— Dr. Atul Grover, Baltimore
Reading the Fine Print on Medicare Advantage Plans
With Medicare Advantage open enrollment open until Dec. 7, millions of seniors will consider costs, benefits and networks when selecting a new plan (“Medicare Plans’ ‘Free’ Dental, Vision, Hearing Benefits Come at a Cost,” Oct. 27).
Many consumers may not be aware that some health plans have frustrating restrictions buried deep within that limit access to critical procedures. For example, Aetna recently began requiring prior authorization for cataract surgeries across all its health plans — including Medicare Advantage. Tens of thousands of Americans covered by Aetna have had their sight-restoring surgeries delayed or canceled, while insurance company representatives decide who gets to see better — and who must wait for their cataract to get worse before insurance will cover cataract surgery.
Congress is working to put guardrails around prior authorization abuse in Medicare Advantage through the Improving Seniors’ Timely Access to Care Act, which now has 239 co-sponsors in the House and was recently introduced in the Senate.
In the meantime, seniors should beware of prior authorization requirements in Medicare Advantage plans and press insurance representatives to be upfront about obstacles that can lead to care delays or denials.
— Dr. Tamara R. Fountain, president of the American Academy of Ophthalmology, Chicago
— Julie Carter, Las Vegas
Your recent article on Medicare Advantage plans provided a good overview but omitted essential information.
Traditional Medicare coverage includes a well-defined set of benefits, rules and regulations with regards to coverage. Adverse coverage determinations can be appealed. The appeals process is well defined.
Medicare Advantage plans claim to cover services that traditional Medicare covers and “more.” The problem is that there is no means to ascertain the validity of such claims. Additionally, coverage under such plans is conditional and at the discretion of such plans. Denials of care have no standardized means of appeal. The appeal is to the plan itself. There is no means to override an adverse coverage decision and the plans tend to uphold their adverse decisions upon appeal as there is no external oversight mechanism that can be used to reverse the plans’ decisions.
Few individual providers have the resources to challenge adverse coverage decisions from the big arealth insurance companies running the Medicare Advantage plans. I am a provider. If a commercial health plan will not resolve a coverage dispute, I can contact the Texas Department of Insurance to resolve the issue. TDI has no jurisdiction over the Medicare Advantage Plans.
I have made numerous inquiries to determine who has jurisdiction over adverse coverage decisions by Medicare Advantage plans, including to the Centers for Medicare & Medicaid Services. No responses!
My warning to those turning 65 is “caveat emptor.” Unfortunately, the public is not provided with the comprehensive information they need to make informed choices.
— Dr. Ed Davis, San Antonio
The Barest of Necessities
My mother raised nine kids with cloth diapers and a washing machine (“‘Down to My Last Diaper’: The Anxiety of Parenting in Poverty,” Oct. 22). We were raised in poverty. My father worked two jobs and my mother even made soap in the basement for much of our early years. Jeans were patched, hand-me-downs might just as well have been a brand, and one pair of shoes a year … well, that was a good year. Yes, we grew up poor, but at the same time we were given a strong work ethic by example. All nine children are now successful, productive contributors to society.
It is impossible, therefore, that disposable diapers are an “essential.”
That leaves this article in the realm of political rhetoric rather than health news. Weakens your brand, don’t you think?
— Steve Meyer, Cincinnati
— Bradford Pearson, Philadelphia
How Covid Had the Run of Hospitals
As a former registered nurse at a hospital in southwest Florida, I can attest positively to the facts presented in Christina Jewett’s article about hospital “safety” and how it relates to the retired pharmacist who died from covid-19 (“Patients Went Into the Hospital for Care. After Testing Positive There for Covid, Some Never Came Out,” Nov. 4). My observations and personal experiences in the hospital during the early days of this infection were just as she stated, with one additional caveat, which may be of interest. Our med-surg unit became an overflow unit for suspected and/or positive cases. What is not being told (yet is accurate) is that when our negative-pressure rooms were occupied (there were only two on our floor), patients were being put into regular rooms with the door closed.
