Surprising Swings In Momentum For Legislation On Surprise Medical Bills

KFF Health News, December 17, 2019

It's been a heavy lift for lawmakers in both parties who are trying to balance the competing needs of powerful stakeholders, factions within their ranks and consumers stuck with high bills.

This article was first published on Tuesday, December 17, 2019 in Kaiser Health News.

By Rachel Bluth, Kaiser Health News

After months of hearings and negotiations, millions of dollars in attack ads, full-court press lobbying efforts and countless rounds of negotiations, Congress appeared to be moving toward a solution to the nation's surprise medical bill problem. Sort of.

Surprise bills, the often-exorbitant medical bills that come when a patient doesn't realize they've been seen by a provider outside their insurance network, have in recent months been viewed as public enemy No. 1 on Capitol Hill.

Two committees, the Senate Health, Education, Labor and Pensions (HELP) Committee and the House Energy and Commerce Committee, have been working on plans and announced a compromise Dec. 8. Later that week, the House Ways and Means Committee followed suit by announcing its solution, though details are few.

It's been a heavy lift for lawmakers in both parties who are trying to balance the competing needs of powerful stakeholders, factions within their ranks and consumers stuck with high bills. With an election year fast approaching and polls consistently showing health care costs are a high priority for voters, the push for action has intensified.

Time Is Not Of The Essence

Despite the rushed way some committee members announced the agreement Dec. 8 — issuing a press release on a Sunday before any official bill text was released — it's now unlikely that Congress will consider the package before it wraps up work for the year.

HELP Committee Chairman Lamar Alexander (R-Tenn.) signaled as much Monday in a press release in which he promised to do everything he could to keep the surprise medical bill issue at the top of the congressional to-do list for 2020 — until it's solved. "The only people who don't want this fixed are the people who benefit from these excessive fees," he said.

Still, the recent signs of progress are significant, even if final passage happens early next year, said Loren Adler, the associate director of USC-Brookings Schaeffer Initiative for Health Policy, a research group.

Even if Congress punts it to February or March, "there's a decent shot of getting it done," Adler said. "It would be pretty darn embarrassing if Congress doesn't pass it after talking about it this long and it being such an egregious problem."

Compromise Bill

The HELP/Energy and Commerce legislative outline shows movement toward compromise on several fronts, from omitting the controversial "all-payer claims database" ― a federal repository for health-pricing information ― to adding more public health provisions.

It includes Senate protections against surprise bills from air ambulances, while adopting most of the House's approach to hospital bills, down to preserving the House's title for that section.

"A sign of a compromise is that nobody particularly loves it," Adler said.

Over the past few months, the biggest debate around remedies for surprise bills has centered on how to determine payment for out-of-network doctors and hospitals. One group wanted an arbitration process while the other sought a benchmark system. It seems neither side got exactly what they were seeking.

Under benchmarking, the government would set a compensation rate for providers when they see out-of-network patients. The most popular proposition was one that paid a "median in-network" rate, when doctors are paid in the middle of the range of what others in the area are paid by insurance companies for the same service.

The other idea was independent dispute resolution, or arbitration. The provider and insurer bring their best offer to a third party, who chooses between the two.

Generally, employers and consumer advocates favor benchmarking. Hospitals and doctors' groups, especially those backed by private equity firms, pushed for arbitration.

The compromise approach tracks closely with legislation advanced by the House Energy and Commerce Committee: a median in-network benchmark with an arbitration "safety valve" where either side can bring a bill to arbitration if it's more than $750. Previous versions allowed arbitration only for charges over $1,250.

"I think what we've seen come out recently is probably what a reasonable bettor would have predicted," said Benedic Ippolito, a research fellow in economic policy studies at the American Enterprise Institute.

This proposal is seen as more favorable than earlier HELP Committee drafts to providers because it allows them to go to arbitration for more bills, but to these stakeholders, it's not enough.

"Without an arbitration mechanism that applies to a legitimate number of claims, the concerns raised by the provider community will persist," read a statement from Envision Healthcare, a physician staffing firm. A large number of surprise bills are generated by physicians employed by such staffing companies, which are often backed by private equity firms. The business model allows these doctors ― often specialists including emergency medicine and radiology, among others ― to set their own rates because they don't work for the hospital.

The American College of Surgeons, Federation of American Hospitals, Association of American Medical Colleges and Greater New York Hospital Association have also pushed back.

To be fair, plenty of groups have come out in support of the compromise. A message from the Energy and Commerce Committee noted 27 patient and consumer advocate groups that signed a letter of support.

James Gelfand, a senior vice president at the ERISA Industry Committee, which represents large employers, said the compromise isn't what his constituents would have written to solve surprise medical billing, but he thinks it's still important to pass, and parties who keep demanding changes are just trying to stall.

"We hate arbitration, and we believe the changes made to please 'team arbitration' will raise costs tens of billions of dollars," Gelfand said. "But we support the bill. We want to get it across the finish line."

The blueprint offered by the Ways and Means Committee is considered friendly to providers because it lays out a system similar to arbitration and favors a go-slow approach. A press release from panel Republicans indicated that stakeholders need to "stay at the table and debate these ideas" into the new year.

To some, it felt like a delay tactic.

"We know that pushing legislative action into 2020 pushes the work into a difficult presidential election year and makes it harder for Congress to act. This would dramatically increase the odds that Congress will fail to enact meaningful legislation to ban surprise medical bills and fail our nation's families," Frederick Isasi, executive director of the advocacy group Families USA, said in a written statement.

Money And Momentum

Political muscle could also factor into the measure's momentum.

Money from private equity has been flowing into the debate, from millions of dollars spent on commercials and online ads, to campaign donations.

According to Open Secrets data, Rep. Richard Neal (D-Mass.), the chairman of the Ways and Means Committee and one of the voices calling for more time on surprise billing, received $29,000 this year from Blackstone Group, the private equity firm that owns TeamHealth, a physician-staffing firm. This was the first year ever that Blackstone was in Neal's top five donors.

Rep. Kevin Brady (R-Texas), that panel's ranking member, received $45,000 from Welsh, Carson, Anderson and Stowe, the private equity firm that owns several staffing companies, including US Acute Care Solutions, U.S. Anesthesia Partners and US Radiology Specialists. U.S. Anesthesia Partners was one of Brady's top contributors last year as well, giving $56,250 in the 2017-18 cycle.

Sen. Bill Cassidy (R-La.) has been one of the strongest proponents of arbitration on the HELP Committee. He received $68,900 from Blackstone and $66,300 from Welsh, Carson, Anderson and Stowe.

Neither Alexander nor Sen. Patty Murray (D-Wash.), the ranking member of HELP, reported similar donations from private equity firms. The same was true for Rep. Frank Pallone (D-N.J.), the chairman of Energy and Commerce, and Rep. Greg Walden (R-Ore.), the ranking member of that committee.

Looking to the future, many questions still need to be answered about how these proposals will shape up.

"Whether this is a good or bad solution to surprise medical billing will depend on how the arbitration system evolves over time," Ippolito said.

