Last winter, Amber Wingler started getting a series of increasingly urgent messages from the local hospital in Columbia, Missouri, letting her know her family’s health care might soon be upended.

MU Health Care, where most of her family’s doctors work, was mired in a contract dispute with Wingler’s health insurer, Anthem. The existing contract was set to expire.

Then, on March 31, Wingler received an email alerting her that the next day Anthem was dropping the hospital from its network. It left her reeling.

“I know that they go through contract negotiations all the time … but it just seemed like bureaucracy that wasn’t going to affect us. I’d never been pushed out-of-network like that before,” she said.  

The timing was awful.

The query: When a Missouri mom’s health insurance company couldn’t come to an agreement with her hospital, most of her doctors were suddenly out-of-network. She wondered how she would get her kids’ care covered or find new doctors. “For a family of five, … where do we even start?”

— Amber Wingler, 42, in Columbia, Missouri

Wingler’s 8-year-old daughter, Cora, had been having unexplained troubles with her gut. Waitlists to see various pediatric specialists to get a diagnosis, from gastroenterology to occupational therapy, were long — ranging from weeks to more than a year.

(In a statement, MU Health Care spokesperson Eric Maze said the health system works to make sure children with the most urgent needs are seen as quickly as possible.)

Suddenly, the specialist visits for Cora were out-of-network. At a few hundred bucks a piece, the out-of-pocket cost would have added up fast. The only other in-network pediatric specialists Wingler found were in St. Louis and Kansas City, both more than 120 miles away.

So Wingler delayed her daughter’s appointments for months while she tried to figure out what to do.

Nationwide, contract disputes are common, with more than 650 hospitals having public spats with an insurer since 2021. They could become even more common as hospitals brace for about $1 trillion in cuts to federal health care spending prescribed by President Donald Trump’s signature legislation signed into law in July.

Patients caught in a contract dispute have few good options. “There’s that old African proverb: that when two elephants fight, the grass gets trampled. And unfortunately, in these situations, oftentimes patients are grass,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation, a nonprofit that helps people who are having trouble accessing health care.

If you’re feeling trampled by a contract dispute between a hospital and your insurer, here is what you need to know to protect yourself financially:

1. “Out-of-network” means you’ll likely pay more.

Insurance companies negotiate contracts with hospitals and other medical providers to set the rates they will pay for various services. When they reach an agreement, the hospital and most of the providers who work there become part of the insurance company’s network.

Most patients prefer to see providers who are “in-network” because their insurance picks up some, most, or even all of the bill, which could be hundreds or thousands of dollars. If you see an out-of-network provider, you could be on the hook for the whole tab.

If you decide to stick with your familiar doctors even though they’re out-of-network, consider asking about getting a cash discount and about the hospital’s financial assistance program.

2. Rifts between hospitals and insurers often get repaired.

When Brown University health policy researcher Jason Buxbaum examined 3,714 nonfederal hospitals across the U.S., he said, he found that about 18% of them had a public dispute with an insurance company sometime from June 2021 to May 2025.

About half of those hospitals ultimately dropped out of the insurance company’s network, according to Buxbaum’s preliminary data. But most of those breakups ultimately get resolved within a month or two, he added. So your doctors very well could end up back in the network, even after a split.

3. You might qualify for an exception to keep costs lower.

Certain patients with serious or complex conditions might qualify for an extension of in-network coverage, called continuity of care. You can apply for that extension by contacting your insurer, but the process may prove lengthy. Some hospitals have set up resources to help patients apply for that extension.

Wingler ran that gantlet for her daughter, spending hours on the phone, filling out forms, and sending faxes. But she said she didn’t have the time or energy to do that for everyone in her family.

“My son was going through physical therapy,” she said. “But I’m sorry, dude, like, just do your exercises that you already have. I’m not fighting to get you coverage too, when I’m already fighting for your sister.”

Also worth noting, if you’re dealing with a medical emergency: For most emergency services, hospitals can’t charge patients more than their in-network rates.

4. Switching your insurance carrier may need to wait.

You might be thinking of switching to an insurer that covers your preferred doctors. But be aware: Many people who choose their insurance plans during an annual open enrollment period are locked into their plan for a year. Insurance contracts with hospitals are not necessarily on the same timeline as your “plan year.”

