Debbie Perlman Blog

   Dual-eligible Medicare beneficiaries were more likely to experience the social determinants of health than non-dual eligibles.    Over half of dual-eligible Medicare Advantage beneficiaries experience the social determinants of health, revealing a need for better social health programming within the program, according to data presented by Avalere at ISPOR 2019. The data, which included administrative claims, CMS data, and other data linked with zip-code level information for nearly 2 million beneficiaries, revealed that more vulnerable Medicare beneficiaries yield poorer outcomes. Specifically, these members have poorer health, higher utilization rates, higher healthcare spending, and lower quality measure scores. The researchers looked at the socioeconomic status of dual-eligible members, or members who qualify for both Medicare and Medicaid. While dual-eligible benefits usually vary by state, it tends to be a marker of extreme health need. Patients rec

  Medicare, Medicaid, and private payers covered 82 percent of prescription drug spending in 2017.   Total prescription drug spending reached $333 million in 2017, but the way that lump sum was divided among Medicare, Medicaid, and employer-sponsored health plans may reveal differences between the populations each payer covers, according to a May analysis from the Kaiser Family Foundation (KFF). The analysis, which looked at claims data from large, employer-sponsored health plans, Medicare Part D plans, and Medicaid, revealed that some payers cover more of that $333 billion figure than others do, likely because of the complexity and size of the populations they cover. Combined, employer plans, Medicare Part D, and Medicaid covered 82 percent of all prescription drug spending in 2017, while out-of-pocket patient costs covered 14 percent. Broken down by payer, the analysis showed that private insurers ate the biggest piece of the prescription spending p

Does my health plan cover my current doctor? Call your doctor’s office directly and ask if they accept your coverage. You can also check your health plan’s website and their provider directory. You may also want to ask your plan if you need prior authorization before your visit. Without it, you may be charged for things your health plan would have paid for. Does my health plan cover the services I need? All private health insurance plans offered in the Marketplace offer the same set of essential health benefits, including prescription drugs, emergency services, and pregnancy, maternity, and newborn care. Some plans may also offer additional coverage. If you have questions about whether a service is covered, contact your plan. What will my costs be? Most health plans give you the best deal on services when you see a doctor who has a contract with your health plan (also called an "in-network" provider). You may be able to see doctors who don’t contract

The Trump administration has decided to put part of its Medicare drug cost-cutting proposals on hold, for now, announcing that it will not give health plans the authority to negotiate pricing for certain drugs considered protected classes and will not require pharmacies to make sure Medicare patients get the lowest price on prescriptions. The Centers for Medicare and Medicaid said Thursday it will not be implementing its lowest pharmacy price proposal for 2020, after receiving more than 4,000 comments on the rule. “CMS is continuing to carefully review these comments as we continue to consider policies that would lower prescription drug costs, address challenges that independent pharmacies face, and improve the quality of pharmacy care,” the agency said. The administration also said it is not implementing a proposal, announced last fall, that would have allowed private Medicare Advantage and Part D drug plans to negotiate prices on so-called protected classes of

Congress held its first-ever hearing on "Medicare for All" legislation that was filled with emotional testimony from single-payer advocates as well as heavy skepticism from Republicans about upending the current health care system. The House Rules Committee heard six hours of testimony on the Medicare for All Act of 2019, a proposal introduced by Democratic Reps. Pramila Jayapal and Debbie Dingell that would eliminate private insurance companies and have all Americans on a government-run plan. While a number of Democratic leaders haven't gotten behind the overhaul plan, "Medicare for All" has gained momentum within the party with 100 co-sponsors in the House and a number of Democratic presidential contenders supporting the proposal. Ady Barkan, a 35-year-old single-payer activist who has ALS, expressed the urgency to shift to a "Medicare for All" system in his emotional testimony. Barkan became a face of the movement when

