We’re ClearHealthCosts — telling people what stuff costs in healthcare and helping them navigate this messy and complicated world. Welcome to our industry newsletter!
NOTE: This story blew up the internet. Therapists are reaching out to me from the four corners of the world saying they have Stuff To Say About This…Stay tuned for the next installment.
Vaughn McLaughlin, a New York City therapist, wants out of his Empire Blue Cross insurance contract. He wants out really badly, but he says he can’t get out. And he’s not alone. McLaughlin has been working on ending his contract with Empire since May 2022, and intensively since March. He’s now been told he can’t leave until the end of the year.
A Long Island therapist we talked to has been trying to leave Empire since November 2021 – well over 18 months, and she’s only now thinking that maybe she has managed to leave.
Their stories of repeated requests to leave a contract, long phone hold times, no response to emails, and appeals to the New York State Department of Financial Services are full of sad detail. And their stories don’t begin to represent the problems of patients, who will be struggling with insurance themselves – who is in network? What will the insurer pay? And how much time do I have to spend on hold to resolve this?
Our examples of insurers holding therapists unwillingly in contracts are all related to Empire in the New York City area. When we put out a call for examples via a professional group, we had responses from more people than we could possibly talk to; we did not hear anything about similar problems with other insurers.
Many hospitals and medical providers have directed people seeking legally mandated financial aid to instead apply for consumer credit in the form of loans or credit cards to pay their bills. Well, finally someone noticed.
It’s actually pretty common: The financial aid pages of hospital websites are supposed to include full explanations of how to request free or discounted care under the “charity care” financial aid policies that hospitals are legally mandated to offer. But increasingly the financial aid pages show options for medical credit cards or loans to pay for healthcare services. Those credit cards and loans, as consumer credit, are treated differently on people’s credit reports than medical debt.
The Consumer Finance Protection Bureau, the U.S. Department of Health and Human Services and the Department of Treasury recently began an investigation into the practice. The agencies called for information from people about their experiences.
The drug Humira is the world’s biggest medication moneymaker: It brought in more than $15.6 billion in the first 9 months of 2022 for its manufacturer, AbbVie. Now it’s coming off patent and losing its exclusive hold on the market – and its manufacturer wants to keep making money, as the drug gains competitors that cost a fraction of the price.
So Humira is a fascinating way to look at drug pricing in the United States — and also to ask whether patients will actually save money now that there is a generic.
Humira (generic adalimumab) is used to treat inflammatory conditions like rheumatoid arthritis, psoriatic arthritis, Crohn’s disease, ulcerative colitis, ankylosing spondylitis and psoriasis. Patients inject it themselves, and it is one of the widest-used and most expensive medications on the market. The cost for patient and insurer is often more than $80,000 annually.
Why is it so interesting? “Humira is at the epicenter of so many earthquakes that are rocking the healthcare system,” said Robin Feldman, distinguished professor of law and head of the Center for Innovation at the University of California College of the Law, San Francisco.
“Humira is a widely used drug with sky-high prices. It is also a biologic drug” – a class of drugs made by using a living organism or its products, she said. “And much of the industry is rushing towards developing biologics these days – in part because, for successful drugs, the profit margins are so high. With Humira, the company has thrown curveball after curveball at potential competitors.”
A problem hiding in plain sight
Gift link: The overlooked reason our healthcare system crushes patients? It’s not a surprise. This will resonate with all of you. Read and weep.
What we’re reading
Fascinating conversations over on the “Take Medicine Back” Facebook page. Medical professionals who want to re-think the way healthcare is supplied in the U.S. No link because it’s a private group — you need to apply to join.
Wendell Potter on Cigna’s second-quarter earnings: Investors were disappointed, despite high PBM profits. And Cigna is asking for 23% rate increases. Wow. Healthcare Uncovered.
Gag clauses: Under the Consolidated Appropriations Act of 2021 (CAA), group health plans and health insurance issuers are prohibited from entering into agreements with service providers restricting certain information that the plan may make available to another party. Making attestations about gag clauses is coming up. National Law Review
The collapse of American Physician Partners, a private equity-owned operator of emergency rooms, was sudden and dramatic. Doctors were left unpaid and uninsured. Two other big P.E.-owned services are also in financial trouble. The American Spectator.
Regulators in the boardroom: This profile of Tom Scully, former C.M.S. administrator and current private equity investor, goes into great detail about how exactly Wall Street got its hands on the healthcare system. The American Spectator.
Employers are yelling at insurers about overspending. But the whole process seems to involve a lot of delay and deny. Bloomberg News (as reprinted in The Star-Tribune).
Surprise billing: The No Surprises Act is apparently protecting consumers. But what does the behind-the-scenes resolution process look like? It’s not pretty. Health Affairs.