When you’re unhappy with the quality of your health care, you might want to talk with whoever gave you the care. If you don’t want to talk to that person or need more help, you can file a complaint. Filing a complaint is your right, so if you think you’re not getting high-quality care, we want to know.
How you file a complaint depends on whether your complaint is about:
Sheri Lewis, 59, of Seattle, needed a hip transplant. Bradley Fuller, 63, of nearby Kirkland, needed chemotherapy and radiation when the pain in his jaw turned out to be throat cancer. And Kim Bruzas, 55, of Waitsburg, hundreds of miles away, needed emergency care to stop sudden —and severe — rectal bleeding.
Each of these Washington state residents required medical treatment during the past few years, and each thought they had purchased health insurance through an online site.
But when it was time to pay the bills, they learned that the products they bought through Aliera Healthcare Inc. weren’t insurance at all — and that the cost of their care wasn’t covered.
Lewis and the others had enrolled in what Aliera officials claimed was a health care sharing ministry (HCSM) — faith-based co-ops in which members agree to pay one another’s medical bills.
But Washington insurance officials this week said the firm doesn’t meet the definition of a sharing ministry and described Aliera’s products as a “sham” aimed at misleading consumers. Other states, including Texas and New Hampshire, are poised to take similar action.
Insurance Commissioner Mike Kreidler on Monday ordered Aliera, which operates Trinity Healthshare Inc., both of Delaware, to halt operations in Washington, alleging the firm was selling health insurance illegally and engaging in deceptive business practices.
Aliera falsely represented itself as a sharing ministry, which would be exempt from insurance regulations, an investigation found. Though he wouldn’t name them, Kreidler said he’s investigating two additional firms over similar concerns.
“They don’t have the direct affiliation with a particular religious group, a church, a pastor,” Kreidler said. “These appear to be ones that come in with an opportunity here to make money.”
In a statement, Aliera officials disputed Kreidler’s conclusions. The company has 90 days to request a hearing.
“Aliera has never misled consumer and sales agents about its health plans,” the statement said. “For example, our website, marketing materials and other communications clearly state that Trinity’s health sharing products are not insurance. Most importantly, they have never been represented as insurance.”
The Washington order followed complaints from nearly two dozen people, including Lewis, a dance teacher who was told her planned hip surgery wouldn’t be covered.
Across the U.S., several state insurance regulators report similar concerns.
Texas insurance officials have scheduled a hearing to consider a similar order against Aliera, which has 100,000 members nationwide and reported revenue of $180 million in 2018, documents showed.
New Hampshire insurance officials on Tuesday warned consumers about Aliera, saying they were concerned about “potential fraudulent or criminal activity.” Officials in at least five other states told Kaiser Health News they are reviewing firms operating as “illegitimate” health care sharing ministries.
Aliera is operated by Shelley Steele of Marietta, Ga., and her husband, Timothy Moses, who was convicted in 2006 of federal securities fraud and perjury. He was sentenced to 6½ years in prison and ordered to repay more than $1 million to victims.
Nationwide, nearly 1 million people are enrolled in more than 100 sharing ministries in at least 29 states, according to the Alliance of Health Care Sharing Ministries. But that’s just an estimate, said James Lansberry, executive vice president of Samaritan Ministries International of Peoria, Ill. No comprehensive data is available.
“We try to track what’s going on out there,” Lansberry said. “Anyone claiming to be a health care sharing ministry could spill over onto our reputation.”
Samaritan is among what have been the three top players in the sharing ministries field. The oldest, founded in 1993, is the Medi-Share program of Melbourne, Fla., operated by Christian Care Ministry. The third is Christian Healthcare Ministries of Barberton, Ohio. All are explicitly religious and emphasize faith as the basis for members to share medical burdens.
Those groups originally were certified by the Centers for Medicare & Medicaid Services and required to meet specific criteria. Consumers who enrolled were shielded from the Affordable Care Act’s individual mandate that required they show proof of insurance or pay a fine.
But CMS no longer certifies HCSMs and, since Congress zeroed out the mandate’s penalty in 2017, a new crop of companies, including Aliera, has sprung up. That worries some of the traditional ministries.
“HCSMs must operate with integrity, transparency, full compliance with the law, and enforcement of the law,” officials with Medi-Share, which has 415,000 members nationwide, said in a statement. “Anything outside of that violates the true spirit of the HCSM community.”
Washington investigators found that Aliera’s marketing materials rarely mention religious or ethical motivations, and they don’t meet government requirements.
Many of these entities mimic the marketing, structure and language of ACA-compliant health insurance plans — but offer none of the protections, said JoAnn Volk and Justin Giovannelli, researchers at the Georgetown University Center on Health Insurance Reforms, who wrote about the issue last summer.
“The way they advertise and the services they are providing, it sounds a heck of a lot like health insurance,” Giovannelli said. “They’re letting folks believe they have a product that has a promise to pay.”
Sheri Lewis teaches a body-rolling class at Balance Physical Therapy in Issaquah, Wash. Lewis, who was enrolled in a health care sharing ministry, found out that the hip transplant she desperately needed was not covered. She got the procedure in Tijuana, Mexico, with the help of a GoFundMe account.(Dan DeLong for KHN)
That’s exactly what Lewis thought.
“It looked like Aliera was health insurance to me,” she said.