Rachel Bluth: rbluth@kff.org, @RachelHBluth

Opinion: In Medical Billing, Fraudulent Charges Weirdly Pass As Legal

KFF Health News, December 16, 2019

No one would accept many of the charges levied by providers if they appeared on bills delivered by a contractor, or a lawyer or an auto mechanic.

This story, which ran in the opinion section of The New York Times. was published on December 16, 2019, by Kaiser Health News.

By Elisabeth Rosenthal

Much of what we accept as legal in medical billing would be regarded as fraud in any other sector.

I have been circling around this conclusion for the past five years, as I've listened to patients' stories while covering health care as a journalist and author. Now, after a summer of firsthand experience — my husband was in a bike crash in July — it's time to call out this fact head-on. Many of the Democratic candidates are talking about practical fixes for our high-priced health care system, and some legislated or regulated solutions to the maddening world of medical billing would be welcome.

My husband, Andrej, flew over his bicycle's handlebars when he hit a pothole at high speed on a Sunday ride in Washington. He was unconscious and lying on the pavement when I caught up with him minutes later. The result: six broken ribs, a collapsed lung, a broken finger, a broken collarbone and a broken shoulder blade.

The treatment he got via paramedics and in the emergency room and intensive care unit were great. The troubles began, as I knew they would, when the bills started arriving.

I will not even complain here about some of the crazy-high charges: $182 for a basic blood test, $9,289 for two days in a room in intensive care, $20 for a pill that costs pennies at a pharmacy. We have great insurance, which negotiates these rates down. And at least Andrej got and benefited from those services.

What I'm talking about here were the bills for things that simply didn't happen, or only kind-of, sort-of happened, or were mislabeled as things they were not or were so nebulously defined that I couldn't figure out what we might be paying for.

To be clear, many of the charges that I would call fraudulent — maybe all of them — are technically legal (thanks sometimes to lobbying by providers), but that doesn't make them right. And no one would accept them if they appeared on bills delivered by a contractor, or a lawyer or an auto mechanic. There were so many of these charges that I came up with categories to keep track of them:

1. Medical Swag

In the trauma bay, someone slapped a hard brace around Andrej's neck until scans confirmed that he had not suffered a grievous spinal injury. It was removed within an hour.

The medical equipment company that provided that piece of plastic billed $319. Our insurer paid $215 (90% of its discounted rate of $239). We were billed $24, our "patient responsibility."

Companies are permitted by insurers to bill for "durable medical equipment," stuff you receive for home use when you're in the hospital or a doctor's office. That yields some familiar marked-up charges, like the sling you can buy at Walgreens for $15 but for which you or your insurer get a bill for $120 after it is given to you at urgent care. The policy has also led to widespread abuse, with patients sent home with equipment they don't need: My mom's apartment, for example, holds an unused wheelchair, a walker and a commode paid for by Medicare, by which I mean our tax dollars. It's as if you were given a swag bag at a conference and then sent a bill for hundreds or thousands of dollars.

At least with swag, you get to keep it. My husband's hardly worn neck brace didn't even come home with us as a souvenir.

2. The Cover Charge

The biggest single item on Andrej's ER bill was a $7,143.99 trauma activation fee. What was that for, since every component of his care had been billed and billed handsomely?

Among the line items: $3,400 for a high-level emergency room visit. $1,030 for the trauma surgeon. Between $1,400 and $3,300 for five purported CT scans. And I say "purported" because one trip into a scanner examined the head, upper spine and maxillofacial bones but was billed as three separate things. There was also an administration fee of more than $350 each for four injections.

Trauma activation fees have been allowed since 2002, after 9/11, when the Trauma Center Association of America, an industry group, convinced regulators that they needed to be compensated for maintaining a state of "readiness."

Wait. Isn't the purpose of an ER to be "ready"? Isn't that why the doctors' services and scans are billed at higher rates when they are performed in an emergency department?

Despite scrutiny from researchers about whether trauma fees are deserved, trauma activation fees have only grown in size, 15% annually in recent years, and can reach into the tens of thousands of dollars. (On average, Medicare pays a fee of about $1,000.) Some have likened trauma activation fees to a cover charge for being wheeled into an ER with major trauma. But does a cover charge typically cost more than the meal?

3. Impostor Billing

We received bills from doctors my husband never met. Some of these bills were understandable, like for the radiologist who read the scans. But others were for bedside treatment from people who never came anywhere near the bed to deliver the care.

Andrej had a small finger fracture with a cut that needed some stitches, which a resident, a surgeon-in-training, sutured. But the $1,512 billed came in the name of a senior surgeon, as if he had done the work.

Physicians and many other health professionals are allowed to bill for the work of "extenders" — stand-ins with less training who see patients and work under the supervising doctor. These might be residents, physician assistants or nurse anesthetists, for example. For billing purposes, this allows the senior providers to be in two, three, sometimes more than half a dozen places at once, often even when they are physically miles away.

The resident did a fine job on my husband. But if an assistant did the work, shouldn't it be billed for less? At law firms, the hourly rates for paralegals and junior attorneys are lower than those for partners.

On a website called Clinical Advisor, a reimbursement expert himself seemed to wonder at the profession's luck that such billing is tolerated: "I hear people ask, 'How can I do that? The doctor never saw the patient, never had any interaction with the patient and yet I can still bill this service under the physician?'"

4. The Drive-By

The day before Andrej left the hospital, a physical therapist visited and asked a few questions. From that brief encounter, the therapist noted "ambulation deficits, balance deficits, endurance deficits, pain-limiting function, transfer deficits." That translated into a bill of $646.15 for what was recorded as a P.T. evaluation "1st session only (billable)." He said he was there for 30 minutes, but he was not. He said he walked Andrej up 10 steps with a stabilizing belt for assistance. He did not. There was no significant health service given. Just an appearance and some boxes checked on a form. It's a phenomenon called drive-by doctoring.

More shockingly, the drive-bys continued at our home, presaged by a call on Andrej's cellphone a day after he was discharged. A physical therapist from a private company wanted to visit him for at-home therapy. In his discharge instructions, no one had mentioned this service, and his injury was clearly too fresh to benefit. She came. She didn't know which body part had been injured and concluded he was in too much pain to participate.

The same company called twice more the following week to schedule visits. By the third time, I told Andrej not to open the front door. Nonetheless, our insurer was billed — and paid — for three visits.

It's as if Alexa noticed that my dishwasher makes too much noise (it does) and took it upon herself to send over a repair guy. But if I turned him away at the front door, saying I'm OK with the racket (I am), would I still be billed for the visit?

5. The Enforced Upgrade

One Monday when Andrej was in pain and out of pills, the trauma doctor suggested we meet in the emergency room, because the trauma clinic was open only from 8 to 10:45 a.m. on Wednesdays and Thursdays.

So we met the trauma doctors in the ER, and they talked to Andrej, who remained in his street clothes. They gave him a prescription. Because the interaction — which could have happened in the lobby — happened in the ER, it resulted in an ER visit charge of $1,330. But when the trauma clinic is open less than six hours a week, billing for an ER visit that doesn't tap into any of the emergency room resources feels like a scam. Is an ER visit determined by the content of the services rendered, or merely by the location?

