tacuin women

Women’s Health – Week 13: Dental Health

From the Office of Research on Women

It is important to take care of your teeth at any age. When your mouth is healthy, you can eat the foods you need for good nutrition and you feel better about smiling, talking, and laughing. You can take steps now to prevent common dental diseases and keep your teeth healthy for a lifetime.

tooth_v03Tooth decay

Our mouths are full of bacteria. A sticky film of bacteria called dental plaque builds up on our teeth every day. Over time, dental plaque can cause decay in the enamel, the tooth’s hard, outer coating. The holes caused by decay are called cavities. Brushing and flossing your teeth can protect you from decay.

Once a cavity develops, a dentist has to fill it before it causes more serious problems. You can also help protect your teeth from decay by drinking water that contains fluorideand by using a fluoride toothpaste.

Diagram showing three different teeth: a normal tooth, a tooth showing signs of Gingivitis and a tooth displaying the traits of Periodontal disease.

Gum disease

Gum disease begins when dental plaque builds up along and under the gum line. Plaque causes infections that hurt the gums and bones supporting the teeth.

Plaque that is not removed can harden and form tartar that can only be removed by a dentist or dental hygienist.

Gum diseases can range from simple gum inflammation to serious disease. The two forms of gum disease are gingivitis and periodontitis.


In gingivitis, the gums become red, swollen, and can bleed easily. You can usually reverse gingivitis with daily brushing and flossing, and regular cleaning by a dentist or dental hygienist.

This form of gum disease does not include any loss of bone and tissue that hold teeth in place.


When gingivitis is not treated, it can advance to periodontitis, which means inflammation around the tooth. In periodontitis, gums pull away from the teeth and the body’s immune system fights the bacteria as the plaque spreads and grows below the gum line.

Bacterial toxins and the body’s natural response to infection start to break down the bone and connective tissue that hold teeth in place. If you do not get treatment, the bones, gums, and connective tissue are destroyed. Your teeth may become loose and have to be removed.

Risk factors for gum disease include:

  • Hormones: Hormonal changes in girls/women can make gums more sensitive making it easier for gingivitis to develop.
  • Diabetes: People with diabetes are at a higher risk for developing infections, including gum disease.
  • Medications: Hundreds of prescription and over the counter medications can reduce the flow of saliva, which has a protective effect on teeth and gums. Without enough saliva, the mouth is vulnerable to infections such as gum disease.
  • Illnesses: Diseases like cancer or AIDS and their treatments can also negatively affect the health of gums.
  • Genetics: Some people are more likely to develop severe gum disease because of their genetic makeup.
NIH and You
Pregnancy and gum disease Hormonal changes during pregnancy can make it easier for women to develop gum disease. Research by the NIH’s National Institute of Dental and Craniofacial Research found that treating gum disease during pregnancy is safe. There were no more adverse pregnancy outcomes in women whose gum disease was treated, than in those who did not receive treatment.
A healthy mouth

  • Brush your teeth every day with a fluoride toothpaste.
  • Floss your teeth every day.
  • See your dentist regularly.
  • Limit sugary snacks.
  • Do not smoke.

For more information: www.nidcr.nih.gov


Think small, save big

myplate_blueThe size of our plate plays a large role in how much we eat.

Studies have shown that the bigger the container, the more we are likely to consume.

The bottom of the bowl is a useful mental cue for us to stop eating and check if we’re full.

Turns out smaller portions can be just as satisfying!

This week, enjoy your meals on a salad plate or in a small bowl.

If eating food out of a package, put it on a plate first.

This simple step can make all the difference in calories consumed!


About the Monday Campaigns:

The Healthy Monday Tips is produced by a national health promotion initiative called the Monday Campaigns.

The thinking behind the initiative derives from two studies done at the Center for a Liveable Future at Johns Hopkins Bloomberg School of Public Health by Jullian Fry and Roni Neff.

In one study, they reviewed the scientific studies that looked at ways to get people to adopt healthy habits.

In that review, they found that one of the most effective ways to keep people on track is simply to remind them from time to time to stick to it.

But when would be the best time send those reminders?

Fry and Neff decided to look at Monday, which many of us consider the start of our week.

To better understand how we thought and felt about Monday, they reviewed the scientific literature as well as cultural references to Monday in movies, songs, books and other forms of art and literature, even video games.

They noted that a number of scientific studies have found that we may suffer more health problems on Monday. For example, a number of studies find that Americans have more heart attacks and strokes on Monday.

There is also evidence that we have more on-the-job injuries on Monday, perhaps because we are not quite back into the swing of things, or are still recovering from our weekend.

Fry and Neff also found that while many of us, facing the return to work, may dread Mondays, Monday is also seen as a day for making a fresh start.

Fry and Neff concluded that Monday might be a good day for promoting healthy habits. Calling attention to the health problems linked to the first day of the work week, such as heart attacks and on-the-job injuries, makes Monday a natural day to highlight the importance of prevention.

And the Monday’s reputation as a day to make a fresh start offers the opportunity to help people to renew their efforts to adopt healthier habits.

Fry and Neff’s findings are put into practice by the Monday Campaigns, which helps individuals and organizations use Monday as a focus for their health promotion efforts, providing free research, literature and artwork, and other support.

To learn more about Healthy Mondays:

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Are international students eligible for health law’s subsidized coverage?

Question Q&ABy Michelle Anderes

Q. Since some noncitizens can receive premium tax credits to buy a health plan on the health insurance marketplace, does that mean that international students are also eligible for tax credits if their income is between 100 and 400 percent of the federal poverty level?

A. They may be. “Lawfully present” immigrants, including international students who are enrolled in a college or university in the United States and visiting scholars who are here teaching or conducting research, for example, may be eligible for subsidized coverage on the health insurance marketplaces.

In general, in order to qualify for subsidized marketplace coverage, international students’ income would have to be between 100 and 400 percent of the federal poverty level, as you noted ($11,490 to $45,960 for an individual in 2013).

If their income is less than 100 percent of the federal poverty level, however, they may also qualify for tax credits on the exchanges under a special rule for people who are lawfully present in the country but not otherwise able to qualify for Medicaid because of their immigration status.

In general, people who are here temporarily, such as students, can’t qualify for Medicaid, says Jenny Rejeske, a health policy analyst at the National Immigration Law Center.

There’s a further twist. In order to receive tax credits, international students must be state residents, and that can be problematic.

“We advise students to talk with an immigration lawyer to make sure that declaring residency won’t interfere with their visas,” says Rejeske.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.


How will health reform affect innovation and research? – CityClub event, Monday, Dec. 2nd

CityClub logo

Innovation & Research

2013 Health Care Series, “Health Care Reform in Puget Sound”

Research and innovation improve quality of healthcare, but also contribute to its expense.  Will the Affordable Care Act’s efforts to manage costs stifle innovation?  How can research organizations invest in developing new products that improve health and quality of life if these medications and devices are not adequately covered for consumers? How will patients be impacted? Join CityClub and a panel of experts as we learn how the Affordable Care Act will affect health care research in Puget Sound.

Panel Guests:

Dr. Jane Buckner,  Associate Director, Benaroya Research Institute
Dr. Scott Ramsey, Director, Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center
Jonathan Seib, Senior Vice President, Healthcare, Strategies 360


KING 5′s Jean Enersen  


Monday, December 2nd
Doors Open: 11:30 a.m.
Luncheon & Program: Noon – 1:30 p.m.


Washington Athletic Club | 1325 Sixth Avenue, Seattle, WA 98101

Luncheon Prices:

CityClub Members – $35 | Guests & Co-Promoters – $40 | General Public – $45
Coffee & Dessert Only Prices:
CityClub Members – $12 | Guests & Co-Promoters – $15 | General Public – $18


About the 2013 Health Care Series, “Health Care Reform in Puget Sound”

CityClub’s 2013 Health Care Series discusses preparing for the Affordable Care Act’s full implementation in 2014, narrowed to a local Puget Sound focus.  How is the Affordable Care Act affecting health care in Puget Sound? What are the emerging impacts of the law – now, in 2014, and beyond? What do “you” – individuals, providers, employers, insurers, etc. – need to do?  Individual forum topics cover 1) The consolidation and realignment of the health care system; 2) The impact on employers and small business; 3) How to navigate the care system; and 4) The impact of the Affordable Care Act on innovation and research.


Deadline for signing up for health insurance extended one week

CalendarBy Mary Agnes Carey

Consumers will have an extra week — until Dec. 23 – to enroll in health insurance coverage that begins Jan. 1, Obama administration officials said Friday.

