October 31, 2020

October 31, 2020

Government Issues New Health Care Cost Transparency Rules

In an effort to inject transparency into the obscure costs of health care the Department of Health and Human Services (HHS) has issued new rules that will require health insurers to publicly post, on the internet in advance, the price for the most common services and procedures.

Information about health care costs, including how much the patient owes after insurance pays its part is currently available only after they’ve received services in what is known as a “EOB” (explanation of benefits).

However, nothing will happen immediately because the new policy will be phased in over the next four years.

Starting in 2022, insurers will be required to make available data files on the costs of various procedures in order to develop websites for the information. The requirement will take effect for 500 of the "most shoppable" services beginning in 2023, and then for all services starting in 2024.

HHS says the goal is to bring more transparency into the health care system with the expectation that it will result in more competition and the lowering of health care costs.  However, although consumers will be "empowered" to shop and compare costs between specific providers, they will have to balance the information about cost with quality.  In other words, is the cheapest doctor going to be the best doctor?

Insurance plans will also be required to make their in-network negotiated rates with doctors and allowable out-of-network rates available to the public and insurers will be required to post their negotiated pharmaceutical prices and the historical net prices for all their covered drugs.

The rule is likely to face a legal challenge from industry groups and possibly individual insurance providers that say it would drive up consumer prices and reduce competition.

Most plans, including employer-based group health plans and health insurance issuers offering group and individual coverage, will be required to post the information.

The insurance industry has argued that the policy will undermine competitive negotiations and actually push health care prices higher, once doctors find out they are being paid less than competitors.

The industry also argued that insurers would be forced to share both their trade secrets and their enrollees’ sensitive, personally identifiable information with third-party developers of the internet sites where the cost information will eventually be posted.

TSCL supports this effort.  But we don’t believe it is the answer for all the issues involved in health care costs.  Health care issues can come up suddenly.  Are you  going to then take the time to shop around?  And what assurance do you have that the cheapest health care provider will give you the kind of care you want?  Do you even live in an area where there are multiple options for the health care you need?

These and other questions will remain even after the new rules come into effect.

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Financial Help for Uninsured Patients with Coronavirus

According to an article in Kaiser Health News, uninsured patients who contract COVID-19 can have their bills covered through a program administered by the Center for Medicare and Medicaid Services (CMS).  The program was authorized through pandemic relief legislation passed by Congress called the CARES Act and most major health systems participate in it.

But hospitals are not required to tell patients about it and apparently most don’t.  This is especially troublesome because research has found that people with the coronavirus often avoid getting care because they can’t afford to pay the bill.

However, if they knew enough to ask questions about what financial help is available, they might qualify for any number of programs.  And it turns out that many doctors don’t know about the existence of the programs or if they do, they don’t know how they work.

According to the article, “Among clinicians, there’s a reluctance to raise the issue of cost in any way and run afoul of federal laws. Emergency rooms must at least stabilize everyone, regardless of their ability to pay….  Asking questions about insurance coverage is often referred to as a ‘wallet biopsy,’ and can result in fines for hospitals or even being temporarily banned from receiving Medicare payments.

“Physicians also don’t want to make a guarantee, knowing a patient still could end up having to fight a bill.”

If you know of someone who is uninsured and either has, or suspects they may have the coronavirus, let them know there may be financial help for them when they seek medical treatment.

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Update on President’s Executive Orders for Lowering Drug Costs

Spending on prescription drugs was up by nearly 22% in the first quarter of 2020 versus the first quarter of 2017 according to a recent analysis by the Los Angeles Times.

President Trump made lowering drug prices a major issue in his election campaign in 2016 and has continued to say he is working on lowering drug costs in this year’s campaign.  Earlier this fall he issued four orders that were supposed to help lower the costs, which we reported on at the time.

One of the orders mandated that manufacturer rebates for drugs for Medicare members be sent directly to enrollees, rather than to the managers or health plans that negotiate those discounts.  However, according to the nonpartisan Congressional Budget Office (CBO), the reduction in rebate money going to health managers meant that premiums would rise for Plan D participants, negating for many the entire suggested savings.

Another of his orders was supposed to reduce the cost of insulin “from big dollars to virtual pennies,” especially for seniors.  However, it turned out that the order affected less than 2% of the health care providers that participate in the federal drug discount program – and of the many rural and low income clinics included, most already offered insulin at reduced or no cost to those below the poverty line.

