Idaho Patient Act a model for other states for protecting consumers from medical debt

I spent a week last month in Boise with two members of the staff of Melaleuca—a company that makes more than 400 nutritional, cleaning, personal care, and cosmetic products—making lobbying visits to the Idaho legislature. Katie Hart and Jay Cobb work for Frank Vandersloot, CEO of Melaleuca. Vandersloot is a highly successful, conservative businessman who is committed to protecting Idaho residents from abusive medical debt collection practices after discovering that one of his employees was hit with thousands of dollars in bills—including hefty lawyers’ fees and court costs—based on a $294 medical debt that she couldn’t even identify. The stark reality is that 50 percent of bankruptcies in America are caused by medical debt. He was championing a bill called the Idaho Patient Act, House Bill 515.

Many people believe federal law provides broad protections for people in debt. While the federal Fair Debt Collection Practices Act (FDCPA), enforced by Federal Trade Commission, makes it illegal for debt collectors to use abusive, unfair, or deceptive practices when they collect debts, it doesn’t address how debts are calculated or curb predatory fees, penalties and court costs.

NCL has worked with Melaleuca for several years, first to fight a bill in Congress that would have essentially legalized pyramid scheme activity. Last October, I flew to Melaleuca headquarters in Idaho Falls to meet nearly half of the state’s legislators who came to town as part of their tour of businesses in Idaho. At that gathering, Vandersloot discussed his hope to pass a bill to address these predatory collection practices, aiming his fire at the practice of ginning up the cost to patients of medical debts with thousands in lawyers’ and court fees; often patients have no idea where the debt is from and debt collectors aren’t required to provide that information to them. The Idaho Patient Act addresses that issue.

Vandersloot also puts his money where his mouth is: not only did he propose a legislative remedy, he and his wife Belinda created a $1 million fund to provide legal counsel to Idahoans who have been hit with these attorney bills. Consumer advocates like NCL have been working for decades to curb the excesses of this industry. But to see  a conservative CEO take on this issue gives the effort a new push.

Sticking up for the little guy is not out of character for Vandersloot. He spoke with the same fervor when we worked together fighting a bill that would have legalized pyramid schemes. In neither case was there any financial reward coming to Melaleuca—Vandersloot took a stand on this issue because he felt it was the right thing to do. Though we may disagree on a host of other matters, on this we are aligned and that is a good thing for vulnerable consumers. Strange bedfellows are a big advantage when it comes to getting things done in the political arena.

Katie Hart has been wisely deployed to live and work in Boise while the legislature is in session and navigate this important bill through the complicated legislative process. She’s a smart and charismatic lawyer—she and Jay Cobb, an expert strategist, could teach Lobbying 101: they’ve met with the Idaho Hospital Association, Idaho doctors, insurance companies, and the Idaho trial lawyers and revised the bill to address their concerns. 

Specifically, the Idaho Patient Act proposes the following:

  1. All health care providers must submit all charges for procedures performed to an insurance carrier within 45 days.
  2. Within 60 days, the patient must receive a summary of services rendered during treatment and recovery, including the names and contact information for all entities that may be billing the patient separately, such as an individual doctor.
  3. All providers must then send a final statement with a total amount owed by the patient after insurance. The bill must correspond with the original list of services.
  4. Health care providers must wait 60 days after sending the final notice before charging a patient interest on an outstanding bill and hiring a collection agency. They must wait 90 days from the final statement before they take “extraordinary collection actions,” which means a lawsuit, or reporting a patient to a credit bureau for failure to pay.
  5. Finally, in medical debt cases that result in litigation, the legislation limits the amount attorney fees and costs that can be shifted to the patient to $350 for uncontested cases and $750 for contested cases. Currently, there is no official cap for fees that can be charged to delinquent patients by collection agencies and their representing lawyers.

In Boise, my first order of business was to register in the Idaho capitol building as a lobbyist, even though I was only going to be there for the day.  We wanted to do everything by the book! For $11 the Secretary of State’s office put me into the system and off we went.

Jay Cobb explained that Idaho is very conservative where rules or regulations are frowned upon. Of the 70 members of the Idaho House, 56 are Republican and some of those lean far right. 14 are Democrats. Of the 35 members of the Senate, only 7 are Democrat. The Governor is Republican, as is the Secretary of State and the Attorney General.

