Months into a new Biden administration policy intended to lower drug costs for Medicare patients, independent pharmacists say they’re struggling to afford to keep some prescription drugs in stock.

“It would not matter if the governor himself walked in and said, ‘I need to get this prescription filled,’” said Clint Hopkins, a pharmacist and co-owner of Pucci’s Pharmacy in Sacramento, California. “If I’m losing money on it, it’s a no.”

A regulation that took effect in January changes prescription prices for Medicare beneficiaries. For years, prices included pharmacy performance incentives, possible rebates, and other adjustments made after the prescription was filled. Now the adjustments are made first, at the pharmacy counter, reducing the overall cost for patients and the government. But the new system means less money for pharmacies that acquire and stock medications, pharmacists say.

Pharmacies are already struggling with staff shortages, drug shortages, fallout from opioid lawsuits, and rising operating costs. While independent pharmacies are most vulnerable, some big chain pharmacies are also feeling a cash crunch — particularly those whose parent firms don’t own a pharmacy benefit manager, companies that negotiate drug prices between insurers, drug manufacturers, and pharmacies.

A top official at the Centers for Medicare & Medicaid Services said it’s a matter for pharmacies, Medicare insurance plans, and PBMs to resolve.

“We cannot interfere in the negotiations that occur between the plans and pharmacy benefits managers,” Meena Seshamani, director of the Center for Medicare, said at a conference on June 7. “We cannot tell a plan how much to pay a pharmacy or a PBM.”

Nevertheless, CMS has reminded insurers and PBMs in several letters that they are required to provide the drugs and other benefits promised to beneficiaries.

Several independent pharmacists told KFF Health News they’ll soon cut back on the number of medications they keep on shelves, particularly brand-name drugs. Some have even decided to stop accepting certain Medicare drug plans, they said.

As he campaigns for reelection, President Joe Biden has touted his administration’s moves to make prescription drugs more affordable for Medicare patients, hoping to appeal to voters troubled by rising health care costs. His achievements include a law, the Inflation Reduction Act, that caps the price of insulin at $35 a month for Medicare patients; caps Medicare patients’ drug spending at $2,000 a year, beginning next year; and allows the program to bargain down drug prices with manufacturers.

More than 51 million people have Medicare drug coverage. CMS officials estimated the new rule reducing pharmacy costs would save beneficiaries $26.5 billion from 2024 through 2032.

Medicare patients’ prescriptions can account for at least 40% of pharmacy business, according to a February survey by the National Community Pharmacists Association.

Independent pharmacists say the new rule is causing them financial trouble and hardship for some Medicare patients. Hopkins, in Sacramento, said that some of his newer customers used to rely on a local grocery pharmacy but came to his store after they could no longer get their medications there.

The crux of the problem is cash flow, the pharmacists say. Under the old system, pharmacies and PBMs reconciled rebates and other behind-the-scenes transactions a few times a year, resulting in pharmacies refunding any overpayments.

Now, PBM clawbacks happen immediately, with every filled prescription, reducing pharmacies’ cash on hand. That has made it particularly difficult, pharmacists say, to stock brand-name drugs that can cost hundreds or thousands of dollars for a month’s supply.

Some patients have been forced to choose between their pharmacy and their drug plan. Kavanaugh Pharmacy in Little Rock, Arkansas, no longer accepts Cigna and Wellcare Medicare drug plans, said co-owner and pharmacist Scott Pace. He said the pharmacy made the change because the companies use Express Scripts, a PBM that has cut its reimbursements to pharmacies.

“We had a lot of Wellcare patients in 2023 that either had to switch plans to remain with us, or they had to find a new provider,” Pace said.

Pace said one patient’s drug plan recently reimbursed him for a fentanyl patch $40 less than his cost to acquire the drug. “Because we’ve had a long-standing relationship with this particular patient, and they’re dying, we took a $40 loss to take care of the patient,” he said.

Conceding that some pharmacies face cash-flow problems, Express Scripts recently decided to accelerate payment of bonuses for meeting the company’s performance measures, said spokesperson Justine Sessions. She declined to answer questions about cuts in pharmacy payments.

Express Scripts, which is owned by The Cigna Group, managed 23% of prescription claims last year, second to CVS Health, which had 34% of the market.

In North Carolina, pharmacist Brent Talley said he recently lost $31 filling a prescription for a month’s supply of a weight control and diabetes drug.

To try to cushion such losses, Talley’s Hayes Barton Pharmacy sells CBD products and specialty items like reading glasses, bath products, and books about local history. “But that’s not going to come close to making up the loss generated by the prescription sale,” Talley said.

His pharmacy also delivers medicines packaged by the dose to Medicare patients at assisted living facilities and nursing homes. Reimbursement arrangements with PBMs for that business are more favorable than for filling prescriptions in person, he said.

When Congress added drug coverage to Medicare in 2003, lawmakers privatized the benefit by requiring the government to contract with commercial insurance companies to manage the program.

Insurers offer two options: Medicare Advantage plans, which usually cover medications, in addition to hospital care, doctor visits, and other services; as well as stand-alone drug plans for people with traditional Medicare. The insurers then contract with PBMs to negotiate drug prices and pharmacy costs with drug manufacturers and pharmacies.

The terms of PBM contracts are generally secret and restrict what pharmacists can tell patients — for example, if they’re asked why a drug is out of stock. (It took an act of Congress in 2018 to eliminate restrictions on disclosing a drug’s cash price, which can sometimes be less than an insurance plan’s copayment.)

