Category Archives: Healthcare Reform

As HMOs dominate, alternatives become more expensive


Twenty-dollar bill in a pill bottleBy Julie Appleby and Jordan Rau

Consumers seeking health policies with the most freedom in choosing doctors and hospitals are finding far fewer of those plans offered on the insurance marketplaces next year. And the premiums are rising faster than for other types of coverage.

The plans, usually known as preferred provider organizations or PPOs, pay for a portion of the costs of out-of-network hospitals and physicians.

They are the most common type offered by employers, and some consumers in the individual marketplaces find them more appealing than health maintenance organizations and other policies that pay only for medical facilities and doctors with whom they have contracts.

“Out of network providers were causing carriers to lose a lot of money, and they really needed to put their thumbs down on that.”

In Kelly Filson’s Indiana hometown of Plymouth, all but two of the 75 insurance policies available on the health marketplace are the restrictive type.

Only one of those would provide substantial coverage to the two hospitals her family wants access to next year, a local community facility and a children’s hospital where her 12-year-old will need special surgery.

But at $1,109 a month, the policy is twice as costly as the cheapest plans in the area. Continue reading


End of Medicare bonus will cut primary care doc pay


Doctor at deskBy Michelle Andrews

Many primary care practitioners will be a little poorer next year because of the expiration of a health law program that has been paying them a 10 percent bonus for caring for Medicare patients.

Some say the loss may trickle down to the patients, who could have a harder time finding a doctor or have to wait longer for appointments.

But others say the program has had little impact on their practices, if they were aware of it at all.

The incentive program began in 2011 and was designed to address disparities in Medicare reimbursements between primary care physicians and specialists.

It distributed $664 million in bonuses in 2012, the most recent year that figures are available, to roughly 170,000 primary care practitioners, awarding each an average of $3,938, according to a 2014 report by the Medicare Payment Advisory Commission.

Although that may sound like a small adjustment, it can be important to a primary care practice, says Dr. Wanda Filer, president of the American Academy of Family Physicians.

“It’s not so much about the salary as it’s about the practice expense,” she explains. “Family medicine runs on very small margins, and sometimes on negative margins if they’re paying for electronic health records, for example. Every few thousand makes a difference.

Doctors who specialize in family medicine, internal medicine and geriatrics are eligible for the bonuses, as are nurse practitioners and physician assistants. Continue reading


Medicaid denies nearly half of requests for hepatitis C drug

Hepatitis C virus

Hepatitis C virus

By Michelle Andrews

People with hepatitis C who sought prescriptions for highly effective but pricey new drugs were significantly more likely to get turned down if they had Medicaid coverage than if they were insured by Medicare or private commercial policies, a recent study found.

Researchers at the University of Pennsylvania Perelman School of Medicine analyzed the hepatitis C prescriptions from 2,342 patients in Maryland, Delaware, Pennsylvania and New Jersey that were submitted between November 2014 and April 2015 to a large specialty pharmacy that serves the region.

The drugs included Sovaldi, Harvoni and Viekira Pak, and others that are part of the treatment regimen. A 12-week course of treatment for one patient can reach more than $90,000. Continue reading


Cancer meds can have high out-of-pocket costs for patients, report


Twenty-dollar bill in a pill bottleBy Julie Appleby

Cancer patients shopping on federal and state insurance marketplaces often find it difficult to determine whether their drugs are covered and how much they will pay for them, the advocacy arm of the American Cancer Society says in a report that also calls on regulators to restrict how much insurers can charge patients for medications.

While the report found fairly broad coverage for prescription cancer medications, most insurance plans in the six states that were examined placed all or nearly all of the 22 medications studied into payment “tiers” that require the biggest out-of-pocket costs by patients, the American Cancer Society Cancer Action Network said. Continue reading


Health plan buyers will save if they shop around


Photo by Sanja Gjenero

By Phil Galewitz

You better shop around.

For holiday gifts?

No, for a 2016 health insurance plan on the federal marketplace,

Millions of consumers who are enrolled this year could pay higher rates if they stay in the same health plan next year, according to a study released Wednesday by the Kaiser Family Foundation.

The KFF analysis found that in nearly three-quarters of counties in 36 states served by, the lowest-priced silver plan this year will not be the lowest priced next year.

People in those plans could save money on premiums by switching to a different silver plan in 2016. (KHN is an editorially independent program of the foundation.) Continue reading


New health plans offer discounts for diabetes care


Glucometer showing a blood sugar of 105By Michelle Andrews

Talk about targeted. Consumers scrolling through the health plan options on the insurance marketplaces in a few states this fall may come upon plans whose name — Leap Diabetes Plans — leaves no doubt about who should apply.

Offered by Aetna in four regions next year, the gold-level plans are tailored for the needs of people with diabetes.

