as the uncertainties related to the upcoming flu season. And, they must do it while also handling the usual pressures of being pregnant.

Moreover, patient/provider relationships have had to shift drastically. Many health care appointments have transitioned to virtual care or other forms of digital communication.

The usual course of prenatal care includes about 15 prenatal and postpartum visits, including services like ultrasound. The shift away from in-person visits drastically changes a woman’s pregnancy journey. Further, many Americans are outright canceling or postponing care because of fear of contracting COVID-19.

Related reading: Fear of COVID-19 Keeps Patients from Seeking Medical Care

The Path to Better Health Study by CVS Health found that 41% of respondents are not tracking their personal health information, such as weight, blood pressure, or cholesterol. In an environment where providers may not have regular contact with their patients, this is an alarming trend.

This suggests that many people who are, or may become, at risk for a chronic condition could develop complications that go undetected. This is especially concerning in maternity care because chronic conditions increase the risk of pregnancy complications.

Further, COVID-19 has highlighted longstanding and deep-rooted racial disparities within our health care system. The pandemic has disproportionately affected communities of color. This places our most at-risk patients in an even more vulnerable position.

Black women are also at an increased risk for chronic conditions. Further, the Path to Better Health Study revealed incidences of chronic disease in African American women more than any other ethnic group.

The maternal health crisis: identifying opportunities for intervention

Despite these myriad challenges, the pandemic has also provided an opportunity for adaption and change. As providers, we should embrace the critical role we play in our patients’ lives, specifically through better:

      • communication
      • education
      • advocacy  
      • empowerment

This is especially important when caring for those most at-risk for complications.

We know that focusing on empowering women works. For example, studies point to positive outcomes related to feelings of self-efficacy in pregnancy. These include: 

      • reductions in perinatal depressive symptoms,
      • reductions in preterm birth, and low birth weight.[2] [3]

As providers, we need a multi-pronged approach to ensure we are providing the kind of additional support women need along their pregnancy journeys:

1. Be ready to adjust.

Aetna initiated its “Time for Care” campaign in order to encourage patients to continue seeking health care during the pandemic. A national survey of 4,400 Americans was conducted to inform the design of the campaign.

It found that 50% of pregnant mothers are not confident that their primary care physicians have put the necessary measures in place to prevent the spread of COVID-19.

This suggests that we have work to do to help patients feel safe in health care settings. We have to adjust and provide new, safer, ways to care for patients.

This may mean implementing and encouraging the use of telehealth. It might also mean making sure proper protocols, such as the CDC recommended steps, are in place when in-person visits are necessary. 

Changes, whether large (moving to virtual care platforms) or small (implementing masking and distancing guidelines) can have a positive impact on patients’ trust. 

2. Listen to, advocate for, and empower patients

Women are often overlooked or underserved in health care.  This is especially true for women of color.

For example, studies have found that Black female patients can experience racial bias when it comes to pain treatment. For example, African American patients who reported pain were 22 percent less likely than white patients to receive medication from their doctors.

We need to make sure that we actively listen to and advocate for our patients when they raise concerns about their health. That can help them feel encouraged and empowered throughout their health journey.

One way to initiate this approach is by learning about your patient’s status so you can ask questions relevant to their health. Also, when appropriate, encourage patients to bring outside support (e.g., a loved one, family member, or doula) into the clinical setting. This can help provide extra encouragement or advocacy in times of need.

Regardless of what steps you’re taking to do so, it’s imperative that moms-to-be feel empowered to speak up throughout their pregnancy. To create the kind of environment where that’s encouraged, we need to not only actively listen to our patients but believe them.

3. Be a champion of education and communication

Putting educational resources directly into expectant patients’ hands, either in-person or digitally, can be a great way to spark dialogue and encourage good decisions.

One way Aetna aims to help in this space is through a new initiative aimed at preventing preeclampsia. Preeclampsia is one of the leading causes of maternal death in the United States. The program consists of sharing kits containing educational materials on the risks of preeclampsia. It also provides information about the use of low-dose aspirin as a proven, low-risk intervention.

The initiative works to encourage and empower high-risk patients to start conversations with their providers about their pregnancies. The program is also notifying in-network OB/GYNs of this outreach and urging them to discuss risk factors with their patients.