Andrej had a similar experience when his broken finger was treated with a plastic splint that folded over his fingertip. He complained because the upper layer pressed on the fracture. At a follow-up visit, someone took a pair of scissors and cut off the upper half of the splint and taped the lower half back in place. That translated into a $481 charge for "surgery," in addition to the $375 charge for the office visit and a $103 facility fee. Doesn't surgery, by definition, involve cutting into flesh or an animate object — not a piece of plastic?

Sure, it sounds fancy to upgrade a meeting to an ER visit, or to call the tweaking of a splint "surgery," but if an airline overbooks my flight and puts me on another flight where the only seat available is in first class, it does not charge me for the more expensive ticket.

My insurer paid for most of these questionable charges, though at discounted rates. But even a discounted payment for something that never really happened or didn't need to happen or that we didn't agree to have happen is still, according to common sense, a fraud.

Why do insurers pay? Partly because insurers have no way to know whether you got a particular item or service. But also because it's not worth their time to investigate the millions of medical interactions they write checks for each day. Despite the advertised concern about your well-being, as one benefits manager enlightened me: They're "too big to care about you." Electronic records, which auto-fill billing boxes, have probably made things worse. For example, the birth of a baby boy may automatically prompt a bill for a circumcision; having day surgery may prompt a check for sedation.

So what is the appropriate payment for swag I didn't ask for, outrageous cover charges, stand-in doctors, drive-by visits and faux surgery? In some cases, zero; in others, far less than was paid. And yet, these are all everyday, normal experiences in today's health care system, and they may be perfectly legal. If we want to tame the costs in our $3 trillion health system, we've got to rein in this behavior, which is fraud by any other name.

Elisabeth Rosenthal: erosenthal@kff.org, @rosenthalhealth

Californians Without Health Insurance Will Pay A Penalty — Or Not

KFF Health News, December 13, 2019

California's penalty is modeled on the one originally in the federal Affordable Care Act.

This article was first published on Friday, December 13, 2019 in Kaiser Health News.

By Bernard J. Wolfson

Californians, be warned: A new state law could make you liable for a hefty tax penalty if you do not have health insurance next year and beyond.

But some of you need not worry: The law contains several exemptions that will allow certain people to avoid the penalty, among them prisoners, low-income residents and those living abroad.

"It will be really important that people get clear guidance and instruction to make sure they don't inadvertently pay a penalty when they are eligible for an exemption," says Laurel Lucia, director of the Health Care Program at the University of California-Berkeley's Center for Labor Research and Education.

California's penalty is modeled on the one originally in the federal Affordable Care Act. Congress eliminated the federal penalty, effective this year.

The Golden State will join Massachusetts, New Jersey, Rhode Island, Vermont and Washington, D.C., in requiring their residents to have health coverage and dinging those without it.

Most types of insurance, including Medi-Cal, Medicare and employer-sponsored coverage, will satisfy California's coverage requirement. People who purchase insurance for themselves and their families, either through Covered California, the state's health insurance exchange, or the open market, will have until Jan. 31 to buy a health plan for 2020.

If you aren't covered and owe a penalty for 2020, it will be due when you file your tax return in 2021. The penalty will amount to $695 for an adult and half that much for dependent children. Some people with higher incomes instead will have to pay 2.5% of their income, which could make their penalty quite a bit heftier.

Penalty payments are expected to raise $317 million in the first year they are collected, according to the state Legislative Analyst's Office. The money will help pay for new state subsidies intended to make insurance more affordable for some people.

You won't have to pay the penalty if you are uninsured for three consecutive months or less during the year, or if you are incarcerated or are Native American. Likewise, if you are in the U.S. illegally.

General hardship exemptions also are available if you are facing personal or family difficulties, including homelessness, domestic violence, bankruptcy, eviction or the consequences of a natural disaster.

And you're off the hook if your household income is below the threshold for filing a tax return. This was the most common exemption from the federal penalty, according to Internal Revenue Service data based on 2016 returns. It might be even more popular under the California law, since the state's filing threshold is higher than the federal one, Lucia says.

You can also claim an exemption if you would have to spend more than 8.24% of your income on insurance premiums in 2020. This so-called affordability exemption was also among the most common under the federal law.

How you claim an exemption depends on the type you are seeking.

Covered California will handle three types of exemptions: religious conscience, general hardship and affordability. Each will require filling out a different application, and the applications will be available starting in January, says James Scullary, an exchange spokesman.

For other exemptions, you'll need to apply when you file your 2020 return with the Franchise Tax Board in early 2021. A tax board spokeswoman promises that "our tax forms and instructions will include information for all exemptions claimed on the tax return."

You can also apply to the tax board for an affordability exemption when you file your return.

Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research, says the 8.24% threshold to qualify for the affordability exemption is too high and pushes many middle-class families to pay a penalty even when they are hard-pressed to buy insurance.

Steven Morelock, a resident of Los Angeles, paid hundreds of dollars in federal penalties for several years because he felt too financially stressed to plunk down $250 a month for a high-deductible health plan. He was already shelling out nearly half of his $2,500-a-month salary in rent alone.

"I would have had to change my habits very dramatically," says Morelock, 41, a labor organizer. "It would have cut the amount of money I had for non-fixed costs by about half." He finally got employer-sponsored insurance late last year.

Another exemption that has stirred some debate is for membership in a health care sharing ministry — an association of religiously like-minded people, primarily Christians, who cover one another's medical costs.

Legislators and others who opposed including this exemption in California's law argued that the ministries are subject to little regulatory scrutiny, the coverage they offer is limited, and it's not guaranteed. More recently, concerns have arisen about sham ministries engaged in deceptive business practices.

Dr. Dave Weldon, president of the Alliance of Health Care Sharing Ministries, acknowledges some of the limitations and says the organizations he represents "all counsel their members that this is not insurance, there's no contract, there's no obligation to pay."

Bob Stedman, 55, says he and his family were exempt from the federal penalty every year because of their membership in Samaritan Ministries International. The Lake Forest, Calif., resident plans to take the same exemption under the California law.

Stedman figures he's saving about $1,000 to $1,500 a month in premiums compared with regular insurance, and was pleased when the $50,000 bill he received following a stroke was heavily discounted by the hospital and then almost entirely covered by other ministry members. And knowing his money is not being used to finance abortions, which most commercial health plans in California are required to cover, gives him "the benefit of a clear conscience," he says.

Weldon says the exemption is warranted on those grounds alone. "This nation has a long history of religious accommodation," he says.

If you're not sure whether you might qualify for an exemption, you can get more information from Covered California or the tax board.

Contact Covered California at www.coveredca.com or by phone: 800-300-1506. For the tax board, log on to www.ftb.ca.gov or call 800-852-5711.

But don't limit yourself to those two agencies. Insurance agents and tax preparers across the state are trying to master the details of the new law, and they can help.

For a list of insurance agents whose help is free, log on to the Covered California website and click on "find help" or go to the website of the National Association of Health Underwriters (www.nahu.org) and hit "find an agent." The California Society of Tax Consultants (https://www.cstcsociety.org/) and the California Society of CPAs (www.calcpa.org) can help you find a tax preparer.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

Battling The Bullets From The Operating Room To The Community

KFF Health News, December 12, 2019

St. Louis trauma surgeon Dr. Laurie Punch is on a mission to stop the bleeding of her patients and the violence-plagued communities around her.