Certain life events, such as getting married, having a baby, or losing a job, can qualify you to change insurance outside of your annual open enrollment period, but your doctors’ dropping out of an insurance network is not a qualifying life event.

5. Doctor-shopping can be time-consuming.

If the split between your insurance company and hospital looks permanent, you might consider finding a new slate of doctors and other providers who are in-network with your plan. Where to start? Your insurance plan likely has an online tool to search for in-network providers near you. 

But know that making a switch could mean waiting to establish yourself as a patient with a new doctor and, in some cases, traveling a fair distance.

6. It’s worth holding on to your receipts.

Even if your insurance and hospital don’t strike a deal before their contract expires, there’s a decent chance they will still make a new agreement.

Some patients decide to put off appointments while they wait. Others keep their appointments and pay out-of-pocket. Hold on to your receipts if you do. When insurers and hospitals make up, the deals often are backdated, so the appointments you paid for out-of-pocket could be covered after all.

End of an Ordeal

Three months after the contract between Wingler’s insurance company and the hospital lapsed, the sides announced they had reached a new agreement. Wingler joined the throng of patients scheduling appointments they’d delayed during the ordeal.

In a statement, Jim Turner, a spokesperson for Anthem’s parent company, Elevance Health, wrote, “We approach negotiations with a focus on fairness, transparency, and respect for everyone impacted.”

Maze from MU Health Care said: “We understand how important timely access to pediatric specialty care is for families, and we’re truly sorry for the frustration some parents have experienced scheduling appointments following the resolution of our Anthem contract negotiations.”

Wingler was happy her family could see their providers again, but her relief was tempered by a resolve not to be caught in the same position again.

“I think we will be a little more studious when open enrollment comes around,” Wingler said. “We’d never really bothered to look at our out-of-pocket coverage before because we didn’t need it.”

Author: Bram Sable-Smith: brams@kff.org, @besables

Illustrations: Oona Zenda: ozenda@kff.org

The post So Your Insurance Dropped Your Doctor. Now What? appeared first on Medika Life.

—Gil Bashe, “Global Marketing Strategies” and “Emotion: The New Brand Integrator,” Pharmaceutical Executive, 2000

Twenty-five years ago, in a series of articles for Pharmaceutical Executive that may have seemed radical at the time, I argued that successful marketing wasn’t built on features but feelings. Back then, people were skeptical. “Emotion?” they responded. “We’re here to sell solutions.” Yet, as I revisit that article from the perspective of today’s fractured health landscape, I realize just how prescient that core message was.

In 2000, I wrote, “A brand must reflect the soul of the company. It must reflect its leadership and people’s beliefs, philosophies, and practices.” That truth remains, but in today’s health sector—beset by cost crises, consumer distrust, and system complexity—the soul of the brand must go even deeper. It must speak to human experience. It must unite the head (facts), heart (feelings), and gut (intuition) to unite the five pillars of the care community: patients, payers, product innovators, policymakers and providers.

The brands that do this don’t just survive, they lead.

The Head: Anchor in Truth, Lead with Clarity

We live in an era of data deluge. The health industry is drowning in numbers, from EMR systems to clinical trial dashboards. Yet many brands still mistake data for direction.

Yes, the head—facts—matter. Health is a science of logic, science, and proof. But it is also an art.

In my original article, I noted that the “hallmark of a strong brand is clarity—a clear promise, consistently delivered.” In health, clarity is more than a brand virtue; it’s a money and mission obligation. Patients need clarity in order to make life-altering choices. Providers need clarity in order to correctly apply new technologies and administer novel treatments. Payers need clarity so that they may judge value and outcomes.

A brand that leads with the head communicates what it does and why it matters. The science, the evidence, the safety profile: these aspects of health products are essential. But they are not enough.

I wrote in 2000, “Even the most successful product will not remain so without continuous reaffirmation of its value and identity.” It’s still true today, but that reaffirmation must be human, not simply clinical.

The Heart: Where Value Becomes Meaning

A quarter-century ago, I argued that “emotional connection” was key to global brand success. In 2024, I echoed that idea, stating that empathy is a strategic imperative, not a “soft skill.” Writing in Medika Life, I asserted that “Empathy—the ability to sense and connect to another’s experience—has clinical consequences.”

Health isn’t delivered in abstracts. It’s experienced in human moments: a nurse’s tone of voice, the wait time for an appointment, a doctor’s bedside manner. Patients remember how they felt, not what was said.