When Aliera denied her surgery, she had to resort to a GoFundMe site organized by friends to raise nearly $13,000 and then travel to Tijuana, Mexico, to get a hip transplant she could afford.
Fuller, who was diagnosed with throat cancer, said he was stuck with $81,000 in bills for his first month of treatment.
“They started checking my insurance and it didn’t cover nothing,” said the retired commercial electrician.
Fuller, his voice still raspy after radiation, said he had insurance through his union for years, but when the premiums spiked, he went online to find something else.
The person he talked to from Aliera said he could get insurance, no problem, Fuller said. The premium would be $350 a month, rather than the $1,300 fee for a gold plan on the state insurance exchange. “And that was with dental, too,” he added.
Low premiums also attracted Bruzas, who left her well-paid government job in Tacoma, and the insurance it provided, after her husband died in 2015. She moved to a small town in southeastern Washington to care for her parents and went online to find health insurance.
“I just sat down and Googled ‘Obamacare,’” she said. “I got a call back from a lady who said she could help me find coverage.” Bruzas was charged $219 for the first month.
Four days later, she was in the local emergency room with massive rectal bleeding. As she was discharged, hospital officials said they had “never heard of Aliera Healthcare,” she said.
The $10,000 bill was not covered. Bruzas, who works part time at a hardware store, filed for charity care and the debt was reduced to $6,500. She is paying it off slowly, $50 each month.
The Washington patients recalled mentions of “sharing” and vague references to spirituality. But none realized they were signing up for a religious cost-sharing ministry, they said.
“I would have hung up the phone if she would have said, ‘We’re a group, and we’ll review your records and pray for you,’” Bruzas said.
Aliera officials said they make the nature of their products clear.
“Aliera disagrees that Trinity’s inclusive and specific statement of beliefs misleads consumers or violates the applicable regulations governing healthcare sharing ministries,” the statement said.
It’s not clear how states can curb the new sharing ministries. If Aliera ignores his order, Kreidler said, he’ll seek a court injunction to force the groups to cease operations. But several states contacted by KHN said that because the ministries are not health insurance, state insurance officials don’t review or regulate them.
Some users of sharing ministries say the lower-priced products should be available for consumers who understand and accept the risks involved.
But consumers need to pay close attention to details when they sign up for any health plans, said Colorado Insurance Commissioner Michael Conway, who is investigating sharing ministries operating in his state.
“Ask if it’s actually insurance,” he advised. “Ask if there’s a guarantee of coverage. Get into the policy documents. Read the contract they’re agreeing to.”
A stroke is a brain attack caused by blocked blood flow to the brain. It can affect a person’s speech, movement, and memory, and may lead to death. According to the Centers for Disease Control and Prevention, over 795,000 people in the United States have a stroke each year. Stroke is a major cause of disability for adults and kills about one out of every 20 people each year.
For the first time, the federal government is shining a spotlight on the quality of rehabilitation care at nursing homes — services used by nearly 2 million older adults each year.
Medicare’s Nursing Home Compare website now includes a “star rating” (a composite measure of quality) for rehab services — skilled nursing care and physical, occupational or speech therapy for people recovering from a hospitalization. The site also breaks out 13 measures of the quality of rehab care, offering a more robust view of facilities’ performance.
Independent experts and industry representatives welcomed the changes, saying they could help seniors make better decisions about where to seek care after a hospital stay. This matters because high-quality care can help older adults regain the ability to live independently, while low-quality care can compromise seniors’ recovery.
“It’s a very positive move,” said David Grabowski, a professor of health care policy at Harvard Medical School. He noted that previous ratings haven’t distinguished between two groups in nursing homes with different characteristics and needs — temporary residents getting short-term rehabilitation and permanent residents too ill or frail to live independently.
Temporary residents are trying to regain the ability to care for themselves and return home as soon as possible, he noted. By contrast, permanent residents aren’t expecting improvements: Their goal is to maintain the best quality of life.
Three separate ratings for the quality of residents’ care now appear on the Nursing Home Compare website: one for overall quality (a composite measure); another one for “short-stay” patients (people who reside in facilities for 100 days or less, getting skilled nursing services and physical, occupational or speech therapy) and a third for “long-stay” patients (people who reside in facilities for more than 100 days).
Ratings for short-stay patients — available for 13,799 nursing homes — vary considerably, according to a Kaiser Health News analysis of data published by the government in late April. Nationally, 30% of nursing homes with a rating received five stars, the highest possible. Another 21% got a four-star rating, signifying above-average care. Twenty percent got three stars, an average performance. Seventeen percent got two stars, a worse-than-average score. And 13% got one star, a bottom-of-the-barrel score. (Altogether, 1,764 nursing homes did not receive ratings for short-stay patients.)
Here’s information about how to find and use the new Nursing Home Compare data, as well as insights from Kaiser Health News’ analysis:
Finding data about rehabilitation. Enter your geographic location on Nursing Home Compare’s home page, and a list of facilities will come up. You can select three at a time to review. Once you’ve done so, hit the “compare now” button at the top of the list. (To see more facilities, you’ll need to repeat the process.)
A new page will appear with several tabs. Click on the one marked “quality of resident care.” The three overall star ratings described above will appear for the facilities you’ve selected.
Below this information, two options are listed on the left side: “short-stay residents” and “long-stay residents.” Click on “short-stay residents.” Now you’ll see 13 measures with actual numbers included (most but not all of the time), as well as state and national averages.
