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Or is it a sign the FDA does not have faith in the future of influenza vaccines? This year's vaccine is ineffective. It is a variant of the Type A virus. Has it already mutated? It requires about a year to produce a new vaccine type. Are we a year behind in producing vaccines?
A meeting by a panel of science advisors to choose flu strains to include in a vaccine for next fall has been canceled on short notice, according to a member of the committee, raising concerns that new HHS Secretary Robert F. Kennedy Jr. may already be influencing US policy on vaccinations.
Paul Offit, a member of the FDA’s panel and a physician at the Children’s Hospital of Philadelphia, confirmed to Endpoints News that the meeting by the Vaccines and Related Biological Products Advisory Committee had been canceled.
The session was expected to be held on March 13. The panel typically meets at the start of the year to give drugmakers the months necessary to ramp up production of tens of millions of vaccine doses.
During his Senate confirmation hearings, Kennedy promised that he wouldn’t take steps to interfere in vaccine policy or discourage people from using vaccines, but said he would undertake a study of vaccine safety. It wasn’t immediately clear if he had any role in Wednesday’s meeting cancellation, or exactly where the decision originated.
A spokesperson for HHS confirmed in a statement to Endpoints on Thursday that the meeting is canceled but that “the FDA will make public its recommendations to manufacturers in time for updated vaccines to be available for the 2025-2026 influenza season.”
Kennedy’s ascension has raised fears that his tenure might lead to declines in vaccine uptake, leading to the reemergence of preventable infectious diseases. Those concerns were driven home by Wednesday’s death of a Texas child who was infected with measles in an ongoing outbreak in the state. The child has not been vaccinated against measles, according to the state.
The final process for picking flu shot strains is a global one. Health bodies from around the world give advice and expertise to try and pick the strains that are most likely to circulate in the next season, which takes place in the fall and winter for the northern hemisphere.
Sanofi, one of the major flu vaccine makers, said in a statement to Endpoints that it would “work with multiple health agencies and national regulatory authorities and will continue to play our part in providing the most timely and best available protection against influenza and its complications inside and outside the US.”
Editor’s note: This story has been updated with comments from HHS and Sanofi, as well as additional details.
This is the Age of Aquarius. The Age of Artificial Intelligence reaches the level of the discovery of bacteria with a microscope, the germ theory by Lister, the discovery of antibiotics, anesthesia, and more.
There is still no cure for Parkinson’s disease, but the U.S. Food and Drug Administration (FDA) approved a new deep brain stimulator that could benefit patients with the motor condition.
On Feb 24, the FDA approved Medtronic’s BrainSense Adaptive deep brain stimulation, a device that surgeons implant in patients’ chests with electrodes connecting to the brain. The system is programmed to respond to and manage abnormal brain signals that contribute to involuntary muscle movements in Parkinson’s, which previous deep brain stimulation systems could not do. The device represents the most personalized and responsive deep brain stimulator for the condition.
“A deep brain stimulator is a brain pacemaker: similar to a cardiac pacemaker, except you insert electrodes in the brain to stimulate brain neurons,” says Dr. Helen Bronte-Stewart, professor of neurology, neurological sciences, and neurosurgery at Stanford University. Bronte-Stewart helped design the international, multi-center trial to test the device.
Here's what to know about deep brain stimulation for Parkinson's disease.
Refining an "always on" device
Doctors have offered deep brain stimulation to Parkinson’s patients since 2002. But until now, devices have only provided continuous stimulation—not the dynamic and responsive activation that the current device does—and followed a one-size-fits-all model that was always “on” to activate the parts of the brain involved in motor function.
Continuous stimulation causes a treatment imbalance for patients who are often also taking medications to control their involuntary muscle movements. Soon after a patient takes a dose, for example, the combination of the medications and deep brain stimulation could lead to overtreatment of their symptoms; once the medication wears off and before they take their next dose, they would likely be undertreated and have more severe tremors or abnormal muscle movements.