Millions of consumers have been frustrated by their inability to sign up for coverage through healthcare.gov, the federal website for residents of 36 states, which went public Oct. 1.

While the administration has said the site will work smoothly for most customers by Nov. 30, some advocates had been concerned that consumers still might not have enough time to sign up for coverage that would take effect Jan. 1.

The previous deadline was Dec. 15.

In a call with reporters, Centers for Medicare and Medicaid Services Communications Director Julie Bataille said the extension would apply only for consumers seeking coverage effective Jan. 1.

In future months, consumers would have to enroll by the 15th of the month for coverage to begin on the 1st of the following month. Open enrollment continues until March 31.

Bataille said the date change was done “in consultation with” insurers.

Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, a trade group, said the deadline extension “makes it more challenging to process enrollments in time for coverage to begin on Jan. 1. Ultimately, it will depend on how many people enroll in those last few days.  It is also important to keep in mind that consumers need to pay their first month’s premium before their coverage can begin.”

Consumers have until Dec. 31 to pay for health insurance that begins Jan. 1, Bataille said.

Jeffrey Zients, the former Obama budget official who is overseeing repairs to healthcare.gov, stood by the pledge he made late last month that for most visitors, the website would work smoothly by Nov. 30, which is just one week away.

“The system will not work perfectly but it will operate smoothly for the vast majority of users,” he said.

Fixes include a new feature that sends consumers an email notification when spikes in website demand create access issues. Te emails indicate “a better time to come back to the site,” Zients said.

By month’s end, he said the site should be able to accommodate up to 50,000 users at any one time — as originally envisioned — and 800,000 each day, he said.

“I think it’s important to keep in mind here that this is not a simple website,” he said. “The system needs to process the millions upon millions of unique circumstances that consumers present. It needs to determine eligibility for hundreds of state and county programs and all their permutations. And it needs to factor in subsidy levels based on family size, income and plan selection.”

To accommodate repair work, healthcare.gov will down for maintenance from 9 p.m. EST on Saturday, Nov. 23 through 9 a.m. EST Sunday, Nov. 24, Bataille said.

Friday’s announcement giving more time for consumers to enroll in health plans follows the administration announcement late Thursday that it is pushing back the start of health law’s 2014 enrollment period next year to Nov. 15 from Oct. 15.

“The reason for doing that is to make sure the [insurers] have the benefit of more time to evaluate their experience from this year and take that into account as they determine what would be necessary for their 2015 rates,” Bataille said. The delay also places the enrollment period beyond the 2014 congressional elections.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.



omgPublic Health – Seattle & King County has launched a text message service to help county residents to find events nearby where they can get help signing put for insurance on the new health exchanges.

Here’s the details form Public Health – Seattle & King County:

New text message service aids health insurance enrollment

King County residents can text King + ZIP code to 468311 for help nearby

Text King + a ZIP code to 468311 and Public Health – Seattle & King County’s new text messaging program will send information about upcoming health insurance enrollment events customized to that ZIP code.

“Now it just takes a quick text to find the most convenient place to sign up for affordable healthcare” said King County Executive Dow Constantine.

For people who would prefer to get in-person assistance signing up for health insurance, the program eliminates the need to search online or call for convenient enrollment event locations. Every week, subscribers will get local event information customized to their ZIP code.

“These days, many people want to receive information by text message, particularly young adults,” said Dr. David Fleming, Director and Health Officer for Public Health – Seattle & King County. “This new service makes information about local enrollment events accessible to anyone with a cell phone.”

The new texting program also sends reminders of how to sign up for insurance online and by phone.

For more information visit: http://coverkingcounty.com/textupdates/


Q&A: Sorting out the controversy over canceled insurance policies

Question marksBy Michael Ollove and Christine Vestal
Stateline Staff Writers

As even casual observers know at this point, the Affordable Care Act is complicated by a combination of partisan politics, hobbled government websites, misinformation and the byzantine practices of the insurance industry.

So it is with President Barack Obama’s seemingly straightforward request that consumers should be allowed to renew health insurance policies that their insurance companies canceled as the ACA required.

Turns out, the president’s request is not so straightforward at all.

Where States Stand on Renewals











































































































Stateline Survey of States

That is why, a week later, many state officials and insurance carriers are still wringing their hands over whether to comply with Obama’s request.

Already, there have been some paradoxes. Some states that have always been on board with the president’s health reforms, such as Washington and New York, have declined the administration’s request and will not allow renewals of insurance policies that do not meet ACA standards.

Meanwhile, other states that have been resolutely opposed to the president all along, such as Mississippi and Oklahoma, were already allowing those renewals.

Here is an explanation of the cancellation issue and a chart showing how states have responded so far to the president’s request.

What is the problem in the first place?

The ACA set minimum standards for all individual health insurance policies sold after Jan. 1, 2014, not just those sold on the insurance exchanges.

For example, all policies must cover a defined set of services, such as maternal health care, mental health care and pediatric dental and vision care.

Insurance carriers that offered policies that did not cover the required benefits or that placed dollar limits on coverage informed millions of policyholders that their existing policies would not be renewable into 2014.

That was actually a choice the insurance carriers made themselves. The policies could have been renewed for a year, even if they didn’t comply with the ACA and even if they remained in effect into 2014. Many insurance carriers simply decided they wouldn’t renew them.

Many consumers were surprised and upset about the cancellations because Obama had repeatedly said about the health law: “If you like your health care plan, you can keep your health care plan.”

Under federal law, the carriers had to accompany the cancellations with an offer of replacement insurance. In many cases, premiums for those policies were much higher.

How many people have these individual health policies anyway?

According to the Kaiser Family Foundation, about 15 million Americans are covered under individual plans.

Does the malfunctioning federal health care web site have anything to do with it?

Everything. The troubled health exchanges made it difficult to impossible for consumers who got cancellation notices to find out how much they would have to pay for new coverage and whether they qualified for subsidies. That increased the pressure on the administration to allow consumers to keep their existing health plans.

Did the president’s request that states allow carriers to renew canceled policies solve the problem?

Not by a long shot. For one thing, many insurance companies are in no mood to reissue old policies when they have gone through the trouble of devising new plans that are ACA compliant. For another, states are largely responsible for the regulation of insurance sold within their borders, so it’s up to each state to decide if they want to comply with the president’s request.

Is there a red state-blue state divide over complying with the president’s request?

Somewhat, but not in the way you might think. Some very blue states, such as Washington, New York and Massachusetts, have said no to Obama. They aren’t going to allow renewals of noncompliant policies because they say it could undermine the success of the ACA.

But not all blue states are taking that position. Some GOP-led states, on the other hand, are saying yes to the president because they disapproved of the ACA and its regulation of insurance carriers in the first place. Most states are still undecided.

Why aren’t all Democratic-leaning states rejecting Obama’s proposal?

Exchange websites in some blue states are not working as well as in others. In Hawaii and Oregon, for example, the state-run sites are still not fully functioning.

Those states reason that it’s not fair to deny renewals when the people in their states can’t see what their new policies would look like and how much they would cost.

Why are ACA supporters worried about Obama’s decision?

They believe that the people most likely to be offered renewals of relatively cheap, noncomplying policies are young, healthy Americans. I

f those people do not participate in the health insurance exchanges, the concern is that the premiums charged to those who do enroll – older, and less healthy people– will be insufficient to support future claims. The result would be higher rates for everyone the following year.

Other supporters, however, believe the number of people who will remain outside the exchanges because of the renewals will in the end be so small that it won’t really affect rates.

Why are any GOP-leaning states agreeing to extend the policies?

Here’s where it gets interesting. Most of those states decided not to build their own insurance exchanges, relying instead on the federal website, which, as everyone knows, has been a mess. Some of those states — North Carolina and South Carolina, for example — have said they will allow the renewals for the same reasons Oregon and Hawaii are allowing them. Many others, however, are still talking with insurance carriers in their states and haven’t reached a decision.

But there’s another reason for some GOP states. Long before the cancellations bubbled up as an issue, a number of states, including Mississippi, Oklahoma, Iowa and Texas, encouraged carriers in their states to allow renewals and early renewals (for those policies that would have expired after Jan. 1) of existing policies for up to a year provided that the new terms began before the new year.

By taking that step, those states essentially complied with the president’s request before he made it while also keeping people off the exchanges. Other states, such as Rhode Island and Illinois, specifically prohibited early renewals, saying they violated the spirit of the ACA to provide affordable, comprehensive coverage to all.

Is there a downside for people to renew these old policies?

As the Obama administration says, many of those old policies don’t have the coverage or protections of the policies sold on the exchanges. They also won’t be eligible for the subsidies that are available to many of those with low and moderate incomes who shop on the exchanges.