The Pharmaceutical Care Management Association, a trade group representing PBMs, warned CMS repeatedly “that pharmacies would likely receive lower payments under the new Medicare Part D rule,” spokesperson Greg Lopes said. His group opposes the change.

Recognizing the new policy could cause cash-flow problems for pharmacies, Medicare officials had delayed implementation for a year before the rule took effect, giving them more time to adjust.

“We have heard pharmacies saying that they have concerns with their reimbursement,” Seshamani said.

But the agency isn’t doing enough to help now, said Ronna Hauser, senior vice president of policy and pharmacy affairs at the National Community Pharmacists Association. “They haven’t taken any action even after we brought potential violations to their attention,” she said.

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(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

Talkspace, a national online behavioral healthcare company, is rolling out its service to 5 million traditional Medicare members in Florida.

The company said its tele-mental health therapy aims to address the high rates of anxiety and depression in seniors. About 20% of people 55 years or older experience some type of mental health concern, according to the American Association of Geriatric Psychiatry. Traditionally, waiting lists for therapists can be long and services costly.

“Given the alarmingly limited number of behavioral health providers that accept Medicare, Talkspace now opens up access to affordable, high-quality care for millions of Medicare members — within days — from the comfort of their own homes,” said Dr. Jon Cohen, Talkspace chief executive officer.

Medicare enrollees using Talkspace undergo a matching process that considers preferences and connects them with a Florida-licensed therapist. The senior can schedule an appointment and see their therapist via a live one-on-one video session using a smartphone, tablet, or home computer.

“All you need is a WiFi connection,” said Dr. Nikole Benders-Hadi, chief medical officer with Talkspace. “You don’t need transportation and there is no copay.” If the match doesn’t work out, she says, Talkspace finds you someone else. “It’s easy to make a switch.”

The platform launched in 2012, has a national presence, and until now, users have accessed it mostly through their employer-sponsored health plans. Talkspace leaders say their goal is to bring it to Floridians in Medicare Advantage plans, too.

Benders-Hadi said seniors became more comfortable with telehealth during the pandemic and should find Talkspace’s service easy to use.

Nationally, the country is experiencing a shortage of mental health professionals, raising concerns about how the platform will keep up with demand. Talkspace has an aggressive recruiting department that attracts new contractors, Benders-Hadi said. The company also helps its therapists get licensed in multiple states. She said the company’s network includes doctorate level physchologists, therapists, social workers, marriage and family therapists, psychiatric nurse practitioners and psychiatrists who can help with medication management.

Other digital platforms such as BetterHelp and Headway also offer mental health services, but Talkspace may be the first to expand to Medicare enrollees.

Charlotte Mather-Taylor, CEO of the Area Agency on Aging Broward County, said she sees firsthand how much seniors suffer from isolation and the stress of daily living, including paying bills as costs increase.

“That can cause mental health issues,” she said.

Also, she said, many older adults are dealing with grief, losing a partner or loved one after many years.. While her agency provides counseling, “some seniors lack transportation or mobility.” Also, she notes, caregivers for spouses may not have time to go to appointments outside their homes.

“This gives them an opportunity to get the mental health support they need,” she said.

Mather-Taylor said the video platform that Talkspace offers is important for seniors, “so a professional can see them and have a visual view of how they are reacting to the conversation.”

Mather-Taylor believes most seniors will be able to use the technology: “You may not get everyone, but you can get more seniors to get help than who get it now.”

Sun Sentinel health reporter Cindy Goodman can be reached at cgoodman@sunsentinel.com or on X @cindykgoodman.

Baptist Health System reached the settlement with the U.S. Department of Justice, according to a Justice Department news release Monday.

The news release said Baptist was accused of violating a federal law known as the False Claims Act by “knowingly causing its subsidiaries to offer discounts to patients to induce them” to purchase services from subsidiaries or for referral of services. The discounts were on patient cost-sharing requirements.

The Justice Department said Baptist reported potential violations in 2022 to the federal government and stopped the discount policies.

The settlement said it is not an “admission of liability” by the hospital system.

“The department will continue to rely on the False Claims Act to address the use of prohibited remuneration to induce federal health care business,” Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division, said in a prepared statement Monday. “We encourage providers to mitigate the consequences of prior improper conduct by making timely self-disclosures, cooperating with our investigations and adopting enhanced compliance procedures.”

Insulin for Medicare beneficiaries “was costing 400 bucks a month on average. It now costs $35 a month.”

President Joe Biden, in a March 22 speech

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The cost of insulin in the United States has risen considerably in recent years, with some estimates finding that Americans have paid around 10 times as much for the drug as people in other developed countries.

But recent changes by the federal government and drug manufacturers have started to drive insulin prices down, something President Joe Biden often mentions at campaign events.

Biden told the crowd at a March 19 campaign reception in Reno, Nevada, that he’s fought for years to allow Medicare to negotiate with drug companies.

“How many of you know someone who needs insulin?” Biden asked. “OK, well, guess what? It was costing 400 bucks a month on average. It now costs $35 a month.”

We’ve heard Biden make this point several times on the campaign trail — in other instances, he has said beneficiaries were paying “as much as” $400 a month — so we wanted to look into it.

The Inflation Reduction Act, which Biden signed in 2022, caps out-of-pocket insulin costs at $35 a month for Medicare enrollees. The cap took effect in 2023. In response, three drug manufacturers said they planned to reduce the price of insulin to $35 through price caps or savings programs.

