We're Watching You - Cancer & Medicare Advantage
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Happy Tuesday Advocates
I would like to encourage comments and suggestions from you if you have time. If there is a special topic you’d like to see please let me know. Please use the comment button below. By the way lots of deep breaths help. So do cute pictures. P.S. If it’s not teddy bears it will have to be kittens and puppies to reduce the stress level.
Cancer Updates
Researchers Develop a Potential “Universal” CAR T-Cell Therapy for Blood Cancers
In the Lord of the Rings, there was “one ring to rule them all.” Now, a team of researchers is developing their own single ruler, an approach to CAR T-cell therapy that could treat all forms and types of blood cancer.
In experiments in mouse models of different blood cancers, the treatment rapidly eliminated tumors, including in mice with acute myeloid leukemia (AML), a difficult-to-treat type of blood cancer for which researchers have struggled to develop effective immunotherapies.
There was also no evidence of serious side effects in the animals. And, finally—and distinctly from the standard approach to current CAR T-cell therapies—it provided the mice with a healthy supply of new blood cells.
Here is a link to the research summary.
Repurposing Common Medications to Prevent Cancer
Researchers are studying treatments widely used for other diseases for possible roles in cancer prevention. A post in the Division of Cancer Prevention’s Cancer Prevention Science blog highlights two recent studies exploring the use of statins, which are typically used to lower cholesterol, to prevent ovarian cancer and the use of the diabetes drug metformin to prevent breast cancer. Watch this space.
Lung Cancer Trial of Osimertinib
In the nearly 700-patient study, people who were randomly assigned to receive osimertinib after surgery to remove their lung cancer tumor(s)—known as adjuvant therapy—lived substantially longer overall than people assigned to receive a placebo after surgery. At 5 years after starting adjuvant treatment, 88% of people treated with osimertinib were still alive, compared with 78% of those treated with a placebo. Typically osimertinib is given after surgery if the cancer recurs. This study provided the medication after surgery. Of those in the placebo group whose cancer recurred 40% were provided osimertinib which somewhat confounds the 78% result. Nonetheless, 88% 5 year survival is impressive. Here is the full report.
Medicare Advantage Shenanigans
Recall that Medicare Advantage is PRIVATE INSURANCE chosen by a subscriber to replace medicare. These private insurers are paid $1000/month by the federal government to pay bills for their subscribers. More if the patient has certain risk factors. Most of the top 10 companies providing such insurance have been accused of criminal fraud for reporting their subscribers were sicker than they really were so they could get the higher payment from the government.
Let’s remember there are only a few ways to make a lot of money. You can increase volume sales (more subscribers - thus the misleading TV ads), you can increase payments from the federal government by upcoding, or you can deny claims.
Let’s look at claims denial. We wrote about that a little while ago here. Remember that Cigna was using a software tool that could deny 150,000 claims/month. United Healthcare, the nations’s largest insurer, uses predictive software when evaluating claims. They use naviHealth, a care management company bought by UHC’s sister company, Optum. Both are part of UnitedHealth Group. NaviHealth’s proprietary “nH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions, and other factors. Based on these comparisons, an algorithm anticipates what kind of care a specific patient will need and for how long. Sadly, if you rely only on the software and not the actual condition of the patient involved, you wind up denying coverage to those who need it.
Patients, providers, and patient advocates in several states said they have noticed a suspicious coincidence: The tool often predicts a patient’s date of discharge, which coincides with the date their insurer cuts off coverage, even if the patient needs further treatment that government-run Medicare would provide.
As a result new federal rules for Medicare Advantage plans beginning in January will rein in their use of algorithms in coverage decisions. Insurance companies using such tools will be expected to “ensure that they are making medical necessity determinations based on the circumstances of the specific individual,” the requirements say, “as opposed to using an algorithm or software that doesn’t account for an individual’s circumstances.”
Let’s see.
RESOURCES
Healthcare Advocacy (Us)
Website
Our Newsletter resources including reproductive healthcare
Healthcare Advocacy Reading List
Find My Elected Officials
Contact the White House https://www.whitehouse.gov/contact/
Contact State and Federal Representatives
By phone: (202) 224-3121
By email: democracy.io
Important Healthcare Resources
League of Women Voters Healthcare Reform Toolkit
Organizations to Contact
National Nurses United Medicare4All
Physicians for a National Health Plan
Reproductive Health
NARAL - Pro Choice America
Charley. chatbot abortion resource - make sure to use a secure incognito browser if you live in a state that has banned abortion
Planned Parenthood
Miscarriage and Abortion Hotline has references about where to procure abortion medications. They also assist women in the process of self managed abortion or miscarriage by phone or text and will respond in an hour. Details and hours of operation at their website.
United State of Women Reproductive health page (bottom of the page) has important resources such as medical support, access to Telehealth, prescriptions by mail, and legal support references.
Practice careful communications - The Digital Defense Fund has a number of tips to keep texts, calls, and internet use private. Here is their site.
If you need financial help with an abortion try abortionfunds.org
Claims Denials and Appeals & What to Do
Appeal a Healthcare Decision
Appeal/Negotiate a Hospital Bill
Disinformation Management
Cybersecurity Infrastructure Security Agency
Save Democracy
Chop Wood, Carry Water by Jessica Cravens
RESISTBOT
Link to the RESISTBOT site to learn more
Link to Chop Wood, Carry Water RESISTBOT write up
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Great post today, Alan!
I see an opportunity to ask our members of Congress to support the CMS rule so that Medicare Advantage plans do not algorithmically deny claims to their constituents. It would be important in this situation to challenge Republican talking points that aim at reducing the ability of regulatory agencies in their pitch to shrink the “administrative state.”