How big a deal is this really?

Some health policy experts, such as Sabrina Corlette, project director at the Center on Health Insurance Reforms at Georgetown University, have characterized the whole cancellation issue as a “red herring.”

Federal law required insurance carriers who canceled policies to offer an alternative. In many cases, Corlette said, those alternatives were priced far higher than the original policies, and that’s what fueled the uproar.  Obama’s assurances that people could keep their old insurance didn’t help.

So, how many people are really affected negatively by all this?

Very few, according to Families USA, a nonprofit organization that backs health reform. It issued a report Thursday, which said that just 1.6 million Americans under age 65 are both at risk of losing their individual policies and also ineligible for subsidies on the health exchanges.

Stateline logo

Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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Health law rollout trouble hits public support

By Jordan Rau

With its troubled rollout of the new insurance marketplaces, the Obama administration has achieved something Republicans have failed to do: seriously dent the popularity of the health care law, according to poll released Friday.

Nearly half of Americans now hold an unfavorable view of the law and only a third like it, according to the poll from the Kaiser Family Foundation. (KHN is an editorially independent part of the foundation.)

The 16-percentage point gap between positive and negative views is almost the largest it has been since the foundation began its monthly tracking poll in April 2010.

The only time the gap was bigger was in October 2011, when the Republican presidential candidates, gearing up for the primary season,  were taking turns bashing the law.


Support among Democrats plunged from 70 percent last month to 55 percent. Women, who were split over the merits of the law month, have turned against it, with views mirroring the overall public view this month.

While most people don’t think it will affect them one way or the other, 43 percent of the public now says the law is going to leave the country worse off, while 34 percent think it will be an improvement.

With 49 percent of people opposing the law and 33 percent favoring it, the Kaiser poll results are broadly similar to those reported earlier this month by other organizations. A Washington Post-ABC poll found a 57 percent majority against the law, with 40 percent favoring it.

Gallup found that 55 percent of people disapprove of the law while 40 percent like it.  Gallup found the most popular criticisms were that the law was “government interference” and “forcing people to do things.” Gallup also found that a minority of the public believes it’s the government’s responsibility to make sure all Americans have health coverage.

The drop in support comes as more people are paying attention, particularly to the insurance marketplaces that opened Oct. 1. According to the Kaiser poll, more than half of the public say they have followed news about the healthcare.gov website problems.

The same portion say they are hearing tales of anecdotal complaints from people unhappy that their individual health policies have been canceled as insurers move to adopt the law’s more rigorous requirements.

The public is suspicious about news coverage of the law. While 40 percent say it’s been mostly balanced, 33 percent believe coverage has tilted against the law and 17 percent believe it’s been too favorable.

People without health insurance now are more likely to say they have not heard much about the marketplaces than those with health coverage. Nearly six in 10 of the uninsured say they plan to obtain coverage next year, while a third say they will refuse.

The pollsters offered one hopeful comparison for supporters of the law, noting that the Medicare “Part D” prescription drug benefit was also unpopular when it started in 2006, but now is viewed positively. Support of the drug benefit has grown from just 28 percent at the end of 2005 to 63 percent this month.

“Of course, it is far too early to tell what will happen to public opinion on the ACA as it moves through the next phase of implementation, but the Medicare Part D experience suggests that it is not unusual for a new law of this sort to be poorly perceived at the outset,” the pollsters wrote.

The poll was conducted by phone Nov. 13 through Nov. 18 among 1,204 adults. The margin of error is +/- 3 percentage points, with larger margins for subgroups.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.


Snohomish to mark World AIDS Day with events, memorial walk, screenings

From the Snohomish Health District


Shared responsibilities: Celebrate World AIDS Day in Everett, Dec. 1

Events in Everett Sunday afternoon; free HIV tests by appointment for at-risk people Dec.2, 4, & 6

The public is welcome to free events in downtown Everett to commemorate World AIDS Day 2013 on Sunday, Dec. 1.

Three community partners will sponsor a memorial walk and program that afternoon to build awareness of the impact HIV/AIDS has on our community.

All activities take place at the Snohomish Health District, 3020 Rucker Ave., Everett, Wash. Testing opportunities are available at the Health District Dec. 2-6.

Sunday, Dec. 1

1 p.m. Remembrance walk leaves the Snohomish Health District, 3020 Rucker Ave., goes to AIDS Memorial of Snohomish County at 3021 Wetmore Ave., Everett

2 p.m. Return to the Health District for a program, music, and light refreshments

The afternoon program includes remarks by Rev. Julie Montague from Everett Unity Church, and comments from Snohomish County residents living with HIV/AIDS. The program also features music by local musicians Terri Anson and Savannah Woods. The program is free and open to the public.

Local sponsors include Snohomish Health District, Snohomish County Gay Men’s Task Force, and AIDS Project Snohomish County. For information about AIDS Project Snohomish County, please contact Jeannine Fosca at 425.923.7656 or Dancing_lively@yahoo.com.

World AIDS Day events remember those lost to AIDS, support those living with the disease, reinforce the need to combat stigma, discrimination and intolerance, and underscore the need for routine HIV screening.

“The medical community has made great advances in treating HIV/AIDS in recent years,” said Dr. Gary Goldbaum, Health Officer and Director of the Snohomish Health District. “However, there still is no cure. Early treatment is critical to both help those who are infected and to prevent spread to others. Screening is key”

An estimated one in five Americans infected with HIV is unaware of itAccording to the Washington State Department of Health, 1,130 people in Snohomish County have been diagnosed with HIV since 1982. Screening for tuberculosis is also recommended for HIV-positive people.

Monday, Dec. 2

9 a.m.-noon, 1-5 p.m. — Free rapid-tests for HIV offered to anyone at risk of the disease, the Health District, 3020 Rucker Ave., Suite 108.Call for appointment: 425.339.5298.

Tuesday, Dec. 3

3-6 p.m., special health event for gay and bisexual men – tests available for HIV, Hepatitis C, and syphilis; also vaccinations for Hepatitis A and B. Come to the Health District, 3020 Rucker Ave., Suite 106, Everett. No appointment needed.

Wednesday, Dec, 4

9 a.m.-noon, 1-5 p.m. — Free rapid-tests for HIV offered to anyone at risk of the disease, the Health District, 3020 Rucker Ave., Suite 108.Call for appointment: 425.339.5298.

Friday, Dec. 6

9 a.m.-noon, 1-5 p.m. — Free rapid-tests for HIV offered to anyone at risk of the disease, the Health District, 3020 Rucker Ave., Suite 108.Call for appointment: 425.339.5298.


Does an insurer have the right to cancel ‘grandfathered’ plan?

canceled man 300Michelle Andrews answers a reader’s question:

Q. I have a question about the grandfathered status of my health insurance. I have had this individual policy since 2005 and have paid the premium continuously. Does the insurer have the right to terminate the plan?

A. Yes, it does have that right. An insurer generally can’t single out one individual and cancel that person’s policy, but it can terminate coverage for everyone in a “block of business” that it sold a particular policy to.

This has long been the way the health insurance market works and it continues to operate this way today, says Karen Pollitz, a senior fellow at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

(This is different from the highly publicized problems that individuals sometimes used to confront when they became ill. In the past, some insurers dropped people after they got sick, claiming they lied on their applications. These rescissions are prohibited under the health law unless someone commits fraud.)

Being in a grandfathered individual plan—meaning you had it when the health law was signed on March 23, 2010, and it hasn’t changed substantially since then—doesn’t prevent an insurer from canceling your policy.

Starting in January, individual plans have to meet new standards for cost and coverage, among other things. Insurers and states have taken different approaches to canceling plans that are already in effect, whether grandfathered or not.

The issue has caused a political and public relations headache for the Obama administration. As consumers began receiving notices in recent weeks that their individual plans were being cancelled so they could be transitioned into plans that meet the new standards, some reacted furiously, claiming that the president was reneging on a promise that they could keep their existing plans if they liked them.

Last week, President Barack Obama announced that the administration would permit insurers to renew some policies slated for cancellation even though they don’t meet the new standards. Some state regulators and insurers have accepted that option but it’s unclear how many will go along.

“I think people do really value continuity of coverage, and on many dimensions it has to be upsetting to get one of these [cancellation] notices, particularly if you thought you were grandfathered,” says Pollitz.

Still, in general people who have held an individual policy for a long time and faced annual premium increases may be paying higher premiums than they would if they had changed plans over the years, says Pollitz. “I would have predicted that grandfathered people would be at the head of the line [to switch].”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Doctors complain exchange plans will pay them less

doctor money thoughts 300By Roni Caryn Rabin

Many doctors are disturbed they will be paid less — often a lot less — to care for the millions of patients projected to buy coverage through the health law’s new insurance marketplaces.