The legislation also helped patients by clarifying how much they would have to pay for insulin and other drugs.

But Biden overstated the average monthly cost that Medicare beneficiaries were paying before the law.

One government estimate for out-of-pocket insulin costs found that people with diabetes enrolled in Medicare or private insurance paid an average of $452 a year — not a month, as Biden said. That’s according to a December 2022 report by the Department of Health and Human Services using 2019 data. Uninsured users, however, paid more than twice as much on average for the drug, or about $996 annually.

About Half of US Insulin Users Are on Medicare

More than 37 million Americans have diabetes, and more than 7 million of them need insulin to control their blood sugar levels and prevent dangerous complications. Of the Americans who take the drug, about 52% are on Medicare.

It’s unlikely that many Medicare enrollees were paying the $400 out-of-pocket monthly average Biden referred to, though it could be on target for some people, especially if they’re uninsured, drug pricing experts told us.

“It would be more accurate to say that it could cost people on Medicare over $400 for a month of insulin, but the average cost would have been quite a bit lower than $400 on Medicare,” said Stacie Dusetzina, a health policy professor at Vanderbilt University School of Medicine.

Medicare Part D, also called the Medicare prescription drug benefit, helps beneficiaries pay for self-administered prescriptions. The benefit has several phases, including a deductible, an initial coverage phase, a coverage gap phase, and catastrophic coverage. What Medicare beneficiaries pay for their prescriptions often depends on which phase they’re in.

“It is confusing, because the amount that a person was supposed to pay jumps around a lot in the Part D benefit,” Dusetzina said. For example, she said, Medicare beneficiaries would be more likely to pay $400 a month for insulin during months when they hadn’t yet met their deductible.

Mariana Socal, an associate scientist at Johns Hopkins Bloomberg School of Public Health, said it’s also difficult to estimate insulin’s precise cost under Medicare because individual prices hinge on other factors, such as how many other prescription medications patients take.

“Because the Medicare program has multiple instances where the patient is required to pay a coinsurance (percentage of the drug’s cost) to get their drug, it is very likely that patients were paying much more than $35 per month, on average, before the cap established by the Inflation Reduction Act went into effect,” Socal wrote in an email.

There are different ways to administer insulin, including through a pump, inhaler, or pen injector filled with the medicine.

In a 2023 report, HHS researchers estimated that about 37% of insulin fills for Medicare enrollees cost patients more than $35, and 24% of fills exceeded $70. Nationally, the average out-of-pocket cost for insulin was $58 per fill, typically for a 30-day supply, the report found. Patients with private insurance or Medicare paid about $63 per fill, on average.

For people with employer-sponsored insurance, the average monthly out-of-pocket spending on insulin in 2019 was $82, according to a report published in October 2021 by the Health Care Cost Institute, a nonprofit that studies health care prices. The study found that the majority of patients were spending an average of $35 a month, or lower, on the drug. But among the “8.7% of individuals in the highest spending category,” the median monthly out-of-pocket spending on insulin was about $315, the study said.

Our Ruling

Biden said Medicare beneficiaries used to pay an average of $400 per month for insulin and are now paying $35 per month.

The Inflation Reduction Act capped the monthly price of insulin at $35 for Medicare enrollees, starting in 2023. The change built in price predictability and helped insulin users save hundreds of dollars a year.

However, most Medicare enrollees were not paying a monthly average of $400 before these changes, according to experts and government data. Costs vary, so it is possible some people paid that much in a given month, depending on their coverage phase and dosage.

Research has shown that patients with private insurance or Medicare often paid more than $35 a month for their insulin, sometimes much more, but not as high as the $400 average Biden cited.

We rate Biden’s statement Half True.

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PolitiFact copy chief Matthew Crowley contributed to this report.

(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

This proposal (which requires voter approval) lacks evidence-based medical support. According to American College of Cardiology guidelines, there is insufficient evidence to warrant cardiac CT angiograms for routine screening purposes in asymptomatic people.

The risks outweigh potential benefits. They include radiation exposure; unnecessary subsequent tests; unnecessary procedures (cardiac catheterization, coronary stenting, surgery); unnecessary patient worry; and excessive medical costs. Emphasis should be on proven preventative strategies: diet, exercise, smoking cessation, weight management, blood pressure, cholesterol and diabetes screening.

Currently, cardiac CT angiograms are indicated tests for select patients with chest pain or a known cardiac condition that warrants the test. Another indicated less-invasive CT called a coronary artery calcium (CAC) test may be appropriate for select at-risk patients. Both should only be conducted after consultation and coordination with trained medical professionals.

We certainly need ethically conducted clinical trials to determine whether widespread use of cardiac CT angiograms saves lives. There is no scientific basis for this approach. Research could prove that this approach makes sense. As a cardiologist, I certainly hope that the science continues to evolve to aid in better early cardiac disease detection and prevention. Cardiovascular disease remains one of the leading causes of morbidity and mortality in the U.S.

Although we applaud the Broward County leadership for taking on public health initiatives to reduce the burden of cardiovascular disease, there are more cost-effective ways to achieve this goal. Individuals should consult with their doctors regarding appropriate vs. inappropriate health screening tests.

Joshua M. Larned, M.D., Fellow, American College of Cardiology (FACC), Fort Lauderdale

Health care is already political

Howard Tescher’s letter vehemently opposing the 0.25% increase in county sales tax raises several questions.