This article was first published on Thursday, December 12, 2019 in Kaiser Health News.

By Laura Ungar December 12, 2019

ST. LOUIS — Dr. Laurie Punch plunged her gloved hands into Sidney Taylor's open chest in a hospital's operating room here, pushing on his heart to make it pump again after a bullet had torn through his flesh, collarbone and lung. His pulse had faded to nothing. She needed to get his heart beating.

She couldn't let the bullet win.

Bullets are Punch's enemy. They threaten everything the 44-year-old trauma surgeon cherishes: her patients' lives, her community, even her family. So, just as she recalled doing two years ago with Taylor, Punch has made it her life's mission to stem the bleeding and the damage bullets cause — and excise them if she can.

In the operating rooms at Barnes-Jewish Hospital, Punch treats gunshot victims, removing bullets that studies show can poison bodies with lead and fuel depression. And in her violence-racked community, she teaches people how to use tourniquets to stop bleeding, creating a legion of helpers while building trust between doctors and community members.

Punch feels a calling to St. Louis, a place with the nation's highest murder rate among big cities, where at least a dozen children were shot to death this summer alone, including a 7-year-old boy playing in his backyard. Punch believes all she's learned has prepared her for now, when gun violence kills an average of 100 Americans a day and mass shootings are so common that two this summer struck less than 24 hours apart.

To her, the battle is personal, in more ways than one.

Besides being a surgeon, she's a multiracial single mom living in Ferguson, Mo., just over a mile from where Michael Brown Jr., a black teenager, was shot and killed by a white police officer five years ago.

She has a son the same age as the little boy killed in the backyard in August. And she said, "I hear the gunshots echoing through my 2-acre backyard all the time."

Stopping A Deadly Disease

In September, Punch brought her message to Washington, D.C., testifying before the House Ways and Means Oversight subcommittee on gun violence. Wearing a jacket and tie, she faced lawmakers to share the story of Shannon Hibler.

The 23-year-old was brought to Punch's hospital last summer, shot seven times. While the nurses gave him blood, Punch said, she cut open his chest, trying to force life back into his body — to no avail.

"I watched his wife sink, as the floodwaters of vulnerability and risk came into her eyes, thinking about the life of her and her child and how they would live without him," Punch told the assembled lawmakers. "I watched his father rage. And I heard his mother wail."

Punch placed the black-and-yellow, blood-splattered Adidas sneakers she'd worn the day of the shooting on the table before her in the hearing room.

"I can't wash these stains out," she told lawmakers.

The trauma surgeon was adamant: Violence is a true medical problem doctors must treat in both the operating room and the community. Until they do that, she said, violence victims will continue to be vectors who spread violence.

"The disease that bullets bring does not yet have a name," she told Congress that day. "It's like an infection, because it affects more than just the flesh it pierces. It infects the entire family, the entire community. Even our country."

But healing also can be contagious — spreading among victims, families and the physicians themselves.

Punch, who regularly visits the neighborhoods where her patients live, attended an event last year for Saint Louis Story Stitchers, an artist and youth collective working to prevent gun violence. She remembers spotting a volunteer she knew — Antwan Pope, who'd been shot some years earlier but had found renewed purpose helping young people.

Punch told Pope about Hibler's case, and learned Hibler was Pope's cousin. Hibler's dad was at the community event, too, and he handed Punch a lapel pin with his son's picture.

She wore it on her white coat for months.

Two Worlds

Punch was born in Washington, D.C., the only child of a Trinidadian father and white Midwestern mother. They separated six months after her birth.

Until she was 7, Punch moved every year with her mom. They eventually settled with Punch's grandmother in the tiny town of Wellsville, Ohio, a close-knit but segregated community.

Classmates bullied her for being different, Punch recalls.

"I was different in every way because I wasn't black; I wasn't white," said Punch, who later came out as gay.

From the time Punch was 9, she took $2 piano lessons from Elizabeth Carter. The local music teacher had transformed former drug dens into places with music lessons, free clothes and meals, and put all the kids who sought her help to work. Punch's assignment was serving food.

"You show someone that they can help," Punch said, "it's revolutionary."

That lesson guided her life as a child and when Punch moved on to Yale University, the University of Connecticut's medical school and then the University of Maryland Medical Center in Baltimore, where poverty and trauma scarred many of her patients' lives.

Punch spent her early career in the shock trauma center in Baltimore, throwing everything she had into saving others.

After marrying a woman she met as a medical intern, Punch became pregnant with twins at 35.

The next few years were marked by highs and lows in her personal life and the unrelenting stress of dealing with the aftermath of violence at work.

She miscarried at five months. No one could tell her why.

Five months later, she became pregnant again, this time giving birth to a healthy boy, Sollal Braxton Punch. But not long later, she and her wife separated. Now she found herself as a single parent as the pressures of her job mounted.

One morning, three shooting victims arrived at the trauma center, quickly followed by a car crash victim who was pregnant. Punch's nanny texted her, saying Sollal had a fever of 102.3.

"I realized I can't do this anymore," Punch said. "I just can't."

The Call Of Community

So, she took a break from trauma for more than two years, focusing on general surgery at Houston Methodist Hospital in Texas.

But in 2015, a former colleague contacted her about a job as a trauma surgeon and educator at Washington University in St. Louis.

She feared going back to another troubled city. Michael Brown Jr. had been killed in Ferguson, Mo., a little more than a year earlier, triggering unrest and riots in that city just outside St. Louis.

Despite the area's well-known history of violence, she flew to St. Louis for interviews, then rode around Ferguson with Dr. Isaiah Turnbull, an assistant professor. He pointed out the spot on Canfield Drive where Brown's body had lain in the road for more than four hours.

"It was almost like seeing Ground Zero," Punch said. "This is where it all went down. And it went down because of deep structural realities that caused the experience of black and brown people in north St. Louis to be fundamentally different. I went from not wanting to go to wanting to be right in the middle of it."

And now she is.

On a recent hot summer evening, 20 people — some black, some white — gathered around Punch. A few feet away, a doctor, a trauma nurse and a medical student stood near tables stacked with "pool noodles," the long foam cylinders kids play with in swimming pools — these happened to be about the width of a human arm.

Punch told the class that a person can bleed to death in a minute, but an ambulance can take 15 minutes to arrive.

"If you can stop the bleed, you can save a life," she said. "Time is life and minutes matter."

Participants practiced packing wounds by pressing gauze into holes in the pool noodles. They tightened tourniquets — first on the foam cylinders, then on each other.

Punch knows one of the doctors who created the "Stop the Bleed" training sessions after the mass shooting at Sandy Hook Elementary School in Connecticut. She realized the same training could save lives after street shootings, too.

Since March 2018, she and her team have trained more than 7,000 community members in the St. Louis metropolitan area. Many come to a rented space she dubbed "The T," for trauma, tourniquet and time. But Punch's team has also held classes in schools, a juvenile detention center and a firing range.

"It's far more than teaching people what to do," Punch said. "They learn: 'I am not simply a victim or a perpetrator or an observer; I'm a helper. I have the capacity to help.'"