Some have complained to medical associations, including those in New York, California, Connecticut, Texas and Georgia, saying the discounted rates could lead to a two-tiered system in which fewer doctors participate, potentially making it harder for consumers to get the care they need.

“As it is, there is a shortage of primary care physicians in the country, and they don’t have enough time to see all the patients who are calling them,” said Peter Cunningham, a senior fellow at the nonpartisan Center for Studying Health System Change in Washington D.C.

If providers are paid less, “are [enrollees] going to have difficulty getting physicians to accept them as patients?”

Insurance officials acknowledge they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors.

But many primary care doctors say they barely have time to take care of the patients they have now.

The conflict sheds light on the often murky world of insurance contracts in which physicians don’t always know which plans they’re listed in or how much they’re being paid to treat patients in a particular plan. As a result, some doctors are just learning about the lower pay rates in some plans sold in the online markets, or exchanges

“If you’re a physician and you’ve negotiated a rate from insurance, shouldn’t it be the same on or off the exchange?” said Matthew Katz, executive vice president of the Connecticut State Medical Society. “You’re providing the same service.”

Blues: No Desire ‘To Gouge’ Docs

A senior executive at Blue Cross Blue Shield Association said some of its 37 member organizations — each of which operate independently and offer a variety of plans – are offering lower rates to physicians in smaller exchange plan networks.

But, she said, plans know that a good network of providers is essential or customers “will go someplace else,” and they are enlisting sufficient numbers of doctors.

“We’re not motivated to gouge the doctor,” said Kim Holland, Blue Cross Blue Shield Association executive director for state affairs. “We depend on good relationships with quality physicians. … I can’t imagine any product we offer is going to have a physician rate that would discourage them from seeing a patient.”

But some physicians see things differently. Contracts between insurers and doctors vary with some allowing insurers to adjust rates unilaterally or to assign a doctor to multiple plans.

“I’ve participated with Oxford since 1985. They don’t send me a contract every year to sign. They don’t send me the rates. You don’t know the rates,” said Dr. Paul Orloff, a physician who is president of the New York County Medical Society. “It’s the only game in town so you sign. They have a right to unilaterally change the rates at any time during the contract.”

The benchmark for physician fees is the rate the federal government sets for services provided to older Americans through Medicare. In many markets, commercial plans may pay slightly above the Medicare rates, while doctors say that many of the new exchange plans are offering rates below that.

Physicians are uncomfortable discussing their rates because of antitrust laws, and insurers say the information is proprietary. But information cobbled together from interviews suggests that if the Medicare pays $90 for an office visit of a complex nature, and a commercial plan pays $100 or more, some exchange plans are offering $60 to $70. Doctors say the insurers have not always clearly spelled out the proposed rate reductions.

Some experts minimized the impact of lower pay rates on enrollees.

People “may experience wait times to get in, but that is not unique to people in exchange plans,” said Sara Rosenbaum, a professor of health law and policy at George Washington University,

Rosenbaum said she was not overly concerned about physicians’ compensation. “I don’t mean to suggest that physicians don’t deserve to do well,” she said. “But physicians are very well-compensated people, no matter what.”

Confusion About Rates, Provider Lists

Many doctors say they have not decided if they will participate in the new plans –in some cases, even when an insurer is including them in their provider list.

A survey by The Medical Society of the State of New York found that 40 percent of more than 400 physicians who had responded so far said they chose not to participate in a health insurer’s exchange plan, and one-third said they did not know whether they were participating or not.

Two-thirds indicated they had received no information about reimbursements; of those who did ge that information, “a significant majority indicated that the reimbursement generally was well below what the insurer pays in other contracts,” according to a statement from the society’s president Dr. Sam Unterricht.

“I have patients calling my office and saying … ‘Oh good, I see you’re in the network,’” said Patricia McLaughlin, an ophthalmologist in New York City. But, she added, “I’m not sure I am or am not at this point.”

Some insurers have contractual arrangements with physicians that allow them to automatically include doctors in a new plan, unless the physician requests to opt out in writing, according to Mike Scribner, CEO of Strategic Healthcare Partners, a health care consulting firm based in Savannah, Ga., that represents about 700 physicians and 30 managed care hospitals in the state.

Doctors say the Blue Cross Blue Shield Association plans have generally been more straightforward about the discounted rates –and some doctors who had the opportunity to “opt out” of their exchange plans did so.

Dr. Richard E. Thorp, an internist who is president of the California Medical Association and heads a physician-owned multi-specialty primary care group in Paradise, Calif., said one plan sold on that exchange “was going to pay us significantly less for doing that business. And we are already very busy.”

His practice delayed signing a contract, he said. But about three weeks ago, the group was informed the insurer was short on physicians and was therefore including doctors from other plans at their old rates.  So his practice was included at the higher rate.

Advocates say that consumers should be wary of information in plan directories and confirm participation with their doctors.

The California Medical Association is so concerned about errors that it has asked Covered California, the state’s insurance marketplace, to remove a search function that lets buyers plug in the names of physicians and get a list of all the plans that they participate in, said Lisa Folberg, vice president for medical and regulatory policy for the California Medical Association.

“There shouldn’t be any ambiguity about who’s in the network,” said Lynn Quincy, a senior analyst with Consumers Union, the policy division of Consumer Reports.

“These consumers are buying a product, one dimension of which is to provide a network–a very important dimension.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.


Washington state disciplines healthcare providers

Periodically Washington State Department of Health issues an update on disciplinary actions taken against health care providers, including suspensions and revocations of licenses, certifications, or registrations of providers in the state.

The department also suspends the credentials of people who have been prohibited from practicing in other states.

Information about health care providers is also on the agency’s website.

To find this information click on “Provider Credential Search” on the left hand side of the Department of Health home page (www.doh.wa.gov).

The site includes information about a health care provider’s license status, the expiration and renewal date of their credential, disciplinary actions and copies of legal documents issued after July 1998.

This information is also available by calling 360-236-4700.

Consumers who think a health care provider acted unprofessionally are also encouraged to call and report their complaint.

Here is the November 19th update issued by the Washington State Department of Health:

Note: Health care providers charged with unprofessional conduct have 20 days to respond to the Department of Health in writing. The case then enters the settlement process. If no disciplinary agreement can be reached, the case will go to a hearing.

State disciplines health care providers

OLYMPIA ¾ The Washington State Department of Health has taken disciplinary actions or withdrawn charges against health care providers in our state.

The department’s Health Systems Quality Assurance Division works with boards, commissions, and advisory committees to set licensing standards for more than 80 health care professions (e.g., medical doctors, nurses, counselors).

Information about health care providers is on the agency website. Click on “Look up a healthcare provider license” in the “How Do I?” section of the Department of Health website (doh.wa.gov).

The site includes information about a health care provider’s license status, the expiration and renewal date of their credential, disciplinary actions and copies of legal documents issued after July 1998.

This information is also available by calling 360-236-4700. Consumers who think a health care provider acted unprofessionally are encouraged to call and report their complaint.

Clark County

In October 2013 the Nursing Commission charged registered nurse Jeanine Marie Wyman (RN00054263) with unprofessional conduct. Wyman allegedly didn’t submit quarterly performance evaluations and proof of completion of the continuing education requirements after she was put on probation in 2013.

Douglas County

In October 2013 the Nursing Commission charged registered nurse Jennifer S. Dechenne (RN00124446) with unprofessional conduct. Dechenne allegedly admitted diverting controlled substances at a hospital where she worked, failed a drug test, and didn’t comply with a substance abuse contract.

Franklin County

In October 2013 the Nursing Commission charged registered nurse Kylee L. Rainwater (RN00166118) with unprofessional conduct. She allegedly hasn’t complied with a 2013 stipulation that requires her to be in compliance with her monitoring contract.

Island County

In October 2013 the Chemical Dependency Professional Program conditionally granted a chemical dependency professional trainee credential to Brooke Michelle Smith (CO60389083), ordered her to undergo evaluation for a substance abuse monitoring program, and placed her on probation. Smith was convicted of two felonies and four gross misdemeanors between 2002 and 2010.

King County

In October 2013 the Medical Commission filed a corrected statement of charges against physician Mitchell L. Cohen (MD00028854). Cohen allegedly violated a boundary and took advantage of a doctor-patient relationship by looking up a patient’s work information on the Internet and by sending her a social media friend request.

