“Another year with a lot of errors and another year of warning letters,” said Mike Adelberg, a principal at Faegre Baker Daniels Consulting who worked at CMS from 2012 to 2015.
Let’s back up for a minute. Medicare Advantage is a program in which the federal government pays private insurers to cover seniors instead of making direct payments to doctors and hospitals, the way traditional Medicare works. Medicare Advantage is becoming increasingly popular, with more than one-third of all seniors projected to select it for 2019.
Conservatives love the program, and for good reason: It promotes competition between private plans and puts seniors into managed care systems, which are believed to result in better health outcomes. And its average premiums are projected to decline 6 percent next year. Moves by Democrats to cut funds from Medicare Advantage to help pay for the Affordable Care Act were once a top point of contention for Republicans criticizing the health-care law.
CMS Administrator Seema Verma appeared to spend more time this fall talking — and tweeting – about enrollment in Medicare Advantage than about enrollment in the ACA marketplaces. She often touts the program’s popularity and its range of plan options for seniors:
Verma should certainly be promoting a program that covers more than 20 million Americans — about double the number of people with marketplace coverage. But some Medicare recipients have recently noted a tone change in emails from CMS urging them to re-enroll for next year. The emails tout Medicare Advantage while saying little about traditional Medicare, which covers about 35 million people.
“Have you looked into Medicare Advantage Plans from private insurance companies yet?” says one such email a reader sent me. “With Medicare Advantage, you can pick from a variety of plans to get the benefits that matter most to you. And it’s a way for you to combine all your Medicare health and drug coverage into a single plan.”
Another such email urges enrollees to consider whether switching to Medicare Advantage might save them money.
“Based on your Zip code and basic health status, you can get an idea of what your 2019 out-of-pocket spending may be for Original Medicare (Part A & Part B) vs. Medicare Advantage,” the email says. “This includes plan deductibles and prescription drug co-pays.”
Richard Foster, who once served as chief actuary of the Medicare program, told the New York Times’s Robert Pear the emails sounded “more like Medicare Advantage plan advertising than objective information from a public agency.”
Foster took issue with the tone of the emails, saying they were one-sided and didn’t equally share potential downsides to buying a Medicare Advantage plan. One potential disadvantage is that, as with other commercial health plans, enrollees typically need to ensure their doctor is within the plan’s network.
Which brings us back to the issue of errors in Medicare Advantage provider directories — an embarrassing problem for the insurance plans that CMS doesn’t seem eager to highlight at the moment.
Errors are a significant problem when you consider that many people choose their health plan specifically because its network includes their own doctor or specialist. An out-of-date directory could lead a senior to choose a particular plan, only to later find out their doctor is out-of-network and that they must find a new one.
And it’s a harder correction for plans than you might think. About 20 to 25 percent of providers move offices each year, and they have little incentive to contact health insurers to update their information, John P. Weis, president and co-founder of Quest Analytics, told me.
Weis, whose company helps hundreds of Medicare Advantage plans with their provider networks, said plans were expecting to start seeing fines for errors in their directories. The Obama administration in its final year had started researching the extent of the problem, but there’s been little to no progress since.
“It’s really a systematic problem,” Weis said. “Not only do you have member dissatisfaction … it impacts the plans negatively as well because they could be paying claims from an in-network provider.”
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AHH: The Trump administration on Monday stated its broad ambitions to tilt the nation’s health-care system in a more free-market direction, issuing a report that prods Congress and state governments to adopt changes to medical insurance, practitioners and facilities that have been long favored by conservatives.
The report, a downstream result of an executive order President Trump issued last year to promote “Healthcare Choice and Competition,” summarizes several steps that federal health officials have taken to try to lower insurance prices by making it easier for people to buy health plans that bypass the ACA’s required benefits and consumer protections.
In its 114 pages, the report makes a fresh plug for federal and state lawmakers to widen the use of health savings accounts, eliminate regulation of where hospitals may be built and try to slow the consolidation of the health-care industry. The recommendations urge Congress to make it easier for physicians to build and expand their own hospitals — a practice the ACA has essentially stopped. And they say insurers should be given more freedom to have fewer doctors in their networks.