Understanding the star rating. Six measures are used to calculate star ratings for the quality of rehab care for short-stay patients. Two of them concern emergency room visits and rehospitalizations, potential indicators of problematic care. Another two examine how well pain was controlled and bedsores were managed. One measure looks at how many patients became better able to move around on their own, an important element of recovery. Yet another examines the rate at which antipsychotic medications were newly prescribed. (These drugs can have significant side effects and are not recommended for older adults with dementia.)
One measure of great interest to seniors is the percentage of residents who return successfully home after a short nursing home stay. But actual numbers aren’t available on the Nursing Home Compare website this time around: Instead, facilities are listed as below average, average or above average. The national average, reported in April, was 48.6%, indicating room for improvement.
Tracking variations in performance. Some facilities outperform others by large margins on measures of quality of care for short-stay residents. And some facilities have high scores in some areas, but not in others.
For instance, the nursing home at Westminster Village, a high-end continuing care retirement community in Scottsdale, Ariz., had the highest score for rehospitalizations — 39.9% — out of 68 facilities in and around Phoenix. (By contrast, the lowest score in the Phoenix area was 15.4% and the state average was 23.5%.) It also had the highest rate of helping residents improve their ability to move around on their own — 88.6%. (The lowest score was 37.6% and the state average was 63.6%.)
In an email, Lesley Midkiff, marketing director at Westminster Village, said that the facility’s staff is vigilant about sending residents back to the hospital if health issues arise. At the same time, she said, staffers “push the residents just enough to regain independence and recover quickly from their short term stays.” Both priorities have the “residents’ best interest” in mind, she said.
If a facility has an average or low quality score, Dr. David Gifford, a senior vice president at the American Health Care Association, a nursing home industry group, recommended that people look closely at various measures and try to figure out where the institution fell short. Call the facility and ask them to explain, he said. Also, review Nursing Home Compare’s information about staffing and health inspections, Gifford suggested, and visit the facility if possible.
Variations within nursing homes. The newly published Nursing Home Compare data also shows that institutions aren’t always equally adept at caring for short-stay and long-stay residents.
Disparities in facilities’ ratings for short- and long-stay patients are common. Of 13,351 nursing homes that received both ratings, 32% received the same star ratings for the quality of care received by short-stay and long-stay residents. Another 32% of facilities received higher star ratings for short-stay residents, while 36% got higher ratings for long-stay residents. About one-third of the time, these rating categories were one star apart, but in another third of cases, they varied by two or more stars — a significant discrepancy. (This analysis does not include 2,212 nursing homes for which data was missing.)
In Phoenix, Desert Terrace Healthcare Center, which bills itself on its website as the city’s “premier location for short-term rehabilitation and long-term care,” is one such facility. Its quality-of-care rating for short-term residents was two stars, while its rating for long-term residents was five stars. Notably, hospital admissions and ER visits for short-stay patients were higher than the state average, while the portion of short-stay residents whose mobility improved was lower than average.
In an email, Jeremy Bowen, the facility’s administrator, wrote that the facility had a good record of managing pain and bedsores and limiting antipsychotic prescriptions for short-stay patients. Factors such as hospital readmissions depend on community resources and patients’ understanding of their health needs, which are difficult to control, he noted.
Sierra Winds, part of a continuing care community in Peoria, Ariz., has a similar split in quality ratings (two stars for short-stay residents, five stars for long-stay residents). On four of six measures used to calculate star ratings for short-stay residents, it performed worse than the state average.
“Sierra Winds remains committed to providing the highest quality care and services to its residents,” wrote Shannon Brown, the facility’s executive director, in an email. “We are proud of our 4-star rating with CMS [the Centers for Medicare & Medicaid Services].”
That’s the facility’s overall rating (this includes data about staffing and health inspections). But it doesn’t address the split in scores for short-stay and long-stay patients, which raises a red flag and should certainly cause seniors and their families to ask follow-up questions.
“If I’m a patient looking for a place for a short-term rehab stay, I really want to know how patients who look like me did,” said Dr. Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania and a quality-measurement expert.
KHN senior correspondent Jordan Rau contributed to this report.
We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.
The health care debate has Democrats on Capitol Hill and the presidential campaign trail facing renewed pressure to make clear where they stand: Are they for “Medicare for All”? Or will they take up the push to protect the Affordable Care Act?
Obamacare advocates have found a powerful ally in House Speaker Nancy Pelosi, who in a recent “60 Minutes” appearance said that concentrating on the health law is preferable to Medicare for All. She argued that since the ACA’s “benefits are better” than those of the existing Medicare program, implementing Medicare for All would mean changing major provisions of current Medicare, which covers people 65 and up as well as those with disabilities.
This talking point — one Pelosi has used before — seems tailor-made for the party’s establishment. It’s politically palatable among moderates who believe that defending the ACA’s popular provisions, such as protecting coverage for those with preexisting conditions, fueled the Democrats’ House takeover in 2018.
Progressive Democrats argue that the time has come to advance a far more disruptive policy, one that guarantees health care to all Americans. Those dynamics were on full display on Capitol Hill, as recently as an April 30 Medicare for All hearing.
But this binary view — Medicare (and, for argument’s sake, Medicare for All) versus Obamacare — oversimplifies the issues and distracts from the policy proposals.