That's because deep brain stimulation and Parkinson’s medications all target a specific arrhythmia in what experts call the beta pattern. But until recently, doctors didn’t understand much about the beta rhythm in the brains of Parkinson’s patients, including how it fluctuates over the course of a day or depending on what patients are doing. Recent studies have shown, for example, that arrhythmia in beta signaling decreases when people sleep.
The previous, continuous devices simply stimulate the signals for motor neurons, regardless of whether someone needs the stimulation at any given time or not. It's analogous to putting someone on medication for high blood pressure without measuring the fluctuations in their blood pressure, says Bronte-Stewart. “It was on all the time and was the same for every patient, so it didn’t sense a person’s specific arrhythmia and didn’t adapt,” she says.
A long road to a new approach
The new adaptive device is the result of decades of research into reading changes in brain signals relevant to Parkinson’s disease, and developing algorithms that can respond to those changes in real time. “Like cardiac pacing, we’ve written an algorithm that responds to when patients take medication, and modulates the beta rhythm to the stable range and stops it from going too high or too low,” says Bronte-Stewart. “Brain pacemakers are finally catching up to cardiac pacemakers.”
The advance also required finding ways to take the same measurements that doctors could collect in the operating room—when they would implant electrodes in the brain—but without repeated invasive procedures. Learning more about which signals and networks to target in Parkinson’s was necessary. “It was very important to spend years determining which signals were relevant to motor problems,” says Bronte-Stewart. “We had a way of measuring movement in humans in our labs that not many had.”
Then came the task of encapsulating all of that activity in an implantable device that could safely live in the brain for years at a time, collect information, and adjust to nerve signals in real time. Data collected from patients with the original continuous devices provided a foundation for the new adaptive model. Continuous deep brain stimulation “really enabled us to get access to these patients’ brains that we wouldn’t have been able to access any other way,” says Scott Stanslaski, senior distinguished engineer at Medtronic who has been working on implantable devices for three decades. Stanslaski says those early devices made it possible to develop brain-sensing technology to read the signals zapping around the brain, and isolate which ones were critical for Parkinson’s. “There were a lot of epic fails in the early phases to figure out the sensing technology,” he says.
A "life-changing benefit" for patients
John Lipp was diagnosed with Parkinson’s just shy of his 50th birthday, after he noticed that his right hand and foot would involuntarily clench, making it difficult for him to walk without tripping. He took the standard Parkinson’s medications, which are the first line of treatment, but experienced severe anxiety and had to switch therapies. As his symptoms worsened, he and his doctors discussed deep brain stimulation, which is generally a last resort intervention since it involves risky brain surgery.
Lipp decided to receive the adaptive device, which Medtronic was still studying in research trials in 2021. He joined the trial Bronte-Steward was running. “I noticed a change almost immediately,” Lipp says. “My most problematic symptom was dystonia, or muscle cramping, which was both painful at times and debilitating." But after surgery, "my dystonia pretty much went away. That, to me, is the most significant, life-changing benefit."
The new device has also allowed him to reduce his Parkinson's medications from 14 or 15 a day to four, he says.
Lipp says the device has quelled almost all of his symptoms. The only time he’s reminded of them is during his regular visits to Bronte-Stewart for check-ups when the doctors briefly turn the device off. “My body kind of collapses,” he says. “I feel a change in my muscle tone, and my ability to sit up straight; it’s like I’m pulled into my center of gravity. So I know it’s working.”
Bronte-Stewart stresses that the device does not slow the progression of Parkinson’s, but it can help patients to live more comfortably with their symptoms.
For now, the device Lipp and others will receive can remain in their brains for about 15 years, and doctors can replace the battery as needed in an outpatient procedure. Lipp is also reassured that having the device won’t exclude him from taking advantage of any new treatment or potential cure for the disease, should these be developed. “Let’s say some miracle cure comes along; I can always have the device removed. That offers me a sense of security,” he says.
Lipp credits the advice with making it possible for him to travel with his husband and even run marathons. He ran the New York City Marathon last year, and plans to do it again this year. Before getting the device, “I thought my running days were over because of my rapidly developing symptoms,” he says. “The fact that I can still do [marathons] is great.”
