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Dr. Annelys Hernandez (left) checks out Cynthia Louis (right) in Florida International University’s Mobile Health Center in Miami on March 3, 2015. Courtesy of WLRN/Peter Andrew Bosch/Miami Herald hide caption
itoggle caption Courtesy of WLRN/Peter Andrew Bosch/Miami Herald
The Affordable Care Act got a big boost from the Supreme Court in June. But some states are still dealing with fallout from a previous Supreme Court decision that left it up to states to decide whether or not to expand Medicaid.
In Florida, which opted not to expand, about 850,000 people were left in health care limbo that some call the coverage gap.
Cynthia Louis, 58, is one of them. She worked for Burger King for most of her adult life, plus a year in high school.
“I worked for Burger King 25 years and loved every day of it, just coming, you know? Not because of the money, but just the people and working, just working,” she says.
A year-and-a-half ago, though, while working at a Burger King in the northern part of Miami, something felt off.
“All of a sudden I just started feeling sick. And I said, ‘What’s going on?’ And then I started sweating.” She says her stomach hurt and after sitting down for a while, she tried to stand up, but couldn’t. Her knees hurt too much.
She left work early that day and hasn’t been able to go back since.
“They miss me. I miss them, you know,” she says. “I just hope and pray if I can come back when I get well, I’ll be glad to come back,”
Louis is 58 and her joints still hurt all the time.
She used to have health insurance through Burger King, but after a while she dropped it because it was too expensive.
Now she needed insurance, but Medicaid wasn’t an option for her in Florida.
“It’s not right. Because it’s a lot of people out here who don’t work, and it’s a lot of people out here sick and don’t get Medicaid,” she says. “So they can’t go to the doctor, and they’re getting sicker and sicker.”
The popular description of Medicaid is that it’s health insurance for the poor.
But in fact it’s more complicated.
To qualify you usually have to also have meet another condition: be pregnant, have a dependent child or a disability. And within each of those groups, there’s even more restrictions.
For example, in a family of four, the most the parents can make to qualify for Medicaid in Florida is just under $8,500. A single parent who makes $6,000 a year and has one kid earns too much to qualify for Medicaid. And if someone is single with no dependent kids and isn’t disabled, no matter how little he or she makes, he or she can’t get Medicaid in the state.
And that’s Louis’s situation.
So when enrollment started for Obamacare in 2013, she thought she had her answer.
“I called, I kept on calling because people kept telling me that I can get it,” she recalls. “And I kept telling them, ‘Well, they told me I can’t get it.’ And they said, ‘No, you can get it!’ So I called again.”
In the end she tried three times.
“So you mean to tell me, I worked all my life, and I can’t get Obamacare? Something wrong with that picture,” she says.
The reason Louis didn’t get Obamacare is that in Florida, only part of The Affordable Care Act ever went into effect.
The federal government helps some people pay for health insurance with subsidies if they make just above poverty level up to four times the poverty level.
For those making less, they were supposed to get Medicaid.
But that second part never happened because Florida is one of 21 states that has chosen not to expand Medicaid after a Supreme Court decision opened that option.
Florida’s legislature discussed it seriously this time around but adjourned in late June without expanding Medicaid coverage.
That means Louis, and hundreds of thousands of others, fall into this gap where they don’t get Medicaid and they don’t qualify for subsidies.
She does qualify for charity care at Jackson Hospital along with a lot of other people.
“You go to Jackson, you see a million people down there. I see so many people at Jackson, it’s ridiculous,” she says.
And, charity care lacks some of the advantages of Medicaid, says Louis’s Doctor, Katherine Chung-Bridges.
“It’s being able to access specialist care. It’s being able to access you know the appropriate labs the appropriate studies in a timely fashion,” she says.
With her Jackson charity care card, Louis can only go to certain primary care clinics and most of them don’t have specialists on staff. She was referred to a rheumatologist at Jackson Memorial Hospital almost a year ago. Wait times there usually range from two weeks up to six months, says Ed Odell with Jackson Health.
“It depends on the specialties,” he says. Urologist, pulmonary specialists and ear, nose and throat clinics have longest waits. Those clinics only see patients four hours a week since they’re mostly teaching and academic clinics.”
