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Selling Screening Tests

Trudy Lieberman
Tuesday, May 8th, 2012

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Forum blog…more.

A few weeks ago, a letter arrived from the Life Line Screening company enticing me to come in for a “simple, potentially lifesaving screening” to assess my risk for strokes and other vascular diseases.  The pitch contained the usual scary messages, noting that “cardio-vascular disease is the #1 cause of death in the United States for both men and women.”  A small flyer inside the envelope warned that the offered “screenings will give you information that your annual check-up may not reveal,”  explaining that “ultrasound screenings can actually see inside your arteries” and reveal bad stuff that doctors can’t see during an annual exam.

As if that weren’t enough to reel in customers, the offer was framed like those bulk sales come-ons you see offered by women’s clothing chains—buy $150 worth of merchandise and get $25 off on your next purchase.  Life Line Screening, which bills itself as the country’s leading provider of community-based preventive health screenings, offered five tests: carotid artery screening, heart rhythm screening, abdominal aortic aneurysm screening, peripheral arterial disease screening and osteoporosis risk assessment, all for only $149.   That was a savings of $126 off the complete package of five screenings, which retailed for $275.

Buying in bulk seemed to make sense.  Or did it?

The answer gets into the controversial realm of screening tests.   Health policy experts implicate unnecessary tests as one reason America’s health care tab is so high, and the uber authority on such screenings, the U.S. Preventive Services Task Force (USPSTF), doesn’t always recommend every test that some physician or some outfit like Life Line Screening wants to sell.  So I went to the USPSTF website for guidance, which is what anyone should do who receives a sales pitch for screenings, no matter how inviting they sound.

The task force has not recommended peripheral artery screening or carotid artery screening for people with no symptoms. It has, however, recommended a one-time screening for abdominal aortic aneurysm in men aged 65 to 75 who have smoked and routine screening for osteoporosis in women 65 and older.  Both those screening tests got a B grade, which means there is high certainty that the net benefit is moderate or that there is moderate certainty the net benefit is moderate to substantial.  Screening tests that get “A” grades are those where there is a high certainty that the net benefit is substantial.  “A” graded tests include blood pressure screening and screening for cervical cancer.

Sometimes screening tests do turn up abnormalities as evidenced by the testimonials that sellers like to point to.  But evidence examined by the USPSTF indicates that as a whole, many widely advertised screening tests are not beneficial.

And your insurance may not cover any screenings that the USPSTF does not recommend.

Life Line Screening’s website tries to push back against official public health guidance about their tests with information they call “Health Screening Concerns & Complaints.”  The questions they pose and answers they provide are carefully worded to give both the company and screenings a favorable gloss.   One question notes for example, that the USPSTF recommends against carotid artery screen for patients with no symptoms and asks if Life Line Screening has “my best interests in mind.”

The company responds that the task force recommendation is “widely misunderstood,” and adds, “The US Preventive Services Task Force does not examine community-based screening for the purposes of early identification and treatment with lifestyle coaching and medical management, which is what Life Line Screening does.”   Another Q & A response assures customers that “even if your health screening found no problems, knowing that you are on the right track should make the time and money spent well worth it.

Doctors are also beginning to review the value of some often-used screening tests.  Nine medical specialty boards, under the leadership of the American Board of Internal Medicine (ABIM), have recently recommended that physicians reconsider the use of 45 common tests and procedures such as M.R.I.s when someone complains of back pain.   The docs’ announcement, accompanied by their partnership with Consumer Reports for a national “Choosing Wisely” campaign, is a big deal and should serve as a warning to patients (aka customers of private screening businesses) to do their homework before agreeing to screenings that are not likely to improve their health.

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What to Do About Long-Term Care Insurance

Trudy Lieberman
Tuesday, April 17th, 2012

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Forum blog…more.

The decision to buy long-term-care insurance and how long to keep it is among the toughest people make as health-care consumers.   The product is difficult to buy—confusing, complicated, and costly.  Many won’t qualify for it because of preexisting health conditions that insurers don’t want to insure.  (Long-term care policies are exempt from the rules of the health reform law, which if upheld by the Supreme Court, will bar carriers from considering applicants’ health.)  And once you have a policy, do you keep it when the premiums continue to climb?

That’s the dilemma thousands of policyholders have faced in the last few months as insurance companies have raised their rates as much as 40 and 50 percent for some policies.  According to the trade group, the American Association for Long-Term Care, average premiums are now six to seventeen percent higher than they were a year ago.