As genetic testing is fast becoming a defining aspect of cancer care prevention, treatment, and recurrence monitoring, its role is becoming more apparent in gastroenterology, according to N. Jewel Samadder, MD, MSc, a professor of medicine at Mayo Clinic Arizona, in Phoenix.
Approximately 10% to 15% of colorectal cancers are clearly hereditary, with mutations in single genes that predispose a person to the development of these cancers. Important monogenic CRC syndromes include Lynch syndrome, familial adenomatous polyposis, MUTYH-associated polyposis, and the rare hamartomatous polyposis syndromes. Another 20% are associated with a strong family history of CRC but no single genetic cause and the remaining 65% are sporadic and likely “a combination of genetic elements plus environment and bad luck,” Dr. Samadder said. In a presentation at ACG 2024, Dr. Samadder discussed areas of genetic testing that are important for GI clinicians to be aware of, so they can help identify these mutations and enhance the prevention and treatment of inherited cancers.
Forms of Genomic Testing
Germline sequencing examines hundreds (or thousands) of genes in a single sample of blood or saliva and identifies inherited genetic disposition for diseases, Dr. Samadder explained. Since a history of cancer in a first- or second-degree relative is an important determinant of inherited risk, such genetic testing should be accompanied by a conventional family history assessment covering three generations in detail.
A second form, somatic testing, identifies genetic features within tumors that can guide the use of targeted therapy. A third method involves the measurement of circulating tumor DNA to detect minimal residual disease after treatment, which can signal disease recurrence and is also the backbone of the new multi-cancer detection (MCD) tests.
Defining Hereditary Cancer Risk
The determination of hereditary cancer risk for a given patient takes into account family history, tumor phenotype, and the expression of mismatch repair (MMR) proteins by immunohistochemistry. “In today’s world, we don’t test patients for one, two or even half a dozen cancer genes at a time. We do multigene testing where we look for up to 100 different cancer-related genes, covering all the major cancers on a single panel using a single sample of blood or saliva,” Dr. Samadder said. “Multigene panel testing is becoming the standard for patients with early-onset GI cancers.”
Once the proband with an inherited cancer is identified, cascade testing is offered to family members, he said. This is commonly done via single-site genetic testing that zeroes in on the newly identified familial variant. Patients with this gene can then take preventive measures.
Genetic testing may be used as a predictive measure for family-based GI Cancer. Studies reveal there are genomic markers for risk and can increase the importance of colonoscopy in high-risk individuals
Follow your physician's recommendations for colonoscopy. At-risk individuals may have indications for earlier screenings.
Care delayed is care denied. While prior authorizations are essential for effective utilization management (UM), they have become excessively burdensome for payers and providers alike, causing delays that impact patient outcomes.
Join us for this exclusive webinar to explore how the prior authorization process can be transformed through AI-driven automation and predictive intelligence. Hear about key strategies and solutions that can drive faster approvals, reduce administrative burden, and deliver significant cost savings.
In this discussion with industry experts, you will learn about:
The top challenges in manual review and rule-based auto-approvals, with a look at how traditional processes create inefficiencies and impact care delivery
How a collaborative, data, and AI-driven approach can effectively tackle prior authorization challenges, including an overview of the latest innovations available to help
Case studies from leading healthcare organizations on how they are successfully shaping the future of prior authorizations with AI-powered intelligence
As Vice President of Advanced Analytics, Pravin leads ZeOmega’s advanced analytics team, working on new and existing AI solutions and social determinants of health (SDOH) solutions with a goal of creating best-in-class software products.
Pravin is an experienced executive leader with a demonstrated history of successfully working in the hospital & health plan industry for over 20 years. He is deeply proficient in team building, leadership, innovation, artificial intelligence, big data, predictive analytics, and population health management.
Pravin started his career as a software engineer for transplant software, then moved throughout various academic healthcare organizations for many years, eventually becoming a Senior Consultant and Vice President focused on healthcare software development and implementation. He also served with Cerner’s engagement leadership team.
His education includes a Bachelor of Science in Computer Science and Software Engineering from the University of Nebraska at Omaha, a Master of Science in Health Informatics with Data Analytics from the University of Alabama at Birmingham and a Professional Development Certificate—Data-Driven Decision Making for Business Leaders—from Harvard Extension School, Harvard University.
