Archive for the ‘Health Insurance’ Category

Service of Insurance: What it Pays For, Making Coverage Easier and When a Company Should Consider Ducking Coverage

Monday, October 28th, 2019

Photo: aiche.org

If I had back all the premiums I’ve paid for everything from renter’s and owner’s to car, life and health–even Social Security–insurance I’d be a wealthy woman as many would be. I admit that when I’ve needed it, I was grateful for the coverage.

For humanitarian reasons I question how insurance companies can get away with not covering a sick person for lifesaving medication and related legitimate health expenses. Drugs that aren’t on approved lists aren’t covered nor is unlimited home health care which is cheaper and in most cases far better than carting off a person to a nursing home. In this post I write about a pharmaceutical company that’s addressing how to help insurance companies pay for a pricey drug.

I also question whether an insurance company should have to pay an organization’s settlement and legal expenses in cases of abuse. The exception would be legal expenses. They should pay them if the accusations prove false.

Medical

Here’s a creative way that pharmaceutical company Novartis is helping insurance companies pay for Zolgensma, the most expensive drug in the world. I first read about it this summer in a Wall Street Journal [WSJ] article by Denise Roland, “Insurers Limit Access to $2 Million Drug.” One dose of the innovative gene therapy helps prevent a rare condition in young children from getting worse.

They are born without a gene that controls the muscles that allow them to sit up and later, stand on their own. When this article was written, insurance companies were reluctant to spring for the money to pay for the one injection because they weren’t sure it would work. It is meant to halt the progression of the disease, it doesn’t reverse or cure it. It is most effective when given in infancy, before symptoms appear.

Photo: zolbensma.com

Things have changed since summer. Recently Novartis made concessions to help patients acquire the drug. Denise Roland and  Carlo Martuscelli explained the company’s compromises in the WSJ article “Novartis Lauds Launch of World’s Most Expensive Drug.”

Novartis agreed to refund some of the cost to the insurance company if the drug didn’t work. It also offered to divide the cost evenly over five years [though few insurers have opted for this choice]. Sales of $160,000 in the first three months have exceeded analyst expectations. CEO Vas Narasimhan “said on a call with reporters that 99 percent of patients who were eligible for Zolgensma were receiving it, although some must go through an appeal process to do so.” Regardless, Narasimhan said patients “on average” received the drug within 30 days of requesting it.

Insuring Abuse

On the other hand I wonder how some insurance customers think that they should collect and why a company should pay them.

The title of a recent WSJ article by Nicole Friedman and Ian Lovett was: “Insurers Face Wave of Costly Child Sex-Abuse Claims–As 22 states move to ease victims’ pursuit of damages against alleged abusers, disputes over decades-old policies loom.” In New York, the Child Victims Act gives victims a year to report abuse with no time limits.

Photo: correllfirm.com

The reporters wrote: “Most of these institutions, such as churches or schools, are expected to try to use liability insurance to cover some of the cost of defending against these lawsuits and paying potential damages.” They continued ” The legal disputes underscore the complexity of litigating decades-old claims and the uncertainty about how much money will ultimately be available to compensate victims.” It could be $billions they estimated.

According to them insurance companies have already paid 20 to 80 percent of settlements for victims against churches. [The New York Archdiocese has been compensated in one or another way since 1954.]

Photo: businessinsurance.com

As the statute of limitations kicked in, insurers calculated what their exposure would be. Now that it has been lifted for a year, those calculations are out the window and exposure to compensation has increased, but not without complications. “Many institutions and insurers don’t hold on to decades-old policy documents, and it can be difficult to track down details. Sometimes ‘insurance archaeologists’ are hired to hunt down evidence of old policies,” Friedman and Lovett reported.

They identified additional reasons to derail compensation: Did the policyholder know about the alleged abuse? “Liability insurance policies typically cover negligent acts but not intentional ones.” And should a claim cover one alleged abuser or each of his victims?

Do you agree that health insurers/Rx plans should cover costs for medicine, generic if necessary–even expensive experimental drugs?

What about an institution with a sexual predator among its employees?  Should court or settlement costs be eligible for insurance coverage if the person is proved guilty? Wouldn’t this be like my buying insurance to cover my legal and bond costs were I to be accused of robbing a bank?