By arming patients with education, we can empower them to ask informed questions and open those additional lines of conversation.

Leading the change in the maternal health crisis

Trust is critical when it comes to building better patient/provider relationships. We know that such relationships provide a solid foundation for effective treatments and better health outcomes.

There is no one, perfect solution to ending the maternity crisis in the United States. However, good communication and building trusting relationships with our expectant patients provide an opportunity to help our patients feel safe getting care during COVID-19.

Further, by prioritizing, empowering, and educating our patients, we can all play a part in improving patient/provider communication. At the end of the day, we all want to be part of a solution that ensures our patients are getting the care they need.

References

[1] Tikkanen R, Gunja, M, et al. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries, The Commonwealth Fund, November 18, 2020. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries – accessed 11/18/20.

[2] Weinstock M. The potential influence of maternal stress hormones on development and mental health of the offspring. Brain Behav Immun. 2005;19(4):296–308. doi: 10.1016/j.bbi.2004.09.006.

[3] Yim IS, Glynn LM, Schetter CD, Hobel CJ, Chicz-Demet A, Sandman CA. Risk of postpartum depressive symptoms with elevated corticotropin-releasing hormone in human pregnancy. https://pubmed.ncbi.nlm.nih.gov/19188538/


Published 10/19/20. Updated 11/18/20.

More than 60 million Medicare beneficiaries are enrolled in either Traditional or Medicare Advantage (MA) plans, all of whom are 65 years and older. More than half (52%) are expected to require long-term care (LTC) at some point in their lives. This can end up costing these individuals and their families many thousands of dollars. The new long-term care benefits added to some Medicare Advantage plans in 2020 may help. The new benefits include:

  • increased access to certain long-term care services – including nutrition services
  • home safety modifications
  • adult daycare.

This article will break down the differences between long-term care benefits offered by Traditional Medicare and those offered by Medicare Advantage plans. It will also provide an overview of new benefits available through MA plans this year. And, finally, it will offer advice for how to prepare for long-term care costs and it will explore alternative options.

Long-term care benefits through Traditional Medicare

As it stands, Medicare will only cover long-term care if a beneficiary requires skilled services or rehabilitative care under Part A. This includes

  • acute hospital care
  • skilled nursing care
  • hospice benefits

These benefits are designed to help beneficiaries who are in the process of recovering from an illness or injury.

In order to meet LTC coverage eligibility through Medicare, a beneficiary must be an inpatient at an approved hospital for at least three days. From there, they must be admitted into a Medicare-certified nursing facility within 30 days of the inpatient visit.

Additionally, the beneficiary must require physical or occupational therapy along with a medical condition that demands skilled nursing services. However, it is important to note that coverage is limited and only available on a short-term basis.

Under Traditional Medicare, long-term care benefits carry a 100-day cap. Once this is exceeded, the beneficiary is responsible for 100% of the costs.

Long-term care benefits through Medicare Advantage

Medicare Advantage plans provide the same coverage as Traditional Medicare so they also cover skilled services or rehabilitative care for up to 100 days. However, due to legislation passed in 2018, Medicare Advantage plans include benefits for supplemental home care services for chronically ill beneficiaries as well.

Starting this year, some MA plans will now offer benefits for a variety of additional supplemental home care services to all beneficiaries. They still don’t provide coverage for assisted living expenses and benefits vary by plan and location. However, these new offerings can make a huge difference in care provided to beneficiaries by allowing them to continue living independently.

Coverage for additional services

Services we can expect to see covered by some MA plans this year include:

  • Adult daycare service 

These centers allow regular caregivers to take a break by providing seniors with an engaging and social environment to interact with each other. In addition, they receive memory care and a variety of exercises to improve well-being. The frequency in which a beneficiary can attend will depend on their individual policy.

  •  In-home personal care services 

These services allow beneficiaries to receive assistance with daily activities such as getting dressed, eating, using the bathroom, etc. The ability to have a home health aid assist with these activities can delay moving into a long-term care facility.

  • Telehealth services 

This is especially helpful for those who are not able to get to the doctor’s office easily. This allows the beneficiaries to video conference with their doctor instead of making the trip. This can provide both convenience and comfort.