In October 2013 the Medical Assistant Program conditionally granted a registered medical assistant credential to Bridgett Dianne Miller (MR60402878), and ordered her to undergo evaluation for a substance abuse monitoring program. In 2004 Miller’s health care assistant credential was revoked for at least seven years after she stole or fraudulently took prescription medications for her personal use.

In October 2013 the Nursing Commission charged registered nurse Cynthia Yvonne Perry (RN00108190) with unprofessional conduct. Perry allegedly admitted falling in love with an 80-year-old home health agency patient and receiving financial assistance from him.

 Kitsap County

In October 2013 the Nursing Assistant Program charged registered nursing assistant KC Marie Betancur (NA60283644) with unprofessional conduct. The Department of Social and Health Services (DSHS) will not allow Betancur to be employed in caring for and having unsupervised access to vulnerable adults. DSHS found that she stole about $100 from an assisted living community resident.

Pierce Count

In October 2013 the Nursing Assistant Program charged certified nursing assistant Kathleen A. Sallade (NC10102214) with unprofessional conduct. Charges say that while Sallade worked at an assisted living facility she took residents’ property, including jewelry that she pawned. In 2013 she was convicted of first-degree trafficking in stolen property.

In October 2013 the Nursing Assistant Program charged registered nursing assistant Suia Seufale (NA60269598) with unprofessional conduct. Seufale was charged with second-degree theft. A complaint made to the Department of Health alleged she stole money and other items from residents at an assisted living facility where she worked. Seufale hasn’t responded to a Department of Health inquiry.

In October 2013 the Nursing Commission charged licensed practical nurse Diana L. Snead (LP00025789) with unprofessional conduct. Snead allegedly admitted to her employer that she’d diverted narcotics from her workplace, and didn’t comply with a substance abuse referral contract.

Skagit County

In October 2013 the Nursing Commission charged registered nurse and advanced registered nurse practitioner Robyn Margot Choffel (RN00103955, AP30003913) with unprofessional conduct. Choffel allegedly falsified her time sheets while working for the Stillaguamish Tribe, resulting in overcompensation of about $5,929.87.

Snohomish County

In September 2013 the Pharmacy Commission charged pharmacy assistant and pharmacy technician Ramsey B. Leggett (VB60115413, VA60167258) with unprofessional conduct. Leggett allegedly admitted diverting a controlled substance for his personal use from the pharmacy where he worked.

In October 2013 the Massage Program conditionally granted a massage practitioner credential to Autumn Kimberly Bercier (MA60402619), and ordered her to undergo screening for a substance abuse monitoring program. In 2011 Bercier was convicted of second-degree taking a motor vehicle without permission, third-degree theft, and theft.

In October 2013 the Nursing Assistant Program ended probation for registered nursing assistant Torel Caravity Bernal (NA00087507).

Spokane County

In September 2013 the Nursing Commission charged licensed practical nurse Gail L. Hunt (LP00038766) with unprofessional conduct. Hunt allegedly directed a nursing assistant to perform treatment beyond her scope of practice, and falsified a diabetic patient’s record after giving the patient insulin when a physician’s order didn’t call for it.

Stevens County

In October 2013 the Mental Health Counselor Program ended conditions on the credential of mental health counselor Layne Serr (LH00004674).

Thurston County

In September 2013 the Nursing Commission charged licensed practical nurse Dora Jean LeBlanc (LP00055043) with unprofessional conduct. She allegedly hasn’t complied with a 2013 stipulation that requires her to be in compliance with her monitoring contract.

Whatcom County

In October 2013 the X-Ray Technician Program charged X-ray technician Jennifer Lynn Wolford (XT00005315) with unprofessional conduct. Charges say she submitted fraudulent disability claims to an insurance company, forging a physician’s signature, and receiving about $64,850 that she wasn’t entitled to. In 2013 she was convicted of three counts of second-degree theft and one count of first-degree theft.

Yakima County

In October 2013 the Nursing Assistant Program charged certified nursing assistant Valerie Esquer (NC10050018) with unprofessional conduct. Esquer allegedly tripped and fell while working at a skilled nursing facility and provided a urine sample that allegedly tested positive for marijuana and cocaine.

In October 2013 the Nursing Commission charged licensed practical nurse Lane M. Willis (LP00024447) with unprofessional conduct. While working for an agency that provides in-home healthcare, Willis allegedly forged physicians’ signatures on patients’ treatment plans. She hasn’t responded to a Nursing Commission inquiry.

In June 2013 the Chemical Dependency Professional Program denied a chemical dependency professional trainee credential to Richard Craig Hill (CO60371105). In 2011 Hill was convicted of possession of a controlled substance, Vicodin, a felony.

Out of State

Oregon: In September 2013 the Chemical Dependency Professional Program denied a chemical dependency professional trainee credential toMartha Melanie Amanda Cole (CO60353155), who was convicted in Oregon of three felonies and one Class B misdemeanor between 2005 and 2009.

Utah: In September 2013 the Nursing Commission granted a registered nursing credential to Jill Ann Smith (RN60387574) that is subject to conditions. Smith’s Utah license is under terms and conditions of a 2012 stipulation.

Note to Editors: Health care providers charged with unprofessional conduct have 20 days to respond to the Department of Health in writing. The case then enters the settlement process. If no disciplinary agreement can be reached, the case will go to a hearing.


All Eyes on Colorado and Washington

Cannabis_leaf_marijuana_potBy Jake Grovum
Stateline Staff Writer

Colorado voters overwhelmingly approved a plan for taxing their state’s legal marijuana market earlier this month. And Washington state will start issuing licenses to retailers next month to sell recreational marijuana.

Washington and Colorado are set to provide a case study in the debate over legalization. That debate is expected to spread to other state legislatures next year – advocates have identified Rhode Island and Maine as potential targets – and also to foreign countries like Uruguay.

It’s unlikely the outcome in Colorado or Washington will settle the issue. But both sides agree the stakes are high.

“Reformers look at these two states as literally laboratories,” said Allen St. Pierre, executive director of NORML, a group that backs marijuana legalization. And if things go well, he said, “This is largely the beginning of the end of cannabis prohibition.”

Opponents aren’t giving up. They, too, see the start of legal markets as a turning point, one that will confirm warnings about ill effects and dash promises of new revenues. They plan to highlight missteps and problems that arise as legalization becomes a reality.

“I don’t accept that marijuana legalization is inevitable,” said David Evans of the Drug Free America Foundation, which opposes legalization. “The states that have legalized it are going to serve as an example of what not to do.”

Already, opponents have seized on anecdotal evidence of increasing use among young people – as chronicled by The Denver Post last week for example – in the 20 states plus the District of Columbia that allow medical marijuana.

Supporters balk at the connection, saying marijuana use among teens is hardly a new phenomenon. They also point to areas where medical marijuana businesses exist that haven’t seen new crime waves or other side effects.

Legal or not, young adults continue to experiment: An annual survey shows 18.7 percent of young adults ages 18 to 25 used marijuana in 2012, compared to 16.1 percent in 2004.

Both Colorado and Washington set 21 as the age for legal marijuana use.

Revenue Watch

Revenue is one measure that both sides will be watching closely as a way to evaluate legalization.

Estimated income in Washington and Colorado varies widely, from tens of millions of dollars in the first few years to as much as $2 billion in the first half-decade of legalization. The disparity comes, in part, over uncertainty about demand.

State officials have been left guessing. Colorado has made no official estimate. A study from the Colorado Center on Law and Policy projected the tax could produce $60 million in new revenue and savings annually in the first years of legalization.

Washington predicted a “fully functioning” market could bring in $1.9 billion in five years, although the state isn’t counting on those dollars in future budgets.

The revenue swing could ultimately prove crucial to the future of legalization and it is one reason the stakes were so high for the ballot question in Colorado on Nov. 5.

The measure offered a two-tiered tax scheme, as approved by the legislature. It passed the House 37-27 with solely Democratic support, although a handful of Republicans backed it in the Senate. The question fell under Colorado’s strict anti-tax policies, which require revenue-raising proposals to go before voters, who gave it 65 percent support this month.

The approved tax includes a 15 percent assessment on the wholesale price of retail marijuana, with the first $40 million set aside for education. Then there’s a 10 percent sales tax, in addition to the state’s 2.9 percent sales tax, with proceeds earmarked for regulation, public health and police activities related to the legal pot market.

In Washington state, recreational marijuana was approved last year with 55 percent of the vote. It will be taxed 25 percent three separate times: producer to processor, processor to retailer, and retailer to consumer. The effective tax for consumers ends up being between 35 percent and 45 percent, depending on how many transfers are involved and other variables. Washington’s tax was subjected to less public scrutiny than in Colorado since it didn’t require a separate vote.