“It’s sort of a silly argument,” said Robert Berenson, a health policy analyst at the Urban Institute, of Pelosi’s talking point. “She’s trying to argue the Affordable Care Act needs to be defended, and Medicare for All is a diversion.”
As the debate continues, one point should be clear: Medicare for All would not look like the ACA or like Medicare today. Instead, it — or any other single-payer system — would drastically change how Americans get health care.
Analyzing Medicare Isn’t That Helpful In Understanding ‘Medicare For All’ Proposals.
Medicare for All is complicated, analysts noted, and the phrase is often deployed to mean different things, depending on who is speaking.
What’s clear is that the “Medicare” described in Sen. Bernie Sanders’ (I-Vt.) legislation — the flagship Medicare for All proposal — would create a health program far more generous than traditional Medicare’s current benefit, or even the vast majority of health plans made available through the ACA.
Sanders relied heavily on this concept during his 2016 Democratic presidential primary run and recently introduced an updated version in the Senate.
To be fair, though, Sanders also sometimes blurs the lines between the programs. In a May 5 appearance on ABC’s “This Week with George Stephanopoulos,” he used existing Medicare as part of his sales pitch: “Medicare right now is the most popular health insurance program in the country,” he said. “But it only applies to people 65 years of age or older. All that I want to do is expand Medicare over a four-year period to cover every man, woman and child in this country.”
As counterintuitive as it sounds, understanding Medicare as it works today isn’t helpful in envisioning a Medicare for All plan. Unlike with existing Medicare, the proposed health plan would cover things like nursing home care, vision care and dental services. It would get rid of cost sharing — meaning no premiums, deductibles or copays. (Sanders has acknowledged that financing the program would mean raising taxes.)
“It’s not Medicare. It’s something different,” said Ellen Meara, a health economist at the Dartmouth Institute for Health Policy and Clinical Practice.
But voters may not grasp the differences between the existing Medicare program for seniors and the hypothetical one being discussed. Pelosi’s comments may add to that confusion. Pelosi’s office did not respond to a request for comment.
Prioritizing efforts to bolster the ACA based on Medicare’s current benefit package “is convenient and not necessarily compelling,” Berenson said, adding: “No one is proposing the Medicare benefit package would be taken and applied nationally.”
That said, many of the presidential candidates have advanced far less sweeping health care options that would lower the Medicare age to 55 or allow people to buy in to the current Medicare program — an approach often referred to as a “public option.” Those would keep the program essentially structured as it is today.
The Democratic Health Care Debate Is More Complicated Than These Familiar Words Suggest.
Every analyst interviewed for this story floated some kind of concern regarding a Medicare for All system. There’s the issue of how people would respond to losing the option of private insurance — a likely consequence of Sanders’ proposal — and the question of what level of tax hikes would be necessary to finance such a system, particularly if it covers a big-ticket item such as long-term care. There are also concerns about the financial impact for hospitals, often large employers in a community, or for the private insurance industry jobs that would likely disappear.
Focusing on current Medicare benefits misses the point, suggested Sherry Glied, a health economist and dean at New York University. When debating the merits of the ACA versus Medicare for All, Medicare’s current generosity is kind of a red herring, she said.
Plus, making Obamacare or Medicare for All an either-or debate ignores a sizable political bloc: Democrats who say they support the ACA and see single-payer as a next step. That tension is at play with presidential candidates like Kamala Harris, who frame Medicare for All as an ultimate goal, while also backing incremental reforms.
Comparing Medicare To Obamacare Is Difficult Since Each Offers Different Benefits To Different People.
The problem is that both Medicare and Obamacare are vast programs. Depending on your income, health needs and the version you sign up for, either one could prove the better choice.
“It’s impossible to say the ACA as a concept has more or less generous benefits,” Berenson said.
Broadly, the ACA has protections in place that traditional Medicare doesn’t. It caps how much patients pay out-of-pocket, and it has more generous coverage of mental health care and substance abuse treatment. But, in practice, those benefits have proved elusive for many since Medicare generally has a more robust network of participating physicians than many of the ACA’s cheaper plans, which restrict patients to a narrower coverage network.
Also, most beneficiaries don’t solely have traditional Medicare.
About a third use Medicare Advantage, in which private insurance companies construct Medicare plans with benefits and protections based on factors like company, tier and geography. They, too, are often restricted to narrower networks.
More than 1 in 5 traditional Medicare beneficiaries also receive Medicaid coverage, according to figures kept by the Kaiser Family Foundation, and about a third of them buy so-called Medigap plans, which are sold by private insurance and are meant to supplement gaps in coverage.
The ACA also encompasses an array of coverage options. Which plans are available in an area and whether earnings qualify a consumer for a government subsidy— a tax break meant to make an ACA plan more affordable — make a significant difference in evaluating whether Medicare or an ACA plan offers better benefits for a particular person or family.
Suggesting that one is clearly better than the other, Meara said, is a “gross oversimplification.”
But that kind of oversimplification may be hard to avoid, especially in a primary season where health care is a top issue.
“The Affordable Care Act is also not one thing, the way Medicare is not one thing,” said Katherine Baicker, dean of the Harris School of Public Policy at the University of Chicago. “So much of health care is more complicated than we can explain in a sound bite.”
