BOSTON - When Massachusetts health insurance policy holders are denied coverage, they have a right to appeal. However, according to consumer advocates, the appeals process is often downright unappealing. It's bad enough when the health insurer refuses to cover a procedure or medication, but then it can get downright confusing, warned Clare McGorrian of Health Law Advocates.
"They don't give enough information about the reasons for denial of coverage," McGorrian said. "Sometimes they give conflicting information, and they don't always give people the information that they are entitled to."
The state's Office of Patient Protection (OPP) is revising its rules on health plan appeals. At a mid-summer public forum, the agency heard suggestions for changes. When the new rules are announced, advocates said, they hope any unfair processes end.
Alyssa Vangeli, a policy analyst at the non-profit group Health Care For All, said she hopes the OPP will make significant changes.
"In general, this is a great opportunity for OPP to play an active role in increasing consumer protections in the appeals processes," Vangeli said. "We did provide detailed recommendations to them."
It is also important that regulations exist to prevent insurance coverage from lapsing while the policy holder is in the midst of appealing, a process that can take a long time, McGorrian said.
"We want OPP to improve the rules and the protections that allow coverage to continue while the insured is arguing with their insurance company whether something will be paid for," she added.
Advocates also said health plans must be prevented from using unqualified clinicians to review consumer appeals. And they urged insurers to do a better job of letting non-English speaking members know they have a right to interpreter and translation services.
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Toughing it out during spring allergy season is not in your best interest if you want to avoid asthma later in life.
New Mexico has plenty of grass and weed pollens carried by the wind which contribute to itchy, watery eyes, a stuffy nose and sneezing fits this time of year.
Dr. Osman Dokmeci, associate professor of internal medicine at the University of New Mexico, suggested for those who suffer acutely, seek an allergy test and possibly medication to prevent asthma from taking hold.
"One out of 10 has asthma in America," Dokmeci pointed out. "Having seasonal allergies increases your chance of developing asthma at least fivefold."
He recommended treating allergies early and as aggressively as possible. May is "Asthma Awareness Month," which aims to bring attention to the health issue and highlight improvements in care and quality of life. Nationwide, asthma affects more than 25 million Americans, including 4 million children, and disproportionately affects certain racial and ethnic groups.
Allergies do not "cause" asthma but people who have allergies, or have family members who have allergies, are more likely to get asthma than those who do not. Research shows allergy season is starting earlier and lasting longer. A 2022 study from the University of Michigan found pollen count could increase by 200% by the end of the century due to climate change, which is why Dokmeci stressed it is important not to ignore the problem.
"There's no treatment that actually makes your asthma not happen," Dokmeci explained. "But once you develop asthma, there are good treatment options."
The estimated economic impact of asthma is more than $80 billion per year from direct and indirect costs, such as missed school and workdays.
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Recent research shows approximately half of people who die by suicide had contact with a health care professional within the month prior to their death.
However, a recent study shows only 8% of hospitals are currently implementing all four recommended suicide prevention practices: safety planning, warm handoffs to outpatient care, patient follow-up and lethal means counseling.
Melissa Tolstyka, director of Behavioral Health Services for Trinity Health Ann Arbor, said a seamless transition from inpatient to outpatient care is critical. At Ann Arbor, she saw a 46% increase in compliance with comprehensive suicide risk assessments and patients discharged on the suicide care pathway now receive a safety plan, which she sees as progress.
"We continue to see a need for really robust programming," Tolstyka explained. "Not just within the behavioral health world, but in the medical world as well. Our organization really wanted to focus on bringing the behavioral health and the medical services together to enhance our safer suicide care practices for our patients."
The initiative is being piloted across various units at Trinity Hospitals in Ann Arbor and Grand Rapids including the emergency department, psychiatric medical and inpatient nursing units. If you or anyone you know is struggling or in crisis, help is available 24 hours a day, seven days a week, by calling or texting 988, the Suicide and Crisis Lifeline.
Casie Sultana, clinical nurse leader for Trinity Health Grand Rapids, prioritizes patient well-being, emphasizing support and improvement over solely managing risks within the facility.
"We want to be someplace that people feel welcome to come to who are dealing with suicide," Sultana emphasized. "You feel so alone. It's a very lonely journey and we want people to come seek help and feel welcomed when they do that."
Susan Burchardt, clinical services manager at Trinity Grand Rapids, advised other hospitals considering a similar program to learn from organizations already using it.
Support for this reporting was provided by The Pew Charitable Trusts.
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Access to reduced-price medication is a necessity for many rural Missourians with low income.
Rep. Cindy O'Laughlin, R-Shelbina, the Senate Floor Leader, said Big Pharma is trying to confuse legislators with unrelated hot-button topics such as abortion access and illegal immigration in a last-ditch effort to stop the state from joining a program to force drugmakers to sell medicines at a discount.
"Appealing to nuclear topics, which really do not apply in this situation, is a disingenuous way to try to defeat a bill that is actually good for Missouri," O'Laughlin asserted.
O'Laughlin pointed out the program is transparent, and uses the tax money saved to help low-income families deal with chronic conditions such as diabetes.
The drugmakers object to the government forcing them to give significant discounts, arguing hospitals' and for-profit pharmacies' bottom lines, particularly those owned by pharmacy benefits managers, are being exploited. Nationally, 46% of contract pharmacy agreements involve pharmacies linked to the three largest benefits managers.
Rep. Tara Peters, R-Rolla, introduced the 340B contract pharmacy access billand said the lobbying is absurd.
"Federally, 340B program does not allow for abortion drugs," Peters stressed. "Why would any legislation that we're trying to pass in the state allow for that? I mean, the thought of that even being in existence is absolutely ludicrous."
The Missouri Senate passed the bill 27-3 on Monday and it now goes to the House.
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