Kaiser Health News

An Arm and a Leg: Meet the Middleman’s Middleman

Published

7 days ago

June 25, 2024

Dan Weissmann
Tue, 25 Jun 2024 09:00:00 +0000

Some people who expected their health insurance to cover some out-of-network care have been getting stuck with enormous bills.

One Kansas City, Kansas, couple paid thousands of dollars out-of-pocket and up-front for care. They expected to get a partial reimbursement from their insurer. So, they were shocked when instead they got a bill saying they owed even more than what they'd already paid.

It turns out, a little-known data firm called MultiPlan was working with their insurance company to suggest cuts to their coverage. MulitPlan says it's helping control ballooning health care costs by keeping hospitals and providers from overbilling. But it's often patients left paying the difference.In this episode of “An Arm and a Leg,” host Dan Weissmann breaks down this confusing world of out-of-network care with New York Times reporter Chris Hamby, who recently published an investigation into MultiPlan.

Dan Weissmann

@danweissmann

Host and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

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Emily Pisacreta
Producer

Claire Davenport
Producer

Adam Raymonda
Audio wizard

Ellen Weiss
Editor

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Transcript: Meet the Middleman's Middleman

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there! Paul and Kristin live in Kansas City with their two kids. Kristin and their daughter, the older kid– they have some complex medical issues, need to see some specialized folks. And some of those folks don't take Kristin and Paul's insurance. They're “out of network,” so Kristin and Paul pay out of pocket– a lot. Maybe $20,000 a year. BUT their health insurance plan does reimburse some out-of-network care.

o, in January 2023, Kristin called a help line connected with the insurance plan to find out how that was gonna work.

Kristin H: They basically said, sure, easy peasy, you pay and then you get online and you click this form, you show what you paid, and then we send you a check and reimburse you.

Dan: Kristin was on it. She built a whole spreadsheet to track every bill she paid, every reimbursement form she'd submitted. And she waited for the checks. The insurance company gave itself months just to process the claims. And when they finally sent statements, the statements seemed … weird. They were like:

Kristin H: Here's what you paid, and here's your discounts, and here's what you may owe.

Dan: And Kristin was like … what?

Kristin H: Because I was thinking, well, I don't owe anything. We paid out of pocket, but then I was thinking, well, this must be the portion that they're paying us back. But then the math didn't add up.

Dan: Yeah. Not at all. Kristin was expecting to get 50 percent back, like her plan said she would. But this amount wasn't anything like 50 percent. And what's this “discount” business?

It took months– and a lot of digging from Paul, and ultimately a talk with a NewYork Times reporter– before Kristin and Paul understood what was going on, and why it was costing them thousands of dollars.

What they didn't know until that New York Times story came out was: Someone was making a multi-billion dollar business out of experiences like theirs. As that story made clear, LOTS of people who expected their insurance to cover them for expensive out-of-network care ended up on the hook for a lot more than they'd expected.

That story introduced readers to a character who's become kind of a TYPE on this show. Not a type of person, but a type of business: A middleman that works behind the scenes with insurance companies. So we've seen that dynamic with pharmacy benefit managers– the folks who decide what drugs you can get and for how much– and more recently, we looked at a company that uses an algorithm to justify kicking folks out of nursing homes. The middleman in this New York Times story was a company called MultiPlan.

Reporter Chris Hamby found MultiPlan and insurance companies they worked with were leaving patients on the hook for huge amounts that they absolutely had not expected to pay. MultiPlan was also, along with those insurance companies, pocketing big fees. That story got some folks' attention. A U.S. Senator has called for action from antitrust regulators. Those regulators might get interested. And we may wanna egg them on– so we're gonna need to understand the whole scheme. Whothis middleman is– MultiPlan– and how they got themselves in the middle of 60 million people's health insurance, by their own estimate … and how they make a lot of money.

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I'm Dan Weissmann. I'm a reporter, and I like a challenge. So, our job on this show is to take one of the most enraging, terrifying, depressing parts of American life– and bring you a show that's entertaining, empowering, and useful.

And this time, I've got help.

Chris Hamby: My name is Chris Hamby. I'm a reporter on the investigations desk at the New York Times.

Dan: Yeah, and of course, Chris is the one who spent months figuring out the story of this middleman company, MultiPlan.

Chris Hamby: I was poking around a number of areas related to health insurance, and this name just kept coming up.

Dan: Like in lawsuits.

Chris Hamby: And it wasn't always terribly clear what they did exactly or how they were compensated.

Dan: Or how doctors and patients– regular people– were affected.

Chris Hamby: So that's why I decided to try and figure this out, and it's sort of an opaque space as so many areas of health care are these days.

Dan: Yeah. In fact, in order to understand this story at all– to understand who's doing WELL in this scenario– we've gotta peel back a layer. It's something we've talked about here before, but not for a while, and you know, not even my mom remembers everything I've ever said here.

This is about the mechanics of how most health insurance people get from their job actually works: about who actually pays medical bills when your insurance settles a claim. It's not the insurance company. It's actually the employer paying those bills.

