Cancer patients shopping on federal and state insurance marketplaces often find it difficult to determine whether their drugs are covered and how much they will pay for them, the advocacy arm of the American Cancer Society says in a report that also calls on regulators to restrict how much insurers can charge patients for medications.
While the report found fairly broad coverage for prescription cancer medications, most insurance plans in the six states that were examined placed all or nearly all of the 22 medications studied into payment “tiers” that require the biggest out-of-pocket costs by patients, the American Cancer Society Cancer Action Network said. Those drugs include some well-known treatments, such as Gleevec for certain types of leukemia and Herceptin for breast cancer, and even some generics.
“That is new this year. We didn’t see generic drugs placed on the highest tier in 2014,” said Kirsten Sloan, the group’s senior policy director.
Often, that tier means patients pay a percentage of the cost of the drugs, rather than a flat dollar amount, which is more common for drugs placed into lower cost-sharing categories. With many cancer drugs costing more than $5,000 a month, paying a percentage, also known as “co-insurance,” means patients must pay hundreds or even thousands of dollars at the pharmacy counter until they reach their annual insurance deductible.
This appears “not to be designed to encourage use of cheaper or more effective alternatives, but to extract the maximum patient cost-sharing for cancer drugs,” the report said.
The study called on the U.S. Department of Health and Human Services and state regulators to restrict insurers from charging policyholders a percentage of the cost of the prescription drugs, a proposal sure to face sharp opposition from insurers, who say it is one way to control overall spending and slow premium increases.Use Our Content This KHN story can be republished for free (details).
Clare Krusing, spokeswoman for America’s Health Insurance Plans, said insurers pick up the majority of the cost of prescription medications in most cases, and the restrictions the advocates urge don’t address what she says is the real problem. “The bigger issue here is the prices being charged by drug makers for these medications and whether those are fair and reasonable,” Krusing said.
But drug makers have a very different perspective. They say insurance plans that lack transparency and shift more costs to consumers are the problem.
“What do drug prices have to do with patient access to information about coverage, formulary placement and cost sharing?” asked Allyson Funk, spokeswoman for Pharmaceutical Research and Manufacturers of America. “Insurers are increasingly singling out medicines for high cost sharing and restrictions on access compared to other more expensive health care services. On average, patients pay out of pocket nearly 20 percent of their total prescription drug costs compared to 5 percent of hospital care costs.”
Meanwhile, in its report, the cancer advocacy group also questioned whether insurance plan designs that place a lot of cancer drugs into the highest cost-sharing tiers are discriminatory. Similar concerns have been raised by HIV/AIDS groups following reports that many plans place all or most HIV drugs — including generics — into high cost-sharing tiers.
Earlier this year, Avalere Health, a consulting firm, reported that some insurance plans sold on state and federal marketplaces place all drugs used for complex diseases like HIV, cancer and multiple sclerosis, into those highest cost tiers.
The study out Wednesday by ACS/CAN reviewed the drug formularies for 66 silver-level plans available to consumers in California, Florida, Illinois, North Carolina, Texas and Washington. These plans cover about half of marketplace enrollees nationwide. The 22 drugs are just a sample of the total number of cancer drugs available, but include several different classes of cancer treatments, and both oral and intravenous treatments.
In other recommendations, the report said that federal and state marketplaces where consumers buy insurance should do a better job of providing direct links to drug formularies, which are the lists of medicines covered by a plan. Additionally, they need to ensure that information about patients’ share of the cost of the drugs is accurately listed.
“Advocacy groups are telling consumers to be vigilant about picking a plan, but consumers then find they don’t have all the tools they need,” Sloan said.
Thousands of California adults are signing up for dental insurance offered for the first time by California’s health insurance exchange, Covered California, officials said Wednesday.
About 33,000 adults have signed up for the dental plans, including about 6,000 who also are signing up for health insurance on the exchange for the first time, said Peter Lee, Covered California’s executive director.
