To prevent medical debt, the U.S. could learn from Germany’s health care system : Shots

Dr. Eckart Rolshoven examines a patient at his clinic in Püttlingen, a small town in Germany’s Saarland region. Although Germany has a largely private health care system, patients pay nothing out-of-pocket when they come to see him.

Pasquale D’Angiolillo for KHN


hide caption

toggle caption

Pasquale D’Angiolillo for KHN


Dr. Eckart Rolshoven examines a patient at his clinic in Püttlingen, a small town in Germany’s Saarland region. Although Germany has a largely private health care system, patients pay nothing out-of-pocket when they come to see him.

Pasquale D’Angiolillo for KHN

PÜTTLINGEN, Germany — Almost every day, Dr. Eckart Rolshoven sees the long shadow of coal mining in his clinic near the big brownstone church that dominates this small town in Germany’s Saarland.

The region’s last-operating coal shaft, just a few miles away, closed a decade ago, ending centuries of mining in the Saarland, a mostly rural state tucked between the Rhine River and the French border. But the mines left a difficult legacy, as they have in coal regions in the United States, including West Virginia.

Many of Rolshoven’s patients battle lung diseases and chronic pain from years of work underground. “We had an industry with a lot of illnesses,” said Rolshoven, a genial primary care physician who at 71 is nearing the end of a long career.

The Saarland’s residents are sicker than elsewhere in Germany. And like West Virginia, the region faces economic hurdles. For decades, German politicians, business leaders and unions have labored to adjust to the mining industry’s slow demise.

But this is a healthier place than West Virginia in many respects. The region’s residents are less likely to die prematurely, data shows. And on average, they live four years longer than West Virginians.

There is another important difference between this former coal territory and its Appalachian counterpart: West Virginia’s economic struggles have been compounded by medical debt, a burden that affects about 100 million people in the U.S. — in no state more than West Virginia.

In the Saarland, medical debt is practically nonexistent. It’s so rare in Germany that the federal government’s statistical office doesn’t even track it.

The reason isn’t government health care. Germany, like the U.S., has a largely private health care system that relies on private doctors and private insurers. Like Americans, many Germans enroll in a health plan through work, splitting the cost with their employer.

But Germany has long done something the U.S. does not: It strictly limits how much patients have to pay out of their own pockets for a trip to the doctor, the hospital or the pharmacy.

Rolshoven’s patients pay nothing when they see him. That not only bolsters their health, he said. It helps maintain what Rolshoven called social peace. “It’s really important not to have to worry about these problems,” he said.

German health officials, business leaders and economists say the access to affordable health care has also helped the Saarland get back on its feet economically, bolstered by the assurance that workers

Read More... Read More

Medical debt soars for consumers with hospital credit cards : Shots

Many hospitals are now partnering with financing companies to offer payment plans when patients and their families can’t afford their bills. The catch: the plans can come with interest that significantly increases a patient’s debt.

sesame/Getty Images


hide caption

toggle caption

sesame/Getty Images


Many hospitals are now partnering with financing companies to offer payment plans when patients and their families can’t afford their bills. The catch: the plans can come with interest that significantly increases a patient’s debt.

sesame/Getty Images

Patients at North Carolina-based Atrium Health get what looks like an enticing pitch when they go to the nonprofit hospital system’s website: a payment plan from lender AccessOne. The plans offer “easy ways to make monthly payments” on medical bills, the website says. You don’t need good credit to get a loan. Everyone is approved. Nothing is reported to credit agencies.

In Minnesota, Allina Health encourages its patients to sign up for an account with MedCredit Financial Services to “consolidate your health expenses.” In Southern California, Chino Valley Medical Center, part of the Prime Healthcare chain, touts “promotional financing options with the CareCredit credit card to help you get the care you need, when you need it.”

As Americans are overwhelmed with medical bills, patient financing is now a multibillion-dollar business, with private equity and big banks lined up to cash in when patients and their families can’t pay for care. By one estimate from research firm IBISWorld, profit margins top 29% in the patient financing industry, seven times what is considered a solid hospital margin.

Hospitals and other providers, which historically put their patients in interest-free payment plans, have welcomed the financing, signing contracts with lenders and enrolling patients in financing plans with rosy promises about convenient bills and easy payments.

For patients, the payment plans often mean something more ominous: yet more debt.

Millions of people are paying interest on these plans, on top of what they owe for medical or dental care, an investigation by KHN and NPR shows. Even with lower rates than a traditional credit card, the interest can add hundreds, even thousands of dollars to medical bills and ratchet up financial strains when patients are most vulnerable.

Robin Milcowitz, a Florida woman who found herself enrolled in an AccessOne loan at a Tampa hospital in 2018 after having a hysterectomy for ovarian cancer, said she was appalled by the financing arrangements.

“Hospitals have found yet another way to monetize our illnesses and our need for medical help,” said Milcowitz, a graphic designer. She was charged 11.5% interest — almost three times what she paid for a separate bank loan. “It’s immoral,” she said.