Of course, employers don't know how to actually RUN an insurance plan. [Unless the employer is Aetna, I guess]. So they hire insurance companies to administer them. You get a card that says Cigna or Blue Cross, but your employer's funds actually pay the medical bills, so these are called “self-funded” plans. But this is all stuff most of us are just not aware of.

Here's Chris Hamby:

Chris Hamby: I hadn't, until about a year ago, even heard of a self-funded plan. And I like to think that I'm reasonably well informed on this stuff.

Dan: Yeah, that is putting it mildly. Chris made his name and won a Pulitzer Prize covering workplace health issues. So, just park that for a minute: self-funded plan, where the employer is the “self,” actually paying the bills, and paying the insurance company a fee. The insurance company is a middleman.

OK, now, next layer: The middleman's middleman. In this case, the company MultiPlan that Chris wrote about. What's their job? So in this story, the job they're doing– their middleman job– is to address what is admittedly kind of a tough question: If you go see somebody– a doctor, a therapist– who doesn't take your insurance, what happens?

Chris Hamby: How do you determine what a fair amount to pay the provider is? And by extension, how much is the patient potentially on the hook for the unpaid balance? And that has long been a contentious issue.

Dan: Because, if they don't take your insurance, a provider could charge … absolutely anything. So is your insurer– and again, that's often actually your employer– supposed to pay absolutely anything? How much are they supposed to pay? Figuring that out, it's a job.

About 15 years ago, another middleman company doing that job got sued by the NewYork state attorney general. The state said this earlier middleman's way of figuring out what to pay was screwing over both providers and patients. And the state's lawsuit produced a solution.

Chris Hamby: The insurance companies agreed to fund the creation of a nonprofit entity that was going be sort of an independent, neutral arbiter of fair prices. It was going to collect data from all the insurers and just make it publicly available. Make sure it was transparent to everyone.

Dan: This nonprofit is called FAIR Health, and its data is actually public. It still exists. Like, you can use it yourself — you can look up the going rate for a knee replacement, a blood test, whatever.

Chris Hamby: You can plug in your zip code, plug in your medical procedure and see an estimate of what, you know, typical out-of-network charges and in-network charges would be for these.

Dan: It's cool! Check it out yourself; it's useful. And all the major insurance companies agreed to use it– to use FAIR Health's benchmarks– to decide what to pay for out-of-network stuff. But, those agreements only committed insurance companies to using FAIR Health for … five years. They expired in 2014.

Enter middleman companies like MultiPlan, saying to insurance companies: Hey, you COULD use FAIR Health– or you could route out-of-network bills to us: Hire us to get you an even better deal– better prices.

Chris Hamby: And it's important to note also that this is a time when private equity is investing in healthcare, and there are some legitimate concerns about driving up those list prices to ridiculously high levels in a lot of cases. So, there were real issues that insurers were saying that they were responding to at the time.

Dan: OK, so that's the pitch. MultiPlan is saying to insurance companies: We'll help you hold the line. We can save you more money than if you used FAIR Health. Well, kind of. Because here's where we come back to the whole thing about self-funded insurance. MultiPlan isn't saying, “We can save YOU, insurance company, more money than if you used FAIR Health.” They're saying, “We can help you save your CLIENTS– employers who do self-funded health insurance– more money. And when you save them money, you're gonna make money. Because you can charge them a percentage of what you're saving them. And we'll get a percentage too.” A percentage of the savings. On every single bill. That's a very different deal than just using FAIR Health's data.

Chris Hamby: FAIR Health is not taking a percentage of the savings that they obtain. They're just selling you their data. And the insurers typically are not charging employers a fee for using FAIR Health's data. But if they use MultiPlan's data, both MultiPlan and the insurer typically charge a fee.

Dan: A percentage. In examples from Chris's story, the insurance company gets 35 percent of those savings.

Chris Hamby: And this has become a significant amount of money for a lot of insurance companies. Overall, UnitedHealthcare, is up to, you know, around a billion dollars per year in recent years.

Dan: UnitedHealthcare collects like a billion dollars in fees for these services, basically, for using MultiPlan specifically?

Chris Hamby: And they couch that by saying some other out-of-network savings programs, but yes.

Dan: Whooh!

Chris Hamby: One thing that the insurers say is that the employers are aware of this; they've signed up for it.

Dan: That employers are hiring, say, Cigna, with MultiPlan to find savings. And employers are agreeing to the fees.

Chris Hamby: Where it gets a little bit dicier from the employer's perspective is when you see claims where, for instance, you end up paying the insurance company more in fees than you paid the doctor for treating your employee.

Dan: yeah, one example from Chris's story: An out-of-network provider wanted more than $150,000 on one bill. And after the insurance company and MultiPlan did their bit, the employer, a trucking company, ended up paying $58,000. Eight thousand for the provider, and $50,000 to the insurance company and MultiPlan. So, on the one hand, the employer maybe saved $90,000. But paying $50,000 for “cost containment?” Maybe doesn't sound like such a bargain.