  • Benefits for over the counter products 

Beneficiaries on MA plans will begin to receive a monthly or quarterly allowance for over the counter products. This will include medications such as allergy and cold medications, daily supplements, and pain relievers.

  • Home Safety Modifications 

If a beneficiary has fallen or has a hard time moving around but does not want to make the transition into assisted living quite yet, some MA plans will provide coverage for safety modifications including grab bars for bathrooms, wheelchair ramps, and stair rails.

  • Meal Delivery and Transportation 

With the growing demand for transportation and meal delivery services, some Advantage plans will now cover transportation services, such as Lyft and Uber. This will help beneficiaries get to doctors’ appointments, fitness centers, or pick up prescriptions, as well as offer benefits for grocery delivery services.

Preparing for long-term care costs

One of the best ways to reduce expenses is by focusing on prevention before treatment. It is important to ensure beneficiaries are attending regular check-ups and addressing any health concerns proactively before they become a larger issue.

Medicare and Medicare Advantage plans don’t offer benefits for nursing home care or assisted living. However, there are ways to limit costs should this care become necessary. Here are two:

  1. Look into getting a long-term care insurance policy
  2. Open a savings account specifically for long-term care expenses

Related content:

-Why You Need to Prioritize Getting the Right Healthcare Coverage

Drug Rebates: New Executive Order Only Addresses Part of the Problem

Long-term care insurance

As stated in the section above, if beneficiaries are not eligible for long-term care or need additional financial help for what Medicare doesn’t cover, they can look into alternative options including long-term care insurance or Medicaid.

Long-term care insurance will cover what Medicare doesn’t. Since out-of-pocket costs can quickly add up to hundreds or thousands of dollars, this insurance plan will provide additional financial help paying for care and services. These services include nursing home care, assisted living facilities, custodial or personal care, and extended home assistance. 

Medicaid

If long-term care insurance isn’t a viable option, look into whether the beneficiary is eligible for Medicaid. It can help pay for assisted living in some states and nursing home care nation-wide.

As the largest payer in the U.S. for long-term and nursing home care, Medicaid is a joint program between federal and state governments. It can assist with healthcare costs not covered by Medicare.

The bottom line

Long-term care can be a huge expense. However, with proper planning and leveraging these newly added benefits to Advantage plans, there is more opportunity to keep the costs manageable.

Currently, Medicare’s long-term care coverage is limited. But, it is important to know that it is also constantly changing. And, the necessity for long-term care coverage is only continuing to grow amongst the Medicare community.

It is still too early to determine what benefits may be added next year and even further down the road. Therefore, it is crucial for beneficiaries to stay up to date with the latest Medicare news whether through research or speaking to a professional.

 

Health care companies, including UnitedHealth Group, have a critical role and responsibility to help strengthen the national response to COVID-19. And, we must ensure that we apply the hard-learned lessons to future efforts. If we do that, we can do the accomplish the following:

  • identify potential outbreaks
  • protect the most vulnerable
  • address gaps in capacity and resourcing early on

All of these efforts can help create safer and more efficient work protocols for our frontline health care providers.

UnitedHealth Group’s approach 

That’s the approach we’ve taken at UnitedHealth Group, the world’s leading health service and health benefits company with more than 100,000 frontline health care providers. We continue to lean into that responsibility and leverage all our resources, expertise and reach to strengthen the national response to the coronavirus.

With so many frontline clinicians, we also have a special obligation to ensure their health and safety while they put themselves in harm’s way while caring for patients. In that regard, we launched a $5 million philanthropic partnership to source protective equipment and supplies for health care workers. And, we fielded a virtual support system to support their mental well-being and resilience.

We also redeployed and trained thousands of health care workers to meet unmet needs, such as

  • remote care
  • 911 phone call triaging
  • COVID-19 testing 
  • use of technology to connect nursing-home patients with their families.

We particularly focused this effort on front line workers who are or live with people at high risk of COVID-19 complications 

Related content:
Are We Prepared for Increased Healthcare Needs Post-COVID-19?
The Critical Importance of Human Behavior in Our Response to COVID-19
Prioritizing Healthcare Workers’ Mental Health During COVID-19

Ensuring workplace safety: The ProtectWell protocol

In partnership with Microsoft, UnitedHealth Group is also laying the groundwork for the continued reopening of the health care system and the larger economy with the ProtectWell protocol.

