Elham Mirshafiei was at the library cramming for final exams during her senior year at California State University, Long Beach when she grew nauseated and started vomiting. After the 10th episode in an hour, a friend took her to the nearest emergency room. Diagnosis: an intestinal bug and severe dehydration. In a few hours, she was home again, with instructions to eat a bland diet and drink plenty of fluids.

That was in 2010. But the $4,000 bill for the brief emergency department visit at an out-of-network hospital has trailed her ever since. Mirshafiei, 31, has a good job now as a licensed insurance adviser in Palo Alto, Calif. But money is still tight, and her priority is paying off her $67,000 student loan debt rather than that old hospital bill.

Once or twice a year she gets a letter from a collection agency. She ignores the letters, and so far the consequences have been manageable. “It’s not like electricity that gets cut off if you don’t pay it,” she says.

Mirshafiei has plenty of company. At least 43 million other Americans have overdue medical bills on their credit reports, according to a 2014 report on medical debt by the federal Consumer Financial Protection Bureau. And 59% of people contacted by a debt collector say the exchange was over medical bills, the most common type of contact stemming from an overdue bill, according to the CFPB.

This month, the CFPB proposed a rule to frame what debt collectors are allowed to do when pursuing many types of overdue bills, including medical debt.

Federal law already prohibits debt collectors from harassing consumers or contacting them before 8 a.m. or after 9 p.m., among other things. But the law, which was passed in 1977, didn’t anticipate email and text messages. The CFPB’s proposal clarifies how debt collectors can use these communication tools. And it would allow consumers to opt out of being contacted through these means.

The rule also specifies that debt collectors can make no more than seven telephone calls weekly over a specific debt.

But some consumer advocates have panned the effort. “This really doesn’t go far enough to protect consumers and make sure that consumers are not abused or harassed or subject to unfair collection practices in debt collection,” says April Kuehnhoff, an attorney at the National Consumer Law Center who specializes in debt collection.

For instance, the center wants a limit of just three telephone attempts each week on a debt. The seven-call limit could be particularly tough on people with medical debt, Kuehnhoff said. They may accumulate bills from several providers for a single medical event — a hospital, doctors, a lab and a nursing home, for example — and all could be in collections separately, potentially resulting in dozens of calls each week.

Debt collectors aren’t necessarily in favor of the seven-call cap either, but for different reasons. They say that limiting the number of calls could lead to more litigation or adverse credit reporting rather than working out a payment plan.

Overall, the proposed rule seems to strike a good balance between the collection industry and consumer concerns, says Leah Dempsey, vice president and senior counsel for federal affairs at ACA International, a trade group representing 2,500 debt collectors, asset buyers and related professions.

The general consensus is that people should pay their debts. But taking responsibility for medical debt isn’t always as straightforward as paying off a large-screen TV that someone put on a credit card. Did health insurance pay the correct amount? Was the person screened for eligibility for Medicaid, charity care or financial assistance?

“The actual debt collector problem is often about the lack of accountability that providers have for the people that they pass their debt along to,” says Leonardo Cuello, director of health policy at the National Health Law Program.

When a debt collector calls, consumers who are confused about the bill should ask — in writing and generally within 30 days — that the debt be validated. Debts are often bundled and sold multiple times to different collectors, which means errors may be introduced along the way.

“There are no magic words. You don’t need to cite the statute,” says Justin J. Lowe, legal director at Health Law Advocates, a nonprofit law firm in Boston that helps people with low incomes who are having trouble accessing or paying for medical care.

At that point, the collection agency has to stop activities until it proves what the consumer owes. The proposed CFPB rule would spell out verification information that must be provided along with instructions for consumers about how to dispute the debt.

The proposal would also address other practices, including the collection of what is sometimes called zombie debt. That term refers to a bill that has passed a time limit — or statute of limitations — for bringing legal action, often between three and six years, depending on the state. In many states, if a collector sues someone for such a time-barred debt, consumers can raise the issue in court in their defense. If a judge agrees, the case could be dismissed.

Consumer advocates have long wanted debt collectors to be prohibited from trying to collect zombie debt. After several years, it can be difficult for patients to locate records or remember whether a bill has been paid, they argue.

The proposed CFPB rule would prohibit debt collectors from suing or threatening to sue consumers for zombie debt, but only if the collectors knew or should have known that the statute of limitations had expired. That puts the onus on the consumer to prove what was in the debt collector’s mind rather than merely show that too much time had passed to collect.

As the federal government moves ahead with the rule to address various types of debt collection activities, legislators in a few states have introduced bills that specifically target medical debt. Their efforts often focus on improving access to financial assistance for medical care and limiting predatory debt collection tactics.