Some employers and a union that runs a health plan have filed lawsuits looking for some of that money back. And there's also a big irony here because MultiPlan's pitch is, you need us because sticker prices are super-wildly high. But MultiPlan isn't doing anything to contain the sticker prices as a systemic problem. In fact, the higher providers crank up their sticker prices, the more money MultiPlan and the insurance companies they work with can make. But then there's a big question too, which is, what happens to the rest of that bill for the sticker price? Who pays that? That's next …

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News. The folks at KFF Health News are amazing journalists. Their work wins all kinds of awards, every year. We're honored to work with them.

So, a provider sends a bill. MultiPlan and the insurance company say, “Woah, way too much.” And then what happens? Well, it depends. Sometimes, MultiPlan negotiates with the provider. They've got people who do this. And those negotiators drive hard bargains. According to Chris's story, negotiators sometimes tell providers: Here's my offer, you've got a few hours to take it or leave it, and my next offer might be lower.

Chris talked with a pediatric therapist who said an offer based on MultiPlan's calculation was less than half of what Medicaid pays. Less than half. And Medicaid rates– they're notoriously pretty low. Chris talked with some of MultiPlan's negotiators too.

Chris Hamby: It was interesting because some of the negotiators felt that they were doing their part to hold down costs and really sort of stick it to providers and hospitals that were price gouging.

Dan: But …one told Chris she knew the offers she made– they weren't fair. “It's just a game,” another one said. “It's sad.” And maybe the difference is that some of these negotiators were thinking of a big hospital charging $150,000 for something. And maybe some of them were thinking of someone like that therapist– the one who got offered less than half of Medicaid's rate.

And I'm not gonna get into the question of who should be doing this kind of negotiating, or what's fair. I mean, not today, anyway. Because: in a lot of cases with MultiPlan, there's no negotiation at all. Negotiation only happens when the employer has told the insurance company, look, protect my people. Figure out SOMETHING with the provider so they don't go after my workers for the rest.

But that doesn't always happen. A lot of the time, what happens is: The provider sends a bill. The insurance company kicks in whatever it decides to … and that's it.

So Chris's story opens with a woman who had surgery. With MultiPlan's help, her insurance company decided to pay about $5,400. And she got stuck with a bill for more than $100,000.

And then there's Kristin and Paul in Kansas City. They paid their bills upfront and then looked to get reimbursed– kept a spreadsheet. But when their claims finally got processed, the numbers didn't add up. Here's what they saw: Like pretty much every insurance plan, Kristin and Paul's had a “deductible”– an amount they had to pay out of pocket before insurance would reimburse anything.

Kristin H: Then I started watching the deductible and you know, when I calculated my spreadsheet of how much we had paid out of pocket, and when we saw what was on like our out-of-network spend, those two weren't matching.

Dan: She really couldn't figure this out.

Kristin H: I just kind of handed over all of my spreadsheets to Paul, and so that's when he started digging into the “your discount.”

Dan: “Your discount…” That was this mysterious number on all the statements from the insurance company. In addition to the provider's rate, and what insurance might pay, the statements listed, quote, “your discount.”

Paul H: And I'm like, what is this? I don't understand why it's talking about a discount. We are paying cash out of pocket to the provider at their billed rate, and our insurance is saying that there's some sort of discount.

Dan: After a bunch of phone calls, he figured it out: The discount was … the difference between the amount on the bill and what the insurance company– with MultiPlan's help– had decided was a “fair price.”

Paul H: For example, an occupational therapy bill that might be $125, this third party adjuster might come back and say, essentially what the market rate for that should be is $76. And so, your discount, quote, unquote, is $49.

Dan: Except of course, it wasn't a discount for Kristin and Paul. They had already paid that $49, when they paid the provider upfront. Once Kristin and Paul learned what the “discount” actually meant, they started to understand who actually got the benefit– the insurer. Because …

Kristin H: That discounted rate is actually what will be applied to your deductible. So you're not going to hit your deductible nearly as quickly as you think. Right? Because we've essentially ignored half of your payment.

Dan: This hits Kristin and Paul in two ways.

First, it means they're actually spending a lot more before their insurance kicks in. It also means that when their insurance does start reimbursing them a percentage of what they've spent, the insurance is only paying a percentage of that lower amount. Overall, it means the reimbursements Kristin and Paul get are gonna be thousands of dollars less than they'd expected.

I mean, it took a LOT of work for Kristin and Paul to figure this out. At one point, Paul posted to Reddit asking for help– that's where Chris Hamby found him. In Paul's post, he noted how nobody ever even mentioned this third-party adjuster– not until he had already talked to his insurance company for what he said was “about 18 times.” Frequently on hold for 45 minutes or more.

Kristin says once they finally figured out what was going on, they could figure out how to budget for it. There were sacrifices. She stopped seeing one of her providers as often. But finally figuring out what was going on also allowed them to live with it.

Kristin H: The infuriating part was telling, like doing exactly what we were told to do, following the process, and then feeling like you are crazy. Like why, why doesn't this make sense? You know? And so I think I'm fortunate that Paul just wouldn't let it die and was gonna research until he figured it out.