They feature:

  • $10 copays for the specialists diabetics need such as endocrinologists, ophthalmologists and podiatrists, and offer
  • free blood sugar test strips, glucose monitors and other diabetic supplies, and
  • A care management program with online tools and coaching helps people manage their condition day-to-day.

The plans also offer:

  • Financial incentives, including a $50 gift card for getting an A1c blood test twice a year to measure blood sugar levels and
  • a $25 card for hooking up a glucometer or biometric tracker to the Aetna site.

“It was a good time to design a product that was a little more personalized, as opposed to generic,” says Jeff Brown, vice president of consumer product, network and distribution at Aetna. “We saw diabetes as a compelling need, and a growing need.”

It’s unclear whether the diabetes plans are a good buy for people with diabetes.

Aetna is debuting the diabetes plans next year in four markets: Charlotte, N.C., Phoenix, Ariz., Northern Virginia and southeastern Pennsylvania.

It’s unclear whether the diabetes plans are a good buy for people with diabetes. The cut rates for specialist visits only apply if they’re related to diabetes care, not for other conditions someone may have.

Meanwhile, coverage for medications, which may cost consumers hundreds of dollars every month, is no different in the diabetes plans than in other gold plans. Continue reading


Obamacare recruiters seek uninsured at food fairs and churches


By Phil Galewitz
FORT LAUDERDALE, Fla. — For the past week, Henry Bowles has stood along a busy road here six hours a day holding a sign that reads “Obamacare Help Center- Free Enrollment” and points to a nearby insurance agency.

With sunny skies and temperatures in the high 80s, Bowles uses a towel to grip the wooden stick bearing the sign so his sweaty hand won’t slip. He is paid about $8 an hour.

Harriet Cohen, 63, gets help enrolling in a health plan for under $7 a month at the Greenacres, Fla., library from navigator Abdius Pierre Cohen who lives in Boynton Beach, Fla. (Photo by Phil Galewitz/KHN)

Harriet Cohen, 63, gets help enrolling in a health plan for under $7 a month at the Greenacres, Fla., library from navigator Abdius Pierre Cohen who lives in Boynton Beach, Fla. (Photo by Phil Galewitz/KHN)

Bowles, 45, is uninsured.

Money is not the reason as he tells it, although he discloses he didn’t file his taxes last year because his income wasn’t high enough.

He’s also aware there’s financial assistance for low-income people like him.

And he knows about the federal requirement to have coverage.

Will he sign up this year before open enrollment ends Jan. 31?

“I’m thinking about it,” Bowles said one afternoon this month. Continue reading


Musicians in a city that thrives on music struggle to buy insurance

Kalu James moved to Austin, Texas, eight years ago, but bought health insurance for the first time this year. Twenty percent of the city's musicians live below the federal poverty line.(Photo by Veronica Zaragovia/KUT)

Kalu James moved to Austin, Texas, eight years ago, but bought health insurance for the first time this year. Twenty percent of the city’s musicians live below the federal poverty line.(Photo by Veronica Zaragovia/KUT)

By Veronica Zaragovia, KUT News

It looks like Kalu James is living the life as a musician. He’s standing under a neon sign, ready to play guitar at Austin’s famous Continental Club. And when he’s not here, he’s hustling to pay his bills.

“Being a full-time musician means you have three other side jobs, you know?” he says.

James moved to Austin about eight years ago and got health insurance for the first time this year. He pays $22 a month, after the $200 subsidy he gets through the Affordable Care Act. Even that is a lot, because he earns only $15,000 a year. He gets help paying his monthly premium through a local nonprofit.

“We still have to worry about counting the quarters and the pennies when we leave these venues,” he says. Health insurance doesn’t come easily.
Continue reading


Humana to offer telehealth coverage through some Medicare Advantage plans


humana new logoThe health insurance company Humana will begin covering telehealth consultations through some of its 2016 Medicare Advantage plans in Washington state.

The telehealth benefit, which will will be provided in partnership with the telehealth company MDLIVE, will be offered through the Humana Community HMO plans available in the King and Spokane counties and the Humana Gold Plus plans available in Benton, Franklin and Pierce counties.

Service will provide members of those plans 24/7 access to doctors through personal computers, telephone or mobile devices for less severe medical issues, such as cold and flu, headaches and skin infections.

“Video and telephone visits allow our members to receive health care when and where they need it,” said Catherine Field, Intermountain Vice President for Humana’s Senior Products.

People with Medicare may select these plans during the annual Medicare enrollment period, which runs Oct. 15 through Dec. 7, 2015. Those selecting a plan with this option will be able to start using the benefit Jan. 1, 2016.

Washington state Medicare beneficiaries living in King, Spokane, Benton, Franklin and Pierce counties who are interested in utilizing MDLIVE should visit<> to search these plans and learn more about this and other plan benefits.


When things go wrong at the hospital, who pays?