While dental coverage for children under age 19 is considered an essential benefit under the Affordable Care Act and is included in their health insurance plans, that’s not the case for adults. Most of the nation’s state-run health exchanges now offer separate dental plans serving adults and the federally run exchange also offers adult dental coverage.
Covered California is the second to last among the state-run exchanges to offer dental coverage for adults, said Jeff Album, a Delta Dental executive. Now only Washington state does not offer it.
In California, adults must purchase a health plan on the state’s exchange to be able to purchase an “add-on” dental policy, and they’ll pay monthly premiums ranging from $11 to $65, Lee said. These premiums are not subsidized like Covered California’s health premiums for lower-income people, but the dental plans can’t turn anyone away for pre-existing conditions.
The dental plans are optional and there’s no tax penalty for not enrolling in them.Use Our Content This KHN story can be republished for free (details).
Open enrollment in the state exchange’s health and dental plans started Nov. 1 and ends Jan. 31, and people who sign up by Dec. 15 can have their benefits start on January 1. Lee said Wednesday that 34,000 new consumers had selected a health insurance plan through the exchange since open enrollment began.
About 1.3 million Californians, including about 66,000 age 18 or younger, already had health insurance through the exchange before open enrollment started.
Covered California’s new dental plans are offered by Access Dental Plan, Anthem Blue Cross of California, Delta Dental of California, Dental Health Services and Premier Access. Delta Dental has signed up 23,000 of the 33,000 people who’ve purchased dental policies so far, Album said.
All of the plans will offer free preventive and diagnostic dental services for both adults and children. Consumers can choose from dental health maintenance organizations, which typically cost less but have more restricted networks of dentists, or dental preferred provider organizations, which offer more choice but higher out-of-pocket costs. Parents do not have to enroll their children in a family dental plan, because their dental coverage is included in their health plan. But some may choose to do so to gain extra coverage.
Dr. Ariane Terlet, a Berkeley dentist who serves as chief dental officer for Oakland-based La Clinica de la Raza and as a trustee for the California Dental Association, said that people without dental insurance are four times more likely to not get preventive care. Many Californians have found it difficult to buy dental coverage on the individual market and the new availability of Covered California’s dental plans expands access to care, she added.
“There isn’t a week that goes by where people don’t ask me what dental coverage is available for individuals,” Terlet said. “Having insurance is a critical step to improving dental care. This is really going to help a lot of people improve their health.”
The age requirement for tobacco sales would rise from 18 to 21 in the city of Boston, under a proposal out Wednesday from Mayor Marty Walsh.
If the plan is approved by the city Board of Health, Boston would become the second major city in the United States, after New York City, to increase the legal age for tobacco sales.
Currently, 83 smaller communities across Massachusetts make 21 the threshold for purchasing tobacco products. (Click the map below to enlarge it.)
Walsh’s proposal would cover all tobacco and nicotine products, including e-cigarettes.
“We know the consequences of tobacco use are real and can be devastating,” Walsh said in a statement. “These proposed changes send a strong message that Boston takes the issue of preventing tobacco addiction seriously, and I hope that message is heard throughout Boston and across the entire country.”
Walsh’s plan follows a strong recommendation from the American Academy of Pediatrics (AAP) last month, calling for a nationwide ban on tobacco sales to men and women under the age of 21.
“Tobacco use continues to be a major health threat to children, adolescents and adults,” Karen Wilson, chair of the AAP Provisional Section on Tobacco Control, said in a statement. “The developing brains of children and teens are particularly vulnerable to nicotine, which is why the growing popularity of e-cigarettes among adolescents is so alarming and dangerous to their longterm health.”
According to the mayor’s office, the rate of cigarette use among Boston high school students was down to 7.9 percent in 2013 — well below the national average of 15.7 percent — though use of other tobacco products is up in Boston over the last several years, the city added in its statement.