The Colorado tax on marijuana passed by a nearly 2-to-1 margin in the same election in which voters also easily defeated a $1 billion proposal to increase the state’s flat income tax and earmark those dollars for education. The pot tax gained more support than legalization itself saw just a year earlier when it was approved by 55 percent of voters.

Had the tax failed, legal marijuana potentially would have been subject to only a 2.9 percent sales tax, short-circuiting one of the key arguments for legalizing the drug in the first place: revenue.

High Tax Concerns

The Colorado measure saw wide support from state lawmakers and Democratic Gov. John Hickenlooper, despite many of them publicly opposing legalization itself. They said the levy fulfilled the promise of the legalization campaign a year earlier.

Opponents, however, see a downside in high tax levies that they say could possibly cause a “gray market,” in which some drug sellers become tax evaders, depressing revenues from the legal market.

“The fact that the government set the taxes so high, paradoxically, is going to reduce the revenue because cheating will be widespread,” said Robert Corry, Jr., an attorney who was involved in the campaign against the marijuana tax measure. “The shops will lose a lot of the market to the gray market.”

Colorado allows home-growing of as many as six plants, while Washington does not, leading to more concern about a “gray market” cutting into tax revenue. Other factors: Washington will not allow pot growers to sell directly to consumers, while Colorado will, and Washington is doing away with much of its medical marijuana system, while Colorado’s medical market will continue alongside the recreational market.

Corry and others said the dual tax system in Colorado could mean the medical marijuana market, which will be taxed much less than the recreational one, could flourish, with recreational marijuana mainly purchased by tourists and other out-of-state consumers.

Federal Uncertainty

Ultimately, it may be the federal government that weighs most heavily on the success or failure of marijuana legalization. It’s still not clear, for instance, if the new retailers and customers will be able to use banking services related to their business.

Observers on all sides have been awaiting word from the Justice Department on whether banks and credit card companies will be allowed to process transactions or even keep deposits from these businesses. For now, it’s likely even an armored car service contracted to move cash could find itself violating federal law for working with a marijuana business.

The broader treatment of marijuana, too, is a wildcard. Federal law enforcement officials have said they don’t plan to go out of their way to crack down on the new markets in the two states, but it’s not clear how much leeway that would ensure, since federal raids on casual users and small-time sellers are already a rarity.

Other cautions: It would only take one incident – not to mention a new administration in Washington – to change that understanding, potentially upsetting any marketplace that’s been established.

“Until the federal law is completely clear, I think any prudent marijuana producer, even in a state where it’s legal, is going to have some concerns about how visible they make their industry,” said Jeffrey Miron, a Harvard economist and analyst at the libertarian Cato Institute. “If it’s illegal federally, it’s really hard for a state to really, in a clean and unambiguous way, try to legalize it.”

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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

March 31 thumbnail

Can I buy a Policy after March 31? What if my employer cancels my spouses coverage?

March 31 300By Michelle Andrews

The news has been focused on the troubles of people trying to use the health care law’s insurance exchanges and new options for people whose individual policies are being canceled.

But open enrollment continues, and people who are shopping for individual or job-based coverage have many questions. Here are some answers.

Q. I know there’s an enrollment period for the health law’s insurance marketplaces, but people can also buy a policy directly from a company or agent, outside the marketplaces. So will people be able to buy a regular health insurance policy from a company or agent after March? If so, won’t people wait until they’re sick or injured to buy insurance?

A. The open enrollment period, when people can buy an individual plan for 2014 directly through the health insurance marketplace or outside it from an insurer or agent, began in October and runs until the end of March.

The law requires that health plans sold either through the marketplace or outside it be comparable in many ways, including the benefits that are covered and consumer cost-sharing requirements, such as the rule that plans pay at least 60 percent of medical costs. In addition, all plans sold on the individual market, whether through the exchange or outside it, must offer open enrollment during the same time period.

So there’s no easy way to game the system by waiting to buy a plan until you get sick. If you skip open enrollment, you’ve generally missed your chance to buy coverage for the year unless you have a significant change in circumstance, such as losing your job-based insurance. You’ll also face a penalty for not having insurance: $95 or 1 percent of your income in 2014, whichever is greater.

Q. We just received a notice from my wife’s health insurance company that says if her spouse is employed and has the option for insurance at his/her workplace, it must be taken. She is paying for a family plan that covers myself and her son, who is living at home and attending college. How can a company charge for a family plan and then revoke coverage for one of the insured? Is this legal or just a way to purge family members to cut costs to the group insurer?

A. Employers aren’t required to offer health insurance to the spouses of employees, and if they do offer it, they can choose to stop at any time. But discontinuing spousal coverage altogether isn’t common, says Amy Bergner, a managing director at PwC Human Resource Services. Employers are more likely to charge for health insurance based on coverage tiers: There’s one premium for employee-only coverage, another for employee plus spouse, another for employee plus children, and another for employee plus spouse plus children, for example.

Under the health law, employers that offer coverage to dependent children have to make it available for young adults up to age 26, however. To cut costs, some are trying to make coverage of spouses and children less attractive by making it relatively expensive or by applying a surcharge to cover a spouse who has coverage available elsewhere.

Bergner advises assessing which plan is the most advantageous for your family’s needs, keeping in mind that all family members may not be best served by staying on the same plan. Don’t limit yourself to evaluating the medical coverage and provider networks.

“Sometimes employee-only coverage at your own workplace may be preferable,” Bergner says. “There may be incentives for wellness programs or not using tobacco that wouldn’t be available under the spouse’s coverage or available to the spouses under the spouse’s plan.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Medicare’s failure to track doctors wastes billions on name-brand drugs

The doctor's office of Dr. Hew Wah Quon, one of Medicare’s top prescribers, in the Chinatown neighborhood of Los Angeles. (Patrick T. Fallon for ProPublica)

The doctor’s office of Dr. Hew Wah Quon, one of Medicare’s top prescribers, in the Chinatown neighborhood of Los Angeles. (Patrick T. Fallon for ProPublica)

by Charles OrnsteinTracy Weber and Jennifer LaFleur
ProPublica, Nov. 18, 2013, 3 p.m.

Medicare is wasting hundreds of millions of dollars a year by failing to rein in doctors who routinely give patients pricey name-brand drugs when cheaper generic alternatives are available.

ProPublica analyzed the prescribing habits of 1.6 million practitioners nationwide and found that a tiny fraction of them are having an outsized impact on spending in Medicare’s massive drug program.

Five Takeaways

Just 913 internists, family medicine and general practice physicians cost taxpayers an extra $300 million in 2011 alone by disproportionately choosing name-brand drugs. These doctors each wrote at least 5,000 prescriptions that year, including refills, and ranked among the program’s most prolific prescribers.

Many of these physicians also have accepted thousands of dollars in promotional or consulting fees from drug companies, records show.

While lawmakers bitterly disagree about the Affordable Care Act, Medicare’s drug program has been held up as a success for government health care. It has come in below cost estimates while providing access to needed medicines for 36 million seniors and the disabled.

But this seeming fiscal success has hidden billions of dollars lost to unnecessarily expensive prescribing over the program’s eight-year history.

The waste is exacerbated by a well-meaning benefit written into the drug program, known as Part D: Low-income patients pay less than $7 per prescription regardless of a medication’s cost. The unintended consequence is that doctors can dole out name brands with little fear of pushback from patients about price.

Taxpayers spent $62 billion last year on Part D — more than a third of it on this low-income subsidy.

King of the Name Brands


Internist Hew Wah Quon of Los Angeles stands out as a high-volume prescriber of name-brand drugs.
Only two of his top 10 drugs are generics. See the slideshow »

Dr. Hew Wah Quon is one of Medicare’s top prescribers. From a worn office in Los Angeles’ bustling Chinatown, he churned out $27 million worth of prescriptions from 2009 to 2011, data show.

All of Quon’s patients in 2011 qualified for the low-income subsidy, sometimes called “Extra Help.” He mostly prescribed name brands, such as AstraZeneca’s Crestor, for high cholesterol. Crestor costs more than $6 a pill; the leading generic costs as little as 20 cents.

If Quon had prescribed the way other internists do in California, choosing drugs so that his average cost was similar to theirs, he alone could have saved Medicare $5 million in 2011, ProPublica’s analysis shows.

“Boy, this doctor is a walking economic disaster,” said Dr. Jerry Avorn, a Harvard medical professor who has written about the risks and benefits of prescription drugs.

When first contacted by ProPublica last year, Quon defended some of his choices but abruptly ended the interview and has since declined to comment. Others who prescribe similarly said they believe name-brand drugs work better.