The 50-something man with a shaved head and brown eyes was unresponsive when the paramedics wheeled him into the emergency room. His pockets were empty: no wallet, no cellphone, not a single scrap of paper that might reveal his identity to the nurses and doctors working to save his life. His body lacked any distinguishing scars or tattoos.
Almost two years after he was hit by a car on busy Santa Monica Boulevard in January 2017 and transported to Los Angeles County+USC Medical Center with a devastating brain injury, no one had come looking for him or reported him missing. The man died in the hospital, still a John Doe.
Hospital staffs sometimes must play detective when an unidentified patient arrives for care. Establishing identity helps avoid the treatment risks that come with not knowing a patient’s medical history. And they strive to find next of kin to help make medical decisions.
“We’re looking for a surrogate decision-maker, a person who can help us,” said Jan Crary, supervising clinical social worker at L.A. County+USC, whose team is frequently called on to identify unidentified patients.
The hospital also needs a name to collect payment from private insurance or government health programs such as Medicaid or Medicare.
But federal privacy laws can make uncovering a patient’s identity challenging for staff members at hospitals nationwide.
At L.A. County+USC, social workers pick through personal bags and clothing, scroll through cellphones that are not password-protected for names and numbers of family or friends, and scour receipts or crumpled pieces of paper for any trace of a patient’s identity. They quiz the paramedics who brought in the patient or the dispatchers who took the call.
They also make note of any tattoos and piercings, and even try to track down dental records. It’s more difficult to check fingerprints, because that’s done through law enforcement, which will get involved only if the case has a criminal aspect, Crary said.
Unidentified patients are often pedestrians or cyclists who left their IDs at home and were struck by vehicles, said Crary. They might also be people with severe cognitive impairment, such as Alzheimer’s, patients in a psychotic state or drug users who have overdosed. The hardest patients to identify are ones who are socially isolated, including homeless people — whose admissions to hospitals have grown sharply in recent years.
In the past three years, the number of patients who arrived unidentified at L.A. County+USC ticked up from 1,131 in 2016 to 1,176 in 2018, according to data provided by the hospital.
If a patient remains unidentified for too long, the staff at the hospital will make up an ID, usually beginning with the letter “M” or “F” for gender, followed by a number and a random name, Crary said.
Jan Crary, supervising clinical social worker at Los Angeles County+USC Medical Center, leads a team who increasingly must play detective when patients cannot be identified.((Heidi de Marco/KHN))
Other hospitals resort to similar tactics to ease billing and treatment. In Nevada, hospitals have an electronic system that assigns unidentified patients a “trauma alias,” said Christopher Lake, executive director of community resilience at the Nevada Hospital Association.
The deadly mass shooting at a Las Vegas concert in October 2017 presented a challenge for local hospitals who sought to identify the victims. Most concertgoers were wearing wristbands with scannable chips that contained their names and credit card numbers so they could buy beer and souvenirs. On the night of the shooting, the final day of a three-day event, many patrons were so comfortable with the wristbands that they carried no wallets or purses.
More than 800 people were injured that night and rushed to numerous hospitals, none of which were equipped with the devices to scan the wristbands. Staff at the hospitals worked to identify patients by their tattoos, scars or other distinguishing features, as well as photographs on social media, said Lake. But it was a struggle, especially for smaller hospitals, he said.
The Health Insurance Portability and Accountability Act (HIPAA), a federal law intended to ensure the privacy of personal medical data, can sometimes make an identification more arduous because a hospital may not want to release information on unidentified patients to people inquiring about missing persons.
In 2016, a man with Alzheimer’s disease was admitted to a New York hospital through the emergency department as an unidentified patient and assigned the name “Trauma XXX.”
Police and family members inquired about him at the hospital several times but were told he was not there. After a week — during which hundreds of friends, family members and law enforcement officials searched for the man — a doctor who worked at the hospital saw a news story about him on television and realized he was the unidentified patient.
Hospital officials later told the man’s son that because he had not explicitly asked for “Trauma XXX,” they could not give him information that might have helped him identify his father.
Prompted by that mix-up, the New York State Missing Persons Clearinghouse drafted a set of guidelines for hospital administrators who receive information requests about missing persons from police or family members. The guidelines include about two dozen steps for hospitals to follow, including notifying the front desk, entering detailed physical descriptions into a database, taking DNA samples and monitoring emails and faxes about missing persons.
California guidelines stipulate that if a patient is unidentified and cognitively incapacitated, “the hospital may disclose only the minimum necessary information that is directly relevant to locating a patient’s next-of-kin, if doing so is in the best interest of the patient.”
Lenh Vuong, a clinical social worker at Los Angeles County+USC Medical Center, checks on a former John Doe patient who was recently identified. (Heidi de Marco/KHN)
Maria Torres visits Felipe Luna, her brother. Luna ended up at Los Angeles County+USC Medical Center after he was hit by a car and suffered head injuries. “The only thing he had on him was a bank card and a receipt,” Torres says. “I think that was a good thing he had that in his pocket, but that’s not an ID.” (Heidi de Marco/KHN)
At L.A. County+USC, most John Does are quickly identified: They either regain consciousness or, as in a majority of cases, friends or relatives call asking about them, Crary said.
Still, the hospital does not always succeed. From 2016 to 2018, 10 John and Jane Does remained unidentified during their stays at L.A. County+USC. Some died at the hospital; others went to nursing homes with made-up names.
But Crary said she and her team pursue every avenue in search of an identity.