When he says he doesn’t want politics in his health care, does he mean we should foot the bill individually for health care and end Medicare and Medicaid? Politics is inevitably part of the equation if health care is provided by the government. How much we should spend is another question.

He criticizes this almost miniscule tax increase as discriminatory against people under age 45. Isn’t his argument like that of someone who argues that school taxes discriminate against people with no children? Is the societal benefit of potentially better health care irrelevant?

Third, he employs the “slippery slope” argument to say that tax increases to pay for sickle cell and diabetes testing at taxpayer expense are next.

We have a problem with obesity, which threatens to inundate us with diabetes sufferers in the future, and might cost billions of tax dollars to treat. Perhaps Ozempic or Wegovy will one day become a simple and cheap solution to the problem, but for now, they are not in wide use. Diabetes, like heart disease, is expensive and difficult to treat.

There may be good reasons to not have a tax-funded heart testing system, but so far, they haven’t surfaced. I hope county commissioners will consult health care providers and heart specialists, ask if screenings make sense from a cost-benefit analysis, and heed their advice.

John Countryman, Plantation

Amendment 4 is needed

As many Southern states limited abortion access in 2023, Florida saw an increase in the number of abortions.

However, the Florida Supreme Court, with its five Ron DeSantis appointees, threatened the lives and bodily autonomy of millions of Southern women on April 1 by permitting a six-week abortion ban to replace Florida’s current 15-week ban.

Though the new ban takes effect May 1, Floridians will have an opportunity in November to void 15-week and six-week abortion bans by voting for Amendment 4, which would protect the right to an abortion prior to fetal viability or when it is deemed necessary to protect the patient’s health.

Eleanor Sobel, Hollywood

The writer is a former Democratic state senator.

Bart Klion, 95, and his wife, Barbara, faced a tough choice in January: The upstate New York couple learned that this year they could keep either their private, Medicare Advantage insurance plan — or their doctors at Saratoga Hospital.

The Albany Medical Center system, which includes their hospital, is leaving the Klions’ Humana plan — or, depending on which side is talking, the other way around. The breakup threatened to cut the couple’s lifeline to cope with serious chronic health conditions.

Klion refused to pick the lesser of two bad options without a fight.

He contacted Humana, the Saratoga hospital, and the health system. The couple’s doctors “are an exceptional group of caregivers and have made it possible for us to live an active and productive life,” he wrote to the hospital’s CEO. He called his wife’s former employer, which requires its retirees to enroll in a Humana Medicare Advantage plan to receive company health benefits. He also contacted the New York StateWide Senior Action Council, one of the nationwide State Health Insurance Assistance Programs that offer free, unbiased advice on Medicare.

Klion said they all told him the same thing: Keep your doctors or your insurance.

With rare exceptions, Advantage members are locked into their plans for the rest of the year — while health providers may leave at any time.

Disputes between insurers and providers can lead to entire hospital systems suddenly leaving the plans. Insurers must comply with extensive regulations from the Centers for Medicare & Medicaid Services, including little-known protections for beneficiaries when doctors or hospitals leave their networks. But the news of a breakup can come as a surprise.

In the nearly three decades since Congress created a private-sector alternative to original, government-run Medicare, the plans have enrolled a record 52% of Medicare’s 66 million older or disabled adults, according to the CMS. But along with getting extra benefits that original Medicare doesn’t offer, Advantage beneficiaries have discovered downsides. One common complaint is the requirement that they receive care only from networks of designated providers.

Many hospitals have also become disillusioned by the program.

“We hear every day, from our hospitals and health systems across the country, about challenges they experience with Medicare Advantage plans,” said Michelle Millerick, senior associate director for health insurance and coverage policy at the American Hospital Association, which represents about 5,000 hospitals. The hurdles include prior authorization restrictions, late or low payments, and “inappropriate denials of medically necessary covered services,” she said.

“Some of these issues get to a boiling point where decisions are made to not participate in networks anymore,” she said.

An Escape Hatch

CMS gives most Advantage members two chances to change plans: during the annual open enrollment period in the fall and from January until March 31.

But a few years ago, CMS created an escape hatch by expanding special enrollment periods, or SEPs, which allow for “exceptional circumstances.” Beneficiaries who qualify can request SEPs to change plans or return to original Medicare.

According to CMS rules, there’s an SEP patients may use if their health is in jeopardy due to problems getting or continuing care. This may include situations in which their health care providers are leaving their plans’ networks, said David Lipschutz, an associate director at the Center for Medicare Advocacy.

Another SEP is available for beneficiaries who experience “significant” network changes, although CMS officials declined to explain what qualifies as significant. However, in 2014, CMS offered this SEP to UnitedHealthcare Advantage members after the insurer terminated contracts with providers in 10 states.

When providers leave, CMS ensures that the plans maintain “adequate access to needed services,” Meena Seshamani, CMS deputy administrator and director of the federal Center for Medicare, said in a statement.

While hospitals say insurers are pushing them out, insurers blame hospitals for the turmoil in Medicare Advantage networks.

Patients get caught in the middle.

“It feels like the powers that be are playing chicken,” said Mary Kay Taylor, 69, who lives near Tacoma, Washington. Regence BlueShield was in a weeks-long dispute with MultiCare, one of the largest medical systems in the state, where she gets her care.

“Those of us that need this care and coverage are really inconsequential to them,” she said. “We’re left in limbo and uncertainty.”

