Health and Medical News and Resources

General interest items edited by Janice Flahiff

American Medical Association (AMA) news: Appealing denied claims seems to work, GAO report says :: April 11, 2011 … American Medical News

amednews: Appealing denied claims seems to work, GAO report says :: April 11, 2011 … American Medical News

Yes, this is old news, but thought it would be worth posting…

The government is looking for a way to track and report denial rates to consumers as part of health insurance exchanges.

By EMILY BERRY, amednews staff. Posted April 11, 2011.

  • A government review of the rates at which insurers decline to write policies and reject claims for payment found that when physicians and patients appealed denied claims, those appeals were “frequently” successful, with 39% to 59% resulting in a reversal.

The Government Accountability Office report, released March 16, also found that many health insurance claims denials stem from miscodings, incomplete information or other paperwork errors, pointing to the need for further automation of claims processing.

The report examined what the GAO called “application denials” — declining to write a policy for someone — as well as “coverage denials” — deciding not to pay a claim. The Patient Protection and Affordable Care Act called on the GAO to examine both. The Dept. of Health and Human Services, which has started tracking application denials, plans to track and publish rates of coverage denials as part of the health insurance exchanges that will be part of the health reform law, according to the report.

Until HHS tracks application and coverage denials in a comprehensive way, there is limited information available about both. The GAO noted that the American Medical Association helped the authors interpret and understand the limitations of denial data available.

Rejected applications, denied claims

The GAO examined application denial data in the individual insurance market, collected by the HHS during the first quarter of 2010 and from six states that already track denials.

Researchers found that the rate at which insurers declined to offer an applicant coverage averaged 19%, but rates varied widely……

February 13, 2012 Posted by | health care | , , , , , , | Leave a comment

Options when your drug copays are too expensive

Picture taken by myself of my Adderall prescri...

Image via Wikipedia

From a article by LESLIE RAMIREZ, MD

You have insurance and, supposedly, it covers your medicines. However, you still get stuck with a portion of the bill that the insurance company calls a “copay.” In some cases these copays can run more than $150/ month per medication (e.g. Enbrel). If you are on more than one of these expensive, branded medications the copays can really add up. What are your options?

 1. Generic alternative. Always ask your doc if there is a reasonable generic alternative. This is always the best option for you in the long run. However, if there truly is no generic medication that comes close, then check into either (or both) of the next two options.

2. Drug specific copay programs. These programs are run by the manufacturers of the drugs, aka Big Pharma (BP). Usually, these discounts are given to all patients, regardless of income.  But make no mistake, it is a way for BP to circumvent your insurance company’s cost control mechanism for prescriptions. By picking up part or all of the cost of your copay, BP trying to make their product more attractive to you and to your physician. But when the manufacturer stops offering the copay discount programs you will be back to square one. However, if according to your doctor, you must be on one of these drugs, then by all means, take advantage of the savings while they last. In the case of Enbrel, the Enbrel Support Card Program picked up the tab for six months worth of copays. To find out more info on whether such a program exists for your medication, there are many websites out there, including the manufacturer’s site.

However, I found the following two websites particularly useful: This website shows you all available drugs that have coupons, copay and otherwise,  associated with them. It’s an ugly little site, and ignore the annoying ads for a prescription savings card. But it couldn’t be simpler to use. And all the coupons I clicked on were still valid- so it seems like the folks behind it keep it up to date. According to the mission statement on the website “[The founder] assembled this database of drug coupons to make it easy for people like my elderly parents to save money on their medications.” This is a super slick website that allows you to look up your medicines, albeit individually, to see what deals are offered. When you see a deal you click on the medicine and you are directed to the manufacturer’s website. According to the About section of the website, was established in 1999 with funding from The Robert Wood Johnson Foundation.