Once, an unidentified and distinguished-looking older man with a neatly trimmed beard was rushed into the emergency room, delirious with what was later diagnosed as encephalitis and unable to speak.
Acting on a gut instinct that the well-groomed man must have a loved one who had reported him missing, Crary checked with police stations in the area. She learned instead that this John Doe was wanted in several states for sexual assault.
“He was done in by a mosquito,” Crary mused.
“It is a case that I will never forget,” she added. “The truth is that I am more elated when we are able to identify a patient and locate family for a beautiful reunification rather than finding a felon.”
This KHN story first published on California Healthline, a service of the California Health Care Foundation.
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In a new set of rules, the Trump administration wants to let not just doctors but almost any health care worker or organization decline to provide, participate in or refer patients for any health service that violates their conscience or religion.
Also this week, the Trump administration is ordering prescription drugmakers to include list prices in their television ads for nearly all products.
And there’s yet another entry in the growing group of bills aimed at overhauling the nation’s health system. This one is “Medicare for America.”
This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Jen Haberkorn of the Los Angeles Times and Alice Miranda Ollstein of Politico.
Also, Rovner interviews Joan Biskupic, author of “The Chief: The Life and Turbulent Times of Chief Justice John Roberts.” Biskupic talks about the behind-the-scenes negotiations that led to the 2012 decision upholding the constitutionality of the Affordable Care Act.
Among the takeaways from this week’s podcast:
Robert Pear, who died this week, was the dean of health policy reporters and will be remembered not just for the many front-page stories he produced for The New York Times, but also as a generous and kind colleague who helped mentor many reporters new to the beat.
The Trump administration’s announcement last week of new regulations to protect health care workers from having to do anything they believe violates their religious beliefs is a stronger policy than past Republicans have adopted. But it follows other efforts to expand past conservative policies, such as the current administration’s more stringent Title X family planning rules.
The administration’s new rule requiring drugmakers to add list prices to their TV ads could confuse some consumers, since few of them actually pay that price. Their insurers often negotiate better prices, and other factors, such as geography and type of pharmacy, affect the consumer’s bottom line.
President Donald Trump this week told Health and Human Services officials to work with Florida on its plan to import drugs from Canada to take advantage of lower prices there. HHS Secretary Alex Azar said he would see if it can be done without jeopardizing the safety of the drugs. That is the rub that his predecessors have used to stop importation efforts, dating to the 1990s.
The increasing interest in Democratic proposals such as “Medicare for All,” which would set up a government-run health care system, and “Medicare for America,” which would offer a government-run option for consumers and businesses, suggests that a public option is not the political hot potato it was during the debate setting up the ACA. It’s also not clear whether consumers are ready to give up their current insurance.
Tennessee is getting ready to ask federal officials for a major change in its Medicaid system. The state wants to switch to a block grant, in which its federal funding would be limited but would come with much more flexibility for spending. The proposal is likely to end up in court because advocates for the poor argue the change would cut off services to some people and would violate laws that have defined Medicaid.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:
Julie Rovner: CNBC’s “Insiders Describe Aggressive Growth Tactics at uBiome, the Health Start-Up Raided by the FBI Last Week,” by Christina Farr, and “Health Tech Start-Up uBiome Suspends Clinical Operations Following FBI Raid,” by Christina Farr and Angelica LaVito
Joanne Kenen: ProPublica and the New Yorker’s “The Birth-Tissue Profiteers,” by Caroline Chen
Jen Haberkorn: The Los Angeles Times’ “Health Insurance Deductibles Soar, Leaving Americans With Unaffordable Bills,” by Noam N. Levey
Alice Miranda Ollstein: Bloomberg News’ “Trump May Redefine Poverty, Cutting Americans From Welfare Rolls,” by Justin Sink
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Private health insurance plans in 2017 paid more than twice what Medicare would have for those same health care services, says a sweeping new study from Rand Corp., a respected research organization.
Its study, which examines payment rates by private insurers in 25 states to 1,600 hospitals, shines light into a black box of the health industry: what hospitals and other medical providers charge. It is among the first studies to examine on such a wide level just how much more privately insured people pay for health care.
The finding: a whole lot. The difference varies dramatically across the country. And as national health expenses climb, this growing gap poses a serious challenge for lawmakers. The Rand data suggests a need for market changes, which could come in the form of changes in industry behavior or government regulation, in order to bring down hospital prices in the private sector. “If we want to reduce health care spending,” said Christopher Whaley, a Rand economist and one of the paper’s two authors, “we have to do something about higher hospital prices.”
Put another way, if, between 2015 and 2017, hospitals would have charged these health plans the same rates as Medicare, it would have reduced health spending by $7.7 billion.
The national discrepancy is staggering on its own. But the data fluctuated even more when examined on a state-by-state level.
In Indiana, private health plans paid on average more than three times what Medicare did. In Michigan, the most efficient of the states studied, the factor is closer to 1.5 — the result, the study authors said, of uniquely strong negotiating of the powerful UAW union, historically made up of autoworkers.
The difference between Medicare and private coverage rates matters substantially for the approximately 156 million Americans under age 65 who get insurance through work-sponsored health plans, researchers said. For them, higher hospital prices aren’t an abstraction. Those charges ultimately translate to individuals paying more for medical services or monthly premiums.