Other breakups this year include Baton Rouge General hospital in Louisiana leaving Aetna’s Medicare Advantage plans and Baptist Health in Kentucky leaving UnitedHealthcare and Wellcare Advantage plans. In San Diego, Scripps Health has left nearly all the area’s Advantage plans.

In North Carolina, UNC Health and UnitedHealthcare renewed their contract just three days before it would have expired, and only two days before the deadline for Advantage members to switch plans. And in New York City, Aetna told its Advantage members this year to be prepared to lose access to the 18 hospitals and other care facilities in the NewYork-Presbyterian Weill Cornell Medical Center health system, before reaching an agreement on a contract last week.

Limited Choices

Taylor didn’t want to lose her doctors or her Regence Advantage plan. She’s recovering from surgery and said waiting to see how the drama would end “was really scary.”

So, last month, she enrolled in another plan, with help from Tim Smolen, director of Washington’s SHIP, Statewide Health Insurance Benefits Advisors program. Soon afterward, Regence and MultiCare agreed to a new contract. But Taylor is allowed only one change before March 31 and can’t return to Regence this year, Smolen said.

Finding an alternative plan can be like winning at bingo. Some patients have multiple doctors, who all must be easy to get to and covered by the new plan. To avoid bigger, out-of-network bills, they must find a plan that also covers their prescription drugs and includes their preferred pharmacies.

“A lot of times, we may get through the provider network and find that that’s good to go but then we get to the drugs,” said Kelli Jo Greiner, state director of Minnesota’s SHIP, Senior LinkAge Line. Since Jan. 1, counselors there have helped more than 900 people switch to new Advantage plans after HealthPartners, a large health system based in Bloomington, left Humana’s Medicare Advantage plans.

Choices are more limited for low-income beneficiaries who receive subsidies for drugs and monthly premiums, which only a few plans accept, Greiner said.

For almost 6 million people, a former employer chooses a Medicare Advantage plan and requires them to enroll in it to receive retiree health benefits. If they want to keep a provider who leaves that plan, those beneficiaries must forfeit all their employer-subsidized health benefits, often including coverage for their families.

The threat of losing coverage for their providers was one reason some New York City retirees sued Mayor Eric Adams to stop efforts to force 250,000 of them into an Aetna Advantage plan, said Marianne Pizzitola, president of the New York City Organization of Public Service Retirees, which filed the lawsuit. The retirees won three times, and city officials are appealing again.

CMS requires Advantage plans to notify their members 45 days before a primary care doctor leaves their plan and 30 days before a specialist physician drops out. But counselors who advise Medicare beneficiaries say the notice doesn’t always work.

“A lot of people are experiencing disruptions to their care,” said Sophie Exdell, a program manager in San Diego for California’s SHIP, the Health Insurance Counseling & Advocacy Program. She said about 32,000 people in San Diego lost access to Scripps Health providers when the system left most of the area’s Advantage plans. Many didn’t get the notice or, if they did, “they couldn’t get through to someone to get help making a change,” she said.

CMS also requires plans to comply with network adequacy rules, which limit how far and how long members must travel to primary care doctors, specialists, hospitals, and other providers. The agency checks compliance every three years or more often if necessary.

In the end, Bart Klion said he had no alternative but to stick with Humana because he and his wife couldn’t afford to give up their retiree health benefits. He was able to find doctors willing to take on new patients this year.

But he wonders: “What happens in 2025?”

(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

A bit of history is revealing.

In 1996, the League of Women Voters of Broward County’s Children’s Issues Committee spearheaded a campaign along with other community organizations and citizens to create a Pediatric Pathology Program that would document specific causes of infant deaths. The information registry would include factors that contribute to the racial disparity in birth outcomes and would be free to Broward residents.

After seven years of concentrated advocacy, the Pediatric Pathology Program was approved on Feb. 4, 2003, and was thought to be the first of its kind in the nation. (An article by Sun Sentinel reporter Nancy McVicar on Feb. 14, 2003, “Program offers parents autopsies on newborns,” described the initiative).

Here it is 21 years later, and we still haven’t solved this problem.

Carol Smith, Coral Springs

The writer is past president of the League of Women Voters of Broward County.

Where Trump belongs

Why isn’t Donald Trump already in jail for this behavior, as any other person would be? (Judge expands Trump’s gag order after ex-president’s social media posts about judge’s daughter, April 2).

“Oh, but that’s what he wants, to be a martyr,” some say.

I don’t care what Trump wants. Instead of going to rallies and hosting deplorables in Palm Beach, he should be sitting in a concrete block room with a stainless steel toilet.

James Carbone, Fort Lauderdale

All you need to know

The juxtaposition of two front-page stories in the March 29 Sun Sentinel tells all you need to know about living in Ron DeSantis’ Florida.

One article describes Gov. DeSantis, self-proclaimed guardian of children’s rights, signing a bill permitting retail sales of larger bottles of wine standing against a backdrop of enormous wine bottles in a store in Fort Lauderdale, as a lectern’s sign proclaimed “Carpe Vinum” (enjoy wine).

Also on the front page was an entirely different article, headlined “Some ill kids to get dropped from Medicaid.” It chronicled the nightmare story of a mom learning second-hand that her medically fragile child would lose Medicaid coverage, and her fight to preserve coverage for her son’s condition.

Our good old governor, whose mantra is “Let kids be kids,” has his bloody hands all over this. Florida has chopped nearly 1.3 million people, including 460,000 children, from Medicaid in one year. That’s a strange way to “let kids be kids.”

