Long waits for mental health treatment are a nationwide problem, with reports of patients waiting an average of five or six weeks for care in community clinics, at Department of Veterans Affairs facilities and in private offices from Maryland to Los Angeles County.

This article was published on Monday, November 29, 2021 in Kaiser Health News.

By April Dembosky, KQED

When Greta Christina fell into a deep depression five years ago, she called up her therapist in San Francisco. She’d had a great connection with the provider when she needed therapy in the past. She was delighted to learn that he was now “in network” with her insurance company, meaning she wouldn’t have to pay out-of-pocket anymore to see him.

But her excitement was short-lived. Over time, Christina’s appointments with the therapist went from every two weeks, to every four weeks, to every five or six.

“To tell somebody with serious, chronic, disabling depression that they can only see their therapist every five or six weeks is like telling somebody with a broken leg that they can only see their physical therapist every five or six weeks,” she said. “It’s not enough. It’s not even close to enough.”

Then, this summer, Christina was diagnosed with breast cancer. Everything related to her cancer care — her mammogram, biopsy, surgery appointments — happened promptly (like a “well-oiled machine,” she said), while her depression care stumbled along.

“It is a hot mess,” she said. “I need to be in therapy — I have cancer! And still nothing has changed.”

A new law signed by Gov. Gavin Newsom in October aims to fix this problem for Californians. Senate Bill 221, which passed the state legislature with a nearly unanimous vote, requires health insurers across the state to reduce wait times for mental health care to no more than 10 business days. Six other states — including Colorado, Maryland and Texas — have similar laws limiting wait times.

Long waits for mental health treatment are a nationwide problem, with reports of patients waiting an average of five or six weeks for care in community clinics, at Department of Veterans Affairs facilities and in private offices from Maryland to Los Angeles County. Across California, half of residents surveyed by the California Health Care Foundation in late 2019 said they had to wait too long to see a mental health care provider when they needed one.

At Kaiser Permanente, the state’s largest insurance company, 87% of therapists said weekly appointments were not available to patients who needed them, according to a 2020 survey by the National Union of Healthcare Workers, which represents KP therapists — and was the main sponsor of the California wait times legislation.

“It just feels so unethical,” said triage therapist Brandi Plumley, referring to the typical two-month wait time she sees at Kaiser Permanente’s mental health clinic in Vallejo, east of San Francisco.

Every day, she takes multiple crisis calls from patients who have therapists assigned to them but can’t get in to see them, she said, describing the providers’ caseloads as “enormous.”

“It’s heartbreaking. And it eats on me day after day after day,” Plumley said. “What Kaiser simply needs to do is hire more clinicians.”

Kaiser Permanente says there just aren’t enough therapists out there to hire. KP is an integrated system — it is a health provider and insurance company under one umbrella — and has struggled to fill 300 job vacancies in clinical behavioral health, according to a statement from Yener Balan, the insurer’s Northern California vice president of behavioral health.

Hiring more clinicians won’t solve the problem, said Balan, who suggested that sustaining one-on-one therapy for all who want it in the future wouldn’t be possible in the current system: “We all must reimagine our approach to the existing national model of care.”

Kaiser Permanente lodged concerns about the wait times bill when it was introduced. And the trade group representing insurers in the state, the California Association of Health Plans, opposed it, saying the shortage of therapists would make meeting the two-week mandate too difficult.

“The COVID-19 pandemic has only exacerbated this workforce shortage, and demand for these services significantly increased,” said Jedd Hampton, a lobbyist for the California Association of Health Plans, in testimony during a state Senate hearing for the bill in the spring.

Hampton referred to a University of California-San Francisco study that predicted California would have nearly 30% fewer therapists than needed to meet demand by 2028.

“Simply put, mandating increased frequency of appointments without addressing the underlying workforce shortage will not lead to increased quality of care,” Hampton said.

Lawmakers pushed back. State Sen. Scott Wiener (D-San Francisco), who authored the bill, accused insurers of overstating the shortage. State Sen. Connie Leyva (D-Chino) said that the therapeutic providers are out there but that insurers are responsible for recruiting them into their networks by paying higher rates and reducing administrative burdens.

