TO PUBLISH AFTER NPR PUBLISHES
Consumers seeking health policies with the most freedom in choosing doctors and hospitals are finding far fewer of those plans offered on the insurance marketplaces next year. And the premiums are rising faster than for other types of coverage.
The plans, usually known as preferred provider organizations or PPOs, pay for a portion of the costs of out-of-network hospitals and physicians. They are the most common type offered by employers, and some consumers in the individual marketplaces find them more appealing than health maintenance organizations and other policies that pay only for medical facilities and doctors with whom they have contracts.This KHN story also ran on NPR. It can be republished for free (details).
In Kelly Filson’s Indiana hometown of Plymouth, all but two of the 75 insurance policies available on the health marketplace are the restrictive type. Only one of those would provide substantial coverage to the two hospitals her family wants access to next year, a local community facility and a children’s hospital where her 12-year-old will need special surgery. But at $1,109 a month, the policy is twice as costly as the cheapest plans in the area.
“I’m just trying to figure out what we can feasibly afford. That’s the bottom line, said Filson, a music teacher.
A Kaiser Health News analysis of costs in the three-dozen states selling policies through the federal healthcare.gov website found a sharp difference in premium prices between plans that offer out-of-network care and those that do not. The analysis compared the monthly premiums for the least expensive silver-level plans — the category that are the most popular purchases — for a 40-year-old in each county.
While the average premium for the least expensive closed network silver plan—principally HMOs—rose from $274 to $299, a 9 percent increase, the average premium for the least expensive PPO or other silver-level open access plan grew from $291 to $339, an 17 percent jump, KHN found. The cost variations hold true for any age.
Katherine Hempstead, who studies insurance offerings for the Robert Wood Johnson Foundation, said there are fewer PPOs because insurers found them more expensive to offer. That’s because out-of-network doctors generally charge more than the contracted rates insurers offer their in-network providers. And, even though insurers only pay a portion of an out-of-network bill, the costs add up.
“Out of network providers were causing carriers to lose a lot of money, and they really needed to put their thumbs down on that,” Hempstead said.
Hempstead found that there will be fewer or no silver-level PPOs in 22 states next year. Federal records show there will be none in Miami and most Florida counties, much of Texas, New Mexico, New York and many counties in Mississippi and South Carolina.
The price gap between PPOs and HMOs is growing in many places where both are offered. In Chicago, the least expensive silver PPO next year will cost $270 a month, $75 more than the least expensive silver HMO, and 27 percent more than the cheapest silver plan costs now. Meanwhile, the price of the least expensive silver HMO in Chicago is dropping by 12 percent.
In Salt Lake City, the premium for the only silver PPO is growing by 30 percent, nearly four times the increase for the least expensive HMO. In Philadelphia, the cheapest silver PPO will be $389, $113 more than the cheapest HMO. This year, Philadelphians wanting a silver open access plan had to pay just $66 more. As in many places, insurers also are selling different bronze, gold and platinum PPOs (the metals indicate how the insurer and patient divide the cost of care), but the cheapest plan in each tier in Philadelphia is an HMO.
In Houston, the only plans available through the federal exchange have closed networks. Blue Cross Blue Shield of Texas, which offered a PPO plan in Houston for 2015, cited rising costs as a reason it will not offer any open access plans next year. There is at least one PPO that consumers can purchase directly or through a broker, offered by the Memorial Hermann Health System, but it is not listed in the federal marketplace offerings so premium subsidies are not available.
“Everyone is up in arms,” said Jo Middleton, a Houston insurance broker. “I do not have a single client who is happy. They want PPOs and can’t get them. They want the flexibility.”
The biggest complaint, she said, is not that the HMOs don’t allow out-of-network coverage, but that their networks are too small.
“If you are someone who needs several doctors and several specialists, it’s difficult to find a network they are all in,” Middleton said. “In many cases, the doctors may be in a network, but only have admitting privileges at a non-network hospital. In the 11 years I’ve been in the business, this is unprecedented.”
None of the plans available through the federal exchange in Houston include the city’s well-known MD Anderson Cancer Center in their networks. “It’s a huge problem,” said insurance broker J. Casey Lowery. “If you’re a cancer patient, think about it. All of a sudden you have to switch doctors. Or, if you want to stay with a doctor because he saved your life, and now you’re in an HMO, you have no coverage.”
Dan Fontaine, an administrator at MD Anderson, said some insurers did not invite the cancer center into their network. Others offered payment rates that he said “we don’t consider serious” because they were too low “and oftentimes less than what Medicare or Medicaid pay us.” He said the center was trying to make arrangements with insurers for patients who are in treatment now.
Plans with out-of-network benefits are not disappearing everywhere. Alaska, Arkansas and Wyoming are bucking the trend by only offering PPOs. Out-of-network costs even with PPOs can be prohibitively expensive since many PPOs will only cover a minority of costs, diminishing the difference from HMOs. Also, people who qualify for government premium subsidies can be insulated from the full cost of a PPO.