Last month, Washington Gov. Jay Inslee signed a law that reduces the maximum interest rate on medical debt prior to a court judgment from 12% to 9%. It also prohibits sending a medical debt to collections until 120 days after the patient is sent the initial bill, and it requires collection agencies to provide itemized statements to patients for medical and hospital debts and to notify them of their possible eligibility for charity care.

In Oregon, a bill sponsored by Rep. Andrea Salinas would require nonprofit hospitals and affiliated clinics to provide care free of charge to families with incomes up to 200% of the federal poverty level (about $43,000 for a family of three) and charge a sliding scale for families earning up to 400% of the poverty level (about $85,000 for a three-person family).

Like the Washington law, the Oregon bill places limits on the interest charged for medical debt. It also requires health care facilities to screen patients for eligibility for financial assistance and insurance.

The bill passed the House in Oregon last week.

Some hospitals already have strong financial assistance policies, but the playing field needs leveling, Salinas says. “We really need hospitals to be a part of the solution to prevent consumers from going into bankruptcy over medical debt.”

It’s unclear how the proposed changes announced by the CFPB might affect Mirshafiei’s situation. The statute of limitations in California on written contracts is four years.

One thing someone in Mirshafiei’s situation should be aware of is that making a payment could reset the statute of limitations, Lowe says. The debt collector could argue that by making a payment, the person is affirming that he or she owes the debt.

Because of her damaged credit, Mirshafiei needed a relative to cosign for student loans for graduate school. She worries that if she tries to buy a house, she’ll have trouble getting approved.

“I just hope that in the next chapter of my life, I don’t have to be denied things because of this stain on my record,” she says.

Kaiser Health News is an editorially independent nonprofit program of the Kaiser Family Foundation and is not affiliated with Kaiser Permanente.

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If you’ve ever had a little one at home with a fever, you might have noticed two options for Tylenol at the store.

There’s one for infants and one for children. They’re contain the same amount of medicine — 160 milligrams of acetaminophen per 5 milliliters of liquid — but the infant version costs three times more.

What gives? It turns out, there’s a backstory.

For decades, Infants’ Tylenol was stronger than the children’s version. The thinking was that you don’t want to give babies lots of liquid medicine to bring down a fever — so you can give them less if it’s stronger.

“It was three times more concentrated,” says Inma Hernandez of the University of Pittsburgh School of Pharmacy. Since it contained more acetaminophen, the active ingredient, she says, it made sense that it was also more expensive. “The price per milliliter was five times higher,” Hernandez says.

But there was a problem: Parents were making mistakes with dosing. Babies got sick — some even died. So in 2011, at the urging of the Food and Drug Administration, the maker of brand-name Tylenol, Johnson & Johnson, announced a change: Infants’ Tylenol would be the same concentration as Children’s Tylenol.

Now it’s the same medicine, but the price is still different

A quick search online shows 4 ounces of Children’s Tylenol selling for $5.99, and Infants’ Tylenol also selling for $5.99, but for only 1 ounce of medicine. With many store brands of acetaminophen, it’s the same story: The infant version is generally three times more expensive than the one for children.

Kim Montagnino of Johnson & Johnson said in a statement to NPR that Infants’ Tylenol is more expensive because the bottle is more sturdy and it includes a dosing syringe, instead of a plastic cup. “These safety features of Infants’ Tylenol (dosing syringe, rigid bottle) are more expensive to manufacture than the dosing cup and bottle for Children’s Tylenol,” Montagnino wrote.

Hernandez doesn’t buy it.

“The cup versus the syringe doesn’t really explain the price difference in my opinion,” Hernandez says. “They’re really cheap because they’re just plastic. When we think of what’s expensive in a drug, it’s actually the active ingredient, and the preparation of that active ingredient in the formulation, not the plastic cup or the syringe.”

But Johnson & Johnson’s explanation makes sense to Edgar Dworsky, a consumer advocate and founder of the website Consumer World. “There’s an extra thing in the box, and extra things usually cost money,” he says.

“Think of a spray cleaner. You can buy the spray cleaner in the spray bottle, and that costs a little more money. Or you can buy the refill that gives you more ounces but it doesn’t have the sprayer on top — it’s kind of the same concept.”

But this, of course, is not a spray cleaner. It’s medicine. And parents are sensitive to marketing because the stakes are so high.

“I would certainly imagine that product-makers know that parents want to be very cautious when buying products for their kids,” Dworsky says. “Really, the lesson is — read the label. See what you’re getting for your money.”

Pediatrician Ankoor Shah at Children’s National Health System in Washington, D.C., knows how confusing all of this is for parents because he gets tons of questions from them about over-the-counter medications.

“The packaging and the dosing is not easy, it’s not simple and — personal opinion — it’s not parent-friendly,” Shah says.