3.  Disease specific copay programs. There are many organizations that offer patients with specific diseases, such as cancer and HIV/AIDS,  assistance with their prescription copays. These programs often require financial ability-to-pay information from you to qualify for assistance. Disease Specific Copay Programs is a very comprehensive list of copay and other assistance programs compiled by a BP-funded site called Partnership for Prescription Assistance, aka

Leslie Ramirez is an internal medicine physician and founder of Leslie’s List, which provides information that enables all patients, but especially the uninsured and underinsured, to find more affordable medications and health care services.

July 27, 2011 Posted by | Consumer Health | , , , , , | Leave a comment

Health Insurance Doesn’t Always Protect People From Medical Debt

From a 1 July 2011 Medical News Today item

In 2010, about 40 percent of Americans-or 73 million people-had trouble paying medical bills, up from 34 percent in 2005. Now, a new study confirms that having health insurance coverage is no guarantee against accumulating medical debt for working-age adults. Not surprisingly, the study likewise finds that both medical debt and lack of insurance coverage lead to reduced access to health care.

“We think of insurance as protecting us from unexpected large financial impact. We have car insurance, house insurance and other kinds of insurance for that reason,” said Patricia Herman, lead study author and an economist at the University of Arizona. “There is an expectation that if you have health insurance that you are protected from being financially devastated by illness or injury. Unfortunately, this isn’t always the case.”

The study, which appears online and in the August issue of the American Journal of Public Health, used data from the 2008 Arizona Health Survey of 4,200 state households.

A link to the abstract of the research article may be found here.
Access to the full text of the article requires a subscription.
Click here for suggestions on how to get this article for free or at low cost. 

July 6, 2011 Posted by | health care, Medical and Health Research News | | Leave a comment

Looking at Healthcare through Payer Lens

Looking at Healthcare through Payer Lens (so far Part I and Part II) gives great insight on how the healthcare industry can successfully work with with individuals and other stakeholders to deliver health insurance coverage.
These items (and realated others) may be found at Chilmark Research:Providing perspective on key IT trends in the healthcare sector

Part I outlines quick current summaries (snapshots) of Accountable Care Organizations, Consumer/Member Engagement, and Health Insurance Exchanges (HIX)

Part II outlines the necessary steps of establishing trust, engagement, and collaboration

June 23, 2011 Posted by | Health News Items, Public Health | , , | Leave a comment

Study Finds High-Deductible Health Plans Pose No Special Risks To The Medically Vulnerable

From a 19 April 2011 Medical News Today article

People who are medically vulnerable – those with low incomes or chronic health problems – who enroll in high-deductible health plans are at no more risk for cutting back on needed health care than other people who enroll in the plans, according to a new RAND Corporation study. [Abstract, for suggestions on how to get this article for free or at low cost, click here] …

…The project examined the first-year experiences of more than 360,000 families nationwide who enrolled in high-deductible health plans offered by their employers from 2003 to 2007. The study, conducted with consulting firm Towers Watson, was published online by the journal Forum for Health Economics & Policy.

“One important issue is whether high-deductible health plans will leave low-income and chronically ill patients with inadequate access to health care,” said Amelia Haviland, lead author of the study and a statistician at RAND, a nonprofit research organization. “We did not find greater cut backs for medically vulnerable families. The evidence suggests that non-vulnerable families, low-income families and high-risk families are equally affected under high-deductible plans.”

High-deductible and consumer-directed health plans have been gaining favor as one way to help control health care costs. By 2009, about 20 percent of Americans with employer-sponsored health coverage were enrolled in such plans. A 2010 survey found that more than 54 percent of large employers offered at least one high-deductible health plan to their employees. …
…Medical spending declined among all families enrolled in high-deductible and consumer-directed health plans, relative to similar families in traditional plans, with the reductions among medically vulnerable families generally being similar to that seen among other families, according to researchers.