Although on the surface this may sound like a “great” plan, I noticed a failure in management’s solution immediately: The room doors have a 1- to 2-inch gap underneath them. The patients in those rooms were not masked. This means, as is intuitively obvious, that the patients’ infected respirations were escaping from their rooms and into the hallways. Additionally, this “air” was then potentially capable of traveling into other patients’ rooms and thereby potentially infecting them with covid-19 as well. Needless to say, before too long, our floor had a couple of infected nurses.
My belief is that it is extremely possible and likely that many, many hospitals “reacted” this way during the earlier days of the pandemic. I wasn’t employed at this hospital far enough into the pandemic to observe where or how patients who were suspicious or positive for this virus were assigned rooms once researchers discovered that transmission was of the airborne variety rather than of the droplet variety, as initially thought.
Finally, as a nurse, I know of many other nurses here in Florida who absolutely refused to get vaccinated early, midway or late into this pandemic. I agree 100% that these nurses and various other “holdout” employees could very easily have “carried without knowledge” the virus to their patients, like the man spoken about in the article. There is no doubt in my mind that a “carrier” (likely unsymptomatic and unvaccinated) carried and infected the retired pharmacist. Great story, well-written.
— Janet M. Konikow, Fort Myers, Florida
— Jen Weidinger, Loudonville, Ohio
‘Daily’ Pill vs. Flushing Out Covid Risks
With luck, molnupiravir may work as well as acyclovir for herpes “A Daily Pill to Treat Covid Could Be Just Months Away, Scientists Say” (Sept. 24). However, as the Centers for Disease Control and Prevention points out on its website: “These [antiviral] drugs neither eradicate latent virus nor affect the risk, frequency, or severity of recurrences.” At the same time, the CDC posts clear and unequivocal warnings about sharing a bathroom used by a covid-19 patient. Don’t.
Their unspoken message is covid could very well be an infectious enterovirus, with flush toilet micro-plume a vector. Cities are studying sewage for presence of the virus and the clinical trials for niclosamide are testing the participants’ stool on schedule for elimination of the pathogen. Why?
Merck’s trial makes no mention of fecal viral load or describes a goal of eliminating the presence of covid in a patient. Will this drug really be a “game changer”? It took over 30 years to recognize polio’s fecal mode of transmission; are we repeating a historical mistake?
— Tom Heusel, Eugene, Oregon
— Peter Zeihan, Denver
Dental Health at the Root of U.S. Productivity
Dental care, like medical care, should be seen as a human right. The idea that support for dental care should be limited to older patients with major dental care issues is shortsighted. To this end, one estimate is that $45 billion of worker productivity is lost yearly because of tooth decay. This affects us all. Provision of good preventive dental care to all young people would increase productivity and thus benefit both the individuals at risk and society at large. (See: doi.org/10.1016/j.adaj.2020.09.019.)
Oral disease and systemic diseases such as cardiovascular disease, Type 2 diabetes and osteoporosis are linked. These conditions obviously are of enormous cost to society. Severe periodontal (gum) disease is associated with increased risk of cardiovascular disease. It is likely that gum disease actually causes cardiovascular disease. Substances produced either by germs infecting the teeth or by our bodies responding to the germs cause systemic disease. Mouth disease is clearly one cause of many systemic diseases. The cost to us of those diseases is obvious.
Including dental care in the health care package is a win for all. “Medicare for All” is the optimal solution.
— Dr. Marc H. Lavietes, board member for Physicians for a National Health Program, Bradley Beach, New Jersey
— Barbara DiPietro, Baltimore
On Oral Health and a Dental Hygienist’s Scope
A recent article published by KHN spotlighted licensed Illinois dental hygienists who also hold public health dental hygienist (PHDH) certification (“Hygienists Brace for Pitched Battles With Dentists in Fights Over Practice Laws,” Oct. 19).
The Illinois Dental Hygienists’ Association (IDHA) has diligently initiated legislation to bring affordable direct preventive oral health services for those who live in skilled nursing facilities and other confined settings. Dave Marsh, lobbyist for the Illinois State Dental Society (ISDS) was quoted as saying, “I just don’t feel anybody with a two-year associate’s degree is medically qualified to correct your health.”
IDHA would like to inform ISDS that the entry-level degree of a registered nurse is also a two-year associate’s degree. Does this mean that registered nurses are also unqualified to care for the elderly? Of course not! This is just another clear example of how ISDS continues to battle licensed dental hygienists and suppress their ability to work to their highest scope.