Health programs run by the U.S. military and the Department of Veterans Affairs control costs by strictly limiting the name-brand drugs doctors can prescribe. Some of the nation’s leading private health insurance plans do as well.

But Medicare, which pays for one in every four prescriptions nationwide, hasn’t asked Congress for the authority to put similar checks in place.

The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers those programs, declined to make an official available for an interview and would not answer specific questions.

“By law, Medicare must cover items and services that are reasonable and necessary,” a CMS spokesperson said in an email. “Within those rules, doctors and their patients are free to make medical treatment decisions that are best for the patient.”

In the past, agency officials have said that while Part D is a government program, private insurers are responsible for running it. They normally decide how to manage their drug plans but cannot increase prices for the poor.

ProPublica’s analysis is part of a broader look at Part D oversight. An article in May found that Medicare has failed to take basic steps to investigate doctors who prescribe large quantities of dangerous, addictive or inappropriate medications.

Some, including the investigative arm of the Department of Health and Human Services, say CMS also needs to do more to stop waste — by investigating doctors who prescribe very differently than their peers. Others say it should establish penalties and bonuses to encourage more cost-effective habits.

“At some point, I think we have to hold prescribers accountable for their prescribing,” said Dr. Nancy Morden, an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice, which has studied Part D. “I just don’t see how that’s different from holding them accountable for the quality of care in the exam room or in the operating room.”

Numerous studies show that generics, which must meet rigid Food and Drug Administration standards, work as well as name brands for most patients. Although some medications do not have exact generic versions, there usually is a similar one in the same category.

Many of the 900-plus primary care doctors who favored name brands shared another trait: Financial ties to the companies whose pills they prescribe.

Since 2009, 48 percent of them have received at least $1,000 for speaking, consulting and other promotional purposes, according to data ProPublica compiled from company web sites. Eleven have accepted $100,000 or more, the data show. Quon has received more than $7,000 in speaking fees and meals.

Among a random sample of doctors who prescribed generics more frequently, only 15 percent accepted drug company money, and the amounts generally were less.

Dr. Jeffrey Grove, a Florida physician who chooses generics 90 percent of the time for his Medicare patients, said it’s irresponsible not to consider cost.

“I don’t care that the government pays for it,” said Grove, president of the American College of Osteopathic Family Physicians. Grove was at the 2003 ceremony when President George W. Bush signed Part D into law.

“How many people could we insure that are uninsured right now if those physicians were practicing responsibly as well?”

King of the Name Brands

Quon’s office, right outside downtown Los Angeles, is wedged between a bank and a budget hotel. His name is half-peeled off the front window. On the waiting room walls, smudges mark where legions of patients leaned their heads.

Dr. Hew Wah Quon’s name is half-peeled off the front window of his office in the Chinatown neighborhood of Los Angeles. (Patrick T. Fallon for ProPublica)

Yet in 2011, nearly 80,000 prescriptionsflowed through this unassuming space and his other office in Monterey Park, a largely Asian city nearby.

Quon, 62, was the nation’s top prescriber that year for a dozen brand-name drugs and second-highest for another 13.

High on his list was Crestor, the most potent of a class of cholesterol-lowering drugs known as statins. Quon prescribed it 5,250 times — more than twice as many as any other doctor in Medicare. About 70 percent of his 948 Medicare patients filled a prescription for it.

Doctors typically find that generics such as simvastatin, the most-prescribed drug in Part D, work well to treat the risks from artery-clogging cholesterol. Crestor is usually reserved for stubborn cases because it costs 30 times as much.

Quon also liked Lovaza, purified and concentrated fish oil. It is marketed by GlaxoSmithKline to help reduce very high triglycerides, a fat in the blood linked to heart disease. At more than $90 per prescription in 2011, Lovaza’s price dwarfed that of over-the-counter fish oil supplements sold for a few dollars per bottle. Quon prescribed it 4,700 times, tops in the country.

Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, said that while high triglycerides are a risk factor for heart attack and stroke, there is no scientific evidence that Lovaza lowers the odds of either event. Even GlaxoSmithKline says on the drug’s website that, “It is not known if Lovaza prevents you from having a heart attack or stroke.”

Nissen said it is “absolutely inconceivable” to treat so many patients “with a drug approved only to treat a relatively rare disorder.”

Another Quon favorite is Forest Laboratories’ Bystolic, which treats high blood pressure. He prescribed it 2,225 times, second-highest among Medicare doctors. Several drugs in the class, known as beta blockers, are generics and cost less than $10 per month. Each of his Bystolic orders cost $58.

The FDA has said Bystolic had no proven advantage over generic beta blockers. In 2008,it warned Forest Labs that its ads overstated the drug’s benefits.

Quon’s prescriptions for Crestor, Lovaza and Bystolic alone cost Medicare $1.3 million in 2011. Overall, his patients received name brands 75 percent of the time, compared to 23 percent for all California internal medicine specialists, including Quon. The average cost of Quon’s prescriptions was $129; the group’s was $65.

Medicare data show a consistent pattern for Quon since at least 2007.

“He is a big brand user. That’s his style,” said David Wong, whose C.T. Pharmacy is down the block. “He’s famous.”

The C.T. Pharmacy, where many of Quon’s patients fill their prescriptions, in the Chinatown neighborhood of Los Angeles. (Patrick T. Fallon for ProPublica)

The prescribing habits of Quon and other primary care doctors with similar devotion to name brands collectively cost Medicare more than $1 billion in 2011. Nearly a third of that could have been saved if their prescribing had the same average cost as their peers.

Other specialties showed comparable patterns, but ProPublica’s analysis focused on primary care doctors because they treat a variety of illnesses and prescribe a range of medications that have generic alternatives.

In June, the HHS inspector general issued a report on potential waste and abuse in Part D. Among a group of “very extreme outliers,” the report cited one doctor with an “unusually large number” of Lovaza prescriptions whose costs in 2009 were 151 times more than average.

The inspector general did not name the doctor, but by matching statistics in the report to Medicare data, ProPublica was able to identify the doctor as Quon. No other physician met the criteria.

For the Poor, Priciest Pills

Part D was created amid a partisan fight over who should run the program — the government or private industry. But it was accepted that no matter who was in charge, poor Medicare enrollees would need extra help paying their drug bills.

Today, this special subsidy has ballooned into the program’s biggest cost, hitting $22.8 billion in 2012, according to the Medicare Payment Advisory Commission (MedPAC), a group that reports to Congress on Medicare. That’s up 35 percent since 2007.

The growth has been fueled in part by the meager co-pays set by Congress.

Note: Counts include initial prescriptions and refills dispensed. Retail price includes patients' out-of-pocket costs but does not reflect drug maker rebates.

Note: Counts include initial prescriptions and refills dispensed. Retail price includes patients’ out-of-pocket costs but does not reflect drug maker rebates.

For the more than 11 million who get the subsidy, generics cost no more than $2.65. Even the most expensive drugs cost the patients $6.60 or less.

Medicare reimburses drug plans for the difference between these amounts and what other enrollees pay.

With little incentive to be cost conscious, these patients and their doctors often use name brands when generics are readily available, studies show.

For others in Part D, typical co-pays for brand-name drugs — $40 to $85 — deliver a strong push towards generics, which generally cost less than $5.

A MedPAC analysis found that if low-income patients were prescribed generic drugs in the same proportion as other Medicare enrollees, the program could save $1.3 billion a year in just seven drug categories.

A separate study this year by the Bipartisan Policy Center, a Washington think tank, says savings could be greater across the program,perhaps as high as $44 billion in a decade.

“I really think that you need both the carrot of lower cost for the generic side as well as the potential stick of higher costs on the brand side,” Bruce Stuart, then a MedPAC member, said at a meeting last year. Stuart heads the Peter Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy.

Experts say that if patients had to pay higher co-pays for name brands, they would likely ask for something cheaper.

There’s no sign that the rules for Part D’s low-income subsidy will change anytime soon, however. Last year, MedPAC urged Congress to modify the co-pays to spur greater use of generics. President Obama proposed raising brand co-pays and reducing generic ones in his 2014 budget, but Congress hasn’t acted on it — and likely won’t,

“Would you really want to pay $10 a day for the same benefit as you would get for paying 10 cents a day?”– Pharmacist Mark Greg

Former CMS administrator Mark McClellan said encouraging greater use of generics makes sense.

But faced with angering either the powerful pharmaceutical lobby or advocates for the poor, he said, lawmakers may see no political benefit in pushing a change.