In 2005, nearby Needham became the first town in the country to pass a so-called Tobacco 21 law. Town Manager Kate Fitzpatrick says there were concerns about the impact on businesses initially, but “nobody has gone out of business because of it.” Fitzpatrick says many town residents are pleased with the results of the law.
A study out earlier this year shows the youth smoking rate in Needham dropped almost 50 percent in the first five years after ban.
Some convenience stores owners in Massachusetts have argued against increasing the legal age for tobacco sales, but no one from the New England Convenience Store Association has responded to a request for comment for this story. Cumberland Farms declined to comment.
The city of Boston Board of Health is expected to vote on Walsh’s proposal on Dec. 17. It approved, the changes would take effect in 60 days.
In September, Walsh signed an ordinance banning the use of smokeless tobacco products at all city sports venues.
This post was updated at 4:55 p.m. with additional reporting by WBUR’s Benjamin Swasey.Related:
The following is a guest post by Elin Hofverberg, a foreign law research consultant who covers Scandinavian countries at the Law Library of Congress. Elin is a prolific writer and has previously written for In Custodia Legis on diverse topics including What’s in an Icelandic (Legal) Name?, Glad Syttonde Mai! Celebration of the Bicentenary of the Norwegian Constitution, Happy National Sami Day!, the bicentenary of Norway’s constitution, and a boarding school scandal in Sweden.
The huge influx of refugees into Europe as a result of the Syrian crisis has drawn global attention to both security concerns as well as the ability of European countries to absorb this large number of asylum seekers.
It had been reported that Sweden and Germany are the target countries for most asylum seekers. In Denmark police reportedly initially followed migrants and asylum seekers to prevent them from crossing into Sweden in an effort to comply with the Dublin Regulation (Regulation (EU) No 604/2013 Of the European Parliament and of the Council (June 26, 2013)), which requires that asylum is sought in the first safe European country entered.
When asked by Danish reporters why they want to continue their travels to Sweden, several asylum seekers were quoted as claiming that Sweden is “much, much better than Denmark”. It is impossible to know exactly what these migrants were referring to. Both media and the Danish prime minister were also reportedly wondering why they prefer Sweden.
Recent reports show that in 2014 the chance of getting asylum were fairly similar in Denmark and Sweden, with Denmark accepting 67.7 percent of the total applications and Sweden 76.6 percent, compared with 41.6 percent for Germany. As measured per capita, however, Sweden far out-numbered both Denmark and Germany by accepting more than 300 refugees per 100,000 inhabitants, whereas Denmark accepted 100 and Germany just 50. Sweden has also been ranked in 2014 as one of the countries having the highest number of refugees per capita in the EU .
To understand why Sweden may be seen as a more attractive destination for asylum seekers, I have researched the different rules that welcome asylum seekers on either side of the Oresund Bridge.
Here is a brief presentation on the differences in asylum rules for Denmark and Sweden.
1. Who has the right to asylum?
Denmark and Sweden are both part of the European Union (EU) and signatories to the 1951 UN Convention Relating to the Status of Refugees and its 1967 Protocol (Convention and Protocol, respectively). As such, both countries are under legal obligation to accept asylum applications.
In accordance with the Convention and the Protocol, a refugee is a person who “owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.” (Id. Convention Art. 1 A(2), p. 14; Protocol Art. 1 (2).)
In addition to those qualifying as refugees under the Convention and the Protocol, the Danish Aliens Act also authorizes the grant of temporary residence to those risking the death penalty or torture if returned home, known as protected status. (Danish Aliens Act § 7 ¶ 2.)
As of 2014 a new type of temporary residence group was established. Temporary residence permits are given for a year at a time to persons needing temporary protective status “because of the risk for death penalty, torture, or other inhumane treatment or punishment as resulted from a specially serious situation in the home country marked by violence and encroachments of civilians,” known as temporary protected status. (Danish Aliens Act, § 7 ¶ 3.)