Dan: You did all of the work, you tracked it down, you identified the problem, and you, as you say, kind of resigned yourself to it. You're like, okay, this Goliath is not– we don't have the slingshot for this. Goliath is stomping all over our town, and we have to live in that reality. Having the knowledge, having done that work, gives you, it sounds like, an ability to have some peace. Like having tracked it down means that this sucks, but it's not the same as living in a situation where like, now what? Like anything could happen.

Kristin H: Yeah, you feel crazy or hopeless. You know? Like I've done everything and this doesn't … So there's just the sense of like, am I missing something? You know, is there anything left for me to do? I recognize that everyone is not like this, but for me, knowledge is a gift.

Dan: Chris Hamby says there's rarely a way to get this kind of knowledge in advance. He says you're unlikely to find these kinds of details in your insurance plan document.

Chris Hamby: It typically will not say when you go out of network, we're going to send your claim to a third party that you've never heard of to price it. It will just give some sort of vague language about competitive rates in your geographic area. And if you call up in advance of seeking the care to try and get an estimate, most of the time you will not get much more specifics than that. They tell you you have to just go and they'll process the claim and you'll see when the explanation of benefits comes through.

Dan: Yeah, and look, I hate to get you even angrier, but Chris says the rules can change on you, without notice.

Chris Hamby: A lot of people that I talk with also have seen no change in their insurance plan, but they've seen their reimbursement rates decline over time.

Dan: Turns out, behind the scenes, their insurance made a switch from a service like FAIR Health, which looks at what's getting paid in general, to a service like MultiPlan, which looks for the steepest possible price cuts.

Chris Hamby: And the difference between those two amounts can be vast. So you have people who in some cases stop seeing their doctors because their costs doubled almost overnight.

Dan: Oh god. And still. Better to know. Better that as many of us know as possible. That's why Chris reviewed more than 50,000 pages of documents, and interviewed more than a hundred people for that story. And why lawyers for the New York Times helped get courts to agree to give him documents that had been under seal.

Kristin and Paul– who had figured most of this out for themselves– they definitely appreciated all that work.

Paul H: When Chris published the article that he did, it was very validating to know we're not the only ones who are in this same boat. And there's actually people who have had far worse experiences than ours. Like, ours kind of pale in comparison. And then immediately, like, within 24 hours to see 1,500 or 1,600 comments on the article talking about it. It's like, okay, I might not have the stone that can slay the giant, but maybe The NewYork Times has the right sling and they might have the right stone to at least start the conversation.

Dan: A few weeks after Chris's article came out, U.S. Senator Amy Klobuchar sent the top federal antitrust regulators a letter: She wanted them to take a hard look at MultiPlan.

Chris Hamby: She expressed concern about the potential for price fixing here.

Dan: Actually, Chris says some providers have already filed lawsuits against MultiPlan based on antitrust allegations.

Chris Hamby: The idea is that all the insurance companies outsource their pricing decisions to a common vendor. They're essentially fixing prices via algorithm is the allegation.

Dan: As we noted here a few episodes ago, these antitrust regulators in the Biden administration have gotten pretty feisty. [That was the episode about the cyberattack on a company called Change Healthcare. It was called “The Hack,” if you missed it. Pretty fun!]

And I mean, those antitrust regulators have their work cut out for them. And a lot of targets. But I do want to egg them on here. I suspect you do too. Meanwhile, you're egging US on.

Listener 1: The first thought that went through my head was I'm going to fight this because this is absolutely ridiculous. I've already paid for this.

Dan: A few weeks ago, we asked you for stories about your experiences with sneaky fees, often called facility fees.

Listener 2: When the facility fee is twice the office visit fee, it's just crazy. I mean, it's a 10-minute appointment for a prescription.

Dan: You came through, and now we're making some calls, digging in for more details, and learning so much. We're gonna have a sneak preview for you in a few weeks. Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport– our summer intern. Welcome aboard, Claire!– and edited by Ellen Weiss. Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Gabe Bullard is our engagement editor. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager.

An Arm and a Leg is produced in partnership with KFF Health News. That's a national newsroom producing in-depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling and journalism. Zach Dyer is senior audio producer at KFF Health News. He's editorial liaison to this show.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about INN at INN.org. Finally, thanks to everybody who supports this show financially. You can join in any time at https://armandalegshow.com/support/

Thanks for pitching in if you can, and thanks for listening.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you've got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

——————————
By: Dan Weissmann
Title: An Arm and a Leg: Meet the Middleman's Middleman
Sourced From: kffhealthnews.org/news/podcast/meet-the-middleman-for-middlemen/
Published Date: Tue, 25 Jun 2024 09:00:00 +0000

Post Views: 46

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Kaiser Health News

The Supreme Court Just Limited Federal Power. Health Care Is Feeling the Shockwaves.