Illinois dentists claim they cannot afford to provide care for citizens who have state-funded dental insurance, are uninsured or poor. Yet they do not want dental hygienists to care for them either. Why? As the article clearly points out, ISDS illustrates the power that lobbying groups have in shaping policies on where health professionals can practice and who keeps the profits. And who suffers? Illinois’ most vulnerable citizens.
The Illinois State Dental Society also claims that after the Illinois Dental Practice Act was modified to allow direct preventive services by a public health dental hygienist, it took the hygiene association years to develop the PHDH curriculum. Conveniently missing was that legislation was tied up in the rules process during this period of time. So, all parties agreed to write the language for the PHDH certification courses in the statute. Once this process was completed in 2019, the hygienists’ association developed, implemented and graduated the first class of PHDHs within nine months.
The article accurately states that Illinois trails many states. To be exact, 38 other states allow dental hygienists unsupervised contact with patients in skilled nursing facilities. The article also accurately states that, politically, the Illinois State Dental Society is rich and powerful. This allows them to donate generously to lawmakers.
The Illinois Dental Hygienists’ Association wishes to thank KHN for uncovering the fact that profits and control are what motivate the Illinois State Dental Society, not increasing access to care. Now lawmakers can see ISDS’ true motives for suppressing the scope of practice of Illinois dental hygienists and pass legislation so that all Illinois citizens can receive the oral health care they need, want and deserve.
— Sherri Foran, president of the Illinois Dental Hygienists’ Association, Chicago
— Laura Baus, legislative chair of the Illinois Dental Hygienists’ Association, Chicago
— Chris Lempa, Park Ridge, Illinois
Socially Constructed vs. Biologically Determined
The Oct. 20 morning briefing states “If You’re Pregnant, Your Baby’s Gender Influences Your Response To Covid.” “Gender” is not the accurate terminology here; “sex” is. Sex is a biological characteristic, whereas gender is a social construction. As the source article states “Sex of the fetus,” KHN’s usage of the word “gender” is not only inaccurate but also unnecessary. The distinction between gender and sex is small, but it is extremely important.
— Jade del Vecchio, Decatur, Georgia
— Joanne Spetz, San Francisco
A Shortage of Funds, Not Caregivers
I am wanting to comment on the article concerning caregiver shortages (“Desperate for Home Care, Seniors Often Wait Months With Workers in Short Supply,” June 30). It is a fact that there is a substantial shortage of caregivers in the industry. The problem will only increase in the foreseeable future. I’ve worked at a nurse registry in Florida for seven years. I believe the focus and terminology that is used in all national articles concerning this issue needs a redirection. You did a tremendous job covering this in your article. I find the layman interprets terms such as “caregiver shortage” in ways that could be misleading and overshadow the core problem.
For example, when I speak to a family member seeking care for a loved one and they hear “caregiver shortage,” they naturally think there are not enough caregivers. Technically speaking, that is true when taking the ratio of elderly to caregivers into account. But the true problem is not a shortage of caregivers. It’s a shortage of funds available, especially Medicaid funds, to pay caregivers what they are worth. Statistically speaking, for the company I work for, there are plenty of caregivers in the system open to work. So, we are not short on caregivers. There’s actually not enough work available for all of our caregivers matching their requested reimbursement rate.
I believe the main tone of this issue should not be “caregiver shortage” but “caregiver reimbursement increase.” Hearing the problem “caregiver shortage” automatically leads to seeking a solution to increasing the quantity of caregivers. Though the quantity of caregivers does need to increase, it will not solve this issue. Being able to utilize caregivers who are available and willing to assist, in my opinion, is the first step to solving this nationwide issue. I thank you for your time.
— Michael Asche, Stuart, Florida
— Democratic state Rep. David Meuse, Portsmouth, New Hampshire
‘Dopesick’ Misses the Big Picture
I think it’s quite deplorable that you promote a program and its creators where no citations are made referencing our nation’s leading medical authorities. No mention of studies that do, indeed, support the <1% addiction rates. Dr. Scott Hadland, whose research was published in BMJ, shows rates well below 1%. These numbers can go higher depending on a patient’s prior risk factors. But Hadland’s study, with a cohort of over 3.2 million, was, I believe, opioid-naive patients ages 11-25 — understandably, a demographic of great concern.