The drug industry’s leading trade group, the Pharmaceutical Research and Manufacturers of America, opposes higher brand co-pays for the poor. And the group has a history of batting away proposals that might cut into the billions of dollars of profits drug makers earn from high-margin products in Part D.

When Congress debated Part D in 2003, the group lobbied to kill a Democratic proposal to let the government negotiate volume discounts on drugs. In 2010, it helped squelch efforts to allow imports of cheaper drugs from abroad as part of the Affordable Care Act’s expansion of Part D.

Matt Bennett, a senior vice president with the group, called Part D a “success for both beneficiaries and taxpayers.” In a statement, he said, “Improved access to medicines in Part D not only leads to better health outcomes for patients, but it also lowers other Medicare spending.”

It’s illegal to pay to doctors to prescribe, but the money drug makers give doctors to speak or consult on their behalf appears to be a good investment. In June, ProPublica reported that 17 of the top 20 prescribers of Bystolic, including Quon, received speaking fees in 2012 from the manufacturer, Forest Laboratories.

The pattern extends to Part D’s top name-brand prescribers. Two doctors, in Kentucky and New Jersey, have each received more than $225,000 in promotional payments from drug makers since 2009. A large chunk came from AstraZeneca, maker of Crestor, the doctors’ most-prescribed drug.

AstraZeneca spokeswoman Michele Meixell said the company doesn’t choose its speakers based on prescribing but on “expertise in a therapeutic area, experience and qualifications.”

Part D’s Ethnic Hot Spots

Along one mile-and-a-half stretch of Los Angeles’ Koreatown, seven primary care doctors have some of the highest rates of name-brand prescribing in the country. Nearly 3,000 miles away in Brooklyn, N.Y., a single building in a Russian community houses six such doctors.

By mapping doctors who favor name brands, ProPublica found unexpected clusters in ethnic neighborhoods in and around the biggest cities. The average cost of a Part D prescription in these enclaves can be more than 50 percent higher than that of surrounding areas, the analysis showed.

Researchers have previously noted regional differences in the way doctors prescribe drugs. But ProPublica’s analysis aimed to unravel which individual doctors drive name-brand prescribing and what, if anything, they had in common.

Many worked solo or in small groups. Often they received their medical training outside the United States, records show.

Doctors’ drug choices can be influenced by many things — their peers, patient requests, a chat with a sales rep or studies in medical journals. In recent years, concern about undue influence has prompted many academic medical centers and large group practices to ban sales reps and to refuse free samples.

But many physicians in ethnic communities continue to embrace these relationships. When reporters visited offices in such neighborhoods of New York City and Southern California, drug reps crowded the reception counters as they unloaded rolling suitcases full of samples or waited to speak to the doctors.

Chinatown is one of the most densely populated parts of Manhattan. Outdoor fish markets crowd next to storefronts selling counterfeit handbags and pirated DVDs. Every block seems to have at least one pharmacy, and hundreds of medical offices are stacked above and around them. More than 90 percent of Part D prescriptions written in 2011 by these doctors were for the poor, Medicare data show.

“At some point, I think we have to hold providers accountable for their prescribing.” – Dr. Nancy Morden

The neighborhood is home to 20 high-prescribing primary care doctors who disproportionately favor name brands.

One of them, internist George Liu, is a founder and longtime leader of a prominent Chinese-American physicians’ association. In 2011, Liu wrote more than 9,000 prescriptions — 47 percent for name brands. By comparison, all internists in New York used name brands, on average, only 27 percent of the time.

Liu, who specializes in diabetes, said he does his own research on drugs and doesn’t depend on sales reps. A “new drug has a reason why it’s on the market,” he said.

Liu has given lectures for the makers of his favored drugs, he said. Three of his top 10 drugs are made by Eli Lilly, which has paid him $123,000 since 2010. One Lilly osteoporosis treatment, Forteo, cost Medicare $1,140 for a month’s supply.

Liu said scrutinizing how doctors use name brands is an “incorrect way of looking at medical care.” He and his peers are saving Medicare money, Liu said, by staying open long hours and keeping patients from costly emergency room visits.

In an office nearby, Dr. Henry Chen praised Part D for making it easy for poor patients to get name brands. He said it’s wrong that state Medicaid programs for the poor and some private insurers force doctors to get prior approval before prescribing them.

Chen wrote more than 50,000 prescriptions in 2011, placing him among the top 100 prescribers nationally in Part D. Forty-five percent of his prescriptions were for name brands. He said picking a drug is like choosing how to get from New York to Washington.

Chen, who also has an office in Brooklyn, was paid $11,400 to deliver promotional talks for Eli Lilly and Merck last year. In 2011, he received more than $2,500 in meals from Lilly alone. Two of the drugs in his top 10 are made by Lilly and another by Merck.

Dartmouth researcher Morden said doctors in these areas are shifting the excess costs to others. “The other person one neighborhood over who’s getting a generic product is subsidizing the brand products for that whole neighborhood,” she said.

Not everyone in Chinatown defends such prescribing.

Dr. Perry Pong, chief medical officer of a local health center, was dismayed to hear that his colleagues stood out for pricey drug choices: “That’s bad. I’m ashamed of that.”

Pong said his center tells doctors to use generics first. But Medicare’s figures show some haven’t done so, and Pong said he couldn’t explain it.

‘The Light Bulb Goes Off’

Pharmacist Mark Greg mimics the time-tested tactics of drug company sales reps. Like them, he studies doctors’ prescribing records, arms himself with medical studies and even provides lunch.

The difference: Greg is pushing generics.

He works for Advocate Physician Partners, part of a Chicago-area hospital chain that gives doctors bonuses for meeting performance measures that include generic use.

Greg, the group’s manager of clinical programs, asks doctors to see things from the patient’s point of view.

“Would you want to pay $10 a day for the same benefit as you would get for paying 10 cents a day?” he said. “In many cases the light bulb goes off.”

At one Advocate clinic in Chicago, 11 primary care physicians prescribed at least 80 percent generics in 2011. One of them, Dr. Tony Hampton, had an average prescription cost in 2011 of $41 — versus $89 among the 900-plus high name-brand prescribers in ProPublica’s analysis.

Dr. Tony Hampton of Advocate Health reviews the medicine prescribed to Annie-Mae Valentine, 85, an elderly patient during a visit at the Beverly Medical Building in Chicago on Nov. 12. (Nathan Weber for ProPublica)

Hampton wrote more than 14,800 prescriptions in Part D, 13 percent of them for name brands. He said he gets very little resistance: “It’s just a few patients who need that little extra push.”

Across the country, private practices and government agencies have tackled the high cost of prescribing and determined that they can trim spending without sacrificing patient care. Some tightly control the drugs doctors can prescribe; others ramp up the co-pays on costly drugs.

Some with the lowest name-brand use have close ties to insurance companies, such as Kaiser Permanente and Southwest Medical Associates in Las Vegas, which is owned by UnitedHealth Group.

At both Southwest and Advocate, patients taking generics have met or exceeded national success rates for lowering cholesterol and controlling diabetes.

“You can be cost-effective and have high quality,” said Dr. Linda Johnson, medical director for primary care at Southwest. Johnson and others said only a small percentage of patients react negatively to slight fluctuations in their medications and require a name-brand drug.

Mitra Behroozi, executive director of the 1199 SEIU Benefit and Pension Funds in New York, said her union’s health plan offers its 400,000 enrollees at least one option in each drug class, usually a generic, that is free. Members who want a name brand must spring for the difference, which can top $100 in some cases.

“We don’t pay for the latest, greatest if it’s not more efficacious,” she said.

The VA is likewise strict, often requiring prior approval for brands when generics are available. More than 80 percent of the 140 million prescriptions written annually by its doctors are for generics, said Mike Valentino, the agency’s pharmacy chief.

“We take out of the equation the marketing and advertising that drives so much of the prescription drug utilization in this country,” Valentino said.

The push has had a massive payoff.

Researchers have compared the VA’s prescribing to Part D’s. In a study that examined diabetes, cholesterol and blood pressure-lowering drugs, they found name-brand use under Part D in 2008 was two to three times higher than in the VA.

Medicare could have saved $1.4 billion if prescription choices mirrored those in the VA, according to the study, published in June by the Annals of Internal Medicine.

Lead author Dr. WalidGellad, an assistant professor of medicine at the University of Pittsburgh, said that Medicare needs to follow the VA or create a system that tracks doctors and rewards or punishes them for their choices.

“There’s this big narrative that Part D has been this huge success because it’s come in under budget,” Gellad said. “My personal opinion is that we could have done a lot better.”

Download data of name-brand prescribing by zip code.

ProPublica’s Eric Sagara contributed to this report.

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