Robin Milcowitz signed on to a no-interest payment plan to pay off $3,000 she owed for a hysterectomy in 2017. When the medical center switched her account to AccessOne, she began receiving late notices, though she was making payments. Turned out her payments were only being applied to the surgery, leaving an account for medical appointments past-due.

Read More... Read More

Medicare Advantage plans overcharged Medicare, audits show : Shots

Eric Harkleroad/KHN /Getty Images/ Unsplash/ Centers for Medicare & Medicaid Services Data

A photo illustration shows four images separated by bars. The first image is of money and a Medicare card, the second is an older man sitting in a chair, the third is a closeup of money, the fourth is of a spreadsheet of overpayments totaling over $8 million.

Eric Harkleroad/KHN /Getty Images/ Unsplash/ Centers for Medicare & Medicaid Services Data

Newly released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans, with some plans overbilling the government more than $1,000 per patient a year on average.

Summaries of the 90 audits, which examined billings from 2011 through 2013 and are the most recent reviews completed, were obtained exclusively by KHN through a three-year Freedom of Information Act lawsuit, which was settled in late September.

The government’s audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled, though the actual losses to taxpayers are likely much higher. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies.

Officials at the Centers for Medicare & Medicaid Services have said they intend to extrapolate the payment error rates from those samples across the total membership of each plan — and recoup an estimated $650 million from insurers as a result.

But after nearly a decade, that has yet to happen. CMS was set to unveil a final extrapolation rule Nov. 1 but recently put that decision off until February.

Ted Doolittle, a former deputy director of CMS’ Center for Program Integrity, which oversees Medicare’s efforts to fight fraud and billing abuse, said the agency has failed to hold Medicare Advantage plans accountable. “I think CMS fell down on the job on this,” said Doolittle, now the health care advocate for the state of Connecticut.

Doolittle said CMS appears to be “carrying water” for the insurance industry, which is “making money hand over fist” off Medicare Advantage plans. “From the outside, it seems pretty smelly,” he said.

In an email response to written questions posed by KHN, Dara Corrigan, a CMS deputy administrator, said the agency hasn’t told health plans how much they owe because the calculations “have not been finalized.”

Corrigan declined to say when the agency would finish its work. “We have a fiduciary and statutory duty to address improper payments in all of our programs,” she said.

Enrollment in Medicare Advantage plans has more than doubled in the last decade

The 90 audits are the only ones CMS has completed over the past decade, a time when Medicare Advantage has grown explosively. Enrollment in the plans more than doubled during that period, passing 28 million in 2022, at a cost to the government of $427 billion.

Seventy-one of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits, according to the government’s records. Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding that $1,000 average in 10 of 11 audits, according to the records.

CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.

What constitutes an overpayment?

Auditors flag overpayments when a patient’s records fail to document that the person had the medical condition the

Read More... Read More

How state abortion bans complicate telehealth abortions : Shots

Allison Case is a family medicine physician who is licensed to practice in both Indiana and New Mexico. Via telehealth appointments, she’s used her dual license in the past to help some women who have driven from Texas to New Mexico, where abortion is legal, to get their prescription for abortion medication. Then came Indiana’s abortion ban.

Farah Yousry/ Side Effects Public Media


hide caption

toggle caption

Farah Yousry/ Side Effects Public Media

Allison Case, a family medicine physician, spends much of her time working in a hospital where she delivers babies and provides reproductive health care services, including abortions.

Case lives and works in Indiana, where a ban on most abortions took effect for a week in late September until a judge temporarily halted the ban. The state has since appealed the judge’s order and asked the Indiana’s high court to take up the case. Meanwhile, Case is also licensed to practice in New Mexico, a state where abortion remains legal.

Before Indiana’s abortion ban took effect, Case would use her days off to provide reproductive health services, including abortion care, via telemedicine through a clinic that serves patients in New Mexico. Many of them travel from neighboring Texas, where abortion is banned.

Some travel solo, she says, and others have their children with them.

“Some people are [staying in] hotels, others might have family or friends they can stay with, some are just sleeping in their cars,” Case says. “It’s really awful.”

During a telemedicine appointment, doctors, nurses or other qualified health professionals review the medical history of the patient and ensure eligibility for a medication abortion. They give the patient information about how the two pills work, how to take them, what to look out for as the body expels the pregnancy, and when to seek medical attention in the rare instance of complications. The medications are then mailed to the patient, who must provide a mailing address in a state where abortion is legal.

In the U.S., more than a dozen states severely restrict access to abortion, and almost as many have such laws in the works. Across the country, since Roe v. Wade was overturned, clinics that do provide abortions have seen an increase in demand. Many clinics rely on help from physicians out of state, like Case, who are able to alleviate some of the pressure and keep wait times down by providing services via telemedicine.

But as more states move to restrict abortion, these providers are finding themselves navigating an increasingly complicated legal landscape.

Is abortion by telemedicine legal? Experts differ

Medication abortions work for most people who are under 11 weeks pregnant, and research suggests medication abortion via telemedicine is safe and effective. Yet many states have enacted legislation to ban or limit access to telehealth abortions.