There is no mention of National Institutes of Health Director Dr. Francis Collins’ views that dependence and addiction are different, with addiction being more severe but with lower rates of addiction present. [Collins said: “Physical dependence will develop in most individuals who take opioids chronically, resulting in withdrawal symptoms if the drug is taken away. Addiction is more severe and happens in only a small percentage of those who take opioids chronically.”] No mention of the views of National Institute on Drug Abuse Director Dr. Nora Volkow, who expressed great concern for the treatment of chronic pain patients. Both of those doctors said that while nobody is thrilled with the long-known downsides of opioids, there is currently nothing more effective.
There is no mention of the American Medical Association’s letter to the Centers for Disease Control and Prevention in June 2020 or the subsequent AMA statements since then, decrying the use of morphine milligram equivalents (MME).
No mention of the Department of Health and Human Services’ Pain Management Best Practices report of 2019 with its chapter on the 2016 guidelines, where it challenges some of the claims that are echoed in “Dopesick.”
Recently, in California, the California Department of Public Health issued a workgroup action notice regarding the closure of 29 Lags pain management clinics, setting adrift over 20,000 pain patients. Part of the state’s response was in the form of a video webinar on YouTube featuring San Francisco Public Health addiction physician Dr. Phillip Coffin. He was an original member of the core expert group that drafted the 2016 CDC guidelines. He again reiterated the plea of the CDC and many other medical authorities that the guidelines not be misinterpreted — that they are intended only for new patients and that if someone has been at 400 MME for 25 years, in general, just let them be.
Beth Macy herself wrote an endorsement for the cover of a new book by Ryan Hampton, a former White House staffer and presidential campaign official who became a heroin addict. Hampton’s new book, “Unsettled,” is about his experience on the committee that negotiated the Purdue/Sackler settlement. He is no fan of the Sacklers. But he reiterates that he has learned much in recent years and believes that chronic pain patients should be protected, that the interests of both pain and substance use disorder communities are aligned. He co-authored an article in the Los Angeles Times with Kate Nicholson, president and founder of National Pain Advocacy Center. Nicholson was an attorney for the Justice Department for 20 years, in the civil/disability rights division. She authored the current regs under the Americans with Disabilities Act and is a chronic pain patient, using opioids to relieve enough pain for her to do her job at DOJ. As the L.A. Times article quipped, “Our stories are two sides of the same pill. Serious pain and addiction are public health conditions that are widespread, stigmatized and misunderstood.”
— Tom Hayashi, Santa Rosa, California
— Sema Sgaier, Washington, D.C.
In-Network Care Can Help Curb Hospitalizations
I would quarrel with Loren Adler’s comment that once the law takes effect, “it’s completely irrelevant whether an emergency room doctor is in network or not” (“Surprise-Billing Rule ‘Puts a Thumb on the Scale’ to Keep Arbitrated Costs in Check,” Oct. 14). It matters to get those hospital-based physicians into global budget arrangements with insurers, like ACOs, so their incentives can be realigned to prevent return trips to the emergency department rather than to profit from them. Chronically ill patients attributed to such programs need all their providers pulling in the same direction to avoid unnecessary hospitalizations. The out-of-network business model has dangers to consumers beyond the fees, and it will be interesting and important to monitor utilization going forward to see if improved care coordination results.
— Jackson Williams, Lancaster, Pennsylvania
— Erica Socker, Alexandria, Virginia
To Top It Off, a Headline Can Steer Readers Wrong
I am really surprised to see this otherwise trustworthy site feeding false information about covid-19 vaccines. You published an article today with the outrageous headline “A Colorado Town Is About as Vaccinated as It Can Get. Covid Still Isn’t Over There” (Oct. 1), clearly suggesting that the story would contain information about the ineffectiveness of vaccinations. Since most people will only see this headline in one or another news aggregator or on social media, this is the message they will get. It turns out, when we read the story, that the individuals representing San Juan County’s serious covid-19 cases “all were believed to be unvaccinated” and the five hospitalized or dead people were all “summer residents.” The story should have been headlined something like “high vaccination rates protect residents of this Colorado county from unvaccinated visitors bringing covid to town.”
— Ira Abrams, Chicago