At the same time, the federal government is giving Florida less money for charity care because of the assumption that more people would have Medicaid.
In January, Louis was finally able to book an appointment with a rheumatologist.
That appointment is this month.
This story is part of a reporting partnership with NPR, WLRN and Kaiser Health News. Daniel Chang of the Miami Herald co-reported the story.
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A Harvard Medical School study found that online symptom checkers, such as WebMD and the Mayo Clinic, are only accurate about half the time.
KELLY MCEVERS, HOST:
There’s a warning out there for those of us who go online to figure out why we have an upset stomach or a nagging cough. Symptom checkers – those tools that ask for information and a offer diagnosis – are only accurate about half the time. Martha Bebinger of member station WBUR has the story.
MARTHA BEBINGER, BYLINE: The finding is from a Harvard Medical School study that reviewed 23 sites such as Web M.D., the Mayo Clinic and DocResponse. One-third listed the correct diagnosis as the first option for patients. Half the sites had the right diagnosis among their top three results. Lead author, Dr. Ateev Mehrotra, urges patients to be cautious.
ATEEV MEHROTRA: These sites are not a replacement for going to a doctor and getting a full evaluation and a diagnosis. They are simply providing some information on what might be going on with you.
BEBINGER: Researchers entered the symptoms of 45 patients from vignettes used to train medical students. The Mayo Clinic’s first diagnosis was right only 17 percent of the time, but have the correct diagnosis on a list of 20 and 76 percent of cases. Dr. John Wilkinson works on Mayo’s symptom checker.
JOHN WILKINSON: We’re always trying to improve, but if most of the time the correct diagnosis is included in the list of possibilities, that’s all we’re attempting to do.
BEBINGER: Wilkinson says the tool directs patients to medical research and prepares them to talk to their doctor. By the way, the diagnosis accuracy rate for physicians is 85 to 90 percent. But Jason Maude, who runs a high-performing tool called Isabel, says he does not want a web-versus-doctor showdown.
JASON MAUDE: The whole point is to make the patient much better informed and to ask the doctor much better questions, and then together, they should do a much better job.
BEBINGER: Giving patients a broad range of diagnoses may mean they seek unnecessary care. Clarifying how and why patients use these tools is critical, say the study’s authors who estimate 100 million uses of symptom checkers this year. For NPR News, I’m Martha Bebinger in Boston.
MCEVERS: This story is part of a reporting partnership of NPR, WBUR and Kaiser Health News.
Copyright © 2015 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
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Government audits just released as the result of a lawsuit detail widespread billing errors in private Medicare Advantage health plans going back years, including overpayments of thousands of dollars a year for some patients.
Since 2004, private insurers that run Medicare Advantage plans, an increasingly popular alternative to traditional Medicare, have been paid using a risk score calculated for each patient who joins. Medicare expects to pay higher rates for sicker people and less for those in good health.
But the internal audits, never before made public, provide striking new evidence of billing mistakes — mostly overcharges — in the Medicare Advantage plans. Four of the audits were recently obtained by the Center for Public Integrity through a court order in a Freedom of Information Act lawsuit.
The audits involve four health plans: an Aetna Health Inc. plan in New Jersey, Independence Blue Cross in the Philadelphia area; Lovelace Health Plan in Albuquerque, N.M, and a Care Plus plan in South Florida. Care Plus is a division of Humana, Inc.
Last month, the Center for Public Integrity reported on a fifth such audit at PacifiCare in Washington state, an arm of giant UnitedHealth Group, the nation’s largest Medicare Advantage operator.
In all five audits, two sets of auditors inspected medical records for a sample of 201 patients at each plan for 2007. If the medical chart didn’t document that a patient had the illnesses the plan reported, Medicare asked for a refund. Auditors also gave plans credit for underpayments they discovered.
Among the findings:
The federal Centers for Medicare and Medicaid Services, or CMS, which conducted the audits, had no comment.
None of the health plans would discuss the audit findings. Aetna, in a statement, said the company had “raised a number of questions and concerns” regarding the results and was “awaiting a response from CMS.”