If insurers want more young people to enter the mental health care profession, they must improve salaries and working conditions now, said state Sen. Richard Pan (D-Sacramento). (A 2016 KQED investigation uncovered multiple ways that insurers save money by keeping provider networks artificially small.)

As bipartisan support for the bill grew in Sacramento, insurers withdrew their formal opposition.

But whether other states have the political will, or the resources, to legislate a similar solution is unclear, said Hemi Tewarson, executive director of the nonpartisan National Academy for State Health Policy in Washington, D.C. Although California may be able to force insurers to hire more therapists, she said, places like New Mexico, Montana, Wyoming, and parts of the South don’t have enough therapists at any price.

“They don’t have the providers, so you could fine the insurers as much as you want, you’re not going to be able to, in the short term, make up those wait times if they already exist,” she said.

The new California law is a solid step toward improving access to mental health care, with communities of color standing to benefit the most, said Lonnie Snowden, a professor of health policy and management at the University of California-Berkeley. African Americans, Asian Americans and Latinos face the most barriers getting into care, Snowden said, and when people of color do come in for treatment, they are more likely to drop out.

Oversight and enforcement are needed for the new rules to work, said Keith Humphreys, a psychiatry professor at Stanford University. Kaiser Permanente has data systems that can track the time between appointments, but other insurers set up contracts with therapists in private practice, who manage their own caseloads and schedules.

“Who would keep track of whether people who’ve been seen once were seen again in 10 days, when it’s hard enough just to keep track of how many providers we have and who they are seeing?” he asked.

Questions like that one will fall to state regulators, primarily the California Department of Managed Health Care. The department has fined insurers $6.9 million since 2013 for violating state standards, including a $4 million penalty against Kaiser Permanente for excessive wait times for mental health care. Previous state law required insurers to provide initial mental health care appointments within 10 days, and the new law clarifies that they must do the same for follow-up appointments.

Greta Christina, who gets her care at a Kaiser Permanente facility, said she is desperate for the new law to start working. It takes effect on July 1, 2022. Christina thought about paying out-of-pocket in the meantime, to find a therapist she could see more often. But in a cancer crisis, she said, starting over with someone new would be too hard. So she’s waiting.

“Knowing that this bill is on the horizon has been helping me hang on,” she said.

This story is part of a partnership that includes  KQED, NPR and KHN.

Sen. Rick Scott (R-Fla.) issued a press release Nov. 16 suggesting that rising general inflation was behind the large increase in next year’s standard premiums for Medicare Part B.

This article was published on Wednesday, November 24, 2021 in Kaiser Health News.

By Phil Galewitz

An increase in Medicare Part B premiums means “America’s Seniors Are Paying the Price for Biden’s Inflation Crisis.” — The headline of a press release from Sen. Rick Scott (R-Fla.)

Republicans blame President Joe Biden for this year’s historic surge in inflation, reflected in higher prices for almost everything — from cars and gas to food and housing. They see last month’s 6.2% annual inflation rate — the highest in decades and mostly driven by an increase in consumer spending and supply issues related to the covid-19 pandemic — as a ticket to taking back control of Congress in next year’s midterm elections.

A key voting bloc will be older Americans, and the GOP aims to illustrate how much worse life has grown for them under the Biden administration.

Sen. Rick Scott (R-Fla.) issued a press release Nov. 16 suggesting that rising general inflation was behind the large increase in next year’s standard premiums for Medicare Part B, which covers physician and some drug costs and other outpatient services.

“Sen. Rick Scott: America’s Seniors Are Paying the Price for Biden’s Inflation Crisis” was the headline. The senator’s statement within that press release said, “We need to be LOWERING health care and drug prices and strengthening this vital program for seniors and future generations, not crippling the system and leaving families to pay the cost.” The press release from Scott says he is “slamming Biden’s inaction to address the inflation crisis he and Washington Democrats have created with reckless spending and socialist policies, which is expected to cause significant price increases on [senior] citizens and Medicare recipients.” Scott’s statement in that same press release also says the administration’s “reckless spending” will leave U.S. seniors “paying HUNDREDS more for the care they need.”

We wondered whether these points were true. Was the climbing annual inflation rate over the past several months to blame for the increase in Medicare Part B premiums?