Published

8 hours ago

July 1, 2024

Staff Editor

Stephanie Armour
Mon, 01 Jul 2024 15:30:00 +0000

A landmark Supreme Court decision that reins in federal agencies' authority is expected to hold dramatic consequences for the nation's health care system, calling into question government rules on anything from consumer protections for patients to drug safety to nursing home care.

The June 28 decision overturns a 1984 precedent that said courts should give deference to federal agencies in legal challenges over their regulatory or scientific decisions. Instead of giving priority to agencies, courts will now exercise their own independent judgment about what Congress intended when drafting a particular law.

The ruling will likely have seismic ramifications for health policy. A flood of litigation — with plaintiffs like small businesses, drugmakers, and hospitals challenging regulations they say aren't specified in the law — could leave the country with a patchwork of disparate health regulations varying by location.

Agencies such as the FDA are likely to be far more cautious in drafting regulations, Congress is expected to take more time fleshing out legislation to avoid legal challenges, and judges will be more apt to overrule current and future regulations.

Health policy leaders say patients, providers, and health systems should brace for more uncertainty and less stability in the health care system. Even routine government functions such as deciding the rate to pay doctors for treating Medicare beneficiaries could become embroiled in long legal battles that disrupt patient care or strain providers to adapt.

Groups that oppose a regulation could search for and secure partisan judges to roll back agency decision-making, said Andrew Twinamatsiko, director of the Health Policy and the Law Initiative at Georgetown University's O'Neill Institute. One example could be challenges to the FDA's approval of a medication used in abortions, which survived a Supreme Court challenge this term on a technicality.

“Judges will be more emboldened to second-guess agencies,” he said. “It's going to open agencies up to attacks.”

Regulations are effectively the technical instructions for laws written by Congress. Federal agency staffers with knowledge related to a law — say, in drugs that treat rare diseases or health care for seniors — decide how to translate Congress' words into action with input from industry, advocates, and the public.

Up until now, when agencies issued a regulation, a single rule typically applied nationwide. Following the high court ruling, however, lawsuits filed in more than one jurisdiction could result in contradictory rulings and regulatory requirements — meaning health care policies for patients, providers, or insurers could differ greatly from one area to another.

One circuit may uphold a regulation from the Centers for Disease Control and Prevention, for example, while other circuits may take different views.

“You could have eight or nine of 11 different views of the courts,” said William Buzbee, a professor at Georgetown Law.

A court in one circuit could issue a nationwide injunction to enforce its interpretation while another circuit disagrees, said Maura Monaghan, a partner at Debevoise & Plimpton. Few cases are taken up by the U.S. Supreme Court, which could leave clashing directives in place for many years.

In the immediate future, health policy leaders say agencies should brace for more litigation over controversial initiatives. A requirement that most Affordable Care Act health plans cover preventive services, for example, is already being litigated. Multiple challenges to the mandate could mean different coverage requirements for preventive care depending on where a consumer lives.

Drugmakers have sued to try to stop the Biden administration from implementing a federal law that forces makers of the most expensive drugs to negotiate prices with Medicare — a key cog in President Joe Biden's effort to lower drug prices and control health care costs.

Parts of the health care industry may take on reimbursement rates for doctors that are set by the Centers for Medicare & Medicaid Services because those specific rates aren't written into law. The agency issues rules updating payment rates in Medicare, a health insurance program for people 65 or older and younger people with disabilities. Groups representing doctors and hospitals regularly flock to Washington, D.C., to lobby against trims to their payment rates.

And providers, including those backed by deep-pocketed investors, have sued to block federal surprise-billing legislation. The No Surprises Act, which passed in 2020 and took effect for most people in 2022, aims to protect patients from unexpected, out-of-network medical bills, especially in emergencies. The high court's ruling is expected to spur more litigation over its implementation.

“This really is going to create a tectonic change in the administrative regulatory landscape,” Twinamatsiko said. “The approach since 1984 has created stability. When the FDA or CDC adopt regulations, they know those regulations will be respected. That has been taken back.”

Industry groups, including the American Hospital Association and AHIP, an insurers' trade group, declined to comment.

Agencies such as the FDA that take advantage of their regulatory authority to make specific decisions, such as the granting of exclusive marketing rights upon approval of a drug, will be vulnerable. The reason: Many of their decisions require discretion as opposed to being explicitly defined by federal law, said Joseph Ross, a professor of medicine and public health at Yale School of Medicine.

“The legislation that guides much of the work in the health space, such as FDA and CMS, is not prescriptive,” he said.

In fact, FDA Commissioner Robert Califf said in an episode of the “Healthcare Unfiltered” podcast last year that he was “very worried” about the disruption from judges overruling his agency's scientific decisions.

The high court's ruling will be especially significant for the nation's federal health agencies because their regulations are often complex, creating the opportunity for more pitched legal battles.

Challenges that may not have succeeded in courts because of the deference to agencies could now find more favorable outcomes.

“A whole host of existing regulations could be vulnerable,” said Larry Levitt, executive vice president for health policy at KFF.

Other consequences are possible. Congress may attempt to flesh out more details when drafting legislation to avoid challenges — an approach that may increase partisan standoffs and slow down an already glacial pace in passing legislation, Levitt said.