Sudhakar "Sudhi" Ranganadham
Associate Director, Advanced Analytics
ZeOmega
Sudhi has over 17 years of experience in product management, software development, and AI-driven solutions. He specializes in developing data-driven products that enhance operational efficiencies and drive bottom-line improvements by bridging business needs with cutting-edge technology.
A technologist at heart, Sudhi has worked across healthcare, aeronautics, and eCommerce. For 14 years, he has been instrumental in building and implementing ZeOmega’s flagship product, Jiva, for large U.S. healthcare payers. Over the last 9 years, he has focused on AI-driven solutions that revolutionize utilization management, member engagement, and ROI optimization.
Sudhi holds a Bachelor’s degree in Information Technology from Jawaharlal Nehru Technological University, India, and has completed multiple certifications in Data Governance, Natural Language Processing, and Data Analysis & Visualization from the University of Illinois, Urbana-Champaign.
He is passionate about leveraging AI to improve efficiency, reduce administrative burdens, and enhance patient outcomes.
“We’ve got to get into the business of making America healthy again,” said Sen. Mike Crapo, R-Idaho, adding that Kennedy will bring a “fresh perspective” to the office.
Kennedy — joined by his wife, other family members and several members of Congress — was sworn in Thursday afternoon in the Oval Office by Supreme Court Justice Neil Gorsuch, hours after confirmation. He said he’d first been there in 1961, and told stories of seeing his uncle, President John F. Kennedy, there as a child.
Trump announced that Kennedy will lead a new commission on making America healthy again, and Kennedy said Trump has been a blessing in his life and will be for the country, calling him a “pivotal historical figure.”
Kennedy, 71, whose name and family tragedies have put him in the national spotlight since he was a child, has earned a formidable following with his populist and sometimes extreme views on food, chemicals and vaccines.
His audience only grew during the COVID-19 pandemic, when Kennedy devoted much of his time to a nonprofit that sued vaccine makers and harnessed social media campaigns to erode trust in vaccines as well as the government agencies that promote them.
With Trump’s backing, Kennedy insisted he was “uniquely positioned” to revive trust in those public health agencies, which include the Food and Drug Administration, the Centers for Disease Control and Prevention, and the National Institutes for Health.
Last week, Sen. Thom Tillis, R-N.C., said he hoped Kennedy “goes wild” in reining in health care costs and improving Americans’ health. But before agreeing to support Kennedy, potential holdout Sen. Bill Cassidy, R-La., a doctor who leads the Senate Health, Education, Labor and Pensions Committee, required assurances that Kennedy would not make changes to existing vaccine recommendations.
WASHINGTON (AP) — Robert F. Kennedy Jr. was sworn in Thursday as President Donald Trump’s health secretary after a close Senate vote, putting the prominent vaccine skeptic in control of $1.7 trillion in federal spending, vaccine recommendations and food safety as well as health insurance programs for roughly half the country.
Nearly all Republicans fell in line behind Trump despite hesitancy over Kennedy’s views on vaccines, voting 52-48 to elevate the scion of one of America’s most storied political — and Democratic — families to secretary of the Health and Human Services Department. Democrats unanimously opposed Kennedy.
“We’ve got to get into the business of making America healthy again,” said Sen. Mike Crapo, R-Idaho, adding that Kennedy will bring a “fresh perspective” to the office.
Kennedy — joined by his wife, other family members and several members of Congress — was sworn in Thursday afternoon in the Oval Office by Supreme Court Justice Neil Gorsuch, hours after confirmation. He said he’d first been there in 1961, and told stories of seeing his uncle, President John F. Kennedy, there as a child.
Trump announced that Kennedy will lead a new commission on making America healthy again, and Kennedy said Trump has been a blessing in his life and will be for the country, calling him a “pivotal historical figure.”
Kennedy, 71, whose name and family tragedies have put him in the national spotlight since he was a child, has earned a formidable following with his populist and sometimes extreme views on food, chemicals, and vaccines.