For instance, Infants’ Tylenol doesn’t say on the label what the correct dosing is for a baby under age 2. It just says “ask a doctor.” Shah says he still uses a calculator to figure out how much to give a child, based on their weight, and gives slips to parents at kids’ well visits. You can also find the information from reputable sources online.

He says whether you opt for the Children’s or Infants’ bottle of acetaminophen at the store, the most important thing is to get the dosing right.

“When you start giving more acetaminophen than recommended, there are serious side effects that could happen,” he says.

The bottom line is: Know what you need. And if you need to spend that extra couple of dollars for the syringe and the special bottle to get the dosing just right, maybe the markup is worth it.

If you think you might have inadvertently overdosed a child, contact your doctor or call your local poison control center. There are 55 poison control centers across the U.S.; all of them can be reached at the same hotline number: 1-800-222-1222.

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I had always imagined going through pregnancy surrounded by family and friends. But when I found out I was pregnant, my husband, Alex Gourse, and I had just moved from San Francisco to Chicago. I knew almost no one.

I ended up finding a community where I least expected it: at a medical office.

CenteringPregnancy is group prenatal care offered by more than 600 practices across the United States. Rather than the standard 15-minute individual visits in an exam room, women who are due around the same time and their partners meet as a group for two hours with a clinician, usually a midwife.

In other words, take one of the most intimate chapters in a couple’s life and have the two experience it with a bunch of strangers.

I was wary. It seemed like a convenient way to cram more patients through the door and give them less attention. But when, at my first prenatal visit at Northwestern Medicine, midwife Carol Hirschfield told me that the practice happened to be launching its first CenteringPregnancy group, I figured it might be a good way to meet people.

That turned out to be the best decision we made during the pregnancy.

We met up in the early morning on Thursdays, often bleary-eyed from another night of bad pregnancy sleep. The moms each stopped first for a quick weight and blood pressure check, and then we all gathered in a classroom that had previously been an operating suite. Seven couples were in my group, though there can be 10 or more.

One by one, each couple slipped behind a curtain in a corner of the room for a brief medical exam with one of the two midwives who led the group. Our bellies were measured, the babies’ heartbeats were checked and we had a moment to share any major symptoms.

Meanwhile, the rest of the group milled around the main part of the room, a bit awkwardly at first. If we’d been in a waiting room for standard appointments, we might not have given one another more than a nod. But here, munching on banana bread baked by the midwives, we quickly discovered how much the experience of pregnancy gave us in common. Soon we were chatting about the struggles of no longer being able to sleep on our backs, the best pregnancy pillow to buy and the importance of foot rubs from our partners.

After the exams, we gathered in a circle of chairs to talk about all the crazy things happening to our bodies. In the very first activity, the midwives handed out laminated cards with pregnancy symptoms written on them — things like swollen feet or food cravings. We were to go around and read our symptom and then share whether it was something we had experienced. The very first card to be shared: vaginal discharge. And, with a few giggles, the ice was broken.

We met monthly at first and then more frequently as we got closer to our due dates. The curriculum was based on workbooks created by the Centering Healthcare Institute in Boston and was focused on topics like nutrition, relationships, labor and delivery, and newborn care. We often started with a breathing exercise or a short icebreaker, followed by prompts and games to encourage us to share the details of our experiences and fears and to teach us how to take care of ourselves and prepare for our new lives as parents.

It didn’t take much to get us talking, laughing and commiserating. Sometimes it felt a lot like a support group, and that’s part of the point. The goal of CenteringPregnancy is to provide medical care and to educate but also to reduce stress and isolation, which can contribute to poor birth outcomes.

Years of studies — many focusing on teen and low-income moms — have found that babies born to women in CenteringPregnancy groups are less likely to be premature, be underweight or spend time in the intensive care unit. A 2016 study of a South Carolina program, for example, found that participating in CenteringPregnancy reduced the risk of premature birth by 36%. And that saved money — an average of $22,667 for every premature birth prevented under Medicaid, the state’s health insurance program for the poor. Typically, the patient’s insurance company will not know they have been a part of a Centering group, which is billed as standard prenatal care.

The CenteringPregnancy program was started in 1993 in Connecticut by midwife Sharon Schindler Rising, who was frustrated that she had to rush through patients’ exams. Over the past five years, the number of practices that offer Centering has nearly doubled to 600; midwives still lead most of the groups. About half are in community health centers that serve mainly low-income women, but private practices like Northwestern have also started programs.

“I’ve been out-of-my-mind excited with how this has gone,” Hirschfield told me one day in her office. “I end every group by saying, ‘Oh my God, they’re learning so much more than our — quote-unquote — regular patients.’ “

Hirschfield said she was surprised by how open people have been about their lives, sexual relationships and bodies. “There just isn’t time for that when you have 15 minutes every couple of weeks to just really listen to the heartbeat and take your blood pressure and ask how your back is feeling.” If participants had additional questions or concerns, we could schedule separate individual visits or reach out via email.