Agencies are expected to be far more cautious in writing regulations to be sure they don't go beyond the contours of the law.

The Supreme Court's 6-3 decision overturned Chevron U.S.A. v. Natural Resources Defense Council, which held that courts should generally back a federal agency's statutory interpretation as long as it was reasonable. Republicans have largely praised the new ruling as necessary for ensuring agencies don't overstep their authority, while Democrats said in the aftermath of the decision that it amounts to a judicial power grab.

——————————
By: Stephanie Armour
Title: The Supreme Court Just Limited Federal Power. Health Care Is Feeling the Shockwaves.
Sourced From: kffhealthnews.org/news/article/supreme-court-chevron-deference-doctrine-health-care-policy-shockwaves/
Published Date: Mon, 01 Jul 2024 15:30:00 +0000

Post Views: 13

Kaiser Health News

The Concierge Catch: Better Access for a Few Patients Disrupts Care for Many

Published

14 hours ago

July 1, 2024

Staff Editor

John Rossheim
Mon, 01 Jul 2024 09:00:00 +0000

“You had to pay the fee, or the doctor wasn't going to see you anymore.”

That was the takeaway for Terri Marroquin of Midland, Texas, when her longtime physician began charging a membership fee in 2019. She found out about the change when someone at the physician's front desk pointed to a posted notice.

At first, she stuck with the practice; in her area, she said, it is now tough to find a primary care doctor who doesn't charge an annual membership fee from $350 to $500.

But last year, Marroquin finally left to join a practice with no membership fee where she sees a physician assistant rather than a doctor. “I had had enough. The concierge fee kept going up, and the doctor's office kept getting nicer and nicer,” she said, referring to the décor.

With the national shortage of primary care physicians reaching 17,637 in 2023 and projected to worsen, more Americans are paying for the privilege of seeing a doctor — on top of insurance premiums that cover most services a doctor might provide or order. Many people seeking a new doctor are calling a long list of primary care practices only to be told they're not taking new patients.

“Concierge medicine potentially leads to disproportionately richer people being able to pay for the scarce resource of physician time and crowding out people who have lower incomes and are sicker,” said Adam Leive, lead author of a 2023 study on concierge medicine and researcher at University of California-Berkeley's Goldman School of Public Policy.

Leive's research showed no decrease in mortality for concierge patients compared with similar patients who saw non-concierge physicians, suggesting concierge care may not notably improve some health outcomes.

A 2005 study showed concierge physicians had smaller proportions of patients with diabetes than their non-concierge counterparts and provided care for fewer Black and Hispanic patients.

There's little reliable data available on the size of the concierge medicine market. But one market research firm projects that concierge medicine revenue will grow about 10.4% annually through 2030. About 5,000 to 7,000 physicians and practices provide concierge care in the United States, most of whom are primary care providers, according to Concierge Medicine Today. (Yes, the burgeoning field already has a trade publication.)

The concierge pitch is simple: More time with your doctor, in-person or remotely, promptly and at your convenience. With many primary care physicians caring for thousands of patients each in appointments of 15 minutes or less, some people who can afford the fee say they feel forced to pay it just to maintain adequate access to their doctor.

As primary care providers convert to concierge medicine, many patients could face the financial and health consequences of a potentially lengthy search for a new provider. With fewer physicians in non-concierge practices, the pool available to people who can't or won't pay is smaller. For them, it is harder to find a doctor.

Concierge care models vary widely, but all involve paying a periodic fee to be a patient of the practice.

These fees are generally not covered by insurance nor payable with a tax-advantaged flexible spending account or health savings account. Annual fees range from $199 for Amazon's One Medical (with a discount available for Prime members) to low four figures for companies like MDVIP and SignatureMD that partner with physicians, to $10,000 or more for top-branded practices like Massachusetts General Hospital's.

Many patients are exasperated with the prospect of pay-to-play primary care. For one thing, under the Affordable Care Act, insurers are required to cover a variety of preventive services without a patient paying out-of-pocket. “Your annual physical should be free,” said Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation. “Why are you paying $2,000 for it?”

Liz Glatzer felt her doctor in Providence, Rhode Island, was competent but didn't have time to absorb her full health history. “I had double mastectomy 25 years ago,” she said. “At my first physical, the doctor ran through my meds and whatever else, and she said, ‘Oh, you haven't had a mammogram.' I said, ‘I don't have breasts to have mammography.'”

In 2023, after repeating that same exchange during her next two physicals, Glatzer signed up to pay $1,900 a year for MDVIP, a concierge staffing service that contracts with her new doctor, who is also a friend's husband. In her first couple of visits, Glatzer's new physician took hours to get to know her, she said.

For the growing numbers of Americans who can't or won't pay when their doctor switches to concierge care, finding new primary care can mean frustration, delayed or missed tests or treatments, and fragmented health care.

“I've met so many patients who couldn't afford the concierge services and needed to look for a new primary care physician,” said Yalda Jabbarpour, director of the Robert Graham Center and a practicing family physician. Separating from a doctor who's transitioning to concierge care “breaks the continuity with the provider that we know is so important for good health outcomes,” she said.