Grounded in CDC guidance, workers screen themselves daily for risk signs of COVID-19 infection. An app guides them to care and/or testing if needed.

We have begun rolling it out within our company and have offered it to employers across the country free of charge to help ensure the workplace is as safe as possible.

Accelerating provider payments

The company also accelerated nearly $2 billion in provider payments to help them stay on the front lines throughout the crisis. And, we made it easier to treat patients and encouraged patients to seek care by implementing the following:

  • waiving COVID-19 cost-sharing and prior authorizations
  • encouraging the use of telehealth
  • processing early prescription refills
  • granting provisional provider credentials to expand our network of providers.

Addressing the testing bottleneck

As UnitedHealth Group’s chief medical officer, I’m also excited about our efforts to improve the clinical response to COVID-19. As the disease emerged and spread, the shortage of personal protective equipment became quite acute. We quickly identified testing as a major bottleneck in containing the spread of infection and protecting health care workers.

Our doctors in Everett, Washington, working with the Bill &Melinda Gates Foundation, seeded the ground for expanded testing. They showed the FDA that less invasive, self-collected tests worked as well as more invasive nasopharyngeal ones collected by a health care provider.

We built on that work and helped the FDA further expand testing by demonstrating that tests could be accurately conducted with shorter, less-invasive swabs and they can be carried in cheap, widely available saline.

Now we’re applying those streamlined methods at scale to help the state governments in California and Indiana to roll out expanded testing throughout their states. We are especially focusing on communities that don’t have easy access to health care providers.

The ventilator shortage

One other bottleneck that we recognized early was a shortage of ventilators. In response, we worked with the University of Minnesota to develop its concept of a ventilator that is lighter, cheaper, and easier to deploy than traditional ventilators. The result was an FDA-authorized product that could be mass-produced in 30 days with Boston Scientific and Medtronic.

UnitedHealth Group proudly fielded 3,000 light ventilators to address concerns that surging COVID-19 infections would overwhelm hospitals’ ventilator capacity.

The brilliance of these ventilators is that they are powered by a robotic arm that compresses an oxygen bag. Its simple design means more people can be helped. This is because a health care worker doesn’t have to be there to manually compress the bag for a patient to breathe.

The light ventilators, which went from concept to FDA authorizations and mass production in just 30 days. This exemplifies the collaborative approach that must become the new norm across the health care system.

Physicians at the University of Minnesota came up with the initial idea. Then, UnitedHealth Group, Boston Scientific, and Medtronic contributed their technical, regulatory, and production expertise. All of this ensured that the light ventilators were safe and could be deployed at a scale large enough to address surge-capacity concerns. 

Jumpstarting COVID therapy clinical trials

We also helped jumpstart the Mayo Clinic’s clinical trial of convalescent plasma to treat COVID-19.

Many experts suggest that it may take more than a year to develop a vaccine. In the meantime, coronavirus patients need better treatments right now. The use of convalescent plasma is one of the most promising approaches. This is because we’ve seen it work before to successfully treat other diseases similar to COVID-19.

Testing has expanded to more than 2,400 sites across the country. Preliminary results have demonstrated the safety and efficacy of the approach.

While research continues, the trials need more plasma donated from people who have recovered from COVID-19 to test whether it helps others who are fighting the infection.


WATCH OUR VIDEO BELOW TO LEARN MORE ABOUT THE CONVALESCENT PLASMA CLINICAL TRIAL!


 


I urge anyone who might have had COVID-19 to go to https://www.uscovidplasma.org to see if they might be able to help.

Further underscoring our engagement, UnitedHealth Group’s president, Sir Andrew Witty, recently took a leave of absence to co-lead the World Health Organization’s global effort to accelerate the development of a COVID-19 vaccine.

Going forward

I have every confidence that we will beat COVID-19. As long as we make habits out of how we worked and what we learned during this crisis. The experience will change not only our country but it also alters other aspects of healthcare, including:

  • how we deliver and receive care,
  • protect our frontline health care workers,
  • help the most vulnerable.