His audience only grew during the COVID-19 pandemic, when Kennedy devoted much of his time to a nonprofit that sued vaccine makers and harnessed social media campaigns to erode trust in vaccines as well as the government agencies that promote them.
With Trump’s backing, Kennedy insisted he was “uniquely positioned” to revive trust in those public health agencies, which include the Food and Drug Administration, the Centers for Disease Control and Prevention, and the National Institutes for Health.
Last week, Sen. Thom Tillis, R-N.C., said he hoped Kennedy “goes wild” in reining in healthcare costs and improving Americans’ health. But before agreeing to support Kennedy, potential holdout Sen. Bill Cassidy, R-La., a doctor who leads the Senate Health, Education, Labor and Pensions Committee, required assurances that Kennedy would not make changes to existing vaccine recommendations.
The scales of Justice are tipping in favor of patient care
Multiple prior authorization reform bills are in the works in the Montana state legislature,KFF Health Newsreported on Feb. 13.
Three things to know:
1. State Rep. Jonathan Karlen is sponsoring two bills, according to the report. The first aims to remove prior authorization for most generic drugs, inhalers, and insulin. The second bill would ensure that patients cannot be denied medication when switching payers and awaiting authorization from their new insurer. Additionally, the second bill would only allow a physician with a matching specialty to deny a treatment or procedure.
2. State Rep. Ed Buttrey plans to introduce a bill that would impose a seven-day limit to decide whether to authorize expensive biologic treatments, according to the report. If payers don't meet that deadline, the treatment will be automatically approved. His bill would also eliminate most retroactive denials.
3. State Sen. Vince Ricci told KFF Health News that he is drafting bills that could impose even stricter limits on prior authorization for medications used to treat various conditions.
HELENA, Mont. — When Lou and Lindsay Volpe’s son was diagnosed with a chronic bowel disease at age 11, their health insurer required constant preapproval of drugs and treatments — a process the Volpes say often delayed critical care for their son.
“You subscribe to your insurance policy, you pay into that for years and years and years with the hope that, if you need this service, it will be there for you,” Lou Volpe said. “And finally, when you knock on the door and say, ‘Hey guys, we need some help,’ they just start backpedaling.”
The Volpes, who live in Helena, and their health care providers spent more than 18 months pushing for these approvals from Blue Cross and Blue Shield of Montana — including a four-month wait last year for approval of costly infusions that worked to control their son’s disease where other treatments had failed.
“It just really slowed everything down on his treatment, and I feel like he could have been recovering from this situation a lot sooner,” Lindsay Volpe said.
Now, the Volpes, other patients, and their health care providers are bringing the issue to the 2025 Montana Legislature, saying it’s time Montana joined many other states in limiting how and when insurers can deny drugs or treatments through their preapproval process, known as “prior authorization.”
This month, Democratic and Republican lawmakers introduced or were drafting separate bills restricting health insurers’ ability to require prior authorization for certain treatments and medications. A third lawmaker was preparing other measures as well.
Many of the state’s medical providers are behind the effort, saying prior authorization is denying vital care and needlessly sucking up more and more of their time, which they say could be better spent with patients.
“It has increased incredibly in the last couple of decades, to the point that it’s one of the leading causes of burnout for physicians,” said Lauren Wilson, a Missoula pediatrician and past president of the Montana chapter of the American Academy of Pediatrics. “It’s just delaying patient care for no good reason.”
Subscribe to KFF Health News' free Morning Briefing.
Montana health insurers, however, insist they are authorizing drugs and treatments that are shown to be needed. If their review power is stripped away, costs will continue to increase due to insurance paying for unnecessary treatments, they said.
Blue Cross and Blue Shield of Montana said it doesn’t comment on individual cases, such as the Volpes’, but said it approves the “vast majority” of prior authorization requests. Blue Cross, which insures or manages health insurance for 384,000 people in Montana, also said it regularly audits its prior authorization procedures and is taking steps to speed up the process.
“Prior authorizations are a way to ensure members receive the right care at the right place at the right time, avoiding unnecessary services and helping providers understand coverage before a service is delivered,” the company said in a statement.