Allen Gjersvig, an executive at the Arizona Alliance for Community Health Centers, says one PPO in the state requires approval before seeing a specialist—a restriction often associated with HMOs—while there are HMOs that don’t mandate pre-approval of specialist visits. “The meaningfulness of HMO and PPO is starting to really blur,” he said.
Brokers say they are scrambling to help customers find new plans.
“I’m 31 and hardly go to the doctor,” said broker Michael Ledgerwood, president of the Houston Association of Health Underwriters. “If my doctor isn’t in the network, I don’t care. But my response would be quite different if I had more health care issues or saw more specialists.”
Our post last week on “sundowning” — a syndrome in which seniors’ behavior changes dramatically after dark — generated an outpouring of stories from patients, caregivers and people working in hospitals, in hundreds of comments on Facebook.
Many brought up the fact that delirium and sundowning are related. While sundowning is thought to happen in elderly patients with advanced dementia, many people described seeing sundowning in others — like a relative after surgery. While experts aren’t sure how much sundown syndrome and delirium overlap, they agree that not everyone who gets confused at night is sundowning.
Delirium is very common and also gets worse at night. So the first time someone experiences delirium they should be checked for underlying and reversible causes like infections or mind-altering medications.
People also pointed out that sundowning can happen at home as well as in the hospital. For people with severe dementia like Alzheimer’s, this is especially true.
Some commenters referenced “The Visit,” a recently released horror movie where two children are visiting their elderly grandparents who exhibit erratic and violent behavior each night. I haven’t seen it myself, but it seems to be taking the concept to the extreme in the most frightening way possible.
Many of the stories on Facebook were particularly moving. We thought we’d share a few:
The nurses told me this might happen and requested someone stay all night with her, which I did. She was seeing red roses everywhere and wanted to get out of bed and pick them! Her hands were moving just as if she had scissors and a basket to hold them. Another time she saw waterfalls. At least she saw something beautiful.
I watched my mom suffer through this. She would sleep all day unless the staff of the nursing facility kept her engaged in activities but she became increasingly agitated as evening fell. She actually got out one evening and a staff nurse who happened to be driving to work found her driving her wheelchair down the street at 2 a.m. “Going home” is what she told the nurse.
The article suggests keeping hearing aids within easy reach. My late father had dementia and had a habit of flushing inappropriate things down the toilet. His hearing aids disappeared while he was in a rehab hospital following hip surgery. We believed he may have flushed them down the toilet.
There also were a number of heartwarming stories of family and caregivers dealing with this condition in creative and heroic ways:
My grandmother had senile dementia and lived in her own apartment in our home. As her confusion increased, I began sleeping on the floor in her room because she was up all night and endangering herself. One night she screamed that she had to push the baby out. Not knowing what else to do, I said OK PUSH! And she did and I said Here’s the Baby! She calmed down and went back to sleep. The next morning she asked me where the baby was. Luckily my uncle (who had schizophrenia and lived her her apartment but with us also) was sitting across from her. I said, here’s your baby right here. Since it was true, she believed me and let it go…
We deal with this every night. We have kept my husband’s 91 year old grandmother in her own home with her husband through a lot of effort and determination but when that sun sets, it’s easy to consider putting her in a facility because she completely loses it and starts looking for kids and dogs that aren’t there, talking to herself, and being obsessed with electronics having lights…. if they have lights, she HAS to turn them off somehow and she will not go to bed until they turn off…. Sometimes she says the most bizarre things… It’s sad to watch, but we continue to work hard to keep her and her 99 year old husband in their home, and not in a facility.
Some years ago (I’ve been a nurse just over 20 years), I had a patient offer me a small stack of tri-fold paper towels, saying “These are all my war bonds. Can you help me escape?” It took an army itself to hold back my tears…this man trusted ME…. I said to him… I have have a safe place for you to sleep; I will watch over you while you rest…. I lead him back to his bed whilst he laid his head down, unable to take his “money” as he may need it for later. I think to myself… This man fought for ME; I will not let him down. We all have our inner fight… What are you struggling for??
While a few people lamented that some hospitals were clueless about sundowning and delirium, others talked about hospitals that were success stories:
The hospital I currently work in has an strong non-pharma approach to sundowning including “a sense of security,” “knowing baselines” (when possible), “providing hobbies” or simple activities,” and often we provide a “sitter” (someone who has received a brief training on how to interact w/ confused patients by implementing the previously listed interventions). As an RN, I would often direct support staff to initiate activity (walking when possible), but the fact that these patients are confused, usually a bit anxious or downright afraid, and the fact that we have other patients trying to sleep at night often made walking the halls prohibitive. These “sundowning” patients often have a goal of getting off the floor and out of the hospital, and walking by doors and elevators can often escalate their focus on wanting to “escape.” The interventions listed in this story are a jumping off point, but, in my experience (18 years as an RN and 2 years as a CNA), these interventions are ineffective. We need more research to help keep our sundowning patients safe.