I’m incredibly proud of the work my 325,000 colleagues have done to ensure that millions of Americans get the care they need during this pandemic. I am certain we will continue innovating and collaborating our way to a stronger health care system. One that delivers better care for everyone.


Be sure to watch every minute of Dr. Pat Salber’s three-part interview series with Dr. Migliori here:

First part: https://youtu.be/bcGDs5xZKLA
Second part: https://youtu.be/1GtX_WaZSZs 
Third part: https://youtu.be/9hX0NkMwtDg

 

Enjoy!


Financial disclosure: TDWI did not receive compensation for publishing this story.

At 4:29 PM on May 26, 2016, my husband’s doctor said to him,

I have bad news. You have cancer.

As a medical oncologist, I have delivered those words countless times to my patients. But I now understood in a way I could not before, how this news can turn one’s world on its axis. I have seen the unprecedented uncertainty my patients and their loved ones face when I confirm a cancer diagnosis.

Many decisions have to be made quickly

Decisions have to be made—often quickly:

  • What is the best treatment path?
  • How will I tolerate the next weeks and months?
  • Will I be able to work?
  • How will my family cope?

My personal journey after my husband’s diagnosis made me more acutely aware that despite tremendous advances in detecting, diagnosing, and treating cancer, uncertainty remains a potent side effect of the disease.

The uncertainty of coverage for cancer care 

Now, imagine adding on worry and uncertainty about what changes may come with continued assaults on the Affordable Care Act (ACA). How will these changes to, or elimination of, the ACA affect your ability to access cancer care?

Will you continue to have health coverage? Will you be able to afford the cost of your care? And if not, will you have to stop life-saving treatment?

Even as a healthcare professional with a stable job and comfortable income, I felt the pressure of these concerns. And, I worried about what would happen to my husband’s care if I no longer had a job with insurance benefits.

The future of healthcare in America

In Washington, D.C., the debate about the future of the Affordable Care Act (ACA) continues even though multiple attempts in Congress to “repeal and replace” it have failed.

In the latest attempt to undo Obamacare, a federal judge declared the ACA unconstitutional. The case has been appealed and is now expected to be heard by the Supreme Court later this year. So, the uncertainty about its fate drags on.

Meanwhile, cancer patients and survivors across the country are coping with fears about access to health insurance coverage, affordability of that coverage, and access to care.

Worries about coverage for cancer care are compounded when there is financial instability

Worries about health insurance are significantly compounded for those without financial stability. This issue was highlighted in this Washington Post article. As one cancer survivor interviewed for the article commented,

For cancer survivors, we literally live and die by insurance.

To put this in perspective, consider that in 2016, the American Cancer Society estimated that there were 15.5 million cancer survivors in the U.S., which is approximately 4.8% of the population. According to the National Institutes of Health, this number is expected to rise to almost 20.3 million by 2026.

The good news is that the overall cancer death rate is declining and cancer survivors are increasing. However, there is still much work to be done. This is particularly important as risk factors such as aging and obesity are expected to increase cancer rates.

Related content: Why You Need to Prioritize Getting the Right Healthcare Coverage

Association of Community Cancer Centers

In my more than 20 years as a practicing medical oncologist, I’ve had the privilege of caring for patients in rural communities, as well as in urban and academic settings.

My experience as a physician, as a past president of the Association of Community Cancer Centers (ACCC), and as the spouse of a cancer patient, has driven home some certainties.

  • I am certain that every day in cancer programs across the country, multidisciplinary teams are delivering quality cancer care to patients in their home communities.
  • Further, I am certain that these patients are anxious for our healthcare system to right itself. They need and want treatment now.
  • Finally, I am also certain that cancer patients do not need the added stress of worrying about accessing care. And, neither do healthcare providers on the frontlines of cancer care delivery.

Over the past several years, the oncology community has increasingly come to understand the critical need to address the financial burden cancer can place on patients and their loved ones. The economic havoc cancer can wreak impacts those at all income levels of our society. That includes insured and uninsured, young and old, those living in urban as well as rural communities.

Cost of cancer care drugs is a top concern

A 2016 survey by the Association of Community Cancer Centers’ (ACCC) on trends in cancer programs found nearly all healthcare professionals (83%) reported the cost of cancer care drugs is the top challenge and concern. It is followed by reimbursement of patient care services like financial advocacy and nurse navigation.