Photo: witc.edu

Service of What You Don’t Know CAN Hurt You: Essential Facts Relating to Health, Yours and the Country’s

Monday, December 18th, 2017

Donna Hammaker, Esq & Dr. Thomas M. Knadig, EdD

Did you know that:

  • Congress defines what “equivalent” means when it comes to generic drugs and that the therapeutic effectiveness of a generic might actually be half as that of the brand according to this definition? More below.
  • About 1/10th of the U.S. population has no health insurance; most of them are earning middleclass incomes and the lack of coverage causes two deaths every hour?

I learned this at an eye-opening program of the Healthcare Public Relations and Marketing Society of Greater New York [HPRMS]. Nancie Steinberg, president, introduced the speakers Donna K. Hammaker, Esq. and Dr. Thomas M. Knadig, EdD, who addressed representatives of some of New York City’s most prestigious hospitals and health organizations and the marketers and PR professionals who counsel them.

While some of what I heard was shocking, the takeaway as a consumer was nothing new: When it comes to your health, be informed and ask questions.

About the reference to generic drugs above, Hammaker said you could not pay her to take generic drugs from India or Israel. She mentioned “brand generics” by Novartis and Pfizer that seemed to pass muster.

The speakers, on the faculty of Saint Joseph’s University, Philadelphia, and authors of three textbooks for students and health care managers, the most recent of which is Health Care Management and the Law, shared data-driven facts and statistics gathered in the last two years.

Laced in the discussion were factoids about the Affordable Care Act, such as that much of it was first addressed during the Nixon administration and that many people are unaware of what’s in it. Healthcare has been Hammaker’s professional focus as a lawyer and yet even she was surprised by bits that she learned by studying it. [One wonders how many lawmakers are still in the dark and yet they call for changes.]

Photo: racolblegal.com

A caveat: I’ve posted sound bytes throughout this post. On just one of these topics alone, Clinical Trials, Hammaker gives a three hour lecture in which she addresses the differences between brand and generic drugs. There is similar backup in her latest 830 page book and hours-long lectures relating to her other contentions and conclusions. For example in Health Care Management and the Law the authors reference court decisions relating to the use of reprocessed medical devices which, in the interest of brevity, I don’t go into here.

Following are just a few highlights based on a list the authors handed out and subsequent discussion.

 

  • “Reprocessed medical devices are a cause for concern, as the FDA standards are not always strictly adhered to, patients are not necessarily informed they are receiving a reprocessed device, and such devices are often obtained from unregulated sources, such as the Internet.” Hammaker recommended that before undergoing a procedure that a patient specify on the hospital consent form that he/she wants a new device as well as the name of the manufacturer of the device. She explained, for example, that some hip replacement devices are made of cheaper metals that tend to break. In addition, she reported, the FDA is lifting restrictions in this area.
  • Photo: WebMD.com

    “Over 60 percent of the yearly $1.9 trillion employers spend on health care costs go toward treating tobacco-related illnesses.” We learned that it is legal for an employer to refuse employment to a smoker. In addition, an employer can charge current employees who smoke more for insurance; force them to take smoking cessation classes as a term of employment and conduct random tests [of hair] to identify smokers.

  • “Estimates indicate 90 million people in the US live with a preventable chronic disease [such as diabetes and hypertension often caused by such factors as smoking and obesity], the ongoing care for which amounts to 75 percent of the annual $3.3 trillion health care budget.” As health insurers are no longer covering illnesses and disease that could have been prevented, Hammaker asked, “Is this a direction we want to take?”
  • “While the biggest burdens to the U.S. health care system are depression and gun violence, they receive scant attention in the health care reform debates; yet the cost of gun violence in the US is equal to the cost of smoking, obesity and other preventable health care illnesses combined. Estimates of civilian gun ownership have been as high as 330 million vs. the U.S. military and law enforcement that possess approximately 4 million guns. The nation’s risk pools absorb $1.4 billion yearly to cover anticipated costs of treating victims of fatal firearm assaults.”

There are a lot of hot topics here and no doubt people who disagree with some conclusions. [We know people who suffer from a disease–chronic Lyme–that many physicians and insurance companies don’t recognize.] Were you surprised by any of this information? Are you more assertive in dealing with your health issues and those of family members today than you were in the past? Are you concerned that information like this is not readily available making it hard to protect yourself appropriately?

Photo: techlicious.com

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