Katie and Jay have been working for months with elected officials, revising the bill without compromising its impact, and last week the measure was  reported favorably from the House Business Committee by a 15-2 vote (after a 5 hour hearing with many witnesses and terribly sad stories). Adding to the challenge of getting this bill enacted the second Vice Chair of the Republican Party in Idaho, and a member of the Idaho legislature were adamantly opposed to the legislation because as their egregious medical debt collection practices were epicenter of the problem.  Now the bill goes to the full House and over to the Senate.

While in the state house, we met with Senator Grant Burgoyne, a democrat who has provided legal representation to the collections industry. His observation? this bill would rein in “bad actors,” and the collections industry as a whole doesn’t oppose it. Senator Michelle Stennett, a democrat from Ketchum, told us about the challenges of getting what she thought were reasonable measures out of committee in Idaho because members are so loathe to pass any laws. The longest serving Democratic House member told us she believes the bill will pass, and the very smart and entertaining newly elected Boise Representative Steve Berch, who ran five times as a democrat in a red district and finally got elected, also predicts a positive outcome for this bill.  

To cap off the day, both U.S. Senators were in the State House and I had the chance to say hello to one of them, Senator James Risch (R-ID) and meet his DC staff.

The calculus changes when a conservative CEO with political clout backs a bill to offer protections to consumers who -through no fault of their own -have medical debt. Thanks to Frank Vandersloot, Katie Hart and Jay Cobb and the whole team at Melaleuca for making their case to the Idaho legislature so persuasively.

We hope this bill gets enacted in Idaho. If it does, the law will become a template for other states to put reasonable guardrails around collection of medical debt and offer some much-needed consumer protections. And maybe we can even hope that Vandersloot’s willingness to use his clout and bully pulpit to speak out on behalf of those who have no voice will be emulated by other CEOs.

Postscript

On March 9, the Idaho Senate passed the Idaho Patient Act 32-1. On March 16 Idaho Governor Brad Little signed the bill into law.

Congratulations to Frank Vandersloot, Melaleuca’s CEO, to his talented team of Katie Hart and Jay Cobb, and to all the members of the Idaho state legislature, who stood up for consumers and understood that one in seven Idahoans struggle with medical debt.

To quote the words on the Hanukkah dreidel, “A great miracle happened there.”

Strategies to improve rural health care – National Consumers League

Stephanie_Sperry.jpgBy Stephanie Sperry, NCL health policy intern

Stephanie is a 4th year Public Health Policy student at the University of California Irvine, interning at NCL as part of the University of California Washington DC Academic Internship Program.

“Just because we live in rural areas in this country, we shouldn’t have to settle for anything less than the best health care services” – Darrold Bertsch, CEO, Sakakawea Medical Center

The rural health care landscape in the United States is vastly different from the health care found in urban and suburban areas. On January 17, 2018, the Bipartisan Policy Center (BPC) and the Center for Outcomes Research and Education (CORE) held a briefing at which they released a report on the current state of rural health care in seven Upper Midwest states (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wyoming) and identified opportunities for improvement. The panel included Senator Heidi Heitkamp (D-ND); Senator Mike Rounds (R-SD); Keith Mueller, Ph.D., Interim Dean, University of Iowa College of Public Health and Director, RUPRI Center for Rural Health Policy Analysis; John Dunn, R.N., MPA, Director Physician Services, Nebraska Methodist Health System; Heidi Duncan, M.D., Physician Director of Health Policy, Billings Clinic; and Darrold Bertsch, CEO, Sakakawea Medical Center. The BPC/CORE report focused on four key areas: rightsizing health care services to fit community needs, creating rural funding mechanisms, building and supporting the primary care physician workforce, and expanding telemedicine services.

The Centers for Medicare and Medicaid Services (CMS) has implemented programs to monitor the quality of health care and drive its improvement. However, many of these programs are not tailored for rural areas, and in turn, rural facilities often lack resources to provide more advanced procedures. As Senator Rounds noted, people in rural areas end up overpaying for their health care – the quality of which would not be accepted in urban areas. Health care policies should not come in a “one size fits all” option, but should be tailored to fit the needs of the community. Senator Heitkamp argued that flexibility from CMS would allow health care professionals in rural areas to provide higher quality care, like incorporating care options for the elderly that wouldn’t require relocation.