Among ACA rules it says are harmful, the report criticizes the law’s requirement that insurers cover many preventive services at no cost to patients. It cites research suggesting that preventive care can prove more expensive in the long run and can lead to unnecessary treatment, without addressing the question of what is best for patients’ well-being.
While most of several dozen recommendations fall outside the administration’s own power, it calls on federal health officials to soften the interpretation of an ACA provision intended to prevent discrimination — for instance, easing the burden on health-care facilities by lowering the number of languages in which they are required to provide notice that translation services are available for patients who do not speak English. On the other hand, the report urges states to make it easier for foreign-trained doctors to become licensed to practice in the United States to stave off doctor shortages.
Trump’s executive order in October 2017 specified that the Health and Human Services secretary, working with two other Cabinet members and other senior officials, would submit such a report within 180 days. In a conference call on Monday, two senior administration officials, who spoke with journalists on condition of anonymity, did not mention why the report is being issued 15 months after the order, instead.
— Amy Goldstein
OOF: A new study has found that painkillers prescribed by dentists to teens and young adults following wisdom teeth removal may be contributing to the risk of opioid addiction.
The new report published in JAMA Internal Medicine “shines a light on the largely overlooked role dental prescriptions play in an epidemic of addiction that has swept the United States, leading to a record 70,237 drug overdose deaths in 2017,” Ronnie Cohen reports for The Post.
“Adolescents and young adults often are introduced to highly addictive opioid painkillers when they have their third molars pulled,” Cohen writes. “Millions of Americans undergo the procedure every year, and dentists routinely prescribe opioids to the vast majority. Only recently have dentists — the most frequent prescribers of opioids for youths between the ages of 10 and 19 in 2009 — started to reconsider the use of narcotics in managing post-surgical pain."
The report found that about 6 percent of the nearly 15,000 people ages 16 to 25 who were prescribed opioids in 2015 from dentists were diagnosed with opioid abuse within a year. That’s compared with 0.4 percent in a similar group who were diagnosed with opioid abuse who did not receive opioids from dentist.
“These are kids who could have gotten Advil and Tylenol, and 6 percent showed evidence of becoming addicted,” Andrew Kolodny, who co-directs opioid treatment research at Brandeis University, told Cohen. “That’s huge.”
OUCH: Cases of the rare polio-like disease acute flaccid myelitis seem to have hit their peak for 2018, the Centers for Disease Control and Prevention said.
There have been 134 cases of AFM in 33 states this year, with another 165 under investigation. “In a statement, the CDC said officials expect the number of cases to decline for the remainder of the year. Most of the latest confirmed cases occurred in September and October,” our Post colleague Lena H. Sun reports.
This year’s surge was the third spike in the illness since 2014, and health officials are still scrambling to understand what exactly is causing AFM. There were 120 confirmed cases in 2014 and 149 in 2016. “The CDC has established a new task force that is meeting in Atlanta this week to study the condition and come up with fresh leads on the factors behind it and how to treat it,” Sun writes.
“Competing theories have emerged about what triggers AFM,” she adds. “Several experts say there is a strong correlation between AFM and outbreaks of a common respiratory virus called enterovirus D68. Some enteroviruses are known to attack the spinal cord. The CDC is also looking into other possible causes, including whether AFM is caused not by a viral infection but by the patients' immune systems.”
— In a new poll from Gallup, a majority of Americans say it’s the federal government’s responsibility to make sure all people have health care. But just 4 in 10 respondents -- fewer than last year -- say there should be a government-run health-care system, underscoring the challenges Democrats face in trying to advance their "Medicare-for-All" ideas.
The differences are stark between the parties, the poll found. "The overwhelming majority of Democrats and Democratic-leaning independents, including 85% this year, have consistently said it is the government's responsibility to make sure all have healthcare coverage," Gallup writes. "In contrast, the percentage of Republicans and Republican leaners sharing this view has always been below the majority level, and in recent years it has been closer to 25%."