Contagious Healing

Two years ago, Sidney Taylor was shot outside his brother's comedy club in north St. Louis County while trying to help a friend who was drunk. When Taylor arrived at Punch's hospital, profuse bleeding had left his blood pressure dangerously low.

At one point, the father of four technically died on the operating table, but Punch and her team pulled him back.

After 10 days in intensive care, the longtime wrestling coach was still in physical and mental agony.

That's the point when many patients slip back to their communities unhealed. But Taylor, now 47, showed up in Punch's clinic a month after he had been shot, and they bonded during a 25-minute visit. Punch described to him how her team had removed part of his lung and inserted a breathing tube.

"Wow," he told her. "I have another chance at life."

Punch mulled a thought, then asked. "Would you ever want to share your story?"

Taylor agreed.

Punch recruited his hospital caregivers to create a video of their memories of saving him. When the taping finished, Taylor hugged each one.

Punch uses the video during talks, sometimes inviting Taylor to join her. Giving back to the community in that way has saved him a second time, he said.

After getting shot, "I could've basically turned to the dark side and done straight revenge," Taylor said. "But I didn't because of her."

Laura Ungar: lungar@kff.org, @laura_ungar

Supreme Court Seems Sympathetic To Insurers In Obamacare Case

KFF Health News, December 11, 2019

The administration argues it doesn't have to pay the money because a Republican-controlled Congress stripped away most of the funding.

This story was published December 10, 2019, by Kaiser Health News.

By Phil Galewitz, Kaiser Health News

No clear split between conservative and liberal Supreme Court justices emerged Tuesday as justices heard arguments over whether the federal government could renege on Congress' promise to pay health insurance companies billions to motivate them to participate in the Obamacare marketplaces.

Health insurers hope to recoup $12 billion they believe is owed to them from that Affordable Care Act incentive program.

During the hour of oral arguments, six justices appeared to favor the insurers' argument — Chief Justice John Roberts, plus justices Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor, Elena Kagan and Brett Kavanaugh. Samuel Alito seemed to side with the Trump administration. Neither Clarence Thomas nor Neil Gorsuch spoke during the session.

The Trump administration argues it doesn't have to pay the money because a Republican-controlled Congress stripped away most of the funding in 2014 and only Congress can appropriate money under the law.

The so-called risk-corridor payments were designed to help health plans recover some losses in the first three years of the Obamacare marketplaces. Congress gave the incentive because of the uncertainty insurers faced regarding how sick or costly this previously uninsured population would be.

Insurers that made large profits were to pay some of it back to the government to share with money-losing insurers. But the money taken in under the program fell billions short of the amount owed to insurers. The Obama administration told insurers it would make up the difference with funds from the Centers for Medicare & Medicaid Services' budget. But in late 2014 ― after insurers began selling policies to millions of Americans with the expectation that the safeguard would back them up ― Congress barred the federal government from using that funding stream.

Kagan noted how the profitable insurers are still obligated to pay money into the risk-corridor program even though the federal government says it no longer has to pay out.

"You pay in, that's obligatory. We commit ourselves to paying out. It turns out, if we feel like it. What, what kind of, what kind of a statute is that?" she asked.

No justice was more critical of the administration's position than Breyer. He questioned why the 2010 health law promised money to insurers who lost money but later took it away after the insurers began covering millions of customers.

"My hat's on the flagpole. If you bring it down, I'll pay you $10. You bring it down. I owe you $10. Now how does this differ?"

Deputy Solicitor General Edwin Kneedler, who was arguing the case for the Justice Department, responded that insurers had many reasons to participate in the Obamacare marketplaces beyond the promised risk-corridor payments, most notably that they are the only places millions of people could get federal subsidies to lower their health insurance premiums.

Roberts interjected: "It's a good business opportunity for them because the government promised to pay."

Kavanaugh, the newest and one of most conservative justices, suggested to Kneedler that a high court ruling against the insurers could set a precedent to not fund other federal programs with no specific appropriation amount. "If we were to rule for you, everyone will be on notice going forward, private parties and Congress itself, that 'shall pay' doesn't obligate actual payments."

A ruling on the case, Maine Community Health Options v. United States, is expected in the spring.

'Food Pharmacies' In Clinics: When The Diagnosis Is Chronic Hunger

KFF Health News, December 10, 2019

It's not that patients are starving. It's that they may have a lot of food one day and none the next.

This story was published December 10, 2019, by Kaiser Health News.

By Blake Farmer, Nashville Public Radio

There's a new question that anti-hunger advocates want doctors and nurses to ask patients: Do you have enough food?

Public health officials say the answer often is "not really." So clinics and hospitals have begun stocking their own food pantries in recent years.

One of the latest additions is Connectus Health, a federally qualified health clinic in Nashville, Tenn. This month, part of LaShika Taylor's office transformed into a community cupboard.

"It's a lot of nonperishables right now, just because we're just starting out," she said, but the clinic is working on refrigeration so it can also stock fresh food.

It's not that patients are starving, Connectus co-director Suzanne Hurley said. It's that they may have a lot of food one day and none the next. That's no way to manage a disease like diabetes, she said.

"I can prescribe medications all day, but if they can't do the other piece—which is a decent diet and just knowing they're not going to have to miss meals," she said, "medications have to be managed around all of those things."

Second Harvest Food Bank of Middle Tennessee, a local food bank, is encouraging more health care providers to consider on-site pantries. The food bank also wants every patient—not just those suspected of being low income—to be asked about their food situation.

"We're really pushing for universal screening, so you're not picking who you're asking that question to. The doctor already asks you really personal questions, and we don't think twice about it," said Caroline Pullen, Second Harvest's nutrition manager. "I think people have always been scared to ask this question because they didn't really have the resources of where to send them."

"Food insecurity," as it's known, has become a particular concern among seniors. The anti-hunger group Feeding America found that more than 5 million older Americans don't have enough food to lead a healthy life—a figure that has doubled in the last two decades.

In response, food banks are increasingly meeting seniors where they get their health care. Hospitals from Utah to Massachusetts are sending patients home with food.

Trudy Hoffman now gets free groceries at her monthly visits to Nashville General Hospital.

"They just asked me, did I want a bag of food to carry home?" she recalled. "And I said, 'Yeah.'"

The city-funded hospital started its pantry just for cancer patients in recent years but opened it to all patients this year and received a $100,000 grant in October to fund its expansion.

Organizers call it a "food pharmacy," following the lead of places like Children's Hospital of Philadelphia, with patients getting a "prescription" for what to pick up. Some shelves have high-calorie superfoods for cancer patients to keep their weight up. Others have low-sugar staples for people with diabetes and low-sodium items for patients with hypertension.

Vernon Rose, who oversees the Nashville General Hospital Foundation, said no one is surprised to see dozens of patients using the pantry each day.

"Because when you're in a place like ours, where 40% of the folks can't even afford their health care, you can imagine the choices they're making," she said—such as deciding whether to pay for food, utilities or medicine.

The pantry operates mostly with grant funding. So Rose said the biggest challenge now is keeping it fully stocked with important but more expensive items like fresh produce and spices, which can be used to help patients keep some flavor while reducing salt in their diet.