And many people were thankful for the compassionate individuals who work in hospitals who went the extra mile to provide care for a loved one who may have been sundowning.
I will never forget one particular nurse who decided it was perfectly alright to let my mom sit in her wheelchair at the nurses station and answer a phone that they disconnected from the switchboard. It gave my mom a feeling of purpose in an otherwise scary and overwhelming time. I received one or those middle of the night “we can’t get her to calm down or cooperate” phone calls but by the time I got there the head nurse had decided to approach the situation differently than medicating and sending her back to her room. My mom was sleeping peacefully in a wheelchair at the nurses station having answered so many pretend calls.
Thank you so much for your compassion. When my grandpa had cancer, he had to be admitted to hospital for tests we already knew it was the worst. Sundowning was the hardest to see. The RNs and the CNAs were so amazing. The first couple of weeks we would rotate staying over night at the hospital. So we saw the Sundowners first hand, one night the RN pull us aside and said, “Go home and get some rest. I will personally see that he’s okay.”
David Scales, M.D., Ph.D. is a third year resident in internal medicine at Cambridge Health Alliance.Earlier:
Around the country, prisoners are clamoring to be cured of a potentially deadly disease, while prison administrators are reeling from the treatment’s price tag. Hepatitis C, a virus that can eventually cause cirrhosis, liver cancer, and other serious outcomes, affects some three million Americans, one-third of whom pass through U.S. prisons and jails each year.
One 12-week treatment course can cost upwards of $90,000. With a constitutional obligation to provide medical care to inmates, prison officials—whose health-care budgets are a zero-sum proposition—are struggling to treat even a fraction of those with the disease.This copyrighted story comes from The Marshall Project, a nonprofit news organization that covers the U.S. criminal justice system. All rights reserved.
But a new study suggests that despite its cost, testing all prison inmates for hepatitis C—and treating them when appropriate—is extremely cost-effective. Using an “opt-out” system—testing each prisoner as a matter of course unless he specifically declines—could prevent between 10,900 and 12,700 new hepatitis C infections, most of which would occur in the community after infected prisoners returned home. The study also found the testing and treatment would lead to a significant decrease in the number of liver transplants, cases of liver cancer, and other liver-related deaths in the community.More About This Story This story was written by Beth Schwartzapfel for The Marshall Project, a nonprofit news organization that covers the U.S. criminal justice system. Sign up for their newsletter, or follow The Marshall Project on Facebook or Twitter.
“Hepatitis C is a progressive disease—it could take 30 years to progress to advanced liver cancer,” says Dr. Jagpreet Chhatwal, a radiologist at Harvard Medical School and the study’s senior author. “If you compare that to the average time spent inside prison, which is three to five years, it would make sense these people would be part of the community when this started happening.”
Transmitted primarily by injection drug use, hepatitis C afflicts 17% of prisoners, compared to 1% of the general population. Public health advocates have for years described testing and treatment of hepatitis C in prison as a “public health opportunity.” Given high rates of the disease, “testing, education, and, when appropriate, treatment of prisoners should be a cornerstone of the public health response to the hepatitis C epidemic in the United States,” argued three correctional and public health physicians in a medical journal 10 years ago (and again last year).
That’s not how things panned out. Because the most serious complications of hepatitis C can take decades to emerge, cash-strapped correctional officials have been reluctant to treat seemingly healthy inmates whose medical problems won’t show themselves until long after they are released. What’s more, first-generation treatments took up to a year, caused serious side-effects, and were only effective about half the time for most patients. Even prisons with dedicated treatment programs were treating a few dozen people out of the hundreds of thousands of prisoners with hepatitis C.
Now, new hepatitis C medications can cure 90% of patients in as few as 12 weeks; guidelines from the major medical societies recommend treating all patients with hepatitis C—and single out incarcerated people as a group for whom treatment could have the secondary benefit of preventing transmission to others. But still prison administrators in most states have been slow to offer testing or treatment in any substantial numbers. (In Massachusetts and Minnesota, prisoners have filed class-action lawsuits to gain access to the drugs.)
“There is an incentive for prisons to put their head in the sand,” says Emory Medical School’s Anne Spaulding, one of the co-authors of the paper. “The more cases you find with aggressive screening, the more cases you might need to treat.”
This new paper, which appears in the medical journal Annals of Internal Medicine, found that universal screening—and treatment of any prisoner whose liver disease is found to be moderate or severe—could avert $760 million in spending on liver transplants and other medical care over thirty years. At least 80% of that spending would have been in the general population. “That’s the whole motivation of this paper, showing if we start treating people in prison, the whole society benefits,” says Chhatwal. Because the benefits would accrue to society at large, and not to the prison, Chhatwal suggests that state and federal governments should step up and provide supplemental funding to manage hepatitis C in prisons. The paper put the first-year cost of implementing the screening and treatment programs at $1.1 billion across the state and federal systems—about 12 percent above what they’re spending on health care now. “Cost effective” is not the same as cost saving: “It means something will cost additional money, but it’s worth spending,” Chhatwal said.