Now the state will begin terminating children with complex chronic medical conditions from Medicaid due to “procedural issues.” DeSantis knew this was coming, as the federal government warned the state as to what the situation would become with a delay in processing appeals.

Apparently the “children’s governor” was more concerned with the populace being able to buy larger containers of wine than how and who would treat and pay the bills for kids with cancer and other debilitating medical conditions. DeSantis and his people can try to deflect blame, but the bottom line is if you’re a child living in Florida and you need Medicaid benefits for treatment, you may be out of luck.

It’s easier to buy wine in volume than to get KidCare. How truly sad.

Dr. Mark Neil Levine, Coconut Creek

Console yourself, Florida

To struggling Florida parents who may have to watch your state’s Medicaid-stripped children sicken and die from otherwise treatable illnesses, cheer up!

You’ll soon be able console yourself with an oversized bottle of wine.

And to those Florida women with medically complicated pregnancies who may be turned away from lifesaving medical care by the state’s new six-week abortion ban, cheer up!

You’ll soon be able to enjoy your demise by smoking a legal joint.

Laurence Miller, Boca Raton

Billy Abbott, a retired Army medic, wakes at 6 every morning, steps on the bathroom scale, and uses a cuff to take his blood pressure.

The devices send those measurements electronically to his doctor in Gulf Shores, Alabama, and a health technology company based in New York, to help him control his high blood pressure.

Nurses with the company, Cadence, remotely monitor his readings along with the vital signs of about 17,000 other patients around the nation. They call patients regularly and follow up if anything appears awry. If needed, they can change a patient’s medication or dosage without first alerting their doctor.

Abbott, 85, said he likes that someone is watching out for him outside his regular doctor appointments. “More doctors should recommend this to their patients,” he said.

Increasingly, they are.

Dozens of tech companies have streamed in, pushing their remote monitoring service to primary care doctors as a way to keep tabs on patients with chronic illnesses and free up appointment time, and as a new source of Medicare revenue.

But some experts say remote monitoring’s huge growth — spurred on during the covid-19 pandemic, when patients were hesitant to sit in crowded doctors’ waiting rooms — has outpaced oversight and evidence of how the technology is best used.

“It is the wild West where any patient can get it if a doctor decides it is reasonable or necessary,” said Caroline Reignley, a partner with the law firm McDermott Will & Emery who advises health providers.

In 2019, Medicare made it easier for doctors to bill for monitoring routine vital signs such as blood pressure, weight, and blood sugar. Previously, Medicare coverage for remote monitoring was limited to certain patients, such as those with a pacemaker.

Medicare also began allowing physicians to get paid for the service even when the monitoring is done by clinical staff who work in different places than the physician — an adjustment advocated by telemedicine companies.

In just the first two full years, remote monitoring services billed to Medicare grew from fewer than 134,000 to 2.4 million in 2021, according to federal records analyzed by KFF Health News.

Total Medicare payments for the four most common billing codes for remote monitoring rose from $5.5 million in 2019 to $101.4 million in 2021, the latest year for which data is available.

Part of the allure is that Medicare will pay for remote monitoring indefinitely regardless of patients’ health conditions as long as their doctors believe it will help.

For doctors with 2,000 to 3,000 patients, the money can add up quickly, with Medicare paying an average of about $100 a month per patient for the monitoring, plus more for setting up the device, several companies confirmed.

Medicare enrollees may face 20% in cost sharing for the devices and monthly monitoring, though certain private plans through Medicare Advantage and Medicare supplement policies may cover those costs. The government allowed insurers to waive the patient cost sharing during the pandemic.

About 400 doctors and other providers repeatedly billed Medicare for remote patient monitoring in 2019. Two years later, that had mushroomed to about 3,700 providers, according to Medicare data analyzed by KFF Health News. (The data tracks providers who billed more than 10 patients for at least one type of remote monitoring.)

Federal law enforcement officials say they are conducting investigations after a surge in complaints about some remote patient monitoring companies but would not provide details.

The Department of Health and Human Services’ Office of Inspector General in November issued a consumer alert about companies signing up Medicare enrollees without their doctors’ knowledge: “Unscrupulous companies are signing up Medicare enrollees for this service, regardless of medical necessity,” and bill Medicare even when no monitoring occurs.

In a statement to KFF Health News, Meena Seshamani, director of the federal Center for Medicare, part of the Centers for Medicare & Medicaid Services, did not say how CMS is ensuring only patients who can benefit from remote monitoring receive it. She said the agency balances the need to give patients access to emerging technology that can improve health outcomes with the need to combat fraud and make proper payments to providers.

While some small studies show remote monitoring can improve patient outcomes, researchers say it is unclear which patients are helped most and how long they need to be monitored.

“The research evidence is not as robust as we would like to show that it is beneficial,” said Ateev Mehrotra, a Harvard Medical School researcher.

A January report by the Bipartisan Policy Center, a Washington, D.C.-based think tank, warned about “a lack of robust evidence on the optimal use of remote monitoring” and said some policy and medical experts “question whether we are effectively ‘rightsizing’ the use of these services, ensuring access for patients who need it most, and spending health care dollars in effective ways.”

Denton Shanks, a medical director at the American Academy of Family Physicians, said remote monitoring helps patients manage their diseases and helps physician practices be more efficient. He has used it for the past two years as a doctor at the University of Kansas Health System.

It has worked well, he said, though sometimes it can be challenging to persuade patients to sign up if they have to pay for it.