Researchers note that the medically vulnerable families studied all had a member working full time with benefits and the results here may not hold for families with less financial stability, and in addition that similar reductions may have different health or economic impacts for these vulnerable families. …

April 19, 2011 Posted by | Medical and Health Research News | , , | 1 Comment

18.3 million baby boomers could benefit from the Affordable Care Act

18.3 million baby boomers could benefit from the Affordable Care Act

Affordable health insurance, comprehensive benefits and stronger financial protections will be available to 8.6 million currently uninsured adults ages 50 to 64, and 9.7 million who have inadequate health insurance

From the press release

December 14, 2010, New York, NY—18.3 million men and women ages 50 to 64 stand to benefit from provisions in the Affordable Care Act that expand access to affordable health insurance, assure that all health insurance provides a standard comprehensive benefit, prevent insurers from denying coverage or charging higher premiums to people with pre-existing conditions, and eliminate lifetime and annual limits in health insurance policies, according to a new Commonwealth Fund report released today.

Adults ages 50-64 are currently suffering the highest rates of longtime unemployment among working-age adults, and millions are without health benefits. Of the 8.6 million currently uninsured in this age group—4.3 million men and 4.2 million women—3.3 million with incomes under $29,000 for a family of four will gain Medicaid coverage, 3.5 million with incomes up to $88,000 for a family of four will be able to gain subsidized private coverage through the new health insurance exchanges, and 1.4 million with higher incomes will gain new coverage with consumer protections.

In addition, an estimated 9.7 million older adults who have health insurance but have such high out-of-pocket costs relative to their income that they are effectively underinsured, will gain improved coverage through the implementation of essential benefit standards, limits on out-of-pocket spending, and elimination of lifetime benefit limits.

Uninsured adults in this age group face serious difficulty with access to needed care: three-quarters (75 %) report forgoing needed health care and medications because of costs and nearly half (46%) report not getting recommended preventive care. More than half of uninsured women in this age group had not had a mammogram within the past two years. Nearly 70 percent of uninsured and underinsured baby boomers report that they have problems paying medical bills or are paying off medical debt.

“A loss of employer health benefits can be devastating to men and women in this age group since their older age and higher rates of chronic health problems places them at risk of facing exorbitant premiums, having a condition excluded from their coverage, or being denied insurance altogether if they try to buy it on their own,” said Commonwealth Fund Vice President Sara Collins, lead author of the report. “The Affordable Care Act will change all of that. Once its provisions are in full effect, older adults who lose their employer health insurance will have access to affordable and comprehensive health benefits regardless of their age or health.”…..

Additional Benefits for Baby Boomers in the Affordable Care Act

The Affordable Care Act includes many additional features that will improve health insurance coverage for adults ages 50 to 64:

  • Beginning in 2010, adults in this age group with chronic health problems who have been uninsured for more than six months can join new plans for people with pre-existing conditions.
  • A ban on lifetime limits on insurance benefits beginning in 2010 will help an estimated 102 million people who currently have these limits on their plans; older adults are at greater risk than younger adults of exceeding their limits and being saddled with a crushing debt load as a result.
  • Requiring coverage of preventive care and immunizations without cost-sharing will assure access to services such as mammograms and colorectal cancer screenings for baby boomers beginning in 2010.
  • Requiring health plans to insure all who apply, preventing health plans from charging higher premiums to sicker people, and limiting how much premiums can rise by age will remove many of the barriers baby boomers face when they have to buy coverage on their own beginning in 2014.

Two lesser-known ACA provisions will also provide significant benefits to baby boomers, the report finds:

  • The Early Retiree Health Benefits Reinsurance Program for Employers helps public and private sector employers pay for health benefits for employees who retire before age 65. This $5 billion temporary program has already enrolled 3,600 employers and will run through 2014, when people who retire before age 65 will be eligible to purchase health insurance through the new insurance exchanges.
  • The Community Living Assistance Services and Supports (CLASS) Program will provide employers and their workers as well as self-employed individuals the option of participating in a national long-term care insurance program aimed at providing better access to affordable long-term care insurance.