We reached out to Scott’s office for more detail but received no reply. Upon further investigation, we found there is little, if any, connection between general inflation in the past few months and the increase in Medicare Part B premiums.

What’s the Status of Medicare Premiums?

Medicare Part B premiums have been growing steadily for decades to keep up with rising health spending.

The U.S. inflation rate, for years held at bay, has been above 4% since April, hitting 6.2% in October, the highest rate in decades.

On Nov. 12, the Centers for Medicare & Medicaid Services announced that the standard monthly premium for Medicare Part B would rise to $170.10 in 2022, from $148.50 this year. The 14.5% increase is the largest one-year increase in the program’s history.

Scott’s press release refers to the CMS report.

CMS cited three main factors for the increase: rising health care costs, a move by Congress last year that held the premium increase to just $3 a month because of the pandemic, and the need to raise money for a possible unprecedented surge in drug costs. Inflation was not on that list.

In fact, half of the premium increase was due to making sure the program was ready in case Medicare next year decides to start covering Aduhelm, a new Alzheimer’s drug priced at $56,000 per year, per patient. It’s been estimated that total Medicare spending for the drug for one year alone would be nearly $29 billion, far more than any other drug.

How Big a Hit Will Seniors Feel?

The Part B premium is typically subtracted automatically from enrollees’ Social Security checks. Because Social Security recipients will receive a 5.9% cost-of-living increase next year — about $91 monthly for the average beneficiary — they’ll still see a net gain, though a chunk will be eaten away by the hike in Medicare premiums.

About 70% of Medicare beneficiaries won’t face a 14.5% increase, anyway, because a “hold-harmless” provision in federal law protects them from premium increases that exceed Social Security’s cost-of-living increase, said Gretchen Jacobson, a vice president of the nonpartisan Commonwealth Fund. So their increase will be limited to 5.9%.

Those not covered by the hold-harmless provision are mainly high-income beneficiaries (people with incomes over $91,000 for individuals), those newly enrolled in Medicare Part B, people who receive both Medicaid and Medicare, and enrollees not receiving Social Security because they are still working.

What Role Does Inflation Play?

Several Medicare experts said the spike in the general inflation rate has little or nothing to do with the Medicare premium increase. In fact, Medicare is largely immune from inflation, because the program sets prices for hospitals and doctors.

“This is so false that it is annoying,” Paul Ginsburg, a professor of health policy at the Sol Price School of Public Policy at the University of Southern California, said of Scott’s claim that general inflation is behind the premium increase. “The effect of the inflation spike so far on prices is zero because Medicare controls prices.”

Medicare Part B premiums, he said, reflect changes in the amount of health services delivered and a more expensive mix of drugs. “Premiums are tracking spending, only a portion of which reflects prices,” Ginsburg said. “I can’t see that the administration really had any discretion” in setting the premium increase due to the need to build a reserve to pay for the Alzheimer’s drug and make up for the reduced increase last year, he said.

Stephen Zuckerman, co-director of the Urban Institute’s health policy center, said a rise in wages caused by inflation could spur a small boost in Medicare spending because wages help determine how much the program pays providers. But, he said, such an increase would have to occur for more than a few months to affect premiums. Continued soaring inflation could influence 2023 Medicare premiums, not those for 2022. “The claim that premium increases are due to inflation in the last couple of months doesn’t make sense,” Zuckerman said.

CMS faced the challenge of trying to estimate costs for an expensive drug not yet covered by Medicare. “It is a very difficult projection to make, and they want to have enough contingency reserved,” said Jacobson, of the Commonwealth Fund.

Still, the 5.9% jump that will hit most enrollees is a relatively large premium increase, she added. Those beneficiaries will see an $8.76 monthly increase in premiums, or about $105 more for all of 2022.

Our Ruling

Scott said in a press release about the 2022 increase in Medicare Part B premiums that “America’s seniors are paying the price for Biden’s inflation crisis.”

Though his statement contains a sliver of truth, Scott’s assertion ignores critical facts that create a different impression.

For instance, Medicare policy experts said, current general inflation has little, if anything, to do with the increase in premiums. CMS said the increase was needed to put away money in case Medicare starts paying for an Alzheimer’s drug that could add tens of billions in costs in one year and to make up for congressional action last year that held down premiums.