“For the vast majority of patients, once they are enrolled, they see a benefit, and we see a benefit as their vital signs come in the normal range,” Shanks said.

The size of the market is tantalizing.

About two-thirds of the more than 66 million Medicare beneficiaries have high blood pressure, the most common metric monitored remotely, according to physicians and the monitoring companies.

“The patient need is so enormous,” Cadence CEO Chris Altchek said. The company has about 40 nurses, medical assistants, and other providers monitoring patients in 17 states. He said patients enrolled in remote monitoring experience a 40% reduction in emergency room visits. Cadence says 82% of its patients use the devices at least once every two days.

Timothy Mott, a family physician in Foley, Alabama, said valuable appointment times in his office open up as patients who previously needed vital signs to be checked there turn to remote monitoring.

Cadence nurses regularly contact Mott’s patients and monitor their readings and make changes as needed.

“I was concerned early on whether they were going to make the right decisions with our patients,” Mott said. “But over time the dosage changes or changes in medication they are making are following the best guidelines on effectiveness.”

At the six-month mark, about 75% of patients have stayed with the monitoring, Mott said.

The advantages are apparent even to some providers who do not get paid by Medicare to offer the service. Frederick Health, a Maryland health system, provides remote monitoring to 364 high-risk patients and estimates the program saves the nonprofit system $10 million a year by reducing hospital admissions and ER visits. That estimate is based on comparisons of patients’ Medicare claims before they started the program and after, said Lisa Hogan, who runs the program.

The hospital pays for the program and does not bill Medicare, she said.

___

(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

We cut the federal deficit by $160 billion because Medicare will no longer have to pay those exorbitant prices to Big Pharma.

President Joe Biden in his State of the Union address, March 7, 2024

____

President Joe Biden has been making his case for reelection to voters by telling them he is good for their pocketbooks, including at the pharmacy counter.

During his State of the Union address, Biden said legislation he signed gave Medicare the power to negotiate lower prescription drug prices.

“That’s not just saving seniors money and taxpayers money,” Biden said, a reference to the Inflation Reduction Act, which passed in 2022. “We cut the federal deficit by $160 billion because Medicare will no longer have to pay those exorbitant prices to Big Pharma.”

Biden added, “This year, Medicare is negotiating lower prices for some of the costliest drugs.” He called for giving Medicare the power to negotiate prices for 500 drugs over the next decade.

In August, the federal government announced the first 10 drugs that it will negotiate for lower prices as part of the Inflation Reduction Act. A respected source of legislation analysis projects the change will save the government a lot of money, but those dollars haven’t been realized.

There is a reason Biden touted this legislation during his address: Polling by KFF shows that people, regardless of their political leanings, overwhelmingly support the idea of allowing Medicare to negotiate drug prices. But most people don’t know that such negotiations are underway.

Impact of Inflation Reduction Act Will Take Many Years

In August 2022, Biden signed the Inflation Reduction Act, which will allow the federal government to negotiate prices with drugmakers for Medicare. Biden kept his promise to repeal the law that barred Medicare from negotiating prices.

The nonpartisan Congressional Budget Office projects a 10-year cumulative savings of $161.7 billion from two provisions of the Iaw: a phased-in effort to negotiate with drugmakers for lower prices and a rebate for price increases above the overall inflation rate. (The White House has previously pointed to this analysis.)

However, not all the savings will be permanent. About $44.3 billion over 10 years will be funneled into related provisions that expand access and lower out-of-pocket costs for Medicare beneficiaries.

“Negotiations are still ramping up, so the savings generated by the Inflation Reduction Act negotiation provisions are still in the future,” said Matthew Fiedler, a Brookings Institution expert on the economy and health studies. “The Congressional Budget Office did expect the inflation rebate provisions of the IRA (which are encompassed in the $160 billion) to begin generating modest savings during 2023 and 2024, but there, too, most of the savings are in the future.”

The legislation involves price negotiations for 10 brand-name medications that lack generic equivalents. Those drugs include the blood thinners Eliquis and Xarelto; the diabetes drugs Januvia, Jardiance, and NovoLog; Enbrel, for rheumatoid arthritis; the blood-cancer drug Imbruvica; Entresto, for heart failure; Stelara, for psoriasis and Crohn’s disease; and Farxiga, a drug for diabetes, heart failure, and chronic kidney disease.

The CBO has estimated that the negotiated prices will translate to nearly $100 billion in federal savings from 2026 to 2031.

“Biden is jumping the gun on claiming savings for seniors,” said Joe Antos, an expert on health care at the conservative American Enterprise Institute. “Price negotiations haven’t been completed; the new prices for selected drugs aren’t in place until 2026.”

Biden said the legislation is “saving seniors money and taxpayers money,” which could be interpreted to mean it is saving them money now on prescription drugs. But the negotiations for these drugs would define the prices to be paid for prescriptions starting in 2026. For 2027 and 2028, 15 more drugs per year will be chosen for price negotiations. Starting in 2029, 20 more will be chosen a year.

That said, other provisions in the legislation have already led to savings for seniors, said Tricia Neuman, a senior vice president at KFF:

• Certain recommended adult vaccines covered under Medicare Part D, such as shingles, are covered at no cost.
• The act established a cap on Part D spending that begins phasing in this year. This year, Part D enrollees will pay no more than $3,300 on brand-name drugs. In 2025, the cap for all covered Part D drugs drops to $2,000.
• The Inflation Reduction Act included the $35-a-month insulin cap, improvements in coverage for low-income beneficiaries, and the inflation rebate.