Funding for rural health care (and health care as a whole) is a recurring challenge. The current passage of short-term continuing resolutions does little to provide financial stability for health care delivery, hospitals, and any organization in a contract with the federal government. According to Senator Rounds, the best course of action to address this issue will start with Congress passing a budget for more than three weeks at a time, to provide stability for organizations that depend on federal funding.

Rural areas face different types of challenges in health care delivery, with transportation and shortage of workforce personnel presenting major struggles. The distances that must be travelled to reach necessary health services in rural areas place an added burden on the rural population. Not only are people spending more time to travel, they spend more money making the trip. To address this issue, the BPC and CORE study suggests an expansion in the use of telemedicine services. Senators Heitkamp and Rounds praised the work of the Helmsley Trust in the areas of e-pharmacy and telemedicine. Telemedicine relies on high-speed broadband connectivity, the current state of which Senator Rounds criticized when he said “if you can watch your favorite college team on TV or on a computer, you ought to be able to also provide appropriate connections in emergency situations, between professionals and institutions with huge capabilities, to make contact with people in rural areas.” Senator Heitkamp uses Netflix as her benchmark for measuring successful broadband connectivity, believing that “there isn’t any millennial who is going to live in any community where they can’t stream Netflix. So, if you don’t have it, then we’re failing.”

Dwindling numbers of primary care physicians have placed an added strain on rural health care accessibility. BPC and CORE support the encouragement of completion of medical residencies in rural areas, thus paving the way for more practices to be established nearby. Because less than 8 percent of all physicians and surgeons choose to practice in rural settings, the hope is that increased exposure to rural communities during medical training will increase the number of physicians who choose to stay upon completion, as noted by Heidi Duncan, Physician Director of Health Policy at the Billings Clinic. Physician Assistants, guided by physicians via broadband connectivity, present another promising option – utilizing the expansion of telemedicine to provide the same essential services to rural communities that would otherwise be easily accessible in an urban setting.

As detailed in the BPC/CORE report, additional strategies to build a diverse and sustainable rural health workforce include distributing Graduate Medical Education (GME) positions to rural institutions and reauthorizing the Primary Care Residency Expansion and Area Health Education Center programs. Loan-forgiveness programs could also be expanded to include dental therapists and community paramedics.

In alignment with the strategies outlined by BPC and CORE, the National Consumers League is working with the Patient Access to Pharmacists’ Care Coalition (PAPCC) to build support for the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 109), which would amend Medicare to increase medically underserved seniors’ access to health care through pharmacist-provided care. Since nearly 95 percent of the population lives within 5 miles of a pharmacy, improving access to pharmacists’ services can help to improve the care of our nation’s rural residents.

Health savings accounts: dubious benefits for the wealthy, disastrous for the rest of us – National Consumers League

Spotlight on Health Care Series, Part 3: As America’s health care system is facing uncertainty, NCL staff is exploring the topic in a new weekly blog series.

The failure to successfully repeal and replace the Affordable Care Act (ACA), if nothing else, exposed a Republican party divided (perhaps irreparably so) on how to reform America’s healthcare system. Despite the GOP’s devastating legislative defeat, we should not underestimate their determination to resuscitate their repeal/replace efforts. 

It’s clear there aren’t too many things the party as a whole agrees on these days, particularly surrounding healthcare, but there are a few ideas that are likely to re-appear in future attempts at healthcare reform. One of those ideas is the expansion of health savings accounts (HSAs). The American Health Care Act (AHCA) was a huge endorsement of HSAs, expanding Americans’ latitude to use them as a primary means to cover their health expenses. 

Under current law, HSAs are married to high deductible health insurance plans (HDHPs). HSAs supplement HDHPs by allowing consumers to set aside funds to pay for out-of-pocket medical expenses. Despite the high deductible, HDHPs are attractive to many consumers as premiums are typically much lower than those of traditional plans. Another draw of HSAs is the tax advantage; the money you contribute is untaxed, the money grows tax-free, and you pay no taxes if/when you take the money out, as long as it’s used on health expenses. Even so, the long-term benefits of HSA-driven healthcare are dubious at best, even for the wealthy who can afford to take full advantage of these accounts. For the rest of us, it could be a disaster.