And most seniors will not pay hundreds of dollars more for premiums because of the hold-harmless provision. About 30% of Medicare enrollees — those with high incomes and those who do not receive Social Security — will have to pay the full $21.60 a month, or about $259 for 2022, a 14.5% increase. People in this category either have higher incomes or are not yet receiving Social Security because they are still working.

The other 70% of enrollees will face a 5.9%, or $8.76 a month, increase. This means most Medicare enrollees will see a $105 increase in premiums for all of 2022, not hundreds of dollars.

We rate the claim Mostly False.

SOURCES:

Telephone interview with Stephen Zuckerman, co-director of the Health Policy Center at the Urban Institute, Nov. 19, 2021.

Telephone interview with Paul Ginsburg, professor of health policy at the Sol Price School of Public Policy at the University of Southern California, Nov. 18, 2021.

Telephone interview with Gretchen Jacobson, vice president of the Medicare program at the Commonwealth Fund, Nov. 18, 2021.

Telephone interview with Joe Antos, senior fellow with American Enterprise Institute, Nov. 18, 2021.

Sen. Rick Scott’s press release, Nov. 16, 2021.

Statista, monthly inflation rates, accessed Nov. 19, 2021.

Centers for Medicare & Medicaid Services press release about Medicare Part B premiums, accessed Nov. 19, 2021.

Medicareresources.org’s fact sheet about the Medicare hold-harmless provision, accessed Nov. 19, 2021.

Medicareresources.org fact sheet about high earners not subject to the hold-harmless provision, accessed Nov. 19, 2021.

Social Security blog about the hold-harmless provision, accessed Nov. 19, 2021.

AARP blog about the biggest-ever increase in Medicare Part B premiums, accessed Nov. 18, 2021.

Medicare Trustees Report, 2021 (see page 90 for Medicare Part B premiums by year since program inception).

KFF brief on the impact Aduhelm could have on Medicare costs, accessed Nov. 18, 2021.

CMS’ “2022 Medicare Parts A & B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts” report, accessed Nov. 12, 2021.

Doctor groups and medical associations have lashed out at the interim final rules that HHS unveiled last month, saying they favor insurance companies in the arbitration phase.

This article was published on Tuesday, November 23, 2021 in Kaiser Health News.

By Michael McAuliff

Overpriced doctors and other medical providers who can’t charge a reasonable rate for their services could be put out of business when new rules against surprise medical bills take effect in January, and that’s a good thing, Health and Human Services Secretary Xavier Becerra told KHN, in defending the regulations.

The proposed rules represent the Biden administration’s plan to carry out the No Surprises Act, which Congress passed to spare patients from the shockingly high bills they get when one or more of their providers unexpectedly turn out to be outside their insurance plan’s network.

The law shields patients from those bills, requiring providers and insurers to work out how much the physicians or hospitals should be paid, first through negotiation and then, if they can’t agree, arbitration. Doctor groups and medical associations, however, have lashed out at the interim final rules that HHS unveiled last month, saying they favor insurance companies in the arbitration phase. That’s because, although the rules tell arbiters to take many factors into account, they are instructed to start with a benchmark largely determined by insurers: the median rate negotiated for similar services among in-network providers.

The doctor groups say giving the insurers the upper hand will let them drive payment rates down and potentially force doctors out of networks or even out of business, reducing access to health care.

The department has heard those concerns, Becerra said, but the bottom line is protecting patients. Medical providers who have taken advantage of a complicated system to charge exorbitant rates will have to bear their share of the cost, or close if they can’t, he said.

“I don’t think when someone is overcharging, that it’s going to hurt the overcharger to now have to [accept] a fair price,” Becerra said. “Those who are overcharging either have to tighten their belt and do it better, or they don’t last in the business.”

“It’s not fair to say that we have to let someone gouge us in order for them to be in business,” he added.

Nonetheless, Becerra said he did not foresee a wave of closures, or diminished access for consumers. Instead, he suggested that a competitive, market-driven process will find a balance, especially when consumers know better what they are paying for.

“We’re willing to pay a fair price,” he said. But he emphasized that “I’ll pay for the best, but I don’t want to have to pay for the best and then three times more on top of that and get blindsided by the bill.”