When we pressed the White House to provide examples of savings that have already occurred, a spokesperson pointed to the insulin cap.

Meanwhile, Antos said that although the Part D rebate has kicked in, the savings come from a small subset of Part D drugs taken by older Americans and that the government reaps the savings, not older Americans.

“There is no reason to expect that seniors will see significant savings since there’s no obligation for the feds to distribute savings to Part D enrollees,” Antos said.

Our Ruling

Biden said, “We cut the federal deficit by $160 billion because Medicare will no longer have to pay those exorbitant prices to Big Pharma.”

Biden’s statement omits the time frame; the savings have not been realized. The CBO projected 10-year cumulative savings of $161.7 billion from two provisions of the legislation. And as for saving older Americans money on their prescriptions, that hasn’t happened yet. The federal government is negotiating the first 10 drugs with the new prices set to take effect in 2026.

We rate this statement Half True.

(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

The investing information provided on this page is for educational purposes only. NerdWallet, Inc. does not offer advisory or brokerage services, nor does it recommend or advise investors to buy or sell particular stocks, securities or other investments.

At age 65, some couples may need as much as $413,000 to cover health care costs in retirement, according to a January report from the Employee Benefit Research Institute. That’s an extreme case, representing two people with high prescription drug costs — but it’s not outside the realm of possibility.

“It’s one of the most difficult expenses to predict in retirement,” says Nancy Nawn, a certified financial planner in Cherry Hill, New Jersey.

Your costs will depend on your insurance choices, your health, your prescription drugs and your city. (Costs are higher in some places than others.) As you approach retirement, try these tactics to get a handle on future health care expenses.

Save to a health savings account

If you have a high-deductible health plan and access to a health savings account (HSA), max it out. The money you save is triple tax-advantaged: You pay no taxes on the money you save, the interest you earn or any withdrawals used for qualified health expenses.

“I think most people use them as they go, which is fine too,” says Ed Snyder, a CFP in Carmel, Indiana. “But I think there are even more benefits to using the investment account in those [and] letting that money be invested for many years, just like a retirement account.”

In 2024, you can save up to $4,150 for an individual health savings account and up to $8,300 for family coverage. If you’re 55 or older, you can contribute an extra $1,000. (Note: You can’t save to an HSA once you’re signed up for Medicare.)

Pick the right Medicare plan

Once you’re 65, advisors typically recommend selecting Original Medicare with Medicare Supplement Insurance, or Medigap. Since Medigap plans cover many out-of-pocket expenses of Medicare, this keeps your monthly health care costs predictable.

Many older adults are attracted to the $0 premiums of most Medicare Advantage plans, but using these private health plans means you may be limited to in-network doctors and hospitals. “I have seen many situations where people wind up needing to go see a provider who doesn’t take the coverage, and they pay the full bill themselves,” says Melinda Caughill, co-founder and CEO of 65 Incorporated, which offers guidance on Medicare.

Out-of-pocket maximums for Medicare Advantage plans also can be as high as $8,850 per year in 2024, and that doesn’t include your Medicare Part B (medical insurance) premiums. That said, if you can’t afford a Medigap plan, Medicare Advantage may be the better option. Without Medigap, Original Medicare has no out-of-pocket maximum.

Get help with tax planning

If your income exceeds a certain threshold, you will pay more each month for Medicare Part B and Medicare Part D prescription drug coverage (if you have it). This is where it helps to be strategic about your retirement income, making sure you have both pretax and post-tax accounts to pull from as needed. (Pulling from pretax accounts raises your income.)

“If you have saved a lot of money in tax-deferred vehicles, and you haven’t planned to do either Roth conversions or spend down that money, you could wind up having a much larger monthly Medicare premium than you think,” Nawn says.

Pay down your mortgage

If you’re 62 or older and have at least 50% equity in your home, you may have access to a reverse mortgage later if you really need it. This is a loan or line of credit on your assessed home value — and you don’t have to make payments. The loan is repaid when you move out or die.

Reverse mortgages once had a scary reputation, but today’s products are safer, Nawn says. “There was abuse many, many years ago,” she says. “It’s been cleaned up, and it’s a really great tool to have in your back pocket.”

Keep in mind that reverse mortgages require at least one borrower to live in the home, and they cost more than a traditional home mortgage over time. Work with an advisor who’s familiar with the product before you take the plunge.

Consider a HELOC

If you’re younger than 62 and you’re still working, a home equity line of credit (HELOC) can provide you with a stream of income to tap later if you need it. (It’s easier to qualify for a HELOC while you’re still getting a paycheck.)

The catch: Unlike a reverse mortgage, a HELOC requires you to make payments. “At some point in the future, you’re going to have to pay it back,” Nawn says.

Keep things in perspective

In the end, don’t lose too much sleep over the big figures. Consider how intimidating it would be if experts also told you how much you should save to cover 30 years of food or utility bills in retirement. With the right planning, health care costs can be manageable.

“A reasonable cost is about $6,000 a year for an individual, and if you price that out on a monthly basis, it’s $500 a month,” says Dick Power, a CFP in Walpole, Massachusetts. “That $500 a month typically includes your insurance coverage and your copays.”

This article was written by NerdWallet and was originally published by The Associated Press. 

The article Can You Afford Health Care in Retirement? originally appeared on NerdWallet.