That’s especially true for the increasing number of people who are covered by “high-deductible” health plans and have to pay more of their health care costs out-of-pocket, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy. He was not associated with this study.
The gap between Medicare and private plans — and how it plays out across the country — underscores a key point in how American health care is priced. Often, it has little to do with what it costs hospitals or doctors to provide medical care.
“It’s about how much they can charge, how much the market can take,” said Ge Bai, an associate professor at the Johns Hopkins University Carey Business School who studies hospital prices but was not affiliated with the study.
The paper’s authors suggest that publishing this pricing data — which they collected from state databases, health plans and self-insured employers — could empower employers to demand lower prices, effectively correcting how the market functions.
But, they acknowledged, there’s no guarantee that would, in fact, yield better prices.
One issue is that individual hospitals or health systems often have sizable influence in a particular community or state, especially if they are the area’s main health care provider. Another factor: If they are the only facility in the market area to offer a particularly complex service, like neonatal intensive care or specialized cardiac care, they have an upper hand in negotiating the price tag. In those situations, even if an employer is made aware that Medicare pays less, it doesn’t necessarily have the ability to negotiate a lower price.
“Employers and health plans in a lot of cases are really at the mercy of big, must-have systems. If you can’t legitimately threaten to cut a provider or system out of the network, it’s game over,” said Chapin White, a Rand policy researcher and Whaley’s co-author. “That’s when you come up against the limits of market-based approach.”
It wasn’t always this way, said Gerard Anderson, a Johns Hopkins health policy professor and expert in hospital pricing, who was also not involved with the study. Anderson began comparing Medicare prices to that of private insurance in the 1990s, when they paid virtually the same amount for individual services.
Since then, private health plans have lost the ability to negotiate at that same level, in part because many hospital systems have merged, giving the hospitals greater leverage. “Most large, self-insured corporations do not have the market power in their communities to take on the hospitals even if they wanted to do so,” Anderson said.
The RAND findings come as Democrats campaigning for 2020 are reopening the health care reform debate. Single-payer advocates argue, among other points, that covering everyone through a Medicare-like system could bring lower prices and increase efficiency to the rest of the country, or at least give the government leverage to negotiate a better price.
That’s certainly possible, but it isn’t guaranteed. Under single-payer, Anderson said, the challenge would be to make sure Medicare doesn’t simply end up paying more, or that cuts aren’t so dramatic that hospitals and doctors go out of business.
And there’s the political calculus, Ginsburg of Brookings noted. Hospitals, doctors and other health care industries are all influential lobbies and could successfully ward off any efforts to lower prices.
“It’s one thing to have regulatory control of prices. It’s another to set them low enough to make a difference,” he said.
Other strategies, such as a “public option” — which would allow people to opt into a government-provided plan but preserve multiple health care payers — could also make a difference, he said. Lawmakers on the state or federal level could limit what hospitals are allowed to charge for certain medical services, as Maryland does.
Some states have taken smaller-scale approaches, too, by tying their payment rates to a percentage of Medicare, rather than negotiating case by case. In Montana, state employees get coverage that pays about 230% of the Medicare rate on average — an arrangement that saved the state more than $15 million over two years.
For its part, the American Hospital Association, an industry trade group, points to the importance of lowering the cost of prescription drugs or reducing overuse, among other things.
Policy fixes are debatable, White said. But the data makes one point clear: From an efficiency standpoint, the current system isn’t working.
“There are right now the secret negotiations between health plans and hospitals,” and the system is “dysfunctional,” he said.
Unraveling how much of a prescription drug price gets swallowed by “middlemen” is at the forefront of Tuesday’s drug price hearing in the Senate. One thing bound to come up: rebates.
Both major political parties have shown interest in remedying high drug prices, and drugmakers have bemoaned how rebates to middlemen keep them from reaping every dollar associated with those price tags.
Pharmacy giant CVS Health criticized the Trump administration’s proposal to end these post-transaction discounts as they apply to Medicare. Yet, in January the company rolled out a Medicare drug plan that experts say is similar “in spirit” to the administration’s proposal.
The CVS Caremark plan wasn’t popular with customers, and CVS Health, which owns CVS Caremark, was quick to point this out as evidence that consumers prefer the current rebate system.
“We had a very, I would say, small number of seniors enroll in that program,” Larry Merlo, CVS Health’s CEO said on a February earnings call with investors. “And we think one of the barriers to that was the increase that we saw in the monthly premium.”
The CVS plan’s premium was $80 a month, which is about double the average Medicare Part D monthly charge. But since it is designed to pass on a portion of rebates directly to patients at the pharmacy counter, certain patients would wind up with smaller out-of-pocket costs than they previously paid.
“Even very well-informed consumers would not necessarily understand that a higher premium plan in this case means that they’re incurring smaller amounts at the point of sale,” said Rachel Sachs, an associate law professor at Washington University in St. Louis who specializes in health care.
So why did only 25,000 people sign up for the plan, called SilverScript Allure? Either consumers didn’t want the plan or perhaps they just didn’t understand it.
We’ll break it down for you.
Untangling Jargon: The Way Things Are And How They Could Change
A pharmacy benefit manager, or PBM, handles drug claims for health insurance companies. The big ones are Express Scripts, CVS Caremark and OptumRx. Every time you fill a prescription and use your drug plan, your PBM is involved in paying the claim and determining how much money you owe the cashier.