Denmark also provides temporary residence permits on humanitarian grounds in rare cases, for example when an asylum seeker is suffering severe illness. (Danish Aliens Act, 9 § ¶ 1.)
The Swedish Aliens Act grants the right to asylum to three different groups of asylum seekers: refugees, persons deemed in need of subsidiary protection, and persons in need of other protection who are present in Sweden. (Swedish Aliens Act, § 1.)
Similar to the Danish Aliens Act, the definition of a refugee under Swedish law is based on the 1951 UN Convention. Accordingly, a refugee is defined as a foreigner who is in a country where he or he is not a citizen because of “experiencing a well-founded fear of persecution because of race, nationality, religious or political beliefs or because of sex, sexual orientation or membership of other societal group” in the country of his or her nationality and “cannot, or because of this fear does not want to avail him or herself of the home country’s protection.” (Swedish Aliens Act, ch. 4 § 1.) The same definition also applies to a stateless person who is outside a country where he or she has previously had his or her residence. (Id.)
- Persons Deemed in Need of Subsidiary Protection
A person deemed in need of subsidiary protection is a “foreigner who does not qualify under the Ch.. 4 §1 Aliens Act definition as a refugee, and who is outside of his or her country of citizenship because there is a well-founded reason to believe that the foreigner would be at risk of being punished by death or be subject to corporal punishment, other inhumane or degrading treatment or punishment, or [being] a civilian, be in serious risk of injury due to an armed conflict, and the foreigner cannot, or because of the risk mentioned above, does not want to avail himself to the home country’s protection.” (Swedish Aliens Act, ch. 4 § 2.) The same applies to a stateless person who is outside a country where he or she has previously had his or her residence. (Id.)
- Persons in need of other protection
A person in need of other protection is defined as a “foreigner who [is not recognized as a refugee under the definition and] is outside the country where he is a citizen, because he or she is in need of protection due to external or internal military conflict, or because of other tensions in the country, [who] feels a well-founded fear of being subjected to encroachment, or [who] cannot return to his or her homeland because of a environmental disaster.” (Id.)
In addition to these three grounds for asylum, the Swedish Migration Office may, in “exceptionally distressing circumstances in exceptional cases,” grant residence permits to individuals who otherwise do not qualify as refugees. This typically applies to cases where there are young children who are ill and cannot receive care in their home countries.
Neither Denmark nor Sweden has set any numerical limits on how many refugees they will take in.
2. Are asylum seekers awarded permanent or temporary residence permits?
In the EU, the types of residence permit granted to asylum seekers are regulated on the national level.
Denmark only grants temporary residence permits ranging from five years for refugees to one year for individuals qualifying under Temporary Protective Status (not the same as asylum, see above). Denmark does not currently award permanent residence permits before the applicant has held a temporary residency permit for at least five years.
Sweden only grants two types of residence permits to asylum seekers: permanent or three-year temporary ones (which must at a minimum be extended by two years at a time). In exceptional cases due to national security, shorter temporary residence permits may be issued, but no shorter than one year. (Swedish Aliens Act, ch. 5 § 1.)
As of September 2014, the Swedish Migration Authority has adopted a policy that all Syrian refugees who are granted asylum in Sweden shall receive permanent residence permits. A review of this decision was requested by a parliament member representing the Sweden Democrats earlier this year.
On October 23, 2015, the Swedish government struck a deal with the opposition in which asylum seekers (excluding families or unaccompanied children) will receive temporary residence permits. The rules will apply to all asylum decisions that are made after the rules take effect regardless of when the application was first logged.
3. When can family unification be a ground for a residence permit?
In Denmark family unification is granted to spouses, partners and children of immigrants. However, individuals with a one year residence permit must first have this permit renewed before applying for family unification. In effect these asylum seekers must at minimum wait one year to be reunified with their family.