Becerra also pointed to a report on surprise medical bills that HHS released Monday and that was provided to KHN in advance, highlighting the impacts of negotiation and arbitration laws already in effect in 18 states.

The report, which aggregates previous research, found people getting hit with surprise bills averaging $1,219 for anesthesiologists, $2,633 for surgical assistants, $744 for childbirth and north of $24,000 for air ambulances.

In the states that use benchmarks similar to what doctors are suggesting HHS use, such as New York and New Jersey, the report found costs rising. New York has a “baseball-style” system in which the arbiter chooses between the offers presented by the provider and the insurer, although the arbiter is told to consider the offer closest to the 80th percentile of charges. “Since the amount providers charge is typically much higher than the actual negotiated rate, this approach risks leading to significantly higher overall costs,” the report found. In New Jersey, billed charges or “usual and customary” rates are considered.

“When the arbitration process is wide open, no boundaries, at the end of the day health care costs go up, not down,” Becerra said of the methods doctors prefer. “We want costs to go down. And so we want to set up a system that helps provide the guideposts to keep us efficient, transparent and cost-effective.”

The system chosen by the Biden administration was expected to push insurance premiums down by 0.5% to 1%, the Congressional Budget Office estimated.

“Everyone has to give a little to get to a good place,” Becerra said. “That sweet spot, I hope, is one where patients … are extracted from that food fight. And if there continues to be a food fight, the arbitration process will help settle it in a way that is efficient, but it also will lead to lower costs.”

While the administration chose a benchmark that physician and hospital groups don’t like, the law does specify that other factors should be considered, such as a provider’s experience, the market and the complexity of a case. Becerra said those factors help ensure arbitration is fair.

“What we simply did was set up a rule that says, ‘Show the evidence,’” Becerra said. “It has to be relevant, material evidence. And let the best person win in that fight in arbitration.”

The interim final rules were published Oct. 7, giving stakeholders 60 days to comment and seek changes. More than 150 members of Congress, many of them doctors, have asked HHS and other relevant federal agencies to reconsider before the law takes effect Jan. 1. The lawmakers charge that the administration is not adhering to the spirit of the compromises Congress made in passing the law.

Rules that are this far along tend to go into effect with little or no changes, but Becerra said his department was still listening. “If we think there’s a need to make any changes, we are prepared to do so,” the secretary said.

The HHS report also noted that the law requires extensive monthly and annual reporting to regulators and Congress to determine if the regulations are out of whack or have undesirable consequences like those the physicians are warning of.

Becerra said he thinks the rules strike the right balance, favoring not insurers or doctors, but the people who need medical care.

“We want it to be transparent, so we can lead to more competition, and keep costs low — not just for the payer, the insurer, not just for the provider, the hospital or doctor, but for the patients especially,” he said.

On the whole, Washington has been especially cautious when it comes to covid, which has helped the city avoid the worst of the pandemic.

This article was published on Monday, November 22, 2021 in Kaiser Health News.

By Amanda Michelle Gomez

A mile northeast of Capitol Hill in Washington, D.C., along what’s known as the H Street corridor, about half the people crowding the sidewalks are wearing masks. Perhaps it’s because they know that when they step into any business or establishment here, they will have to put one on anyway. The capital, after all, is one of the few remaining cities or states nationwide that mandate masks for public indoor spaces — at least it has, until today.

“We have a bunch of rule followers,” said Claire Bengur, the owner of Atlas Salon, which has been in the neighborhood since 2018. “I am so thankful that my salon is in D.C.” She’s been glad to have a mask requirement, she said, because it’s impossible to do clients’ hair without standing close to them.

Bengur is unsure how to feel about Mayor Muriel Bowser’s decision to roll back the mandate. As the covid-19 pandemic has worn on, many Washingtonians have come to view masking as something between a habit and a security blanket. Even when the rule was lifted for about two months starting in May, many people continued to use masks in places like grocery stores. While face coverings will still be required in select spaces, such as public transit and schools, the District of Columbia will no longer require them in private businesses like Atlas Salon. And that has triggered mixed feelings.

