Oct 17, 2018

Axios Vitals

By Caitlin Owens
Caitlin Owens

Good morning ... Everything is so bad, all the time, especially on the Internet, and just when you think it couldn’t get worse, bam: There’s a robot dancing to “Uptown Funk.”

1 big thing: How to stop surprise hospital bills

Illustration: Aïda Amer/Axios

Getting an unexpected bill for thousands of dollars is a gut-level problem. Both the size of these bills and the fact that they’re surprises contribute to the outrage over surprise billing.

The big picture: That blunt-force problem is a product of the health care system’s complexity.

  • So, even as policymakers turn their attention to surprise billing, every potential solution runs into roadblocks: from an industry that wants to protect its profits; or skepticism from policy experts; or political opposition.

How it works: These surprise bills are often “balance bills” — patients who are treated by an out-of-network provider get billed for the difference between the provider’s price and what their insurer pays.

Getting patients off the hook requires shifting the cost to someone else, or reducing the size of the bill, or both, Axios’ Caitlin Owens explains.

  • "Far and away the biggest challenge is deciding on the 'right price,'" the American Enterprise Institute's Benedic Ippolito said.
  • Tying out-of-network payments to Medicare rates is one option, but providers say Medicare’s rates are unsustainably low.
  • Sen. Bill Cassidy’s proposal would spare providers, shifting the burden instead to insurers. But they’d just build those costs into their premiums.
  • And in some cases, under Cassidy’s bill, out-of-network providers could end up getting paid more than their in-network counterparts. Experts fear that leaves them without much incentive to negotiate with insurers at all.

What's next: “The emergency room and the out of network billing… is the gateway drug to larger price control conversations," said Rodney Whitlock, a health care lobbyist and former Senate GOP health policy aide.

Go deeper.

2. Insurers go all in on Medicare Advantage

Medicare’s annual enrollment period started Monday, and health insurers are banking that a lot more seniors and people with disabilities will sign up for private Medicare Advantage plans instead of traditional Medicare coverage, my colleague Bob Herman reports.

Driving the news: UnitedHealth Group executives yesterday said earnings per share next year will increase by roughly 13%, due in large part to MA's “extraordinary growth opportunity.”

  • Devoted Health, a startup founded by Todd and Ed Park, just raised $300 million in venture funding as it starts selling MA plans for the first time in eight Florida counties.
  • MA plans are all the rage among hospital-owned insurers, too.
  • MA enrollment increased 8% in 2018, and the feds expect a 12% enrollment bump for 2019.

The bottom line: Both Democrats and Republicans support MA, so the enrollment wave likely won’t subside in the near term. But there are still deep concerns about insurers gaming the program.

3. Minnesota sues insulin makers

Minnesota Attorney General Lori Swanson is suing three drug companies — Sanofi-Aventis, Novo Nordisk and Eli Lilly — over price increases for their insulin products.

Details: Insulin prices have jumped significantly over just a few years. Some products’ prices have gone up 400% since 2002, according to Swanson’s office.

  • Specifically, Swanson says the drugmakers set “artificially high” list prices for their drugs, then agreed to steep rebates with pharmacy benefit managers, which made those drugs more profitable for PBMs. The PBMs then were more inclined to cover those drugs in the insurance plans they help manage, she said.

The other side: Novo Nordisk said in response to the suit that its “business practices are consistent with legal and regulatory requirements,” per the Minneapolis Star Tribune.

Flashback: Officials in New Mexico and Washington state have also launched investigations into Eli Lilly’s insulin pricing.

4. “Mystery illness” flummoxes CDC

The Centers for Disease Control and Prevention is “frustrated” by the mysterious spread of an illness similar to polio, cases of which have now been confirmed in 22 states. Seems like a very reasonable cause for frustration, to be honest.

By the numbers: 127 cases of acute flaccid myelitis, or AFM, have been reported so far in 2018, including 68 confirmed cases, according to CDC data. There were 33 confirmed cases last year.

  • AFM affects the spinal cord and causes partial paralysis, similar to polio, especially in children.
  • The disease remains extremely rare — less than one in 1 million people contract it, CDC says — but cases have been spreading since 2014 and health officials don’t know why.

“We have not been able to find a cause for the majority of these AFM cases,” the CDC’s Nancy Messonnier said yesterday, via STAT. “There is a lot we don’t know about AFM and I’m frustrated that despite all of our efforts, we haven’t been able to identify the cause of this mystery illness.”

5. Get a flu shot

Parents remain deeply skeptical about the flu vaccine, according to a report from the American Association for the Advancement of Science.

  • In a recent national survey, “more than half of parents with children under age 18 believe that their child can get the flu from the flu shot, while a third think that the shot does not protect against the flu.”

My thought bubble: The flu shot isn’t perfect, but you should still get a flu shot. It’s a lot better than getting the flu, and definitely better than helping to transmit it.

Caitlin Owens