The healthcare landscape in a system dominated by HSA supplemented-high deductible health plans would be drastically different than that under the Affordable Care Act. The ACA was designed to ensure healthcare for all Americans- and not just access to care, but quality health coverage. The law requires that insurers cover a wide range of benefits, from preventive services to maternity coverage to mental health. Republicans argue that mandating these benefits drives up costs, so they propose skinnier benefit packages to lower premiums and increase “access.” Proponents of HSAs submit that putting more of consumers’ skin in the game will compel them to shop for cheaper care since they are spending their own money rather than an insurer’s. The idea is that this will drive down health care costs, all while bolstering competition in the marketplace and increasing consumers’ flexibility to choose the care they want. Too bad this lofty goal isn’t bound to reality. 

The fact of the matter is that HSAs have not been and will not be a feasible means to achieving health care for all. HSAs tend to benefit the wealthy, as those with lower incomes often have minimal, if any, disposable income to set aside in a savings account. In fact, a 2015 study found that people from high-income households were not only significantly more likely to have an HSA, but more likely to max out their contributions than people from low-income households. Considering that nearly half of Americans can’t come up with $400 to cover an emergency expense, we can hardly expect most Americans to have the ability to come up with cash to meet a high deductible. Even the wealthiest among us could go broke should a costly medical emergency occur. Moreover, the idea that HSAs afford consumers more flexibility is misleading — the real flexibility most Americans will have is deciding which health services they will have to forego. Studies have shown that even those who are able to contribute nominally to their accounts ultimately reduce the amount of care they seek, rather than shopping around for cheaper prices. Patients especially avoid things like filling their prescriptions, or proactively seeking preventive care that can mitigate health risks down the line. While the primary goal of the Republicans may be to reduce health care costs, we cannot sacrifice the well-being of the American people in those efforts.

President Trump called on Congress to create a “better healthcare system for all Americans,” however much of what he and his party have put forth only creates a better system for a fortunate few. HSAs are most valuable to those who earn the most and have the most to gain – it is not a solution that works for everyone. We cannot stand for higher cost burdens and coverage cuts across the board, only to give another tax break to the wealthy, and we must not let the Republicans shift us towards a system that will leave millions of low-income and middle-class Americans behind. While the future healthcare landscape is anything but certain, we would all be well served to stay clear-sighted about what could still lie ahead.

From patient To consumer: Reimagining health care from a consumer perspective – National Consumers League

family-on-bikes.jpgThe following Huffington Post op-ed was published August 18, co-authored by NCL’s Sally Greenberg and Marilyn Tavenner, the President and CEO of America’s Health Insurance Plans.

Navigating our health care system is no easy task. For decades, consumers have been forced to contend with a fragmented health system that makes decision making an all-consuming challenge. Whether it’s choosing a provider, knowing where to get information about cost or quality of doctors, or understanding a dictionary of complex health care terms, many consumers often feel left to fend for themselves in a system that is working against them.

For many individuals, it’s hard to know where to start. A recent state analysis by Rice University in Texas found that 42 percent of consumers who bought their own insurance felt like they lacked a clear understanding of their health insurance plans. Nearly a quarter of those surveyed who had employer-sponsored coverage still struggled with understanding their benefits.

We need to find a way to change this. While we all recognize the seismic shift underway as the age of consumerism in health care finally takes hold, we have to ask ourselves if we are truly practicing what we preach. We all have a responsibility to provide consumers with the transparent, actionable information they need to make smart choices about their care.

The good news is that online and mobile apps are making it increasingly easy for consumers to access information on their own time and with relative simplicity. Health plans have rolled out provider cost and quality calculators, and websites like FAIR Health make it possible for patients to see what a typical doctor’s visit or MRI will cost before they even walk into a provider’s office.

But even with this push towards more available data, we know that individuals and families still struggle when it comes to understanding and using their insurance benefits. Commonly searched online terms around insurance include, “what are deductibles?”, “finding a doctor,” and “how much will I pay in premiums?” Consumers are clearly telegraphing the need for simple, easy-to-understand information about their coverage.