A Consumer Reports study conducted in the late 1990s found that many policies sold then were under priced and projected that companies would need large rate increases as the years went on.  That’s happening now.  But insurers are increasing premiums not just on older policies but on new ones too, and consumers who hold them are trying to keep them despite the large premium hikes, says Bonnie Burns, a long-term care expert with California Health Advocates.  They are following the advice Burns and others have given:  once you have a long-term care policy, you need to hang on to it.

I asked Burns what strategies consumers are using to stay insured.  None are ideal, she explained.  They are reducing the benefits they will eventually get which will leave them with large out-of-pocket expenses if they do go to a nursing home.  Or they are robbing assets that, too, will be gone when they will need them in very old age.

Some people simply stop paying premiums in exchange for a benefit equal to the amount of premiums they have already paid.  In other words, if they’ve paid $40,000 in premiums over the years, the benefit will be $40,000 when they need care.  You can do that only if your state insurance regulations allow it.   Be sure to check with your state’s insurance department to see if it has adopted regulations that permit this protection if this option sounds appealing to you.

What do you do if a sales agent or a financial planner suggests that you buy long-term-care insurance?  Think very carefully about whether you can afford the premium now and in five or ten years.   You’ll have to consider your current resources and what they’ll be down the road.  You’ll also need to consider future expenses. Health care will be a big one and is likely to get bigger.

If you’re under age 65, consider that you will likely have to pay more out-of-pocket for your medical expenses as employers increasingly offer skimpier policies that cover less.  If you’re over 65, you’ll be paying more too.  Congress is considering changes to Medigap policies that will result in seniors paying more out-of-pocket for health care.  A new issue brief from the Kaiser Family Foundation warns that even with Medicare coverage, medical costs are a significant portion of a senior’s budget.

Given higher premiums for long-term care insurance combined with expanding out-of-pocket health care costs, the prospect of many seniors being covered for nursing home care appears slim.  “It looks like seniors with moderate incomes will be less likely to have this coverage and less likely to afford it,” Burns says.  “This is the population most likely to spend down and become eligible for Medicaid.  The promise of long-term-care insurance being the savior of Medicaid is less and less likely.”

That still leaves one huge question on the political table since the Obama Administration junked the CLASS Act, which represented the beginnings of a national program for paying for long-term care under the health reform law:

How will Americans pay for their long-term-care?   

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The Supreme Court’s Health Care Decision and Your Pocketbook

Trudy Lieberman
Thursday, April 5th, 2012

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Forum blog…more.

Last week’s drama at the Supreme Court and most of the media coverage that followed omitted crucial information:  how a decision either upholding or junking the Affordable Care Act (ACA) will affect ordinary Americans.  Because the health reform law is not well understood by most people, it’s worth recapping what might happen.

Insurance Coverage Mandate

Most of the 160 million Americans who have health insurance from their employers won’t be affected directly by the Supreme Court’s ruling either way.  Most will continue to get job-based coverage.

A mandate for everyone to have health insurance is at the center of the Supreme Court case. If the individual mandate is upheld, every state will implement “exchanges” where people without health coverage will be able to shop for insurance.  However, those with employer-sponsored coverage will not be eligible to purchase insurance from the exchange unless their share of the premium for their employer insurance is greater than 9.5 percent of their gross income.   If employer coverage is skimpy or too expensive, they—and their family members—are stuck.

If the Supreme Court upholds the mandate, then people who do not have coverage either from government programs or from their employers will have to buy it.  Those with incomes less than about $92,000 (about $45,000 for individuals) will receive subsidies that will help cover the cost of a policy.  Those with lower incomes will receive more help.  If the mandate is struck down, people without coverage are in the same fix they are now.  They will still be at the mercy of the individual insurance market where premiums are very high, and insurers often reject those with preexisting conditions.

Whether young adults will still be able to obtain coverage under their parent’s insurance until they turn 26 will depend on whether the court strikes down the entire law or just the mandate.   The requirement to cover young adults is already in effect, giving coverage to some 2.5 million young adults.  If that provision goes, then this group will be in the same position they were in before the law was passed.  Some carriers might allow them to stay on their parents’ insurance; others might not.  In that case, they, too, will have to shop in the individual market.

More on Those Exchanges

If the mandate stays, states will set up shopping exchanges where insurance companies would sell their policies in a kind of insurance bazaar.  Policies will have to meet minimum standards, but states will have a lot of discretion about what the basic plan will cover.  Consumers will be able to choose from among four types of policies:  bronze policies will be the cheapest and will cover only 60 percent of a policyholder’s medical costs; the silver policy will cover 70 percent; a gold policy 80 percent; and the most expensive platinum policy will cover 90 percent and offer Cadillac coverage for a price, of course.    If the mandate goes, some states may operate their own exchanges similar to what Massachusetts does.  Those who will have to buy health insurance in the individual market and even those with employer coverage will find policies that will cover varying amounts of their medical expenses.  They won’t be called bronze, silver, gold, and platinum, but they will be similar.