— A federal judge expressdc concern about the merger between CVS Health and Aetna and is considering requiring CVS to “halt its integration of Aetna’s assets while he considers the merger’s implications,” the Wall Street Journal’s Brent Kendall reports.
“When the Justice Department identifies concerns with a merger—and reaches an agreement with the merging companies to address them—a federal law called the Tunney Act requires the government to file the proposed settlement for approval by a federal court, which determines whether the deal is in the public interest," Kendall writes. “Such settlements are almost universally approved, often without a judge calling a hearing."
U.S. District Judge Richard Leon said at a Monday hearing he was "concerned that the department hadn’t adequately addressed the potential competitive harms raised by the merger," Kendall adds. If the judge requires CVS to hold Aetna assets separate, "it could cause considerable disruption for the newly merged company, since CVS began integrating Aetna’s assets immediately after the deal closed last week."
A hearing on the matter is schedule for Dec. 18. A spokesman for the now-merged company told the Wall Street Journal the two are already operating as one.
— The Urban Institute released a new brief on the Trump administration’s proposed expansion of its “public charge” rule and found the potential changes could lead to less access to health care for families and a negative impact on children.
The Trump administration’s proposal would make the use of public assistance programs such as Medicaid or food stamps a negative factor in determining legal status for immigrants.
“Among a range of such concerns, the rule is expected to discourage immigrant families from seeking out public health insurance coverage through Medicaid or the Children’s Health Insurance Program (CHIP) for their children,” the Urban Institute writes in its new report.
Some of the findings include that from 2008 yo 2016, efforts including policies implemented “to increase health insurance coverage rates among the general population that also” led to a 10 percent drop in the uninsurance rate among citizen children with noncitizen parents. It also found that during that period, “Medicaid/CHIP participation increased by 15.5 percentage points to 93.3 percent for citizen children with noncitizen parents and by 10.5 percentage points to 94.0 percent for those with citizen parents.”
“The proposed public charge rule puts the recent coverage progress for citizen children at risk. If the regulation’s chilling effects reduce Medicaid/CHIP coverage in immigrant families, the impact could be large, given that one in five Medicaid/CHIP-enrolled children is a citizen child with noncitizen parents,” the report said.
— Here are two things you should never mix up. Officials at a preschool in Hawaii apologized after young kids were mistakenly given Pine-Sol during snack time instead of apple juice.
“A classroom assistant prepared the snacks — which should have been crackers and apple juice — in the preschool’s kitchen, according to an inspection report by the Hawaii State Department of Health,” our Post colleague Amy B Wang reports. “Instead of juice, however, the assistant reportedly grabbed a container of Pine-Sol, a decades-old brand of household cleaner that comes in a variety of scents, though none particularly reminiscent of apple juice.”
Health officials said the mixup occurred because the two liquids are the same color. The classroom teacher “smelled that it was not apple juice and stopped the students from drinking it,” according to the inspection report. “However, Honolulu Emergency Medical Services confirmed to The Washington Post that paramedics examined three female students, two 5-year-olds and one 4-year-old, who had taken at least a sip from their cups,” Wang writes.
Honolulu EMS spokesman Dustin Malama said there was “no obvious signs of injury, trauma or sickness.” “As far as the incident goes — aside from the obvious [question of] how do you mistake Pine-Sol and apple juice? — it was fairly unremarkable,” Malama added.
— And here are a few more good reads from The Post and beyond:
- The Brookings Institution holds an event on “a conversation on the most pressing issues facing America’s veterans community.”
- The House Veterans Affairs Subcommittee on Disability Assistance and Memorial Affairs is scheduled to hold a hearing on “Is VA Ready for Full Implementation of Appeals Reform” on Wednesday.
- The House Energy and Commerce Committee Subcommittee on Oversight and Investigations is scheduled to hold a hearing on "Examining the Availability of SAFE Kits at Hospitals in the United States" on Dec. 12.
Grand pageantry for the late George H.W. Bush at U.S. Capitol: