CMS, Medicare Advantage

Uncle Sam Wants You … to Help Stop Insurers’ Bogus Medicare Advantage Sales Tactics

By Susan Jaffe, KHN  | November 30, 2023 | This story also ran on  

People gathered at the U.S. Capitol in Washington, D.C. in July protested denials and delays in private Medicare Advantage plans. (Alex Wong/Getty Image)

After an unprecedented crackdown on misleading advertising claims by insurers selling private Medicare Advantage and drug plans, the Biden administration hopes to unleash a special weapon to make sure companies follow the new rules: you.

Officials at the Centers for Medicare & Medicaid Services are encouraging seniors and other members of the public to become fraud detectives by reporting misleading or deceptive sales tactics to 800-MEDICARE, the agency’s 24-hour information hotline. Suspects include postcards designed to look like they’re from the government and TV ads with celebrities promising benefits and low fees that are available only to some people in certain counties.

The new rules, which took effect Sept. 30, close some loopholes in existing requirements by describing what insurers can say in ads and other promotional materials as well as during the enrollment process. [Continued on Kaiser Health News and NPR]

Appeals, CMS, Medicare Advantage

Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients

By Susan Jaffe, KFF Health News | October 5, 2023

This article also ran in The Washington Post.

Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from h when she got surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to go home.

At the time, she could not walk more than a few feet, even with assistance — let alone manage the stairs to her front door, she said. She still needed help using a colostomy bag following major surgery.

“How could they make a decision like that without ever coming and seeing me?” said Sullivan, 76. “I still couldn’t walk without one physical therapist behind me and another next to me. Were they all coming home with me?”

UnitedHealthcare — the nation’s largest health insurance company, which provides Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. It does have naviHealth, a care management company bought by UHC’s sister company, Optum, in 2020. NaviHealth’s proprietary “nH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions, and other factors. Based on these comparisons, an algorithm anticipates what kind of care a specific patient will need and for how long. 

 

…Next year, the Centers for Medicare & Medicaid Services will begin restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.[Continued on Kaiser Health News and The Washington Post.]

Uncategorized

More US states ban teenagers’ gender-affirming care

Volume 402, Issue 10405
9 September 2023 

WORLD REPORT  Most health-care provider organisations oppose the bans, calling them harmful. Susan Jaffe reports from Washington, DC.  

With the last-minute approval of the Texas Supreme Court earlier this month, Texas became the latest and largest US state among 22 to ban gender-affirming care for people younger than 18 years. The prohibition applies to medically necessary surgery, hormone therapy, and puberty blockers. Similar efforts are underway across the country, despite numerous healthcare provider groups saying that adolescents should be able to access these safe and effective treatments, with the exception of surgery, which is rarely provided to minors.  [Continued here.]

The Lancet

Abortion foes threaten PEPFAR

Volume 402, Issue 10402
19 August 2023 

 

WORLD REPORT  Republicans question funding for the President’s Emergency Plan for AIDS Relief, one of the USA’s most effective global health programmes. Susan Jaffe reports from Washington, DC.

As Congress considers next month whether to renew funding for the President’s Emergency Plan for AIDS Relief (PEPFAR), global health advocates fear its two decades of bipartisan support might fracture. Created by President George W Bush in 2003, the programme is often cited as proof that adversaries across the political spectrum can agree on healthcare policy. …But this time is looking different.  [Continued here.]

CMS, Drugs, Medicare, Medicare costs, The Lancet

US pharmaceutical companies sue to halt cuts in drug prices

Volume 402, Issue 10399
29 July 2023 

 

WORLD REPORT  Medicare will soon be able to negotiate some drug prices to reduce costs for patients and taxpayers. Susan Jaffe reports from Washington, DC.

The first set of ten drugs subject to price negotiations by the US Medicare programme will be unveiled on Sept 1, 2023, but some pharmaceutical companies and their allies are not waiting to find out which products will be on the list. So far, four manufacturers and two trade associations are suing to stop the process before it begins. [Continued here.] 

 

The Lancet

US affirmative action ruling may harm health equity

 8 July 2023
Volume 402, Issue 10396 

WORLD REPORT  Health and science groups warn the Supreme Court ‘s decision threatens workforce diversity and patient care. Susan Jaffe reports from Washington, DC.

Leading medical and scientific organisations have criticised the June 29 US Supreme Court decision severely limiting how colleges and universities consider an applicant’s race in the admissions process. A 6 to 3 majority abandoned 45 years of legal precedent protecting affirmative action, which is widely expected not only to reduce the number of Black and Latinx college students but also roll back their representation in medicine, law, science, and other postgraduate programmes, diversity advocates say.  [Continued here.] 

The Lancet

Sackler money to go towards reducing overdose deaths

Volume 401, Issue 10392  ||  10 June 2023  

WORLD REPORT  A US $6 billion settlement must help to expand treatment access, harm reduction programmes, and recovery services. Susan Jaffe reports.

Federal, state and local governments along with community organisations may soon receive an infusion of US$6 billion to fight the opioid epidemic, including at least $775 million for victims and their families, after a federal appeals court approved a bankruptcy settlement for Purdue Pharma and its founders, the multi-billionaire Sackler family. However, in a controversial move last month, the court also restored protections for the Sacklers from civil lawsuits, despite accusations that their illegal schemes to boost sales of the company’s strongly addictive pain killer, OxyContin (oxycodone), vastly increased their wealth. But without this shield, the agreement would have remained mired in court challenges. [Continued here.] 