This story is part of a partnership that includes WPLN, NPR and Kaiser Health News.

U.S. Supreme Court

Obamacare Back At The High Court—With Billions For Insurers On The Line

KFF Health News, December 9, 2019

Lower courts were split on whether the government should be forced to make the payments. Here are five reasons you should pay attention to the case.

This article was published December 9, 2019, by Kaiser Health News.

Phil Galewitz, Kaiser Health News

More than $12 billion is at stake for the nation's health insurers Tuesday when the Supreme Court hears another Affordable Care Act case.

For the federal government, the potential damages could be far greater, as its reputation as a reliable partner to private businesses is on the line.

Unlike earlier Obamacare cases before the high court—where the entire 2010 law and health coverage for millions of Americans was at risk—the latest case has largely flown under consumers' radar.

The case revolves around a temporary Obamacare provision—called the "risk-corridor" program—that was designed to help health plans recover some losses in the first three years of the health law marketplaces.

The Republican-controlled Congress in late 2014 stripped most of the money out of the program in a budget bill signed by President Barack Obama. This occurred a year after insurers began selling policies to millions of Americans with the expectation that the safeguard would back them up.

Republicans led by Sen. Marco Rubio (R-Fla.), who were determined to repeal the ACA, called the original provision an insurer "slush fund." But researchers later found that the loss of the risk-corridor program was largely responsible for soaring premiums in 2016 and 2017, and contributed to several startup insurers going out of business.

Dozens of insurers have cried foul and sued the government. Lower courts were split on whether the government should be forced to make the payments.

Here are five reasons you should pay attention to the case:

1. The integrity of the federal government is at stake.

Health insurers say the government's decision on the risk-corridor program amounts to a bait-and-switch. The health plans took a chance with the new marketplaces, where they had little knowledge of how sick or expensive new enrollees would be. They said they expected the risk-corridor funding would back them up.

The latest data shows the government owes insurers more than $12 billion in payments to cover losses on the insurance exchanges between 2014 and 2016.

"This case warrants comparison to Lucy Van Pelt pulling the football away from Charlie Brown—with our nation's government cast as the capricious bully," the Association for Community Affiliated Plans, an industry group representing nonprofit health plans, wrote in an amicus brief to the Supreme Court. "If the Federal Circuit's rule stands, then from now on no business can trust a statutory promise of payment from the government."

The risk-corridor program was one of several ACA safeguards for insurers. The law called for insurers that made large profits to pay some of it back to the government to share with money-losing plans.

But the money taken in under the program fell billions short of the amount owed to insurers. The Obama administration told insurers that it would make up the difference with funds from the Centers for Medicare & Medicaid Services' budget. The General Accountability Office, the investigative arm of Congress, supported that decision for 2014.

The Trump administration argued the federal government never had power under the law to make the payments out of the CMS budget. The December 2014 budget deal confirmed that, according to the administration.

The federal government's top lawyer rejects insurers' notion that the risk-corridor money was ever guaranteed to them.

Congress did not "lure private parties into expensive undertakings with clear promises, only to renege after private parties have relied to their detriment and incurred actual losses," Solicitor General Noel Francisco argued in court briefs.

2. Obamacare consumers may benefit if the court sides with the insurers.

The Supreme Court case combined suits from four insurers: Moda Health Plan of Oregon, Maine Community Health Options, Blue Cross Blue Shield of North Carolina and Land of Lincoln Mutual Health Insurance, a now-defunct health plan from Illinois. But dozens of other insurers also have filed lawsuits. If the court rules in favor of insurers, it could force the federal government to pay them $12 billion.

Experts say that could have a marginal effect on those insurers in setting future premiums. It could also force some plans to make rebate payments to customers based on another ACA provision that plans pay money back to members if they spend more than 20% of their premium dollars on administration, marketing and profits.

Meg Murray, CEO of the Association for Community Affiliated Plans, said the government owes $627 million to about 20 of her organization's plans. "The money would help them going forward in paying back debts or investing their plans or reducing premiums," she said.

3. The co-ops have been stymied.

When the Affordable Care Act was nearing its final votes, Democrats removed a controversial provision that would have set up a government-operated plan that would be a "public option" for consumers. It was replaced with federal money to start new, nonprofit insurers to bring more competition into many markets, which lawmakers hoped would help hold down premium costs. There were 23 new health cooperatives that started enrolling members in 2014. Today, just four are still in business.

More than other insurers, the co-ops were most at risk when the money was eliminated because they operated on the smallest budgets.

"This was a huge factor in the failure of the co-ops," said Timothy Jost, a retired law professor at Washington and Lee University in Lexington, Va., who has studied the ACA.

Kevin Lewis, CEO of Maine Community Health Options, said his company is owed $59 million. Without that money, his plan had to withdraw from New Hampshire and raise premiums in areas it still serves. Community Health Options is one of three health plans on the marketplace in Maine and has 38,000 members.

Lewis said that, while many factors caused the demise of the co-ops, the loss of risk-corridor money is high among them.

4. The U.S. Chamber of Commerce—a leading opponent of Obamacare—is defending the risk-corridor provision.

The chamber has spent nearly a decade and millions of dollars fighting to overturn the Affordable Care Act. That's why its amicus brief supporting insurers' fight to restore its risk-corridor funding is so notable.

In its brief, the chamber said the health law promised funding to private insurers, and when the government reversed its commitment, "it pulled the rug out from under them."

The court's ruling would reverberate well beyond just the health insurance industry if it does not reverse lower court rulings, according to the chamber.

"If allowed to stand, the decision will chill the business community from working with the federal government in the future," the chamber said.

5. A ruling could influence another big Obamacare case.

If the justices rule in favor of the insurers on this case, they may strengthen the industry's argument in a separate ACA lawsuit working its way through lower courts.

Insurers have sued the federal government for $2.3 billion in unpaid "cost-sharing reduction" payments after the Trump administration stopped making the payments in 2017. Six insurers—in front of three different federal judges—have succeeded in their challenges over unpaid payments.

These ACA payments were intended to compensate insurers for reducing deductibles, copayments and coinsurance mandated by the ACA for marketplace enrollees with low incomes.

Some lawsuits from insurers have been stayed, pending the court's ruling on risk corridors.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Patient-Induced Trauma: Hospitals Learn To Defuse Violence

KFF Health News, December 6, 2019

Scripps Mercy Hospital officials have made a number of changes to help protect employees from what they refer to as an epidemic of violence.

This story was published December 6, 2019, by Kaiser Health News.

By Heidi de Marco, Kaiser Health News

SAN DIEGO—When Mary Prehoden gets dressed for work every morning, her eyes lock on the bite-shaped scar on her chest.

It's a harsh reminder of one of the worst days of her life. Prehoden, a nurse supervisor at Scripps Mercy Hospital San Diego, was brutally attacked last year by a schizophrenic patient who was off his medication. He lunged at her, threw her to the ground, repeatedly punched and kicked her, and bit her so hard that his teeth broke the skin and left her bleeding.

The incident lasted about 90 seconds, but the damage lingers.

"Even if I didn't have a scar, the scar is in your head," said Prehoden, 58. "That stays with you for the rest of your life."