A rebate is a discount the PBM negotiates with a drug manufacturer off the price the drugmaker sets, which is called a list price. Rebates are not made public, and they typically don’t get passed on to the patient at the pharmacy counter in the form of a lower copayment, experts say.
When the drugmaker eventually pays the rebate back to the PBM, the PBM often uses this money to lower premiums, which are the monthly fees that Medicare Part D plans charge beneficiaries. They differ for each drug plan.
In a way, patients taking drugs with high list prices and big rebates wind up subsidizing other patients’ premiums, said Erin Trish, the associate director of the University of Southern California Schaeffer Center for Health Policy and Economics. Premiums on average haven’t substantially increased in more than a decade, but it may be “unfair” to the patients paying higher prices for drugs at the pharmacy counter.
“Some may argue, ‘They’re sicker… Maybe they should [pay more],’” Trish said. “Look. We decided everyone should pay the same premium in this market. [Rebates] shouldn’t be a roundabout way to make a subset of beneficiaries pay more.”
That could all change under a new Trump administration proposal that would ban rebates as they exist today. The negotiated discounts would be applied at the pharmacy counter, meaning discounts would be passed on to patients as out-of-pocket costs that are calculated based on the discounted price, not the higher list price.
For patients taking drugs with high list prices and large rebates, like insulin, it could mean noticeable savings, Sachs said. For patients taking drugs without big rebates, like generics or brand-name drugs without other branded competition, they’re not likely to see much change at the pharmacy counter.
Everyone, however, will see premiums go up. It’s unclear yet how much, but Trish said the SilverScript Allure plan CVS Caremark is offering isn’t necessarily the best indicator. Consultants hired by the Department of Health and Human Services estimated premiums will go up $3.20 to $5.64 per month if the rule takes effect in 2020. The average Medicare Part D premium for 2019 was $41.21, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
So Why Didn’t Patients Want The CVS Caremark Plan?
It’s not clear how well seniors shopping for drug plans understood the SilverScript Allure plan, among their many options. They could see it had a high premium, but no deductible. They might not have realized it required smaller payments on drugs at the pharmacy counter.
Research shows that the premium is the most important factor seniors consider when choosing a plan, Sachs said.
On top of that, people are unlikely to leave their current plans even if there’s a better one available.
What’s more, we don’t know how well CVS Caremark marketed the plan to seniors who would benefit. They wouldn’t tell us, despite multiple calls and emails.
OptumRx, a competing PBM, started offering customers similar discounts at the pharmacy counter — but for people with commercial insurance, not Medicare or Medicaid. Unlike CVS Caremark, it has a web page with basic language, like “point of sale discounts mean lower costs,” and a link to request more information about switching. OptumRx did not respond to a request for comment.
PBMs: Helping Or Hurting?
Rebates for individual plans and drugs are confidential, but in Medicare Part D, they’ve increased on average from 9.6% of total spending in 2007 to 19.9% in 2016, according to annual reports to the Medicare boards of trustees.
So it’s perhaps unsurprising the brand-name drug trade group, the Pharmaceutical Research and Manufacturers of America, said it “applaud[s]” the proposal to overhaul the rebate system. PhRMA says it pushes them to raise prices in order to offer larger rebates, because drugs with larger rebates often get preferential treatment by PBMs.
Still, PBMs offer the benefit of batting down net prices (the price after rebate), and keeping down drug spending overall.
There are multiple estimates on how much the rebate proposal would cost the Centers for Medicare & Medicaid if it took effect, and they indicate that unless there are other changes to Medicare Part D, it would likely cost more money than the current system, Sachs said.
“It is startling to see the administration moving forward so rapidly with this proposal without a better understanding of how different actors might respond,” she said. As a result, there’s a “huge amount of uncertainty” over how this could all play out.
Doctors may prescribe opioids, a class of drugs used to treat pain, after surgery or an injury. Although opioids can be an important part of treatment, they have serious risks like addiction, abuse, and overdose, especially if used continuously.
That’s why Medicare is working with doctors and pharmacists to perform safety checks to help you use opioids safely. Medicare is also using new drug management programs to look for potentially high-risk opioid use.
These checks and programs generally won’t apply to you if you have cancer, are in hospice, get palliative or end-of-life care, or if you live in a long-term care facility.
Safety checks at the pharmacy
When a prescription is filled at the pharmacy, your Medicare drug plan performs additional safety checks and may send your pharmacy an alert to monitor the safe use of opioids and certain other medications.
These safety checks may cover situations like possible unsafe amounts of opioids, first prescription fills for opioids, or use of opioids at the same time with benzodiazepines (commonly used for anxiety and sleep). If your pharmacy can’t fill your prescription as written, the pharmacist will give you a notice explaining how you or your doctor can call or write to your plan to ask for a coverage decision. Visit the Medicare drug plan coverage rules page for more information about safety checks.
Drug management programs
As of January 1, 2019, some Medicare drug plans have a drug management program in place to help you use opioids safely. If you get opioids from multiple doctors or pharmacies, your drug plan may talk with your doctors to make sure you need these medications and are using them safely and appropriately.
Safety checks and drug management programs are just some of the ways that Medicare, Medicare drug plans, and pharmacies are working together to make sure you’re getting the pain relief treatment you need while keeping you safe. Read your Medicare drug plan’s materials for more information on their specific drug coverage rules.