Physician and Nurse Pushing Gurney

By Shefali Luthra
KHN/Washington Post

When Charles Thompson checked into the hospital one July morning in 2011, he expected a standard colonoscopy.

He never anticipated how wrong things would go.

Partway through, the doctor emerged and said there were complications, remembered Ann, Charles’ wife. Charles’ colon may have been punctured. He needed emergency surgery to repair it.

Charles, now 61, from Greenville, S.C., almost died on the operating table after experiencing cardiac distress. His right coronary artery required multiple stents. He also relies on a pacemaker.

If treatment makes things worse – meaning patients need more care – who pays? The answer, it seems, is that it depends.

“He’s not the same as before,” said Ann, 62. “Our whole lifestyle changed – now all we do is sit at home and go to church. And that’s because he’s scared of dying.”

When things like this happen in the hospital, questions arise: Who’s responsible? If treatment makes things worse – meaning patients need more care – who pays?

The answer, it seems, is that it depends. Continue reading


Attention small businesses . . .


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Complete your SHOP Marketplace application today

Complete your SHOP Marketplace application by November 15 for coverage starting December 1.

If you submit your initial group enrollment by November 15 and make your initial payment, your coverage can be in place as early as December 1.

Remember: All SHOP Marketplace applications submitted between November 15-December 15 each year are not required to meet participation requirements.

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Need Assistance?: Call the SHOP Call Center at 1-800-706-7893 (TTY:711) Monday through Friday from 9am to 7pm ET or visit For in-person assistance, find a SHOP-registered agent or broker in your area.

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Shop around to get the best exchange health plan for you


Coverage is hereTo get the best health exchange plan for you, it’s important to shop around. Doing so will help make sure you pick a plan that meets your needs — and may save you money. That’s because lower premiums can also mean a lower subsidy — and higher out-of-pocket costs.

From the Washington Health Benefit Exchange

The Washington Health Benefit Exchange, which operates the state’s insurance marketplace, Washington Healthplanfinder, is urging renewing Qualified Health Plan customers to carefully review their 2016 eligibility for tax credits that are used to reduce the monthly premium cost for health insurance coverage.

The federally provided tax credit is designed to help offset the cost of health insurance premiums and is only available through the Exchange.

Those with household income under 400 percent of the federal poverty level – $97,000 for a family of four – qualify for assistance based on a sliding scale.

The price of the second lowest cost silver or “benchmark” plan offered through Washington Healthplanfinder is used to calculate the tax credit.

Last year customers received on average a monthly tax credit of more than $207.

“Premium prices change every year, including the second lowest cost silver plan. This means that the tax credits that are available will change as well,” said Pam MacEwan, CEO of the Exchange. “It is important that customers consider these changes when shopping for coverage to ensure that they are leveraging their tax credit to find the health plan that best fits their needs and budget.”

Because health plan rates for the second lowest cost silver plans are declining in most Washington counties, the tax credit for 2016 could actually decrease for many enrollees who are renewing their coverage in 2016. Continue reading


Health systems dipping into the business of selling insurance


H for hospitalBy Michelle Andrews

In addition to treating what ails you, a number of health care systems aim to sell you a health insurance plan to pay for it. With some of the most competitively priced policies on the marketplaces, “provider-led” plans can be popular with consumers. But analysts say it remains to be seen how many will succeed long term as insurers.

Doing so funnels more patients to a health system’s hospitals and doctors.

It’s not surprising that health systems might get into the insurance business. Doing so funnels more patients to a health system’s hospitals and doctors. And it makes sense that combining clinical and claims data under one roof could lead to better coordinated, more cost-efficient patient care. Continue reading


‘Do the math’ when shopping for a health plan


CalculatorBy Julie Appleby

With the health insurance markets open for next year’s enrollment, Eve Campeau says she’s planning to look carefully at the fine print.

Last time she shopped, she switched to a plan with a lower monthly premium, but found herself paying far more out-of-pocket for medications and doctor visits.

While she might be saving money on the premium, she is reluctant to go to seek medical care because of the up-front cost.

“It just becomes this whole guessing game: What is the least hit to the pocketbook?” said Campeau, 49, of Bedminster, New Jersey.

And it’s not easy to calculate. Nonetheless, experts say consumers who buy their own insurance under the federal health law should shop around, even if they’re already in a plan they like. They should spend the time doing the math to ensure their plan suits their situation.

Even then, estimating total costs will be a best guess.

That’s because, aside from set monthly premiums, other costs during the year will vary depending on an individual’s medical use.

Consumers who hardly ever see a doctor and don’t take any drugs, for example, could expect to have few other costs – unless they have an unforeseen health issue, like breaking a leg. Other consumers who know they take specific medications monthly or see certain specialists at regular intervals, should factor those costs into their calculations when selecting a health plan. Continue reading