Ariel Yellin Derringer, the other midwife who led our group, told me that so far, “the biggest positive outcome here is the growth of community — having people go through the most difficult transition in their life with other women going through the same thing.”

She said it also has been rewarding professionally. “We do so much educating during one-on-one prenatal care, and sometimes I feel like a broken record,” Derringer said. “I think, ‘I could have done this with eight to 10 people and taken it three levels deeper, but we just don’t have the time to do that.’ “

The practice has now had a year’s worth of experience with the program, and Derringer said it has been easy to recruit patients to participate. So far, most of the sessions have been full. “My vision in the future is really an opt-out as opposed to an opt-in,” she said.

I worried at first that I might miss one-on-one attention during group visits. What I found instead was the Chicago tribe I’d been seeking. I managed to make it to our group’s final session on our first day after leaving the hospital. Our son was one of the three brand-new humans in attendance.

We all went around in a circle and shared what the experience had meant for us. “You don’t feel as alone or neurotic when you can talk about things and everyone else is going through the same thing,” said Grace Tuman. She surprised herself by getting teary as she spoke. I felt the same way.

We moved back to California just two months later, but it didn’t mean the end of our group. Instead, we went from a pregnancy crew to a parenting crew, commiserating over email about nighttime wakings and reminding each other to breathe in the midst of the chaos. In April, my family flew back to Chicago to attend a reunion during a snowstorm. Even the midwives showed up.

It’s a long way to travel, but this little community, forged at a medical office, is one I’m hoping to be a part of for a long time to come.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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As nearly 7.5 million Americans contend with covering the skyrocketing costs of insulin to manage the disease, diabetics in Colorado will soon have some relief.

A new law, signed by Gov. Jared Polis earlier this week, caps co-payments of the lifesaving medication at $100 a month for insured patients, regardless of the supply they require. Insurance companies will have to absorb the balance.

The law also directs the state’s attorney general to launch an investigation into how prescription insulin prices are set throughout the state and make recommendations to the legislature.

Colorado is the first state to enact such sweeping legislation aiming to shield patients from dramatic insulin price increases.

“One in four type 1 diabetics have reported insulin underuse due to the high cost of insulin … [t]herefore, it is important to enact policies to reduce the costs for Coloradans with diabetes to obtain life-saving and life-sustaining insulin,” the law states.

The price of the drug in the U.S. has increased exponentially in recent years. Between 2002 and 2013, it tripled, according to 2016 study published in the medical journal JAMA. It found the price of a milliliter of insulin rose from $4.34 in 2002 to $12.92 in 2013. And a March report from the House of Representatives, found “prices continued to climb, nearly doubling between 2012 and 2016.”

Dramatic price hikes have left some people with Type 1 and Type 2 diabetes who use insulin to control their blood sugar levels in the unfortunate position of making dangerous compromises. They either forego the medication or they ration their prescribed dose to stretch it until they can afford the next prescription.

In some instances, those compromises can lead to tragedy. As NPR reported, an uninsured Minnesota man who couldn’t afford to pay for $1,300 worth of diabetes supplies, died of diabetic ketoacidosis, according to his mother. The man, who was 26, had been rationing his insulin.

The move in Colorado comes on the heels of recent commitments by manufacturers to limit the drug’s cost to consumers, which in turn comes on the heels of mounting pressure (and some skewering) from elected officials.

Following a U.S. Senate Finance Committee hearing in February and a subcommittee hearing in the House in April, pharmaceutical company leaders have reluctantly admitted they have a role to play in reducing drug prices.

Last month Express Scripts, one of the largest pharmacy benefit managers in the country, announced it is launching a “patient assurance program” that will place a $25 per month cap on insulin for patients “no matter what.”

In March, insulin manufacturer Eli Lilly said it will soon offer a generic version of Humalog, called Insulin Lispro, at half the cost. That would drop the price of a single vial to $137.35.

“These efforts are not enough,” Inmaculada Hernandez of the University of Pittsburgh School of Pharmacy tells NPR, of the latest legislation in Colorado.

Hernandez was lead author of a January report in Health Affairs attributing the rising cost of prescription drugs to accumulated yearly price hikes.

While the Colorado out-of-pocket caps will likely provide financial relief for diabetes patients, she noted “the costs will kick back to all of the insured population” whose premiums are likely to go up as a result.

“Nothing is free,” Hernandez said.

“It also doesn’t fix the real issue,” she added, pointing to her own research which found “that prices have increased because there’s not enough competition in the market, demand will always be high and manufacturers leverage that to their advantage.”

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