That disruption has consequences. “People don't get the preventive services that they should, and they use more expensive and inefficient avenues for care that could have otherwise been provided by their doctor,” said Abbie Leibowitz, chief medical officer at Health Advocate, a company that helps patients find care and resolve insurance issues.

What happens to patients who find themselves at loose ends when a physician transitions to concierge practice?

Patients who lose their doctors often give up on having an ongoing relationship with a primary care clinician. They may rely solely on a pharmacy-based clinic or urgent care center or even a hospital emergency department for primary care.

Some concierge providers say they are responding to concerns about access and equity by allowing patients to opt out of concierge care but stay with the practice group at a lower tier of service. This might entail longer waits for shorter appointments, fewer visits with a physician, and more visits with midlevel providers, for example.

Deb Gordon of Cambridge, Massachusetts, said she is searching for a new primary care doctor after hers switched to concierge medicine — a challenge that involves finding someone in her network who has admitting privileges at her preferred hospitals and is accepting new patients.

Gordon, who is co-director of the Alliance of Professional Health Advocates, which provides support services to patient advocates, said the practice that her doctor left has not assigned her a new provider, and her health plan said it was OK if she went without one. “I was shocked that they literally said, ‘You can go to urgent care,'” she said.

Some patients find themselves turning to physician assistants and other midlevel providers. But those clinicians have much less training than physicians with board certification in family medicine or internal medicine and so may not be fully qualified to treat patients with complex health problems. “The expertise of physician assistants and nurse practitioners can really vary widely,” said Russell Phillips, director of the Harvard Medical School Center for Primary Care.

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By: John Rossheim
Title: The Concierge Catch: Better Access for a Few Patients Disrupts Care for Many
Sourced From: kffhealthnews.org/news/article/concierge-medicine-primary-care-doctor-pay-to-play/
Published Date: Mon, 01 Jul 2024 09:00:00 +0000

Did you miss our previous article…
https://www.galvestontrendingnews.com/kaiser-health-news/supreme-court-oks-local-crackdowns-on-homelessness-as-advocates-warn-of-chaos/

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Kaiser Health News

Supreme Court OKs Local Crackdowns on Homelessness, as Advocates Warn of Chaos

Published

3 days ago

June 29, 2024

Staff Editor

Angela Hart
Fri, 28 Jun 2024 20:27:00 +0000

The U.S. Supreme Court's watershed decision on homelessness Friday will make it easier for elected officials and law enforcement authorities nationwide to fine and arrest people who live on streets and sidewalks, in broken-down vehicles, or within city parks — which could have far-reaching health consequences for homeless Americans and their communities.

In a 6-to-3 ruling in City of Grants Pass v. Johnson, the justices in the majority said allowing the targeting of homeless people occupying public spaces by enforcing bans on public sleeping or camping with criminal or civil penalties is not cruel and unusual punishment, even if there are no alternative shelter or housing options available for them.

“It's hard to imagine the chaos that is going to ensue. It'll have horrible consequences for mental and physical health,” said Ed Johnson, director of litigation at the Oregon Law Center and lead attorney representing homeless defendants in the case.

“If people aren't allowed to engage in survival while living outside by having things like a blanket and a pillow, or a tarp and a sleeping bag, and they don't have anywhere else to go, they can die,” he said.

The case, the most consequential on homelessness in decades, comes amid widespread public frustration over the proliferation of homeless encampments — especially in Western cities such as Los Angeles, San Francisco, Phoenix, and Portland, Oregon — and the unsafe and unsanitary conditions that often fester around them.

An estimated 653,100 people were homeless in the United States in 2023, according to the most recent federal estimates, the vast majority residing in shanties, broken-down recreational vehicles, and sprawling tent camps scattered across urban and rural communities.

The Oregon city of Grants Pass, at the center of the legal battle, successfully argued that it was not cruel and unusual punishment to fine and arrest homeless people living outdoors or illegally camping on public property.

Mike Zacchino, a spokesperson for Grants Pass, issued a statement Friday that the city was “grateful” to receive the decision and is committed to assisting residents struggling to find stable housing. Theane Evangelis, the city's lead attorney, told the Supreme Court in April that if it couldn't enforce its anticamping laws, “the city's hands will be tied. It will be forced to surrender its public spaces.”

In the majority opinion, Justice Neil Gorsuch argued that the homelessness crisis is complex and has many causes, writing, “With encampments dotting neighborhood sidewalks, adults and children in these communities are sometimes forced to navigate around used needles, human waste, and other hazards to make their way to school, the grocery store, or work.”

However, Gorsuch wrote, the Eighth Amendment does not give the Supreme Court justices primary responsibility “for assessing those causes and devising those responses.” A handful of federal judges cannot “begin to ‘match' the collective wisdom the American people possess in deciding ‘how best to handle' a pressing social question like homelessness,” he wrote.