In response, many cancer programs and providers across the country have added financial advocates or financial navigators to their staff. The survey also found that 64% of healthcare professionals are offering cancer patients the services of financial advocates or counselors.

These new members of the cancer care team help patients through the intricacies of health insurance plan coverage. They also help with issues related to pre-certification/prior authorization processes, accessing patient assistance programs, and more.

Through its Financial Advocacy Network, the Association of Community Cancer Centers provides tools and resources such as their Financial Advocacy Boot Camp. This online curriculum trains advocates to help cancer patients navigate the complex and fragmented healthcare system to pay for their treatment.

Cancer is policy agnostic

Cancer is policy agnostic. It won’t wait while politicians and policymakers debate how best to reform the U.S. healthcare system.

As we await the decision of the Supreme Court on the ACA and the outcome of the upcoming Presidential election, we need to remember why we set out to tackle this issue in the first place. Simply stated, it is to improve the care provided to all Americans.

Congress has the power to put aside partisanship and build on the undisputed improvements made through the ACA.

Congress has the power to provide clarity about how these improvements will affect our nation’s cancer patients, their families, and their healthcare providers.

Moreover, Congress has the power—and the responsibility—to ensure their constituents that patient-centered protections supporting access to care will remain.

The Trump administration and Congress have the power to alleviate some of the unbearable uncertainty for cancer patients and their families. As you decide what direction to take, we ask that you put patients first.


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Originally published on 4/8/2017, this post was reviewed and updated by TDWI editors for republication on 5/2/20.

Most physicians who have been practicing for a few decades remember the days when private payer reimbursements dwarfed Medicare reimbursements. That dynamic has long since changed, starting with the 2008 recession. Further, reimbursements have been flat or have lost value from inflation while practice costs have seen double-digit increases.

Meanwhile, hospitals and insurance-owned health networks have seen reimbursements increase to 300% or more of Medicare in some cases. This is occurring even though it is not uncommon for some private practices to receive rates far below Medicare standards.

Ironically, even as COVID-19 disease is ravaging communities across the U.S., many physicians’ practices have seen their patient volumes decrease from 30% to up to 90% because of the pandemic. A significant number of them are closing their doors for now.

As states start to allow elective surgeries to resume in the coming months, some physician specialties will see increases in patient volume. However, I believe that the pandemic will have long-lasting repercussions for every practice and every specialty. 

With that in mind, let’s take a look at some examples from our consulting business in order to illustrate how the COVID-19 pandemic is affecting some specialties across the nation in real-time:

A solo physician primary care practice: an unsung hero of the pandemic

One solo physician primary care practice in southern Florida has been hit particularly hard by the pandemic. The physician owner took it on himself to create a separate ‘isolation’ intake entrance with safety gear and safety partitions. He went to these lengths so he could still see patients who might be COVID-19 positive without putting his other patients at risk.

It is noteworthy that every patient that this doctor sees in his clinic that is prevented from going to the emergency room with a false positive saves the system, and the payers, tens of thousands of dollars. Despite this physician’s efforts to do right by patients, none of these measures are reimbursable. Everyone can see just how unfair and intolerable that is, yet he refuses to stop seeing sick patients.

Our society has chosen to give the lion’s share of the revenue and resources to the hospitals, even though they are overwhelmed and unequipped for this sort of a pandemic.

Doctors like this one are the heroes of the pandemic.

Related Content:
Are We Prepared for Increased Healthcare Needs Post-COVID-19?
Greater Risk of Blood Clots in COVID-19 Patients

 

A creative podiatry practice

A podiatry group practice in New Mexico was also frustrated with the ever-increasing practice costs and narrowing margins caused by years of stagnant reimbursement rates. The owners decided to merge their practice with another group to find savings thus creating efficiencies, consolidating costs, and increasing patient volume.

As the pandemic hit, they saw their patient visits decrease by 65%. The practice had to furlough most of the staff. They then started the process of converting to a multi-specialty with Medicare and the payers to try to capture more revenue from more lucrative procedures. It was hoped that this would allow them to capture more revenue from more lucrative procedures.