Denial of care through insurers’ prior authorization processes has struck a nerve nationwide as well.
In the wake of the December shooting death of UnitedHealthcare CEO Brian Thompson in New York City, customers of the health insurance giant and other consumers took to social media to denounce the industry for denied claims and puny reimbursements.
And since then, one of the nation’s largest health insurers, The Cigna Group, announced it would spend $150 million this year to reform its prior authorization process and related services for patients and health care providers.
In the past two years, multiple states have passed laws restricting prior authorization, according to the American Medical Association, with New Jersey enacting restrictions over New Year’s. The laws, spearheaded by health care providers, generally narrow when and how prior authorization can occur and create stricter timelines for the review.
Legislators in several states, including Indiana, Nebraska, North Dakota, Virginia, and Washington, have introduced prior authorization bills this year.
In Montana, local health insurers aren’t quietly giving in to increased regulation.
They note that state regulation of prior authorization affects only about a fourth of Montanans with health insurance because large, self-insured plans managed by national health insurers are under federal rules.
State restrictions on prior authorization will increase costs primarily for three in-state insurers, they say — and, eventually, their customers.
“We feel like our job is to say, ‘Is that the best use of money for our membership?’” Jackie Boyle, senior vice president of external affairs for Mountain Health Co-Op, said of prior authorization. “If we approve something, we are doing it for every patient like them.”
Mountain Health, based in Helena, insures 55,000 people in Montana, Idaho, and Wyoming.
Democratic state Rep. Jonathan Karlen of Missoula is sponsoring two bills: one to remove prior authorization for most generic drugs, inhalers, and insulin, and another that says patients can’t be denied a drug when they switch insurers and are waiting for authorization from the new insurer. The second bill also says a procedure or treatment may be denied only by a physician with a matching specialty.
Karlen said insurers are putting up barriers to care to increase their profits and said it’s time to break those barriers down.
“People should be making medical decisions based on what they and their doctors think, not what their insurance company thinks,” he said. “If a doctor says you need a medication, that’s why you have insurance — so you can get that.”
Republican state Rep. Ed Buttrey of Great Falls said he plans to introduce a bill to help kids with chronic bowel diseases, such as the Volpes’ son, imposing a seven-day limit to decide whether to authorize expensive biologic treatments. If insurers don’t meet the deadline, the drug would be automatically approved.
Buttrey’s bill also would eliminate most retroactive denials — when insurers refuse to pay for the treatment they’d authorized.
State Sen. Vince Ricci (R-Billings) said he is preparing other bills that may include even stronger language to restrict prior authorization for drugs for various conditions.
Healthcare providers and patients have heard the rationale of insurers and promises that improvements will be made, but they say nothing has happened and that it’s time for the state to step in.
“When there are no consequences and no teeth to anything, I can complain all I want, but it doesn’t seem to incite change,” said Kim Longcake, the pediatric nurse practitioner who’s treating the Volpes’ son.
Longcake said she and another specialist in her office tracked the time they spent on prior authorization requests in a two-week period.
“Depending on where you want to see me, I’m booking out four to six months,” Longcake said. “If I wasn’t spending 12 hours a week doing prior authorization stuff, it would improve access to care.”
The Volpes said their son, now 13, couldn’t absorb food and didn’t gain any weight for a year and a half while he went through treatments that didn’t work and repeated preauthorization waits, including for his current treatment, which appears to be working.
“What he’s gone through at that age was really excessive, beyond what was needed for treatment, because we couldn’t get the care that he needed,” his mother said. “If we didn’t get switched to this medication, he’d still be doing that.”
CMS is taking complaints more seriously about denial of care by payors. United Health Care, which has been on the carpet because of its high denial rates for prior authorization appealed and won its case against CMS for downgrading the Medicare Star rating from a five to a four because of a phone call from a patient. What was the lawsuit about?
UnitedHealth alleged that CMS lowered its ratings based on a single unsuccessful phone call from a CMS test caller.
UnitedHealth claimed that CMS was arbitrary and capricious in docking the star ratings based on a single call.