The same is true of brand impressions. A health brand’s heart is measured by its humanity: how it listens, responds, and affirms the lived experience. Consider the rise of narrative medicine, patient-centered care design, or trauma-informed policy. These are not trends. They are a return to what medicine truly is: a human endeavor.

In 2000, I wrote that “People buy brands because they trust them and because those brands represent a relationship.” It’s never been more true. That relationship must be emotional. If we don’t move hearts, we will never move health.

The Gut: The Compass for Courage and Change

If the head is what we know, and the heart is what we feel, then the gut is what we sense. It’s instinct informed by experience. It’s the courage to take a stand when the data is inconclusive. It’s also the discipline to say no when a decision doesn’t align with the brand’s soul.

In 2000, I observed that “Global brands are built not just on strategy, but on intuition—on understanding the culture and values of the people they serve.” That same intuition now guides how we engage health audiences. Do we sense distrust? Fear? Exhaustion? Our gut tells us when a message is too technical, dense or transactional to resonate. It urges us to simplify and re-center on the human.

Great leaders trust their gut because it helps them detect the intangibles: tone, timing and truth. In brand leadership, that same sense keeps us authentic.

Reuniting the Quintet: Patients, Payers, Product Innovators, Policymakers and Providers

Today’s health ecosystem is fractured along functional lines. Patients seek access, providers seek time, and payers seek value. Too often, they work in silos, leaving innovation and empathy at the margins.

But brands can be bridges. When built with head, heart, and gut, they become platforms for unity.

I wrote in 2000 that the “challenge is to ensure that everyone in the organization consistently communicates the brand through behavior, not just brochures.” That principle is now essential in aligning care delivery. Health brands must operate across disciplines, sectors, and even continents, but always with a singular message: we see, hear, and serve you.

Whether you’re a Medicaid insurer, a diagnostics company, or a telehealth platform, your brand is a promise. And that promise must connect the person in the exam room with the person writing the policy.

The ROI of Human Experience

In 2025, health leaders face dual pressures: cut costs and elevate care. This seems like a paradox, but it’s not. Investing in human experience is not a detour from efficiency; it’s the gateway to it.

Empathy reduces readmissions, clear communication improves medication adherence, and trusted brands drive engagement. When we center on people, we improve systems.

Put simply, mission and money must align. One cannot exist without the other in sustainable health ecosystems.

Final Thought: A New Brand Equation

As I wrote in Global Marketing Strategies 25 years ago, “A brand is the product of what people feel, not just what they see.” That message, once contrarian, is now the compass.

The future of health brands is in the hands of those willing to embrace complexity with clarity, wield emotion with discipline, and make instinct an asset, not a liability. In short, the best brands will speak to the head with intelligence, the heart with empathy, and the gut with courage.

In an age when trust is currency and gaining attention means cutting through the information jungle, this is not just good branding. It’s savvy mission-centered business leadership.

The post Beyond Data: Why Human Decisions Are Shaped by Facts, Feelings—and the Fire Within appeared first on Medika Life.

Today, however, the answer might surprise you. The smartest presence in the room could very well be the computer. With the rise of large language models (LLMs), the exam room now includes an unprecedented repository of knowledge and computational power. These systems process vast amounts of medical information faster than any human, creating new opportunities—but also introducing new tensions—about authority, collaboration, and trust in healthcare.

The Emerging Triad: Patient, Clinician, and AI

The integration of LLMs into healthcare has transformed the exam room into a three-way conversation. Each participant brings unique strengths and perspectives. The patient, armed with AI tools, often arrives better informed and prepared than ever before, ready to engage in their care. The clinician, meanwhile, uses AI to enhance their practice, drawing on tools that analyze patient histories, identify rare conditions, and recommend treatments with remarkable speed. And then there is the AI itself, a neutral and tireless presence offering access to an expansive universe of medical knowledge.

This triad—the patient, the clinician, and the AI—has the potential to create a richer and more informed dialogue. It promises to refine how diagnoses are made, treatment plans are crafted, and information is shared. However, it also introduces a new dynamic, one that demands careful navigation. When the AI holds the most raw knowledge in the room, who becomes the ultimate authority? And how do we resolve the inevitable conflicts that arise between machine-driven insights and human expertise?