This report is part of a series of Fund issue briefs that examines the way the Affordable Care Act of 2010 will benefit different populations and groups, as well as improve insurance coverage and change the delivery of care. For more information, please visit:

December 14, 2010 Posted by | Health News Items, Public Health | , , , | 1 Comment

How Will The Affordable Care Act Affect 15 Million Uninsured Young Adults?

From the Commonwealth news release

New York, NY, October 8, 2010—Young adults continue to represent one of the largest groups of Americans without health insurance, with nearly 15 million people aged 19-29 uninsured in 2009—an increase of more than 1 million over 2008, according to a Commonwealth Fund report released today. However, the Affordable Care Act (ACA) is poised to make a significant difference for this population, as up to 12.1 million could gain subsidized insurance once all of the law’s provisions go into effect in 2014

The report, Realizing Health Reform’s Potential: Young Adults and the Affordable Care Act of 2010, by Commonwealth Fund researchers Sara Collins and Jennifer Nicholson, is an update of a May 2010 report, with new numbers reflecting the latest data on the number of uninsured Americans released by the U.S. Census Bureau last month.

According to the report, by 2014, when most of the bill’s provisions will have taken effect, up to 7.2 million uninsured young adults will gain coverage through Medicaid expansions and up to 4.9 million will gain subsidized private coverage through new insurance exchanges. About 1 million uninsured young adults up to age 26 are projected to join their parents’ policies beginning in 2010. The report estimates that 1.8 million uninsured young adults are not legal residents and will not be eligible for federally subsidized health insurance under the new law.

The authors conclude that, “when fully implemented, the ACA will allow young adults of all income levels to undergo a new rite of passage: establishing necessary ties with the health care system, without fear of accumulating medical debt, as they pursue their educational and career goals.”

This report is the fourth in an ongoing series of Commonwealth Fund reports designed to explain how health reform will affect various groups. More on this series, as well as access to the Fund’s new Health Reform Resource Center, can be found



December 2, 2010 Posted by | Health News Items, Public Health | , , | Leave a comment

Access to Health Care (CDC Vital Signs Web page)

CDC Vital Signs

The recent CDC (US Centers for Disease Control and Prevention)  page Access to Health Care provides general information about health insurance coverage.

Here is the summary

New 2010 estimates show that the number of Americans without health insurance is growing, affecting middle-income Americans as well as those living in poverty. About 50 million adults 18–64 years old had no health insurance for at least some of the past 12 months. People in all income brackets have been affected, not just adults living in poverty, according to a 2009 survey. In the past few years, the number of adults aged 18–64 who went without health insurance for at least part of the past 12 months increased by an average of 1.1 million per year. About half of those additional adults were middle-income.* Adults without consistent health insurance are more likely to skip medical care because of cost concerns, which can lead to poorer health, higher long-term health care costs, and early death.

*About $43,000–$65,000 household income for a household of four

This Web page includes the following links

  • Learn about your role in expanding access to health care, with tips for employers, health care providers, and everyone
  • Latest Findings with a summary of current health insurance coverage statistics
  • Who’s at Risk with a chart on the relationship between disability and health care insurance coverage
  • What can be done with tips for employers, health care providers, and everyone

November 18, 2010 Posted by | Consumer Health, Health Education (General Public), Librarian Resources, Professional Health Care Resources | , | Leave a comment

Health Care Reform Law – Informational Web Sites

From recent postings at Medlib-L, a discussion list for medical librarians about informational sources for the Patient Protection and Affordable Health Care Act (the Health Care Reform Law)

MedlinePlus Trusted Health Information for You

  • Health Insurance (MedlinePlus, published by US National Institutes of Health)
    Links to health care reform Web sites include