UnitedHealth said that an error by the test caller was responsible for failing to connect with a representative.
What was the outcome?
The judge ruled that CMS violated the Administrative Procedure Act of 1946 by incorrectly marking the test call as unsuccessful.
The judge ordered CMS to recalculate the ratings without considering the disputed call.
The ruling could boost UnitedHealthcare's Medicare Advantage earnings by millions of dollars.
What does this mean for other insurers?
This ruling could also benefit other insurers with pending suits seeking to boost their ratings.
The recent murder of CEO Brian Thompon (United Health Care) elevated the
practice of high rates of denials of prior authorization to public attention
What else could possibly go wrong?
Charlotte-area patients sue United HealthCare over high bills
A class-action lawsuit filed by UnitedHealthcare patients has reignited conversations about unfair billing practices by healthcare providers and insurers.
What’s happening: The class-action suit filed in Mecklenburg County Superior Court last week is the result of a dispute between UHC and Providence Anesthesiology Associates, which left people with UHC insurance out of network with PAA’s services.
Why it matters: That’s a big issue because Novant Health, one of our area’s largest health systems, exclusively works with PAA for anesthesiology services. So any UHC patient needing anesthesia at a Novant facility between February 2020 and now has gotten an out-of-network bill.
Many of those patients are new mothers who received an epidural during childbirth.
Of note: Many of these bills were lowered after individual negotiations with UHC and or help from PAA.
Zoom out: We’ve been reporting on this dispute since September 2020. Some patients say they didn’t know about PAA’s out-of-network status before reading our stories. And some mothers have told us the dispute has caused them to skip the epidural altogether.
The lawsuit alleges that UHC “violated North Carolina’s Patient Protection Act by forcing members to use out-of-network providers, then refusing reasonable reimbursement.”
The suit also says that UHC “subjected patients to unnecessary financial hardship and related stress when it moved longtime provider Providence Anesthesiology Associates out of network.”
Six Charlotte-area patients, along with PAA, are plaintiffs in the lawsuit.
What they’re saying: UHC sent Axios a statement in response to the lawsuit:
“The fact that Providence has joined a lawsuit focused on the surprise bills that Providence itself has been sending to patients is just the latest example of the extreme lengths to which it will go to protect its egregious billing practices. Providence’s out-of-network charges are 15 times higher than Medicare pays on average, and when insurers don’t pay those exorbitant charges and instead offer market-competitive reimbursement, Providence surprise bills patients. Fortunately, the No Surprises Act will make it illegal for Providence to continue this practice starting in 2022. In the meantime, we will vigorously defend ourselves against the claims in this lawsuit and will continue doing everything we can to protect our members from Providence’s surprise bills.”
Pointing fingers: Over the last year and a half, UHC and PAA have placed responsibility for the dispute on the opposing party. UHC has blamed PAA for charging too much for their services, and PAA has blamed UHC for undercutting anesthesiology groups like theirs.
Multiple attempts to negotiate and get PAA back in network have failed.
The big picture: The lawsuit, the dispute that caused it and the resulting medical bills highlight the complexities of the American healthcare system.
Currently, measures like the Hospital Price Transparency rule have been implemented to make the healthcare industry more competitive and transparent. But these changes take time. As of right now, reports show that most hospitals are out of compliance with the rule.
The transparency rule is further complicated because the hospital itself may be in-network while the anesthesia group (PAA) is out of network. While the hospital is transparent, PAA may not disclose that the anesthesiology group is out of network. One solution would be for the hospital to disclose proactively the PAA is not in the network. Most patients would not be aware of this practice and at risk for higher charges.
Attorney General Josh Stein’s office says it’s received seven complaints involving PAA, and many other complaints involving UHC, but those are regulated by the Department of Insurance.
Stein says he’s dealt with other cases similar to the PAA/UHC dispute. He sees price transparency as a big part of the solution.
“The biggest problem is the incredible complexity of our health care financing system. Having transparency of the pricing procedures in health systems is a critical first step,” Stein tells me.
Currently, the attorney general says his office is working to determine which hospitals are out of compliance with the price transparency rule.