Rising Health Care Costs

The big pocketbook issue for consumers will be whether there will be a slow down in the increase of health care costs.  Those ever-rising prices are responsible for a large chunk of the premiums everyone pays, and they also make it tough to cover those high deductibles and coinsurance the newer models of skimpy coverage require.

The Affordable Care Act contains a number of measures designed to provide better care that will ultimately result in lower prices, or so the designers of these provisions have hoped.  These include so-called medical homes and accountable care organizations (ACOs), which are supposed to better manage patients’ conditions.

The law also calls for rewarding hospitals with larger Medicare reimbursements if they give better care.   Some of these efforts will continue regardless of a Supreme Court decision to overturn the ACA. But it is unclear whether the ACA provisions can lower costs or improve care.  A study published last week in the New England Journal of Medicine  found that paying hospitals to improve their quality of care did not appear to help patients live longer.  The health reform law calls for bonus payments to hospitals that show improvement.

No one knows yet what the Supreme Court will decide, but either way its decision will affect everyone’s pocketbook.

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Medicare Games: When Is a Stay in the Hospital Really a Stay?

Trudy Lieberman
Wednesday, March 21st, 2012

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Forum blog…more.

It may seem like a no-brainer. If you or a family member is on Medicare, you would assume that if they are in the hospital their care would be covered under Medicare’s Part A hospital benefit. Right? Well, not always. The definition of a stay is tricky and depending on how a stay is defined, families can be left with unexpected bills totaling thousands of dollars.

Here’s the problem: It’s not uncommon for a hospital to admit patients for what’s called “observational status.” That means hospital personnel watch the patient while doctors decide if he or she can go home or if they are sick enough to be admitted as a bona fide inpatient.

Medicare considers “observational status” to be an outpatient service, which is paid for under Medicare Part B and not Part A, the hospital benefit. With Part B coverage, there is 20 percent coinsurance, or 20 percent of the bill, a patient must pay plus a deductible. Medigap policies usually cover this amount, but with Medicare Advantage plans, the insurers’ rules determine what’s paid. And 20 percent of a bill for several days in the hospital adds up to big dollars quickly.

Observational stays are not supposed to last more than 48 hours, but the Medicare Payment Advisory Commission (MedPac), which advises Congress, has found that there are an increasing number of observations lasting longer than that. The number of observational stays is growing, too, making it more and more likely that you or a family member will experience one.

Why are hospitals doing this? Toby Edelman, a senior attorney at the Center for Medicare Advocacy in Washington, explained, “It’s one way to keep Medicare fraud investigators off their backs. If they classify someone as an inpatient who should simply be held for observation, they could get in trouble with Medicare’s fraud police looking for overpayments to providers.” So, Edelman says, they try to stay beneath the radar and take the advice of hospital consultants to play it safe.

The health reform law gives hospitals even greater incentive to keep patients under observation. Soon Medicare will start penalizing hospitals financially if patients are readmitted. Readmissions are expensive for Medicare, and curbing them is a way to reduce their costs. Edelman says that if a patient is admitted for observation and later must return to the hospital, it is not counted as a readmission. But if a person is admitted as an inpatient at first and later must be readmitted as an inpatient, the hospital can be penalized.

Like so many things in health care, trying to solve one problem simply creates another. This observational versus inpatient status sure creates some big headaches for Medicare beneficiaries. If you or your family finds yourselves in this pickle, you may need to appeal Medicare’s decision to classify your family member’s hospital bills as outpatient care. Here are some steps that will help you:

If the patient is still in the hospital, try to get the status changed to inpatient.

Seek your doctor’s help in persuading the hospital to change a patient’s status.

Obtain hospital records, which will be necessary to show why someone should have been an inpatient.

Check the Medicare Summary Notice that summarizes the patient’s stay, and then follow the appeal steps the notice outlines.

There’s a lot of paperwork involved, but the Center for Medicare Advocacy’s website can help with the task of appealing a decision. “It’s crazy the way we do it,” says Edelman. “It doesn’t make sense from the patient’s perspective. You’re in a bed, you get hospital food, you have tests done, and yet it’s not a hospital stay. It’s not the way to get good health care.”

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