They viewed COVID19 as an opportunity to diversify their services to better weather future disruptions. There is, however, no guarantee such a move will insulate their practice from further disruptions if the pandemic continues or sees another wave of outbreaks. But they want to invest in the future while they have the time to see the change through.

Related content: Strategic Planning for Physicians in the Age of COVID

A solo neurology practice calls it quits

A single physician Neurology practice was successfully operating in a fairly saturated marketplace in the Baltimore area for over two decades. As reimbursement rates stagnated over the last ten years, it became harder and harder to make the same revenue as each previous year. 

The physician owner cut costs and staff, outsourced billing, moved to a cheaper location, and even worked an additional day or two a month. She enjoyed running her own practice and practicing medicine the way she deemed fit. She valued her autonomy over a large income. 

In early March the owner saw the pandemic writing on the wall. She started preparation to close the doors to her practice for good. She had seen a 35% reduction in visits. This would not have been sustainable for more than a few weeks, let alone a few months.

She has resolved close her practice for good and is planning to go work for a local hospital or join a larger neurology group that had been recruiting her for years. 

An OB/GYN practice chooses to negotiate reimbursement rates

One gynecology and obstetrics practice in Chicago took yet another approach. There is no delaying visits and procedures for this specialty. Although they’ve had to make dozens of safety protocols and stretch resources and staff, they’ve kept their doors open.

They have been able to absorb the increasing costs because they decided to negotiate their reimbursement rates with their payers. The practice was being reimbursed an average of 16% below Medicare before the COVID-19 pandemic. They decided that the current rates were not sustainable and could not support the practice during disruptions. 

Although the payers might argue that increasing rates isn’t realistic during the pandemic, this is exactly the time for practices to use their leverage and hold the payers accountable.

4 strategies to overcome poor payer reimbursement

These four cases exemplify different strategies that practices are employing during this pandemic:

  1. Soldier on and hope for the best 
  2. Consolidate and change the focus of the practice to try to find new revenue streams
  3. Give up on owning and operating a private practice and consolidate or join a larger group 
  4. Negotiate your rates and hold the payers accountable

Most practices fall into category one or two, and very few have the option of category three as their resources are already at a breaking point. But, I believe that every practice should be employing the fourth strategy.

Negotiating with the payers to increase reimbursement rates is not only possible but maybe the only viable solution to saving many practices in the long term. Why should practices carry the burden of the pandemic when the payers are doing little to battle the pandemic or help physicians carry the financial and systemic load? 

Many physicians don’t pay enough attention to their contracts, even though fair paying contracts are fundamental to the long term success of a practice.

The bottom line for payer reimbursement in the Age of COVID-19

Practices can and should utilize their current time and resources to start negotiating their payer contracts.  Alternatively, they can retain an experienced contract negotiator to help them hold the payers accountable.

This is the simplest way for almost every specialty to find more revenue when the shutdown eases in the months to come. Remember, the payers aren’t returning their premiums even though overall healthcare encounters have plummeted. This means that, now more than ever, physician practices have the right to pursue proper and fair compensation.

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As a veteran, you may have questions about what dental care options are available for you. The problem is that veteran dental care benefits can be quite confusing. It can be difficult to make heads or tails of what you qualify for.

As a dentist of two decades, and a veteran myself, I understand the frustration. I’ve worked with countless veterans and have helped them secure the dental care they deserve.

With this article, I hope to detail some of my experience with VA dental benefits and help you determine which types of benefits you may qualify for. And by the end, you’ll hopefully have a good understanding of the VA benefits offered to you, as well as non-VA options that can help if you don’t qualify.

What Type Of Care Does The VA Cover?

Unfortunately, there’s no easy answer to this question. It depends on which classes(s) you qualify for. The amount of care can vary from specific issues to all care needed. It’s difficult to generalize, but most classes cover dental care that deals with some sort of service-related issues and injuries. For more details, read on to learn about different classes.

Understanding the VA Dental Care Classes

One of the more confusing aspects of VA dental is the large number of classes that qualify you for treatment. Each one of these classes has slightly different requirements. Some limit the types of treatment you can receive. Understanding if and which class you fit into is key to understanding which dental benefits you are eligible for.

Below, you’ll find each class along with a brief explanation of who qualifies. Some of these are a bit hard to completely understand, so if you have any further questions don’t be afraid to reach out to your local VA office. They are there to help you and will be able to explain what benefits you might qualify for.