HealthCare.govTake health care into your own hands

Economic Stimulus for the Healthcare IT Industry

Centers for Medicare & Medicaid Services

Web sites I discovered through my parish’s Pax Christi meetings

Faithful Reform ( with an email sign up…and easily found links to…

  • “A Daily Dose of Truth” [currently 9 items, including the titles Medicare in Health Care Reform, The Requirement to Buy Insurance,The “R” word (Rationing), Small Business]

  • Resources [currently includes items as  A Moral Vision for our Health Care Future, Power Point presentation: The Heart in Health Care Reform ]

Herndon Alliance: Healing America’s Healthcare ( with an email sign up…and the tabs (links)

  • The Resources tab includes talking point suggestions that can be used in discussions with others as well as mass communication and writing to representatives
  • The Newsletter tab includes links to past Messages of the Week

A few journal/magazine articles (from Medlib-L postings)

** For suggestions on how to get free/low cost medical articles, go to How to obtain free/low cost medical articles in medical and scientific journals

November 18, 2010 Posted by | Consumer Health, Finding Aids/Directories, Librarian Resources, Professional Health Care Resources | , , , | Leave a comment

Health Care Reform: Will It Empower or Perplex Consumers?

Choosing health plans, managing chronic conditions requires basic health literacy
(Part one of three-part series)

A large part of the recent health care reform package centers on uninsured adults making complex choices through state insurance packages. This is requiring people to have a high level of health literacy to obtain, understand, and process information so that they can make informed choices that are safe, cost-effective, and high quality.

Health organizations and insurers are being encouraged to communicate their information through plain language, graphics, and graphs. Non traditional methods being tested include the use of text messages and iphones.

September 9, 2010 Posted by | Health News Items | , | Leave a comment

Questions About the Temporary High-Risk Pool

The Kaiser Foundation has recently published an online one page summary providing responses to basic questions about the temporary high risk pool.

Short factual answers address eligibility, benefits, costs, and effective dates.

For more information about the Patient Protection and Affordable Care Act, see the summary of the new health reform law at For more information about current state high-risk pools see “State High-Risk Pools: An Overview” at For more information about Secretary Sebelius’ April 2nd letter see

Some additional “Health Care Reform Law”informational sites

  • Health Insurance  Health Topic Page (National Library of Medicine)
    Includes links to overviews, news items, specific conditions, law & policy, and much more
  • Frequently Asked Questions about the Health Insurance Portability and Accountability Act (HIPAA) Nondiscrimination Requirements(Dept. of Labor)
  • State Health Insurance Counseling and Assistance Program (SHIPs)(Centers for Medicare & Medicaid Services)
  • State Insurance Departments Web Sites(National Association of Insurance Commissioners)
  • August 21, 2010 Posted by | Health News Items | | Leave a comment

    A Consumer Advocacy Group Focuses on Insurance Issues and Consumer Rights

    [via Resource Shelf]

    Have insurance related questions?
    Whether they are related to health insurance, auto insurance, or other policies, United Policy Holders just might have the information needed to help make informed decisions.

    United Policyholders was founded in 1991 as non-profit tax-exempt organization dedicated to educating the public on insurance issues and consumer rights.

    Much of their work centers on natural disasters. Their first major project was a firestorm in California.
    Their publications (generally free) include: Tips for Flood Claimants, Tips for Fire Claimants, Tips for Earthquake Claimants, Tips for DisabilityClaimants, Hiring an Attorney; Why, When and How, and a half hour videotapetitled; Ten Steps…Settling Your Insurance Claim.

    Web pages include State by State Help, Newsletters, and Buying Tips.

    August 6, 2010 Posted by | Health News Items | , | Leave a comment

    AHRQ State Snapshots Expanded to Include New Data on Health Insurance Coverage

    The Agency for Healthcare Research and Quality’s annual release of state-by-state quality data has been expanded to include new data on health insurance, including data on health care quality categorized by source of payment, including private insurance, Medicare, Medicaid and those without insurance. The 2009 State Snapshots released by AHRQ today are available at

    July 23, 2010 Posted by | Health News Items | , | Leave a comment


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