Generally family reunification requires that the sponsoring family member can show that he or she has a connection with Denmark and has the ability to provide for the family member it sponsors. However, refugees can be excepted from this criteria.
Sweden grants family unification for spouses, partners and children of the immigrant. It may also allow other family members in certain cases, typically when the applicant is dependent on a family member who has received a permanent residence permit in Sweden.
Normally, persons requesting to sponsor a relative are required to show ability to support themselves and “have a home of sufficient size and standard” for them and the relative(s). This requirement, however, does not apply to refugees and EU Citizens.
Once again, tomorrow I will provide information on the variety of benefits to which admitted refugees are entitled in Denmark and Sweden.
A Tale Of 2 Hospital Visits: How The Cost Of Care Can Vary Dramatically Depending On Where You’re Treated
The stomach cramp and nausea began one hot Friday evening in August, midway through a vacation on Martha’s Vineyard. The next morning, nearly doubled over in pain, a patient who we’ll call “Nancy” walked gingerly into the emergency room at Martha’s Vineyard Hospital.
Nancy is a 55-year-old former nurse who would prefer not to use her real name because she works with the hospitals in this story.
Even Nancy, who spends hours every day focused on health care costs, would gasp when she saw the bill for this visit.
In the ER, a doctor poked at Nancy’s tender belly and took blood for tests and a urine sample. The doctor ordered a CT scan of Nancy’s abdomen and pelvis, using contrast. It showed bulges, inflammation and thickening in Nancy’s colon. The diagnosis: uncomplicated diverticulitis. Nancy filled a prescription for an antibiotic, took some Advil, and felt better after a few days on a clear liquid diet.
Five weeks later, the diverticulitis monster invaded Nancy’s intestines again. This time she went to an urgent care center closer to home, run by Beth Israel Deaconess Medical Center (BIDMC). A doctor there ordered the same single CT scan of the abdomen and pelvis, again with contrast.
Nancy says the care she received at both places was great. But a month later, when she received the bills and her insurance company’s explanation of benefits for both visits on the same day, she was stunned.
The explanation of benefits show Blue Cross had paid Martha’s Vineyard Hospital almost seven times what it paid BIDMC’s urgent care center for the same CT scan — $3,888.76 vs. $574.97.
(Have a look at the explanation of benefits here. We compare the payment for the test, listed as “Technical Component,” and the payment to the radiologist, listed as “Professional Component.”)
Why a nearly seven-fold difference in payment for one test and the payment to read it?
I posed that question to Martha’s Vineyard Hospital (MVH). A spokeswoman said via email that MVH’s procedures and costs are very different from an urgent care center. The spokeswoman noted MVH is open 24/7 and must comply with lots of state and federal regulations that don’t apply to an urgent care center. MVH also said that Nancy had two scans at its facility, vs. one at BIDMC — that’s even though the Blue Cross summary only shows payment for one CT scan.
MVH also said it’s planning to open a walk-in clinic next year that would have a different, lower cost structure than the MVH emergency department.
The Blue Cross corporate office agreed with MVH that care in a hospital is more expensive than in an urgent care clinic. And a spokeswoman for Blue Cross said that MVH would be even more expensive because it’s an island hospital.
(A side note: If you’re sick on Martha’s Vineyard but you feel well enough to get on a ferry, a CT scan of the abdomen and pelvis, with contrast, goes for $1,398.35 at Falmouth Hospital. That’s the cash rate, which I got from the hospital. My Blue Cross representative said she did not know the Blue Cross negotiated rate.)
Martha’s Vineyard Hospital is part of the Partners HealthCare network, which includes some of the most expensive hospitals in the state. Neither the hospital nor Blue Cross mentioned this as a reason for the nearly seven-fold payment difference.
BIDMC declined a request to comment for this story.