 Class I: If you have a service-related compensable condition or disability then you are eligible for any dental care needed.

Class II: If you were discharged in any other condition than dishonorable, and you did not receive a dental examination upon discharge, then you are eligible to receive one-time care within 180 days.

Class IIA: A non-compensable condition (0%) that resulted from wounds in combat then you may be eligible to receive care to keep your mouth healthy. Per the February 2018 Dental Benefits for Veterans document IB 10-442, a VA Regional Office Rating Decision letter (VA Form 10-7131) or the historical Dental Trauma Rating (VA Form 10-564-D) identifies the tooth/teeth/condition(s) that are trauma related.

Class IIB: If you are a homeless veteran and receive care under VHA Directive 2007-039 then you may be eligible for care to relieve major pain, treat gum disease, or gain employment.

 Class IIC: If you were a former prisoner of war then you are eligible to receive any dental care needed.

Class III: If you have a service-related condition that has been determined to be affected by dental issues then you are eligible to receive treatment of said dental issues. This determination is made by a VA dental professional.

 Class IV: If you have a service-related condition that is rated as 100% (total) disabling then you are eligible for any dental care needed. This only applies to ratings of 100% that are permanent and not for short-term disabilities.

 Class V: If you are currently participating in a VA vocational rehabilitation program under 38 U.S.C. Chapter 31 then you are eligible to receive dental care that helps you participate in and achieve the goals of said program.

 Class VI: If you are receiving or scheduled to receive inpatient care and have dental issues that are determined to be complicating that treatment, then you qualify for treatment of those dental issues. Like above, this is determined by a VA dental professional.

What Are Other Options If I Don’t Qualify?

While there are a lot of ways to qualify for VA dental benefits, the truth is that not all veterans will qualify. It’s unfortunate, but luckily there other options available for veterans. Below are a couple of options that can help veterans afford dental treatment and get the right healthcare they need.

  • National VA Dental Insurance Program:

One very good option is the insurance offered through the National VA Dental Insurance Program. This is insurance, so it’s not free, but it comes at a reduced cost compared to other plans.

This program is specifically offered to veterans, so they understand the issues you’re facing and are looking to help make things easier on you. Check to see if it is available in your area as it is a great way to cut down on the cost of dental treatments.

  • Dental Insurance:

It’s also possible to purchase dental insurance through 3rd party vendors. These are typically a bit more expensive than the VA dental insurance but can help cut down costs on unexpected procedures later.

  • Medicare Benefits:

You may also want to consider looking into Medicare benefits. These benefits can help pay for some dental procedures. Unfortunately, these benefits will not stack with any other VA benefits. Further, Medicare only covers a very select range of dental work.

  • Veteran Specials:

Lastly, there are many dentists around the country that offer special discounts for veterans. This includes things like reduced cost operations or even free services such as cleanings and X-rays.

Many dentists will advertise these services, but it never hurts to inquire if a dentist in your area offers any discounts to veterans. The only downside here is that many of these services will likely be very local and specific to the individual dentist.

  • Veterans Groups:  

Lastly, there are many dentists around the country that offer special discounts for veterans. This includes things like reduced cost operations or even free services such as cleanings and X-rays. Many dentists will advertise these services, but it never hurts to inquire if a dentist in your area offers any discounts to veterans.

The only downside here is that many of these services will likely be very local and specific to the individual dentist. Some military-focused websites might also advertise these specials, so it doesn’t hurt to check them out.

You can also consider reaching out to local VA or other veterans groups to see if they know of any of these specials. They may have contacts with local dentists that offer these types of services to veterans.

Additional Information from Dr. Grillo:  
Veterans Dental Care Resources
Important Questions to Ask Your Dentist

Summary:

With all the above in mind, hopefully, you’ve found a way that works for you to secure affordable dental care. If you’re ever in doubt, reaching out to your local VA is always a great option. They’ll be able to help you navigate the confusing class structures. They may also have additional information that will be useful to you. Work with them, and you may find that you can resolve your dental problems and restore your oral health.

You can find all of our articles on dentistry and oral health here: https://thedoctorweighsin.com/tag/dental-and-oral-health/

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