Violence against health care workers is common—and some say on the rise.

According to the Occupational Safety and Health Administration, workplace violence is four times more common in health care settings than in private industry on average, yet it still goes underreported. Patients account for about 80% of the serious violent incidents reported, but stressed-out family and friends also are culprits. Co-workers and students caused 6% of the incidents.

In a 2018 poll of about 3,500 emergency room doctors conducted for the American College of Emergency Physicians, nearly 70% said violence in the emergency department has increased in the past five years.

About 40% of the doctors believed the majority of assaults were committed by psychiatric patients, and half said the majority were committed by people seeking drugs or those under the influence of drugs or alcohol.

In California, a state law requires hospitals to adopt workplace violence prevention plans and report the number and types of attacks to the state. The state then compiles the data into annual reports.

Workplace Violence Response Training for Healthcare Facilities: Equip Your Staff to Respond Effectively and Mitigate Risk

In the first full report, 365 hospitals tallied 9,436 violent incidents during the 12-month period that ended Sept. 30, 2018, ranging from scratchings to stabbings. Workers were punched or slapped in one-third of the assaults and were bitten in 7% of cases.

"I don't know that you ever expect to have to defend yourself at your workplace," Prehoden said. "It's not anything you're prepared for."

Scripps Mercy Hospital officials have made a number of changes to help protect employees from what they refer to as an epidemic of violence. They've launched a "rapid response" team made up of staff members who try to defuse potentially violent situations. And the hospital has introduced a behavioral screening tool to help identify patients prone to violence. When patients get flagged, they must wear a green wristband, and a green peace sign is placed on their door.

Ryan Sommer, who is the head of security at Scripps Memorial Hospital Encinitas, leads violence de-escalation training for Scripps staff at different locations throughout San Diego County.

On one recent morning, about 20 employees at the Encinitas facility learned how to deter an agitated and combative patient. One tip Sommer shared: Behavior influences behavior, so listen with empathy and establish a personal rapport with the patient. And, he told them, don't lose your cool; the goal is to get agitated patients to calm down.

Sommer also taught self-defense tactics should the situation escalate. In groups of two, employees practiced how to disengage from a hold and block strikes from an attacker.

"How many of you have been attacked on the job?" Sommer asked. Nearly all the participants raised their hands.

"This happens daily. They get punched, scratched, spit on, yelled at," he said later.

Sommer said the number of violent incidents at the Scripps hospitals is rising and the injuries are becoming more severe.

Since earlier this year, security guards at all Scripps hospitals have been armed with stun guns, said Janice Collins, a spokeswoman for Scripps Health. They wear stab-proof vests and are stationed strategically around the facilities. The stun guns are used when security guards believe they are needed to protect life, Collins said. Prehoden's situation would have met that criteria, she said.

Hospitals across California are taking similar measures with the hope of reducing violent confrontations, said Gail Blanchard-Saiger, the California Hospital Association's vice president of labor and employment.

Some sites use panic buttons, metal detectors, security dogs, increased police presence and security cameras, in addition to de-escalation training.

The efforts vary by location and risk, Blanchard-Saiger said.

Additional support from local law enforcement would make a difference, she said. "Unfortunately, I've heard plenty of stories where they don't even come to the hospital," she said. "They're short-staffed, underfunded. They're prioritizing."

Prehoden has attended the de-escalation training and is now on the rapid response team at Scripps Mercy Hospital.

It took her three weeks to return to work after she was beaten in August 2018. A nurse for almost 40 years, she admits being a little on edge now, and feels as if her attacker robbed her of her confidence. He served six months in jail for the attack.

"This cannot be the new face of nursing," Prehoden said. "We can't afford to lose our staff because somebody decides not to take his medication."

Website Errors Raise Calls For Medicare To Be Flexible With Seniors' Enrollment

KFF Health News, December 6, 2019

Although CMS has earned praise for responding to errors identified by Plan Finder users, some people may have signed up for plans before the mistakes were caught.

This story was published December 6, 2019, by Kaiser Health News.

By Susan Jaffe

Saturday is the deadline for most people with Medicare coverage to sign up for private drug and medical plans for next year. But members of Congress, health care advocates and insurance agents worry that enrollment decisions based on bad information from the government's revamped, error-prone Plan Finder website will bring unwelcome surprises.

Beneficiaries could be stuck in plans that cost too much and don't meet their medical needs—with no way out until 2021.

On Wednesday, the Centers for Medicare & Medicaid Services told Kaiser Health News that beneficiaries would be able to change plans next year because of Plan Finder misinformation, although officials provided few details. And the Medicare.gov website and representatives at Medicare's call center had no information about that option.

The overhauled Plan Finder debuted at the end of August, and 2020 plan information was added in October. Over the past three months, Plan Finder problems reported to CMS by the National Association of Insurance Commissioners, the National Association of Health Underwriters, and state and national consumer advocates included inaccurate details about prices, covered drugs and dosages, and difficulty sorting and saving search results, among other things.

CMS made almost daily corrections and fixes to the website, which is the only tool that can compare dozens of private drug and medical plans―each with different pharmacy networks, covered drugs and drug prices. The website provides information for more than 60 million people with Medicare and their families, as well as state Medicare counselors and the representatives who answer the 800-MEDICARE help line.

In an unsigned blog article published on a Medicare website last week, officials said they're "not done improving the Plan Finder." And they promised "in the coming months we'll be scoping out additional improvements that we can implement based on lessons we learn this year."

Related: Medicare Plan Finder Tool Revamped to Make Comparison Shopping Easier

Although CMS has earned praise for responding to errors identified by Plan Finder users, some people may have signed up for plans before the mistakes were caught―mistakes they may not notice until their coverage kicks in next year.

"Seniors should be able to choose the plans that work best for them," said Sen. Susan Collins (R-Maine), chairwoman of the Senate Special Committee on Aging. "Issues with Medicare's new Plan Finder website, however, have reportedly created confusion among beneficiaries as well as those assisting them." She added that she was concerned "this problem even occurred."

Medicare's response, Collins said, "must be vigorous with extensive outreach to inform seniors of special enrollment periods."

Sen. Bob Casey of Pennsylvania, the senior Democrat on that committee, also said Medicare needs to reach out so people know they can request a "special enrollment period" if they discover next year they made a wrong choice due to inaccurate Plan Finder information.

"People with Medicare must be aware that this reprieve exists and should not have to jump through hoops to qualify," he said. The administration should "use all means necessary" to let beneficiaries know about their options for a special enrollment period.

In the statement to KHN Wednesday, CMS said it provides special enrollment periods for a number of reasons. It added that beneficiaries can get a special enrollment period related to Plan Finder issues anytime next year.

They can "call 1-800-MEDICARE and explain to our call center representatives that they have an issue with their plan choice. It is not CMS's expectation that beneficiaries will have documentation or screenshots," the statement said. The call center representatives "are trained and ready to help the beneficiary through the rest of the process."

CMS officials refused to be identified but would not give a reason.

Information about Plan Finder special enrollment periods will be available on the Medicare.gov website and at the call center, a CMS spokesman said.

However, nothing was posted on the website Thursday, and when Kaiser Health News called Medicare twice Thursday, both representatives said it would not be possible to switch plans next year because of inaccurate information from the Plan Finder.