Clare Krusing, a spokeswoman for America’s Health Insurance Plans, the insurance industry’s primary trade group, said the audits “overstated” the payment errors. Health plans have since improved their record keeping and offer better care for people with chronic health conditions than traditional Medicare, Krusing said.
“The evidence is overwhelmingly clear that these programs (Medicare Advantage) deliver the right care for beneficiaries,” she said.
The records are coming to light at a time of rapid expansion — and consolidation — in the Medicare Advantage market. Enrollment has neared 17 million, about 1 in 3 people eligible for Medicare. Last week, Aetna announced plans to buy competitor Humana for $37 billion.
But the industry also is drawing scrutiny over the accuracy of risk-based payments—and a penchant for secrecy.
The Center for Public Integrity first reported last year that billions of tax dollars are wasted every year due to plans that appear to exaggerate how sick their patients are, a practice known as “upcoding.”
The government audits, known as Risk Adjustment Data Validation, or RADV, are the government’s primary tool for catching these sorts of billing mistakes and holding the industry accountable.
Yet the process has proven unwieldly at best, partly due to a complex and lengthy appeals process and partly to indecision over how much the health plans should refund to the government.
It’s not clear how the five audits were settled because CMS officials have refused to release these records.
The five RADV audits were launched in 2008, but findings weren’t issued until August 2012, when CMS officials sent each plan a form letter detailing the amount of the overpayment and the plan’s extensive appeal rights. CMS has refused to make public the status of the audits—or even how many total RADV audits have been conducted. CMS cites an exemption to the Freedom of Information Act that shields “trade secrets.”
This stance has largely concealed Medicare Advantage billing records. It wasn’t until April 15, 2011, that CMS announced it would release minimal billing data annually. Doing so would “inform the public on how their tax dollars are being spent,” the agency said at the time, citing President Obama’s January 2009 Memo on Transparency and Open Government.
But much to the chagrin of some researchers, CMS has never expanded on what is released, even though it has made public a huge cache of billing data and audits centering on thousands of doctors, hospitals and other medical suppliers.
“It’s astonishing,” said Brian Biles, a professor at George Washington University who successfully sued CMS to win release of the limited billing data now available. “They are dumping huge amounts of data in other areas. Medicare Advantage is now 30 percent of the Medicare program.” (Biles assisted the Center for Public Integrity with its 2014 analysis of that data.
Timothy Layton, a Harvard Medical School researcher who recently co-authored a paper on health plan upcoding, said scholars “are definitely hindered” by the lack of data. For instance, researchers can’t examine individual risk scores and the various medical conditions that raise and lower them, he said.
“Without the ability to answer these questions, we can keep pointing out how big the overpayment to MA (Medicare Advantage) is, but we can never really provide the optimal solution to the problem,” Layton said.
David Himmelstein, a physician and professor in the CUNY School of Public Health at Hunter College who supports a single payer medical system, agreed.
“Medicare publishes detailed data on almost every doctor and hospital that gets paid a penny, but it leaves the public — and researchers — almost completely in the dark about the giant Medicare Advantage plans that will collect more than $150 billion from Medicare this year,” he said.
Still, Medicare Advantage insurers are facing calls for closer scrutiny of their operations. In May, Senate Judiciary Committee Chairman Charles Grassley, R- Iowa, wrote to Attorney General Loretta Lynch and CMS administrator Andrew Slavitt asking how many risk score fraud investigations had been conducted over the past five years and their results. He’s still waiting for an answer.
“Sen. Grassley continues to expect responses to his letters and will continue to press for responses,” said Grassley spokeswoman Jill Gerber. “This is an important issue involving a large amount of taxpayer money”
In a separate letter, Sen. Clare McCaskill, the senior Democrat on the Senate Aging Committee, asked CMS officials to advise her of government efforts to curb Medicare Advantage billing abuses.
“After meeting with CMS we have continued concerns about the level of oversight taking place with respect to Medicare Advantage plans and will continue working to increase oversight and accountability in this area,” said McCaskill spokesman Drew Pusateri.
This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. For more, follow the center on Twitter @Publici, or sign up for its newsletter.
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