Insurance, Coverage, and Costs: 111722

$38,398 for a Single Shot of a Very Old Cancer Drug

Arthur Allen

Lupron, a drug patented half a century ago, treats advanced prostate cancer. It’s sold to physicians for $260 in the U.K. and administered at no charge. Why are U.S. hospitals — which may pay nearly as little for the drug — charging so much more to administer it?

A Billing Expert Saved Big After Finding an Incorrect Charge in Her Husband’s ER Bill

Bram Sable-Smith

A medical billing specialist investigated her husband’s ER bill. Her sleuthing took over a year but knocked thousands of dollars off the hospital’s charges — and provides a playbook for other consumers.

How Private Equity Is Investing in Health Care: A Video Primer

Hannah Norman and Oona Zenda

Investors are putting money into everything from emergency room obstetrics units and dermatology practices to nursing homes and hospice care — from cradle to grave.

Medicare Fines for High Hospital Readmissions Drop, but Nearly 2,300 Facilities Are Still Penalized

Jordan Rau

Federal officials said they are penalizing 2,273 hospitals, the fewest since the fiscal year that ended in September 2014. Driving the decline was a change in the formula to compensate for the chaos caused by the covid-19 pandemic.

Look Up Your Hospital: Is It Being Penalized by Medicare?

Jordan Rau

Each year, Medicare punishes hospitals that have high rates of readmissions and high rates of infections and patient injuries. Check out which hospitals have been penalized.

California Stockpiles Penalties From Uninsured Residents Instead of Lowering Care Costs

Angela Hart

California is collecting hundreds of millions of dollars a year in tax penalties from uninsured residents. The state was supposed to use the money to help lower costs for Californians who couldn’t afford insurance but hasn’t distributed any of the revenue it has collected — citing uncertain economic times.

Journalists Tackle the Midterms and Open Enrollment

KHN and California Healthline staff made the rounds on national and local media this week to discuss their stories. Here’s a collection of their appearances.

How Optimism Can Close the Medicaid Coverage Gap

Phil Galewitz and Daniel Chang

Low-income residents in states that haven’t expanded Medicaid are in a tough spot: They don’t qualify for the subsidies that people with slightly higher incomes get to buy marketplace plans because of a glitch in the federal health law. But a court decision last year makes it easier for them to make good-faith estimates of a pay increase, and there is no financial penalty if they don’t hit that figure.

Medicare Plan Finder Likely Won’t Note New $35 Cap on Out-of-Pocket Insulin Costs

Susan Jaffe

In August, Congress approved a $35 cap on what seniors will pay for insulin, but that change came too late to add to the online tool that helps Medicare beneficiaries compare dozens of drug and medical plans. Federal officials say beneficiaries who use insulin will have the opportunity to switch plans after open enrollment ends Dec. 7.

South Dakota Voters Approved Medicaid Expansion, but Implementation May Not Be Easy

Arielle Zionts

South Dakotans voted to expand the state’s Medicaid program to cover thousands of additional low-income residents. But as other conservative states have shown, voter approval doesn’t always mean politicians and administrators will rush to implement the change.

This Open Enrollment Season, Look Out for Health Insurance That Seems Too Good to Be True

Bram Sable-Smith

Complaints about misleading health insurance marketing are soaring. State insurance commissioners are taking notice. They’ve created a shared internal database to monitor questionable business practices, and, in the future, they hope to provide a public-facing resource for consumers. In the meantime, consumers should shop wisely as open enrollment season begins.

Defense Department Health Plan Cuts Its Pharmacy Network by Nearly 15,000 Outlets

Patricia Kime

Many of the pharmacies were small, independent operations that had decided not to participate next year because of the lowered reimbursement being offered. But they were surprised by an early dismissal, and some patients with specialized drug needs could face difficulties in the transition.

Cash for Colonoscopies: Colorado Tries to Lower Health Costs Through Incentives

Markian Hawryluk

State employees could receive checks ranging from $50 to thousands of dollars if they choose the right provider.

Stopping the Churn: Why Some States Want to Guarantee Medicaid Coverage From Birth to Age 6

Phil Galewitz

Oregon has become the first state to allow kids to stay in the government health care program from birth to age 6, no matter if their household income changes. California, Washington, and New Mexico are pursuing similar policies.

Shopping for ACA Health Insurance? Here’s What’s New This Year

Julie Appleby

Consumers may find relief in some key changes made by Congress and the Biden administration, although other issues remain unsettled.

Montana Backs Away From Innovative Hospital Payment Model. Other States Are Watching.

Katheryn Houghton

Montana has been a national model for how employers could gain control and transparency over medical bills. Upcoming changes to its model have health care price experts wondering whether the state is making improvements or losing focus.

Watch: As Health Costs Spike, the Role of Hospitals Often Gets Overlooked

A new documentary, “InHospitable,” explores how disputes between big hospitals can leave patients with few options for care and imperil their health.

Employers Are Concerned About Covering Workers’ Mental Health Needs, Survey Finds

Michelle Andrews

Nearly half of large employers report that increasing numbers of their workers were using mental health services, according to a KFF annual employer survey. Yet almost a third of those employers said their health plan’s network didn’t have enough behavioral health care providers for employees to have timely access to the care they need.

‘An Arm and a Leg’: No Money, No Job, No Health Care? Not Always.

Dan Weissmann

For many Americans, it’s open enrollment season for 2023 health insurance. One listener asked: If you don’t have a job and are too old to be on your parents’ plan, does it make sense to rely on charity care? This episode breaks it all down.

KHN’s ‘What the Health?’: ACA Open Enrollment Without the Drama

The Affordable Care Act’s 10th annual open-enrollment period began Nov. 1 and runs through Jan. 15, 2023, in most states. But for the first time, the health law seems to be enrolling Americans with far less controversy than in previous years. Meanwhile, as Election Day approaches, Democrats are focusing on GOP efforts to cut Social Security and Medicare. Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Tami Luhby of CNN, and Julie Appleby of KHN join KHN’s Julie Rovner to discuss these topics and more. Also this week, Rovner interviews KHN’s Arthur Allen, who wrote the latest KNH-NPR Bill of the Month, about an old but still very expensive cancer drug.

Centene Showers Politicians With Millions as It Courts Contracts and Settles Overbilling Allegations

Samantha Young and Andy Miller and Rebecca Grapevine

Centene, the largest Medicaid managed-care company in the U.S., has thrown more than $26.9 million at political campaigns across the country since 2015, especially focused on states where it is wooing Medicaid contracts and settling accusations that it overbilled taxpayers. Among its tactics: Centene is skirting contribution limits by giving to candidates through its many subsidiaries.

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