But it’s not always clear what that means for doctors like Case who are physically located in a state with abortion restrictions but have a license that enables them to provide care via telehealth

Read More... Read More

Birth control access can be limited in places with Catholic health systems : Shots

Catholic health care systems can limit access to birth control.

Rich Pedroncelli/AP


hide caption

toggle caption

Rich Pedroncelli/AP


Catholic health care systems can limit access to birth control.

Rich Pedroncelli/AP

Last week, students returning to campus at Oberlin College in Ohio got a shock: A local news outlet reported that the campus’ student health services would severely limit who could get contraception prescriptions. They would only be given to treat health problems — not for the purpose of preventing pregnancy — and emergency contraception would only be available to victims of sexual assault.

It turned out the college had outsourced its student health services to a Catholic health agency – and like other Catholic health institutions, it follows religious directives that prohibit contraception to prevent pregnancy. They also prohibit gender-affirming care.

“I would characterize the student’s reaction as outrage,” says Remsen Welsh, a fourth-year Oberlin student and co-director of the student-run Sexual Information Center on campus. “A lot of people in my circles were sending [the news story] around like, what is happening?”

Although the college quickly came up with a new plan to offer reproductive health services to students on campus, the incident at Oberlin shows the wide reach of Catholic health care in the U.S., and how the rules these institutions follow can limit access to contraception.

Now that many states – including Ohio – have adopted restrictions or outright bans on abortion, that’s also raised the stakes for contraception access.

Religious restrictions affect many health care settings

Issued by the U.S. Council of Catholic Bishops, the Ethical and Religious Directives that guide Catholic health care systems “prohibit a broad swath of reproductive care,” including birth control pills, IUDs, tubal ligation and vasectomies, says Dr. Debra Stulberg, a professor of family medicine at the University of Chicago who has researched how these directives play out in health care.

Catholic hospitals have long been a mainstay of health care in America. And these days, the directives apply to a wide range of settings where people seek reproductive health care – including urgent care centers, doctors’ offices and outpatient surgery centers that have been bought by or merged with Catholic health systems.

They can also apply when Catholic health agencies are hired to manage health care services for other institutions, which is what happened at Oberlin.

Four of the 10 largest health care systems in the country are Catholic, according to a 2020 report. In some counties, they dominate the market. In 52 communities, the report found, a Catholic hospital is the only one around within a 45-minute drive.

“After all this consolidation, this is where it shakes out, where we’ve got about 40% of reproductive age women living in areas with high or dominant Catholic hospital market share,” says Marian Jarlenski, a health policy researcher at the University of Pittsburgh, who examined the data in 2020.

‘Not transparent at all’

Patients often aren’t aware that these restrictions might affect the care they get, says Lois Uttley,

Read More... Read More

How Texas abortion law turned a pregnancy loss into a medical trauma : Shots

Elizabeth and James Weller at their home in Houston two months after losing their baby girl due to a premature rupture of membranes. Elizabeth could not receive the medical care she needed until several days later because of a Texas law that banned abortion after six weeks.

Julia Robinson for NPR


hide caption

toggle caption

Julia Robinson for NPR


Elizabeth and James Weller at their home in Houston two months after losing their baby girl due to a premature rupture of membranes. Elizabeth could not receive the medical care she needed until several days later because of a Texas law that banned abortion after six weeks.

Julia Robinson for NPR

New, untested abortion bans have made doctors unsure about treating some pregnancy complications, which has led to life-threatening delays and trapped families in a limbo of grief and helplessness.

Elizabeth Weller never dreamed that her own hopes for a child would become ensnared in the web of Texas abortion law.

She and her husband began trying in late 2021. They had bought a house in Kingwood, a lakeside development in Houston. Elizabeth was in graduate school for political science, and James taught middle-school math.

The Wellers were pleasantly surprised when they got pregnant early in 2022.

In retrospect, Elizabeth says their initial joy felt a little naive: “If it was so easy for us to get pregnant, then to us it was almost like a sign that this pregnancy was going to be easy for us.”

Things did go fairly smooth at first. Seventeen weeks into the pregnancy, they learned they were expecting a girl. They also had an anatomy scan, which revealed no problems. Even if it had, the Wellers were determined to proceed.

“We skipped over the genetic testing offered in the first trimester,” Elizabeth says. “I was born with a physical disability. If she had any physical ailments, I would never abort her for that issue.”

Elizabeth thought of abortion rights in broad terms: “I have said throughout my life I believe that women should have the access to the right to an abortion. I personally would never get one.”

And at this particular point in her life, pregnant for the first time at age 26, it was still somewhat abstract: “I had not been put in a position to where I had to weigh the real nuances that went into this situation. I had not been put in the crossroads of this issue.”

But in early May, not long after the uneventful anatomy scan, the Wellers suddenly arrived at that crossroads. There they found themselves pinned down, clinically and emotionally, victims of a collision between standard obstetrical practice and the rigid new demands of Texas law.

It was May 10, 2022. Elizabeth was 18 weeks pregnant. She ate a healthy breakfast, went for a walk outside and came back home.

In the nursery upstairs, they had already stashed some baby clothes and new cans of paint. Down in the kitchen, images from recent scans and ultrasounds

Read More... Read More