Recently, our two organizations came together to compare notes on how we could collaborate to improve consumers’ health care experience. As a first step, we agreed that while there is a wealth of information in the market available for consumers, it is often poorly organized, out-of-date, or like the health care system itself, requires consumers to search multiple places for the information they need. Our first joint project will bring critical information together and present it in ways that are useful for consumers. We will rely on AHIP’s considerable knowledge of health insurance and NCL’s more than 100 years of consumer education to make information accessible, understandable, and actionable.

Our work builds upon what we have learned over the past several years on the frontlines of this health care transformation. A recent report from McKinsey found that although consumers are beginning to research their health plan choices, many of them are not yet aware of key factors they should consider before selecting coverage, such as the type of health plan and provider network, level of coverage, premiums, cost-sharing, covered services, drug formularies and tiers, and health status and anticipated utilization. Even once they have their insurance plan, many consumers may not be aware of all the benefits that are included, including free preventive services, disease management programs, fitness plans – and equally important, the tools they have available to get the best value for their health care dollars.

As consumers prepare for the upcoming open enrollment periods for Medicare and the Exchanges, AHIP and NCL will share new consumer resources and information answering some of the important questions about insurance coverage and health care ranging from how to choose a health plan to how to choose a doctor, as well as consumers’ rights if they feel they’ve been inappropriately denied a product or service that should be covered by their plan.

We know that health care isn’t always simple, but if we are to be successful in moving towards a patient-centered health system, we have to start by making health care information more accessible and usable for consumers. While this partnership is a first step, our hope is that our combined efforts will encourage and support the important work underway to improve consumers’ experience with the health system and the wellbeing of the country as a whole.

This article originally appeared in the Huffington Post.

So Simple, So Hard tackles adherence challenges in CA – National Consumers League

“So Simple, So Hard” was the theme of the medication adherence conference the National Consumers League (NCL) held on September 15 in Sacramento, California. Sponsored by the Agency for Healthcare Research and Quality (AHRQ), the speakers and attendees explored the challenges and barriers to medication adherence – why it is so hard – and highlighted the tools and strategies to make it simpler and to improve adherence and health outcomes, especially among underserved populations.

NCL gathered more than 80 stakeholders in Sacramento, including health care professionals, community health workers, advocates, industry representatives, policymakers, and researchers. Throughout the day, conference participants heard from researchers and experts on adherence, and engaged with each other about possible collaborations and solutions.

The meeting kicked off with presentations on adherence research and health disparities, and continued with a variety of strategies and tools to improve adherence that could be utilized in health care practices or organizations. Takeaways from the presentations included the following:

  • One size does not fit all – adherence intervention work best when tailored for the patient
  • Quality of communication and a sense of collaboration between patients and health care professionals impact adherence, especially among people of color   
  • Adherence rates are unique to each medication a patient takes 
  • Cultural considerations are vital to understanding barriers to adherence
  • Always consider the health literacy of the patient
  • Determining the reasons for poor adherence is essential to developing effective interventions   

Specific strategies and solutions:

  • Medication synchronization
  • Comprehensive medication review
  • Tools for translating medication labels into the patient’s native language
  • Best practices and tools for more culturally competent clinical care

The conference provided a forum for participants to interact, connect, and lay the groundwork to develop partnerships for collaborative initiatives. We will be following up with all conference participants to determine the benefits of the conference and learn of any connections and /or collaborations developed.  

At NCL, we view poor adherence, with its devastating effect on health outcomes, as a public health problem. Since 2011, we have been leading Script Your Future – a public education campaign to increase awareness among patients, their family caregivers, and health care professionals of the importance of taking medication as directed.

As leaders of Script Your Future, NCL convened an AHRQ research dissemination conference to further explore possible solutions to this public health problem. The adherence issue is complex and taking medications is NOT so simple, especially for ethnic and racial minorities who often face health disparities. Collaboration among stakeholders who are dedicated to keeping the patient at the center of the discussion, is a critical first step toward developing and implementing effective medication adherence strategies to help people better self-manage their care.  