In a dissenting opinion, Justice Sonia Sotomayor wrote that the decision focuses on the needs of local government and “leaves the most vulnerable in our society with an impossible choice: Either stay awake or be arrested.”

Elected officials, both Republican and Democrat, have increasingly argued that life on the streets is making people sick — and they should be allowed to relocate people for health and safety.

“If government offers people help and they can't or won't accept it, there should be consequences. We have laws that need to be used,” said Sacramento Mayor Darrell Steinberg, who is an adviser to California Gov. Gavin Newsom on homelessness, referencing laws that allow the state to require mental health and addiction treatment, for instance.

The high court decision could further embolden cities to sweep encampments and could force homeless people to be more transient — constantly moving around to evade law enforcement. Sometimes they're offered shelter, but often there is nowhere to go. Steinberg believes many cities will more aggressively sweep encampments and keep homeless people on the move, but he does not believe they should be fined or arrested.

“I'm comfortable telling people that you can't camp in public, but I would not criminalize it,” he said. “Some cities will fine and arrest people.”

Advocates for homeless people say constant relocations will further imperil the health of this population and magnify public health threats, such as the spread of communicable diseases. They fear conservative-leaning communities will criminalize street camping, pushing homeless people to liberal municipalities that provide housing assistance and services.

“Some cities have decided that they want to fine, arrest, and punish people for being homeless, and the majority opinion tells communities that they can go ahead and do that,” said Steve Berg, chief policy officer for the National Alliance to End Homelessness. “If communities really want less homelessness, they need to do what works, which is make sure people have access to housing and supportive services.”

As they disperse and relocate — and possibly get arrested or slapped with fines — they will lose connections to the doctors and nurses who provide primary and specialty care on the streets, some health care experts say.

“It just is going to contribute to more death and higher mortality rates,” said Jim O'Connell, the president of Boston's Health Care for the Homeless Program and an assistant professor of medicine at Harvard Medical School. “It's tough, because there's a public safety versus public health” debate cities are struggling with.

As homeless people become sicker, they will get more expensive to treat, O'Connell said.

“Stop thinking about the emergency room, which is cheap compared to what we actually see, which is homeless people being admitted to the ICU,” he said. “I've got 20-something patients at Mass General today taking a huge amount of money to care for.”

In Los Angeles, which has one of the biggest homeless populations in America, street medicine provider Brett Feldman predicts more patients will need emergency intensive care as chronic conditions like diabetes and heart disease go untreated.

Patients on anti-addiction medication or those undergoing treatment to improve their mental health will also struggle, he said.

“People are already getting moved and camps swept all the time, so we already know what happens,” Feldman said. “People lose their medications; they lose track of us.”

Homeless people die at rates two to six times higher than residents living in stable housing, according to a May report from the Los Angeles County Department of Public Health. Drug overdoses and coronary artery disease were the top two causes of death since 2017.

Feldman said it may become harder to house people or place them into treatment programs.

“We rely on knowing where they are in order to find them,” Feldman said. “And they rely on us knowing where they are to get their health care. And if we can't find them, often they can't complete their housing paperwork and they don't get inside.”

The Biden administration has pushed states to expand the definition of health care to include housing. At least 19 are directing money from Medicaid — the state-federal health insurance program for low-income people — into housing aid.

California is going the biggest, pumping $12 billion into an ambitious Medicaid initiative largely to help homeless patients find housing, pay for it, and avoid eviction. It is also dramatically expanding street medicine services.

The Supreme Court decision could interrupt these programs, said Margot Kushel, a primary care doctor and homelessness researcher at the University of California-San Francisco.

“Now you're going to see disconnections from those case managers and housing navigators and people just losing touch in the chaos and the shuffle,” she said. “What's worse, though, is we are going to lose the trust that is so essential to getting people to take their medications or stop their drug use and, ultimately, getting people into housing.”

Kushel said the ruling would make homelessness worse. “Just having fines and jail time makes it easier for a landlord to reject you for housing,” she said.

At the same time, Americans are increasingly frustrated by encampments spreading into neighborhoods, ringing public parks, and popping up near schools. The spread is marked by more trash, dirty needles, rats, and human excrement on sidewalks.

Local leaders across deep-blue California welcomed the decision from the conservative majority, which will allow them to fine and arrest homeless people, even if there's nowhere for them to go. “The Supreme Court today took decisive action that will ultimately make our communities safer,” said Graham Knaus, CEO of the California State Association of Counties.

Newsom, a Democrat who leads a state with nearly 30% of the nation's homeless population, said the decision gives state and local officials “the definitive authority to implement and enforce policies to clear unsafe encampments from our streets,” ending legal ambiguity that has “tied the hands of local officials for years and limited their ability to deliver on common-sense measures to protect the safety and well-being of communities.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

——————————
By: Angela Hart
Title: Supreme Court OKs Local Crackdowns on Homelessness, as Advocates Warn of Chaos
Sourced From: kffhealthnews.org/news/article/supreme-court-grants-pass-johnson-homelessness/
Published Date: Fri, 28 Jun 2024 20:27:00 +0000

Post Views: 27