HHS, The Lancet

US health experts divided on social media age restrictions

27 May 2023
Volume 401, Issue 10390 

WORLD REPORT  Some medical associations support restrictions on social media use to protect adolescent’s health, while others focus on making companies provide safer platforms. 

Laws intended to protect adolescents from the harms of social media are spreading across the USA but, among some of the nation’s leading medical and public health associations, there is not yet a consensus on limiting social media access for young people. Nearly two dozen states are considering legislation. Several have already enacted a patchwork of age restrictions and partial bans. [Continued here.]
CMS, Medicare

A Covid Test Medicare Scam May Be a Trial Run for Further Fraud

By Susan Jaffe, KHN  | May 18, 2023 | This story also ran on  

Medicare coverage for at-home covid-19 tests ended last week, but the scams spawned by the temporary pandemic benefit could have lingering consequences for seniors.

Medicare advocates around the country who track fraud noticed an eleventh-hour rise in complaints from beneficiaries who received tests — sometimes by the dozen — that they never requested. It’s a signal that someone may have been using, and could continue to use, seniors’ Medicare information to improperly bill the federal government. …One beneficiary in Indiana suspected something was amiss after receiving 32 unrequested tests over a 10-day period. [Continued on Kaiser Health News, NPR, Yahoo News, and St. Louis Post-Dispatch]

The Lancet

US Surgeon General: loneliness is a public health crisis

Volume 401, Issue 10388   ||   13 May 2023  

 

WORLD REPORT  A new report by the USA’s leading public health advocate calls for widespread efforts to address social isolation. Susan Jaffe reports from Washington, DC.

The USA has an “epidemic of loneliness”, according to a new advisory from the Surgeon General, Vivek Murthy. “Loneliness is far more than just a bad feeling—it harms both individual and societal health”, Murthy warns. “It is associated with a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death.” [Continued here.] 

FDA, The Lancet

Drug developers caution against US mifepristone ban

Volume 401, Issue 10385
22 April 2023 

 

WORLD REPORT     A lawsuit against the FDA embroils pharmaceutical companies in debates over access to
abortion. Susan Jaffe reports from Washington, DC.

Less than 1 year after the US Supreme Court ended its 1973 constitutional guarantee to an abortion and told state lawmakers that they could decide whether a person ends their pregnancy, abortion is now back before the court. But this fresh legal challenge has dragged the nation’s entire drug approval system along with it, rousing a powerful lobbying group and economic force that has mostly managed to avoid the fray—the pharmaceutical industry. [Continued here.]

EPA, The Lancet

Hazardous train spills prompt calls for tougher safety rules

Volume 401, Issue 10383
8 April 2023 

 

WORLD REPORT  New bipartisan legislation has been proposed to protect health and safety following a train derailment in East Palestine, Ohio, USA. Susan Jaffe reports from Washington, DC.

A flammable brew of toxic chemicals from a freight train that went off the tracks in the Ohio village of East Palestine is no longer burning but the impact of the wreck is far from over. A massive clean-up continues along with water, soil, and air monitoring. Several government agencies are involved in recovery efforts and are investigating what went wrong. And in a rare show of bipartisanship, Democrats and Republicans in Congress have proposed legislation aimed at closing the gaps in rail safety rules that the accident exposed. The accident’s aftermath has also reached the courts. [Continued here.]

CDC, CMS, EPA, HHS

US plan to shield science from “inappropriate influence”

Volume 401, Issue 10375
11 February 2023 

 

WORLD REPORT  The Biden administration is launching a new initiative on scientific integrity in federal agencies following multiple lapses. Susan Jaffe reports from Washington, DC.

Just a week after Joe Biden was sworn in as president in January, 2021, he created a multi-agency Task Force on Scientific Integrity to restore “trust in government through scientific integrity and evidence-based policy making”…Last month, the White House Office of Science and Technology Policy released A Framework for Federal Scientific Integrity and Practice, a follow-up to the task force’s 2022 recommendations that provides a blueprint for implementation. [Continued here.] 

Affordable Care Act, EPA, Global Health, Medicaid, The Lancet

Modest health goals for new US Congress

Volume 400, Issue 10369
17 December 2022 

 

WORLD REPORT  With Congress almost evenly split between Republicans and Democrats, consensus on any major health legislation is unlikely.  Susan Jaffe reports. 

When a new US Congress convenes in January, 2023, the slim Republican majority in the House of Representatives and the Democrats’ even smaller margin in the Senate will not enable either party to make major changes in the health-care system. With President Joe Biden promising to use his veto power to defend his health-care agenda, no significant fixes are expected. But there appears to be bipartisan support for some less ambitious legislation on issues that will overcome congressional gridlock.[Continued here.]

CDC, The Lancet

US CDC begins agency-wide changes after pandemic failures

Volume 400, Issue 10365
19 November 2022 

 

WORLD REPORT  An independent review made several recommendations for improving the public health agency. Susan Jaffe reports from Washington, DC.

The US Centers for Disease Control and Prevention (CDC) is on a mission to reorganise and modernise itself, so that its mistakes during the pandemic will not happen again. The aim is to make the nation’s leading disease detective more nimble and accountable, and fortify its role as public health protector. But although some changes have been made, progress will be limited without support from Congress. [Continued here.]