Safety net health clinics have fared better in states that have expanded Medicaid coverage to more low-income residents than those in states that have not expanded the health program, according to a new survey. Federally qualified health centers, along with look alike clinics that lack the same grant funding, provide low-cost primary, behavioral health and dental care, serving millions of people – and 1 in 6 medical patients across the country. Federally qualified health center patients are more likely to suffer from chronic conditions, but the centers spend considerably less to care for patients than other providers. The Affordable Care Act allocated $11 billion to operate and expand such community health centers over a five-year period. Since the law was enacted in 2010, millions of low-income people have obtained health coverage, in large part through the act's push for states to expand Medicaid coverage. The survey and accompanying report from the Commonweal

Americans can insure just about anything. Drivers are required to get automobile insurance, renters and homeowners insure against theft and damage, and businesses must protect themselves from lawsuits. This is just skimming the surface; the Insurance Information Institute reported that $1.1 trillion in premiums were paid to insurance companies in 2014 to insure everything from properties to pets. To handle the demand, the industry employed about 2.5 million people to set premiums, sell plans, evaluate claims and perform other essential functions. This guide gives readers information about careers within the insurance sub sector along with related degree information, corresponding salaries and job outlook.                         Insurance Degrees and Career Paths                                                                  1.Actuary:   Actuaries assess risk so they can set premiums. They usually specialize in one type of insurance. For instance, propert

WASHINGTON — In a major test case, Medicare is poised to cover a promising but expensive new type of cancer treatment, with significant restrictions meant to hold down the cost.   Cancer patients, doctors and drug companies are urging the Trump administration to remove the restrictions and broaden coverage so more patients can benefit from the treatment, known as CAR T cell therapy, or CAR-T. But insurance companies are pushing for the restrictions. The treatment is manufactured specifically for each patient, and many more such “personalized medicines” are in the pipeline. Medicare’s final decision, expected in the next few weeks, will influence commercial insurers and state Medicaid programs, which often follow its lead. Medicare and other insurers typically pay for drugs as they are used, from month to month and year to year. By contrast, the CAR-T treatments generate high costs up front, but the benefits could last for years. Do you want to know more information about

Healthcare in the U.S. is about twice as expensive as it is in any other developed country. If the $3 trillion U.S. healthcare sector were ranked as a country, it would be the world’s fifth largest economy, according to  Consumer Reports . The cost of this huge financial burden for every household because of lost wages, higher premiums, taxes and additional out-of-pocket expenses is more than $8,000.  Even with all this money being spent on healthcare, the World Health Organization ranked the U.S. 37th in healthcare systems, and The Commonwealth Fund placed the U.S. last among the top 11 industrialized countries in overall healthcare.  Why is the U.S. paying so much more for care and not appearing at the top of the rankings? Here’s a look at six key reasons the U.S. is failing to provide adequate health care at reasonable prices. 1. Administrative Costs The number one reason our healthcare costs are so high, says Harvard economist David Cutler, is “the administrat

Health care in the United States can be very expensive. A single doctor’s office visit may cost several hundred dollars and an average three-day hospital stay can run tens of thousands of dollars (or even more) depending on the type of care provided. Most of us could not afford to pay such large sums when we get sick, especially since we don’t know when we might become ill or injured or how much care we might need. Health insurance offers a way to reduce such costs to more reasonable, affordable amounts. The way it typically works is that the consumer (you) pays an up front premium to a health insurance company and that payment allows you to share "risk" with lots of other people (enrollees) who are making similar payments. Since most people are healthy most of the time, the premium dollars paid to the insurance company can be used to cover the expenses of the (relatively) small number of enrollees who get sick or are injured. Insurance companies, as you can imagine

WASHINGTON — Returning to a central issue of the 2018 campaign, House Democrats on Thursday passed legislation to reverse Trump administration rules that allow expansion of health care plans that do not have to comply with the Affordable Care Act’s mandated coverage of pre-existing medical conditions. The vote — 230 to 183 — was a jab at President Trump, who has pressed for ways around the coverage mandates of President Barack Obama’s signature domestic achievement while claiming he is committed to protecting Americans with chronic illnesses. But it served a larger political purpose, kicking off a push by House Democrats on health care, an issue they see as central to winning back the White House and holding their gains in the House in 2020. Over the next two weeks, Democrats expect to pass a raft of legislation to drum home the point that, even as they clash with the White House over the findings of the Mueller report, they will continue to focus on proposals that help real