The president also signed an order that would allow Americans to import prescription drugs from Canada, but it turns out that program has to run through the states and so far, only Florida has gotten approval to begin operation.  In addition, the Canadian government has let it be known that it will make sure the needs of Canadian citizens are met first before it will participate in any drug reimportation program.

TSCL has long supported drug reimportation as long as there are sufficient safety measures to go along with it, but it appears there needs to be serious negotiations with other countries before such a program can be instituted.  It cannot be simply declared by our government that it will happen.

The last order the President issued calls for the U.S. government to pay drug manufacturers the lowest price for certain drugs that can be found among comparably wealthy countries in Europe and elsewhere.

When the President announced the order in July, he made it clear that it was an effort to drive the big drug companies to the negotiating table, and the president gave the industry a month to come up with its own plan for reducing prices.  However, it didn’t work, and the drug companies initially refused to even go to the White House to meet with him.

He updated his order in September by adding Medicare Part D, which includes most drugs prescribed to seniors. But experts quickly pointed out that the order did not explain what would happen with drugs that aren’t bought by the government and that it left loopholes for HHS to determine which drugs would be included.

It is also highly likely that the drug companies will sue to prevent its implementation.

The costs of drugs will continue to be an issue no matter who wins the election and TSCL will continue to fight to lower them.

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When Will a Coronavirus Vaccine be Available?

According to an article in StatNews, a news service that specializes in medical news, we need to face reality when it comes to the development of a vaccine again the coronavirus.

“Pauses in clinical trials to investigate potential safety issues, a slower-than-expected rate of infections among participants in at least one of the trials, and signals that an expert panel advising the Food and Drug Administration may not be comfortable recommending use of vaccines on very limited safety and efficacy data appear to be adding up to a slippage in the estimates of when vaccine will be ready to be deployed.”

Last Tuesday, Pfizer pharmaceutical company let it be known that its first interim analysis in its Phase 3 clinical trial has not yet occurred. That means there hadn’t yet been enough COVID-19 infections among the trial participants to take a first stab at analyzing whether the people randomly assigned to receive vaccine were infected at a lower rate than people who were assigned to get a placebo injection.

Pfizer had initially said it thought it would know by the end of September if its vaccine worked.  That was subsequently recalculated to be late October and now is estimated to possibly be mid-November.

According to StatNews, “It is important to note that, to date, none of the vaccines being developed for the U.S. market has been proven to be effective in preventing Covid-19 disease. Early stage clinical trials have shown what appear to be promising signals; multiple vaccines have triggered production of important antibodies in people who have been immunized.

“But data generated in a few hundred people aren’t enough to determine whether a vaccine will actually fend off illness. That answer comes from large, Phase 3 trials, five of which are now underway in the United States. Their findings will ultimately tell us how soon vaccines may start to be rolled out to the masses.”

As experts have been telling us all along, developing, testing, and manufacturing vaccines takes time. Vaccines are difficult to produce and there are always bumps in the road.

Again, from StatNews: “While it’s unfortunate, I don’t find it surprising that the timeline is being moved back,” said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy. “Clinical trials like this routinely have unexpected occurrences that delay planned timelines. It’s just not unexpected.”

As for the idea that all Americans will have had a chance to be vaccinated by the early spring, Osterholm suggested it is going to take longer.

“For many of us, we never thought that that was doable,” he said. “I commend Operation Warp Speed for what it has accomplished in the time it has, but to have vaccinated the U.S. population by March in my mind was never a realistic goal.”

The StatNews report closed with this: Anna Durbin, a vaccine researcher at Johns Hopkins Bloomberg School of Public Health, said the public needs to understand that Covid vaccines may be a bit further off than people have been led to believe.

“We may see efficacy in one or more trials by the end of 2020, but that doesn’t mean we’re going to have a vaccine available at the end of 2020,” she said.

“I think what people can take from this is that the process is not being rushed…. That’s a good thing,” Durbin said. “And certainly, I think the other message that has to be heard loud and clear is that even when an [emergency use authorization] is issued, we’re not going to have enough vaccine for everybody [immediately].”

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Despite the coronavirus emergency, TSCL is continuing its fight for you to protect your Social Security, Medicare, and Medicaid benefits.  We have had to make some adjustments in the way we carry on our work, but we have not, and will not stop our work on your behalf.

For progress updates or for more information about these and other bills that would strengthen Social Security and Medicare programs, visit the Bill Tracking section of our website or follow TSCL on Twitter.