Tensions in the Exam Room

This new dynamic in the exam room is both exciting and challenging. On one hand, LLMs empower patients to better articulate their symptoms and advocate for their care. On the other hand, this empowerment can sometimes verge into overconfidence. A patient, buoyed by an AI-generated suggestion of a rare diagnosis, may push for unnecessary tests or treatments. For the clinician, navigating this enthusiasm requires a delicate balance of empathy and expertise. And in an interesting twist, it might be AI—or even the patient—who hears that fabled zebra’s hoofbeats.

Clinicians, too, must grapple with the dual role of AI as both ally and challenger. While LLMs enhance diagnostic capabilities and save valuable time, they can also threaten the perception of the clinician’s authority. Patients may question, “Why should I trust you over what the AI suggests?” This tension forces clinicians to reaffirm their value not just as experts but as interpreters of both data and humanity. Unlike AI, clinicians bring intuition, experience, and empathy to the equation—qualities that are critical in contextualizing and personalizing care.

Efficiency, another hallmark of AI-enhanced communication, is a double-edged sword. Streamlining the exchange of information between patient and clinician can lead to faster diagnoses and treatment decisions. However, speed isn’t always an asset in healthcare. Patients often need time to process complex information and emotionally engage with their care. Clinicians must navigate the subtleties of a patient’s narrative, which cannot always be captured in the algorithmic precision of an AI model. Nevertheless, the tailored articulations of LLMs offer a tremendous opportunity to elevate communication to a new and more engaging level.

Still, one of the most pronounced tensions arises when patient-generated AI insights conflict with clinician-generated AI recommendations. In these moments, the exam room can feel like a battleground of algorithms. The question becomes not just “Who is right?” but “How do we resolve this conflict in a way that maintains trust and collaboration?” My sense is that this might get worse before it gets better, particularly when these conflicts arise in real time.

Beyond the Triad: The Broader Ecosystem

While the triad of patient, clinician, and AI forms the core of the modern healthcare interaction, it is not the entire picture. The exam room exists within a far more complex ecosystem. Payors, regulatory bodies, healthcare systems, and social perception all play varied roles in shaping how care is delivered. The integration of LLMs into this broader framework raises additional challenges.

For example, insurers may begin to rely on AI-driven insights to approve or deny treatments, creating potential conflicts between patient needs, clinician judgment, and algorithmic decision-making. Healthcare systems must grapple with ensuring equitable access to LLMs, preventing disparities between patients who can effectively use these tools and those who cannot. And when errors inevitably occur—an incorrect AI recommendation or a misinterpreted output—questions of accountability will come to the fore. Who is responsible: the clinician, the AI developers, or the systems that integrated these tools?

Amidst these complexities, the triad remains the focal point. It is in the exam room, where patient stories meet clinician expertise and AI’s computational power, that the future of care is being shaped.

The Path (with Bumps) Forward

So, who’s the smartest person in the exam room? The answer is no longer straightforward. Intelligence in healthcare is no longer about who holds the most knowledge; it is about how that knowledge is shared, interpreted, and applied. In this new era, the smartest “presence” is not any single participant—it is the evolving conversation itself.

The triad of engagement—patient, clinician, and AI—has the potential to redefine healthcare, making it more informed, precise, and empathetic. But realizing this potential requires intentional effort. Clinicians must embrace their roles as mediators, patients must critically engage with AI insights, and AI must remain a tool in service of the human relationship.

Looking beyond this triad to the broader orchestration of healthcare, one truth remains clear: the heart of medicine will always be the connection between people. No amount of computational power can replace the trust, empathy, and understanding that make healthcare not just a science, but an art.

The post Who’s the Smartest Person in the Exam Room? appeared first on Medika Life.

As a scientist, I question the efficacy of paper surgical masks in preventing the transmission of COVID-19, as my hospital reintroduced a mandate for healthcare providers to wear them.

Although many debate the effectiveness of paper masks, I am more interested in the evidence supporting wearing one rather than the politics surrounding masking.

Mixed Feelings

I remember wearing a paper surgical mask during a particularly busy shift at the hospital last winter.

As I moved from one patient’s room to another, I couldn’t help but notice the discomfort caused by the mask’s straps constantly tugging at my ears.

Despite the inconvenience, I also couldn’t ignore the sense of protection and responsibility that came with wearing it.