Bengur had been debating whether to continue to ask clients to wear masks because the district gives businesses that option. But at the same time, “there is a certain level of excitement … like I don’t want to wear masks forever.” She ultimately decided to let clients choose for themselves. Bengur and her staff feel more at ease than they did earlier in the pandemic because her salon requires proof of vaccination.

A block away at the H Street Northeast location of Solidcore, a boutique fitness chain that started in the district, CEO Bryan Myers had an it’s-about-time take. “This will be game-changing for our clients’ comfort while working out and the health of our industry,” he said.

On the whole, Washington has been especially cautious when it comes to covid, which has helped the city avoid the worst of the pandemic. Now, the mayor is moving away from ordering protective measures and instead offering recommendations based on vaccination status.

This change can partly be explained by adjustments in the district health department’s goal, which no longer is to reach zero cases. Viewing covid as more of an “endemic” disease — one regularly found in particular populations — Bowser explained her decision this way: “This does not mean that everyone needs to stop wearing their masks. But it does mean that we are shifting the government’s response to providing you risk-based information.” While she’s reserved the right to reinstate the mandate, Bowser has doubled down on her decision. “Quite frankly, I don’t expect many D.C. residents will change their current behavior,” she said Friday during an interview on a local radio show.

The shift has some residents feeling perplexed, if not nervous, especially given the timing.

Children ages 5 to 11 just became eligible for vaccination, so they are not fully immunized yet, and infections are likely to climb with the holidays coming. Cases have already increased in half the states. That neighboring Montgomery County reinstated its mask mandate over the weekend leaves some people all the more baffled. A majority of district council members are already pushing the mayor to reconsider. Meanwhile, the White House, just steps from the mayor’s office, is not lifting its mask requirement, noting that the Centers for Disease Control and Prevention recommends one given the substantial level of community transmission.

“I’m a little bit iffy about the whole thing,” said Sandra Basanti, co-owner of Pie Shop, which offers fresh pies and live music on H Street.

Basanti has two young children who are not yet fully vaccinated. She’s unsure whether she’ll require customers to wear masks but expects to — at least at first. She’s hesitant because staffers received pushback when Pie Shop became one of the first venues in town to impose a vaccine requirement. She would like to see Washington follow New York City’s example and require proof of vaccination to enter public spaces such as shopping centers, sports arenas and theaters.

“We were just kind of waiting for the city to make that call for us so that we wouldn’t have to fight people on it, and they never did,” said Basanti. “I just don’t want to make the staff feel like they now also have to be the mask police again.”

“Being the mask police sucks,” she added.

The owner of the dive bar across the street agrees. “I’m very exhausted with arguing with people about masks and all the different things,” said Tony Tomelden of the Pug, which will not require patrons to wear masks but will insist that they be vaccinated. “Once a week, at least, there’s some kind of argument with some customer.”

Tomelden worries that talk of endemic covid means leaders are moving on without addressing all the pandemic-induced needs of small businesses beyond masking. “I’m so tired of begging for a break on bills and for grants and that kind of thing, but we’re still not fully recovered,” he said.

Like residents, public health experts are not in agreement on whether the district is acting prematurely.

“It makes sense,” Dr. Lynn Goldman, dean of the Milken Institute School of Public Health at George Washington University, said of the mayor’s decision. She reasoned that, thanks to vaccination, the district has few covid hospitalizations and deaths. “At the same time … we don’t really know how it’s going to go.”

Meanwhile, Dr. David Dowdy, an associate professor of epidemiology at Johns Hopkins Bloomberg School of Public Health, said he generally recommends against easing restrictions at a time like this. “My expectation is that we’re likely to see something of an increase in cases over the winter,” he said, “and then this probably is going to become after that point in time something of an endemic disease.”

“We’ve come this far. It probably is not too difficult to keep our guard up for a couple more months,” he added. “But the flip side of that is we’ve been doing this for a really long time and people are very tired.”

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, sees Washington’s experience as emblematic of what can happen when leaders do not clearly explain their response to covid or why mask mandates are imposed or withdrawn.

Part of the challenge, Osterholm said, is that the explanations are unsatisfying. “We do not understand why surges start or stop,” he said. “Why they start and stop surely can’t be tied to human mitigation strategies. What can be tied to those is how big those surges get.”