Applying for a special enrollment period could be tricky. In the blog post, Medicare officials said the information on the Plan Finder is "the most current and accurate information on premiums, deductibles and cost sharing that Medicare Advantage and Prescription Drug Plans provide." They noted that the "information changes frequently because plans regularly update drug formularies and renegotiate drug prices."

America's Health Insurance Plans, the trade group representing health insurers, "is not aware of any systematic problems with the Plan Finder, which is operated by CMS," said spokeswoman Cathryn Donaldson.

People who enroll in a private Medicare Advantage policy, an alternative to traditional government-run Medicare that covers both drugs and medical care, already have an alternative. They have until March 31 to change plans or enroll in traditional Medicare.

Collins and Casey are not the only members of Congress raising the issue. Sen. Sherrod Brown (D-Ohio) wants CMS to provide a special enrollment period in these cases and clearly communicate the details, a spokesman said.

Rep. Richard Neal (D-Mass.), who chairs the House Ways and Means Committee, believes Saturday's deadline should be extended, a committee aide said. The committee has heard about the Plan Finder's problems from numerous seniors' advocates and counselors from state health insurance assistance programs, as well as the insurance companies that sell coverage.

Since enrollment for 2020 coverage began Oct. 1, the National Association of Health Underwriters, which represents 100,000 insurance agents, has sent CMS officials 54 Plan Finder problems and is still receiving reports from agents, said John Greene, the vice president for congressional affairs.

The Medicare counselors at Nebraska's Senior Health Insurance Information Program flagged more than 100 issues as of mid-November, said Alicia Jones, the program's administrator.

After receiving complaints about the Plan Finder, Delaware's insurance commissioner, Trinidad Navarro, issued a consumer alert last week.

Tatiana Fassieux, education and training specialist at California Health Advocates, said her organization wants CMS to offer a blanket, nationwide special enrollment period instead of granting it case by case. The group helps train Medicare counselors for California's Health Insurance Counseling and Advocacy Program, known as HICAP.

Leslie Fried has been an elder law attorney in Washington, D.C., since 1985, so imagine her surprise when she was stumped last weekend helping her mother pick a policy through the Plan Finder.

Fried, who is also senior director of the Center for Benefits Access at the National Council on Aging, did the same search three times for the least expensive plans that cover her mother's drugs and came up with a different result each time.

"Beneficiaries should be able to have confidence in the Plan Finder after a single search," she said.

For assistance reviewing drug and medical plans, call your state's Senior Health Insurance Information Program at 877-839-2675 or the Medicare Rights Center at 800-333-4114.

Opinion: Choosing A Plan From The Impossible Health Care Maze

KFF Health News, December 6, 2019

The current complexity is an outgrowth of countless decisions over the past 30 years, many of which sounded logical at the time but which grew out of financial considerations.

This story, which ran as an opinion piece in The Boston Globe, was published December 6, 2019, by Kaiser Health News.

By Elisabeth Rosenthal

In this highly partisan political moment, there's one issue that nearly every American can agree on: Our health care system is a mess and in need of dramatic overhaul.

That's not just because it is absurdly expensive compared with the systems of other developed countries. It's also because it is so dauntingly complex.

That complexity, in large part, derives from the fact that the health care system has been driven significantly by profit, rather than by measures of health. Countless providers, companies, consultants and intermediaries are trying to get their piece of the $3.5 trillion pie that is U.S. health care. Nora Ephron said, "Everything is copy." In 21st-century U.S. health care, everything is revenue, and so everything is billed.

That has led to a maze-like system—with twists and turns and barriers and blind alleys and incomprehensible signposts—that ordinary people are expected to navigate.

We say American patients should be happy because our system gives consumers choices. We tell people that to benefit they just need to be smarter shoppers.

What we are really telling them is to perform the impossible.

How can they choose an insurance policy when there are endless permutations involving personal budget calculations and modeling that would defy a post-doc in economics? For each policy, there's an in-network deductible and an out-of-network deductible, overlapping for the family and each individual. There are copays and coinsurance (yes, they're different), as well as an annual maximum personal out-of-pocket outlay (which may not include some of the above).

Likewise, how to choose between a PPO and an HMO, especially when the PPO network may be—or may become—so narrow during the term of the policy that it affords little or no choice of doctors? Should patients pair an insurance plan with a tax-advantaged flexible spending account or health savings account—and how to understand the difference anyway?

I'm a medical doctor and have spent years as a journalist covering health care. But I am grateful that my company chooses my PPO health plan—not just because it's good, but also because it means I don't have to try to decide between hundreds of options when there is no good way to make a rational choice.

The system is rigged against patients—thanks largely to its opacity and complexity. Insurance plans list an array of covered services but then can refuse to pre-certify a prescribed treatment or decide it was not medically necessary and deny coverage after the fact. For example, a patient goes to the emergency room with chest pain, which turns out to be just a pulled muscle. So, in retrospect, it wasn't an emergency. Coverage denied!

Informed consent is regarded as a moral and legal obligation by physicians; for every procedure performed, doctors are required to tell patients the chance of success, potential side effects and problems. And yet when it comes to navigating our convoluted system, patients travel in the dark.

The current complexity is an outgrowth of countless decisions over the past 30 years, many of which sounded logical at the time but which grew out of financial considerations. All the players are effectively licensed to reach into our wallets when they can't get the money they want from one another.

As prices spiraled upward, insurers (backed by economists) imposed copayments and coinsurance so patients would have "skin in the game," to encourage them to use health care more sparingly, more wisely. But with prices in medicine now so high, the skin-in-the-game theory now means many patients live with debilitating symptoms, delay needed treatment or don't get treated at all.

In one study, 1 in 4 diabetics reported taking less insulin than prescribed because of costs. Another found that one-fifth of cardiac patients with "financial hardship" cut back on both food and medicines.

In a world where everything is billable (and nothing is under warranty), and when part of the system is found to be broken, the answer has often been to add another layer of complexity rather than to remedy the underlying flaw.

We've turned somersaults not to do what almost every other developed country has done: restrain charges by setting prices or by large-scale national negotiations. We hope that by structuring incentives for providers and patients—with PPOs, HMOs, HSAs, FSAs, coinsurance, copayments, pre-authorization, drug tiering, PBMs and more—the market will respond.

And it does, but often not with cheaper, simpler health care.

"Innovation" in our profit-oriented system is not just about developing lifesaving treatments, but also about inventing new ways to bill and new charges that don't exist elsewhere.

Consider this analysis from a report urging patients to consider changing Medicare drug plans to save money:

"The millions of patients with CVS Health's popular SilverScript drug plan will see a $2 decrease in their average monthly premium, from $31 in 2019 to $29 in 2020 …" That's good, right? Here's the catch: The plan will go from no deductible, in most areas in 2019, to a deductible of $215 to $435 in 2020.

So patients who feel like they're getting a good deal when they hear their premiums are going down will actually pay more.

Americans trying to be smart shoppers are understandably confused about navigating the open enrollment season, as they are doing currently. And just when they have figured it out for one year, they have to do it all over again. The odds of success are small.

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