I work in cancer medicine, after all.

It’s a strange juxtaposition — the physical discomfort versus the mental reassurance.

Moreover, my patients prefer to see my face.

Moments like these make me reflect on the true effectiveness of these masks and whether they are truly making a difference in preventing the transmission of viruses.

Overview

While we adopted widespread mask use as a public health measure, the evidence supporting their effectiveness remains contested.

Observational studies (and even some randomized controlled trials) suggest a benefit, but there is no high-level, conclusive evidence that masks reduce COVID-19 transmission.

You may be surprised to hear this doctor admit that.

Today, I want to examine a recent study that hails the effectiveness of masking.

The big reveal: We need more rigorous investigations to determine the precise role of paper surgical masks in mitigating the spread of the virus.

A New Study

Atle Freithem and colleagues report the results of a pragmatic randomized control trial in the British Medical Journal:

Personal protective effect of wearing surgical face masks in public spaces.

www.bmj.com.

The take-home message is this:

Wearing a surgical mask for two weeks during the winter of 2023 reduced the spread of self-reported viral illness.

This research proves that paper masks work, right?

Study Details

Purpose: This study aimed to see if wearing a surgical mask in public places like stores, streets, and public transport for two weeks could protect people from getting sick with respiratory infections like colds or the flu.

How the study worked: Researchers randomly divided almost 4,700 adults in Norway into two groups. They told one group of participants to wear surgical masks in public for two weeks while asking the other group not to.

What researchers examined: The scientists were mainly interested in whether people got sick with respiratory infections. They also looked at whether people reported getting COVID-19 or had it confirmed by a doctor.

Important note: The investigators did not tell subjects to wear masks at home or work, only when in public.

Study Results

Here are the study results:

Over the study period, about 9 percent of those who wore masks reported cold or flu-like symptoms, compared to 12 percent of those who didn’t.

This finding suggests that wearing masks might slightly lower your chances of contracting a respiratory infection.

My Take

First, kudos to the researchers for completing a practical, randomized clinical trial evaluating paper mask effectiveness.

We can do randomized clinical trials in the COVID-19 realm.

Second, the study does not prove that paper masks reduce COVID-19 transmission.

Many people believe masks are effective, and this study didn’t use a placebo or fake mask to account for that belief.

The results may reflect that people feel better because they wear a mask rather than a mask that prevents illness.

We Need Studies With Objective Measures

I hope we get a study that uses objective measures of infection.

I wish the authors had used regular virus tests or blood tests checking for COVID-19 antibodies.

And mandated mask wearing for more than a couple of weeks.

The study, as conducted, tells us that people wearing masks reported fewer illnesses, not that they were actually sick less often or felt better overall.

While the study didn’t find a benefit in confirmed COVID-19 cases, it might not have been large enough to detect a small difference.

Bottom Line

This study does not prove masks reduce COVID-19 transmission; the study’s primary endpoint was self-reported illness.

After so much trumpeting of the value of paper masks to reduce COVID-19 contagiousness, we still need high-level evidence to convince me.

Per my hospital’s mandate, I will continue to don my paper mask faithfully in designated places in my workplace.

But am I better off donning a mask year after year for a virus that has diminished in lethality for healthy individuals like me?

If I had a big upcoming event, I would wear an N-95 mask.

Many counterfeit N-95 and K-95 masks are out there, and many don’t fit them properly.

But that is another story.

Do you regularly wear a paper surgical mask? What motivates you to do so?

Effectiveness of Face Mask or Respirator Use.

This report describes face mask or respirator effectiveness in helping protect against COVID-19 infection.

www.cdc.gov.

The post Do Surgical Masks Protect You Against COVID? appeared first on Medika Life.

Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to go home.

At the time, she could not walk more than a few feet, even with assistance — let alone manage the stairs to her front door, she said. She still needed help using a colostomy bag following major surgery.

“How could they make a decision like that without ever coming and seeing me?” said Sullivan, 76. “I still couldn’t walk without one physical therapist behind me and another next to me. Were they all coming home with me?”

UnitedHealthcare — the nation’s largest health insurance company, which provides Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. It does have naviHealth, a care management company bought by UHC’s sister company, Optum, in 2020. Both are part of UnitedHealth Group. NaviHealth analyzes data to help UHC and other insurance companies make coverage decisions.

Its 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.

But 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.

“When an algorithm does not fully consider a patient’s needs, there’s a glaring mismatch,” said Rajeev Kumar, a physician and the president-elect of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. “That’s where human intervention comes in.”

The federal government will try to even the playing field next year, when the Centers for Medicare & Medicaid Services begins restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.

Medicare Advantage plans, an alternative to the government-run, original Medicare program, are operated by private insurance companies. About half the people eligible for full Medicare benefits are enrolled in the private plans, attracted by their lower costs and enhanced benefits like dental care, hearing aids, and a host of nonmedical extras like transportation and home-delivered meals.

Insurers receive a monthly payment from the federal government for each enrollee, regardless of how much care they need. According to the Department of Health and Human Services’ inspector general, this arrangement raises “the potential incentive for insurers to deny access to services and payment in an attempt to increase profits.” Nursing home care has been among the most frequently denied services by the private plans — something original Medicare likely would cover, investigators found.

After UHC cut off her nursing home coverage, Sullivan’s medical team agreed with her that she wasn’t ready to go home and provided an additional 18 days of treatment. Her bill came to $10,406.36.

Beyond her mobility problems, “she also had a surgical wound that needed daily dressing changes” when UHC stopped paying for her nursing home care, said Debra Samorajczyk, a registered nurse and the administrator at the Bishop Wicke Health and Rehabilitation Center, the facility that treated Sullivan.

Sullivan’s coverage denial notice and nH Predict report did not mention wound care or her inability to climb stairs. Original Medicare would have most likely covered her continued care, said Samorajczyk.

Sullivan appealed twice but lost. Her next appeal was heard by an administrative law judge, who holds a courtroom-style hearing usually by phone or video link, in which all sides can provide testimony. UHC declined to send a representative, but the judge nonetheless sided with the company. Sullivan is considering whether to appeal to the next level, the Medicare Appeals Council, and the last step before the case can be heard in federal court.

Sullivan’s experience is not unique. In February, Ken Drost’s Medicare Advantage plan, provided by Security Health Plan of Wisconsin, wanted to cut his coverage at a Wisconsin nursing home after 16 days, the same number of days naviHealth predicted was necessary. But Drost, 87, who was recovering from hip surgery, needed help getting out of bed and walking. He stayed at the nursing home for an additional week, at a cost of $2,624.

After he appealed twice and lost, his hearing on his third appeal was about to begin when his insurer agreed to pay his bill, said his lawyer, Christine Huberty, supervising attorney at the Greater Wisconsin Agency on Aging Resources Elder Law & Advocacy Center in Madison.

“Advantage plans routinely cut patients’ stays short in nursing homes,” she said, including Humana, Aetna, Security Health Plan, and UnitedHealthcare. “In all cases, we see their treating medical providers disagree with the denials.”

UnitedHealthcare and naviHealth declined requests for interviews and did not answer detailed questions about why Sullivan’s nursing home coverage was cut short over the objections of her medical team.

Aaron Albright, a naviHealth spokesperson, said in a statement that the nH Predict algorithm is not used to make coverage decisions and instead is intended “to help the member and facility develop personalized post-acute care discharge planning.” Length-of-stay predictions “are estimates only.”

However, naviHealth’s website boasts about saving plans money by restricting care. The company’s “predictive technology and decision support platform” ensures that “patients can enjoy more days at home, and healthcare providers and health plans can significantly reduce costs specific to unnecessary care and readmissions.”

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.”

The CMS-required notices nursing home residents receive now when a plan cuts short their coverage can be oddly similar while lacking details about a particular resident. Sullivan’s notice from UHC contains some identical text to the one Drost received from his Wisconsin plan. Both say, for example, that the plan’s medical director reviewed their cases, without providing the director’s name or medical specialty. Both omit any mention of their health conditions that make managing at home difficult, if not impossible.

The tools must still follow Medicare coverage criteria and cannot deny benefits that original Medicare covers. If insurers believe the criteria are too vague, plans can base algorithms on their own criteria, as long as they disclose the medical evidence supporting the algorithms.

And before denying coverage considered not medically necessary, another change requires that a coverage denial “must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the service at issue.”

Jennifer Kochiss, a social worker at Bishop Wicke who helps residents file insurance appeals, said patients and providers have no say in whether the doctor reviewing a case has experience with the client’s diagnosis. The new requirement will close “a big hole,” she said.

The leading MA plans oppose the changes in comments submitted to CMS. Tim Noel, UHC’s CEO for Medicare and retirement, said MA plans’ ability to manage beneficiaries’ care is necessary “to ensure access to high-quality safe care and maintain high member satisfaction while appropriately managing costs.”

Restricting “utilization management tools would markedly deviate from Congress’ intent in creating Medicare managed care because they substantially limit MA plans’ ability to actually manage care,” he said.

In a statement, UHC spokesperson Heather Soule said the company’s current practices are “consistent” with the new rules. “Medical directors or other appropriate clinical personnel, not technology tools, make all final adverse medical necessity determinations” before coverage is denied or cut short. However, these medical professionals work for UHC and usually do not examine patients. Other insurance companies follow the same practice.

David Lipschutz, associate director of the Center for Medicare Advocacy, is concerned about how CMS will enforce the rules since it doesn’t mention specific penalties for violations.

CMS’ deputy administrator and director of the Medicare program, Meena Seshamani, said that the agency will conduct audits to verify compliance with the new requirements, and “will consider issuing an enforcement action, such as a civil money penalty or an enrollment suspension, for the non-compliance.”

Although Sullivan stayed at Bishop Wicke after UHC stopped paying, she said another resident went home when her MA plan wouldn’t pay anymore. After two days at home, the woman fell, and an ambulance took her to the hospital, Sullivan said. “She was back in the nursing home again because they put her out before she was ready.”

The post Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients appeared first on Medika Life.

But what if an error is made and propagated to the records in other facilities and keeps propagating again and again and again? The error becomes harder to untangle from the original database and all the others that quickly incorporated it in the interests of medical care.

Consider how one drop-down menu mistake for a patient’s medication might introduce bias in treatment into the record. But who would know it was a mistake if the patient never saw their record and felt there was no reason to ask for a copy?

The law is on the patient’s side, but facilities may not always be so willing to release the records. There is an exception where the facility could argue that the information would somehow harm the patient. Harmful to know what’s in your record? Are we children? How and when can a patient be refused access?

With limited exceptions, the HIPAA Privacy Rule (the Privacy Rule) provides individuals with a legal, enforceable right to see and receive copies upon request of the information in their medical and other health records maintained by their health care providers and health plans.

If you want more information on HIPAA regulations and your rights, there is material, and you can also file a complaint online.

How might inaccurate information be placed in your EHR? Many medications have similar names, and there may be two names for the same drug (brand name and generic). If personnel are unfamiliar with all the names and select the wrong one from the computer drop-down menu, your record has that error in it. But would that be a significant problem for you? I think it might.

Medications for psychiatric disorders, if entered into your record as a prior medication or one to which you had an AE (adverse event/allergy), staff reviewing your record will see it. Healthcare personnel is as fallible and biased as anyone else, and they may make certain assumptions about your mental state.

Any other medications that may have been entered incorrectly could also affect the treatments or drugs used in someone’s care. In any case, errors must be corrected, and the facilities that house them in their databases are required to make the adjustments.

Should everyone request a complete copy of their medical records? It’s a personal choice, but keeping your records ensures that you know what is in them, and you can have peace of mind knowing there are no untoward errors about which you were unaware.

Previously, requesting these records meant paying at least $1/page in some states, but today the entire thing can be burned onto a CD/DVD or put on a thumb drive. It’s not cumbersome and can easily be scanned for material information you want to select within the file. Remember that “pdf” documents have that “find” feature.

Obtaining medical records for yourself, a child, or a family member requires that you know the procedures. Here is a website that provides much of this information.

Have you looked at your medical records lately?

The post Unearth Your Medical Records And Be Prepared For Surprises appeared first on Medika Life.

Erin Reynolds had battled bulimia since childhood, but the weeks before she entered treatment were among her worst. At 22, she was preparing to leave her home in Helena, Montana, for an inpatient program in New Jersey with round-the-clock medical care.

Looking back six years later, Reynolds said seeking help was one of the most difficult parts of the recovery process. “I just kept bingeing and purging because I was so stressed,” she said. “I’m leaving my job that I love, leaving all my friends and my town and saying goodbye to normal life.”

Eating disorders, including anorexia, bulimia, and binge-eating disorder, are some of the most fatal mental illnesses. Yet treatment options are sparse, particularly in rural states such as Montana.

Emergency department visits for teenage girls dealing with eating disorders doubled nationwide during the pandemic, according to a study from the Centers for Disease Control and Prevention. The same report notes that the uptick could be linked to reduced access to mental health services, a hurdle even more acute in rural states.

The National Eating Disorders Association’s provider database shows only two certified providers across all of Montana, the country’s fourth-largest state as measured by square miles. By comparison, Colorado, which is nearly three-quarters of the size of Montana but has five times the population, shows nine providers.

That means many people like Reynolds must leave Montana for treatment, particularly true for those seeking higher levels of care, or drive for hours to attend therapy. It also means more individuals go untreated because they lack the flexibility to give up a paying job or leave loved ones behind.

“A lot of people are not able to access treatment, just given the geography and vast ruralness of the state,” said Caitlin Martin-Wagar, a University of Montana assistant professor and psychologist who specializes in eating disorder research.

The most intense treatment involves inpatient or partial hospitalization programs, best for those in need of round-the-clock care and acute medical stabilization. Residential treatment is a step down from there, usually outside a hospital setting at a place akin to a rehab facility.

Once a person in recovery can manage with less hands-on care, a variety of outpatient options may include therapy, meal support, or group counseling. “Finding people with those specialties and availability is often a challenge,” said Lauren Smolar, vice president of mission and education at the eating disorders association.

When Reynolds sought treatment in 2016, not one facility in Montana offered inpatient care, residential treatment, or partial hospitalization. Only one came close: the Eating Disorder Center of Montana, a treatment program based in Bozeman and established in 2013.

Jeni Gochin, who co-founded the center, said there were many barriers to starting an eating disorder treatment facility in Montana, where there were none. There was no licensure process, and challenges abounded, from insurance coverage to the high level of specialization required to provide appropriate care.

The Eating Disorder Center of Montana added a partial hospitalization program in 2017, which provides housing for out-of-towners and requires five to seven days of nearly all-day treatment programming led by a team of experts. The center also plans to open an outpatient therapy facility 200 miles west in Missoula later this year.

A third of people with eating disorders are men, a group that is underdiagnosed and undertreated. Although Black, Indigenous, and other people of color are no less likely to develop an eating disorder, they are half as likely to be diagnosed or receive treatment.

A few studies have shown a higher rate of eating disorders in urban centers, but it’s difficult to know whether that’s due to reduced stigma and more treatment options in metropolitan areas compared with rural settings.

“We know eating disorder rates are quite high,” Martin-Wagar said. “We’ve been seeing them rise pretty consistently, so this isn’t a niche or specialty issue. It’s something that’s impacting lots and lots of folks.”

The pandemic has made telehealth treatment options more common, which could relieve bottlenecks at treatment facilities. For example, the Eating Disorder Center of Montana is launching virtual outpatient care for any Montana resident this month. Emily Wish treatment center in Great Falls, Montana, provides telehealth appointments for individual, family, and group therapy. But telehealth treatment for eating disorders is limited in its effectiveness. Many interventions are best in person, such as meal support and helping people establish healthier patterns around eating.

Cost is a barrier to treatment everywhere, but especially in a place like Montana, where about 1 in 5 residents are covered by Medicaid or Healthy Montana Kids, the state’s Children’s Health Insurance Program. It can cost thousands of dollars and take many months for a person to receive adequate care, whether a person is insured or not. And there’s no formula to know how long treatment will take, or how many times a patient will have to move up and down the ladder of levels of care.

Few insurance companies provide meaningful coverage. Their reimbursement might time out after only a few weeks — far sooner than the average course of treatment takes — or not cover it at all.

Martin-Wagar, the University of Montana researcher, said that eating disorder research also receives very little funding relative to other mental health concerns. Without federal and state dollars going directly into treatment and research, eating disorder symptoms can’t be identified early in adolescents, the easiest way to drive down the costs of overall treatment; stigma is harder to combat; and there’s little incentive for new providers to create treatment programs in places outside urban areas with well-documented demand.

“Even if we create more eating disorder centers, if people can’t afford them, then we are only servicing the most privileged in our society,” Martin-Wagar said. “And that means we are not doing a good job.”

The post As Eating Disorders Spike During Pandemic, Rural Treatment Options Lag appeared first on Medika Life.