Conference participants and others are encouraged to distribute information from the conference to interested colleagues and through their networks. We look forward to hearing how others are sharing the information, tools, and resources from the conference, and the possible collaborations that will grow out of the meeting.   

* Funding for this conference was made possible in part by grant number 1R13HS023948-01A1 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government

A Big Win For California Patients And Consumers – “Refill Reminders” A “Go” – National Consumers League

sg.jpgCalifornia’s Office of Health Information Integrity (CalOHII) just delivered a big victory for patients and consumers by expressly recognizing that sponsored medication adherence programs for a currently prescribed drug (commonly called “refill reminders”) do not require patient authorization in California. In publishing its long-awaited State Health Information Policy Manual, CalOHII takes a step to harmonize the state’s Confidentiality of Medical Information Act (CMIA) with the federal medical privacy laws and regulations (a.k.a., the HIPAA Privacy Rule).

For years now, due in part to privacy concerns, confusion has persisted within the healthcare community about the types of refill reminder programs that can legally run in California. In fact, California is the only state in the U.S. where pharmacies do not, to any meaningful degree, operate sponsored refill reminder programs. California consumers deserve the benefit of refill reminders that provide helpful information to patients about their prescription drugs. Patient access to this information is now guaranteed.

CalOHII’s publication of its Manual makes clear that California adopts the same approach that the U.S. Department of Health and Human Services (HHS) took in its 2013 final rulemaking and “Refill Reminder Guidance.” Under that HHS Guidance, pharmacies are able to provide their patients with sponsored refill reminders. NCL applauds CalOHII for clarifying that the CMIA should be interpreted consistently with the HIPAA Privacy Rule. With that clarification, NCL is hopeful that California pharmacies and their sponsors will jumpstart sponsored refill reminder programs. 

NCL is a longstanding supporter of refill reminder programs. NCL leads  “Script Your Future,” a public education campaign designed to raise awareness of the importance of taking medication as prescribed. Poor medication adherence is a major, and significantly under-appreciated, health problem. Studies establish that nearly three-out-of-four Americans do not take their medications as directed, which costs the healthcare system nearly $300 billion per year and results in almost 125,000 unnecessary deaths per year. To help combat this problem, most pharmacies, health plans, and doctors provide a broad range of patient-directed communications regarding prescription drug therapies, including communications that encourage patients to stay on prescribed therapy. The sponsored refill reminder programs endorsed by CalOHII in its Manual are a key part of these efforts in California.  

 As a founding member of the Best Privacy Practices Coalition, NCL is also a strong believer in the protection of medical privacy. However, medical privacy does not exist in a vacuum. NCL is pleased that CalOHII has arrived at a great middle ground that balances the need for information with privacy concerns of patients. This balance is a win for Californians.

King v. Burwell ruling will keep consumers insured (and healthy!)

Health_Care_Law.jpgThe King v. Burwell ruling in favor of the Affordable Care Act (ACA) has allowed for approximately eight million consumers to keep their insurance coverage. In the King case, petitioners challenged the clause of the Affordable Care Act that stated subsidies are available to people who use an exchange “established by the State” to purchase insurance. 

Consumers living in the 34 states without state marketplaces are able to benefit from the subsidies because the Internal Revenue Service allowed people to receive assistance if they purchased a plan on the federally-run marketplace. The plaintiffs argued that subsidies by law are only given to people living in states with their own health insurance marketplaces. The ruling allows consumers in states where the marketplace is run by the federal government to keep their subsidy and insurance.

The National Consumers League (NCL) applauds the Supreme Court for upholding the ACA subsidies for consumers using the federal marketplace. The Supreme Court decision helps prevent a rise in premiums for all consumers using the health care exchange. The subsidies are a key provision of the law and they are an important part of keeping consumers insured and healthy. This decision provides hope that the ACA will face fewer political and legal obstacles in the future and can continue to provide health insurance to consumers. Despite the naysayers, the numbers speak volumes. Since the ACA’s enactment, more than 16 million Americans have been able to afford quality health insurance they did not have before.

If you do not already have health insurance, you can enroll in person, over the phone, by mail, online at Healthcare.gov, or on your state exchange’s site during the open enrollment period.