Just for fun, I called the member line at Blue Cross to ask how much this CT scan would cost at BIDMC — the hospital, not their urgent care clinic. The member rep told me Blue Cross would pay BIDMC $1,276 for a CT scan of the abdomen and pelvis with contrast at any facility owned by that network. She said the hospital and urgent care center would receive the same payment for the test. She’s wrong, according to the summary Nancy received from Blue Cross, but this illustrates how tricky it can be to unravel the mysteries of this — or any — health care bill.
If you have more tales from the rabbit hole of health care bills and price, do share. Maybe we can find our way out together.
On May 15, a staff member at a rural development organization in India registered with TechSoup because they believed technology could make their organization stronger. They were the millionth to do so.
Focusing specifically on health care, the Urban Institute’s Robert D. Reischauer and Brookings Senior Fellow Alice M. Rivlin write that there are three main health care issues the candidates should focus on. First, on the Affordable Care Act, the GOP must have a detailed plan to “replace” the ACA if they repeal it, while Democrats should go beyond ACA defense and a technical corrections bill to focus on some alternative to the IPAB, possible elimination of the employer mandate, and a restructuring of the Cadillac tax, as well as other modifications. Second, while health care spending has recently moderated, that is expected to end soon; thus both parties must focus on ways to slow down its growth. Third, because Medicare has no legal authority to run a deficit and thus would have to cut spending, the candidates need to take action now to shore up its Trust Fund, which Reischauer and Rivlin say will be difficult since “even more than Social Security, [Medicare] is the third rail of American politics.”
“There are of course other health policy issues that the next president will have to address… But the issues we have focused on in this paper … are likely to dominate election debate. If the candidates present realistic proposals and explain them well, the campaign can be a constructive step toward crafting future health policy solutions. If the candidates mainly bash each other and talk vaguely about panaceas they cannot defend, the public will be confused and it will be harder for the next administration and Congress to work together to improve health policy,” they conclude.Downloads
- Robert D. Reischauer
- Alice M. Rivlin
Seventy clinicians from Boston Children’s Hospital have sent hospital administrators a petition imploring them to “reverse course” on plans to demolish Prouty Garden, a healing garden that was gifted to the hospital 60 years ago.
The petition calls Prouty Garden a “precious asset,” an “enduring therapeutic resource” and a testament to the hospital’s commitment to compassionate care.
The doctors, nurses and nurse practitioners who signed the petition say they’ve been left out of the hospital’s decision to construct an 11-story clinical building on the site of the garden and build other smaller, green spaces throughout the property.
Dermatology program director Dr. Stephen Gellis helped organize the petition.
“You cannot replace [Prouty Garden] with indoor gardens or with the [outdoor] garden they’re planning,” Gellis told WBUR. “It’s just depressing. I think so many people have gotten joy from the garden and solace.”
Boston Children’s Hospital spokesman Rob Graham issued a statement saying the planned clinical building is “essential to meeting the needs” of the hospital’s patients and families, it has the support of the Prouty Garden donor’s family members and foundation, and it’s been subject to public approvals since 2012.
The planned building will feature a new state-of-the-art neonatal intensive care unit and will allow the hospital to offer all private patient rooms, thereby eliminating double-bedded rooms, according to administrators.
“Boston Children’s has great appreciation for what the Prouty Garden offers patients, families and our staff,” the hospital statement reads. “That is why our clinical expansion will focus on open and green spaces to support healing for everyone throughout our campus, year round.”
Hospital officials say the facility will ultimately have 25 percent more “green space” than it has now.
Dr. John Mulliken is a pediatric plastic surgeon, director of the Craniofacial Center and co-director of the Vascular Anomalies Center at Boston Children’s Hospital. He also signed the petition.
“Until I see a hole in the ground we still have a chance to save the Prouty Garden. It’s the soul of the hospital. It’s the sanctuary that we all need — particularly the kids, but the parents and the staff, as well, ” Mulliken says. “I’ve always been proud to work at Children’s Hospital for the last 40 years. But now I really question what they’re doing.”
Hospital administrators say construction on the new building will start next year.Earlier: