Lambda Legal seeking policy info on transplanting HIV patients from 12 top US health insurance companies.(Lambda Legal Defense and Education Fund) - Transplant News

Twelve of the nation's top health insurance companies have received letters from a gay/lesbian civil rights group asking them to release their policies for covering organ transplants for patients with HIV.

'We are hearing from more and more people with HIV who are being denied life-saving transplants, despite medical and scientific standards. These insurance companies have a duty to clearly tell people where they stand,' the Lambda Legal Defense and Education Fund said in a press release announcing the new drive.

Lambda Legal said its HIV Project has worked with a number of people who were denied coverage for transplants simply because they have HIV-even though more than a decade of scientific and medical research shows that organ transplants for people with HIV are effective and safe.

The organization, the oldest and largest legal organization in the US dedicated to the civil rights of lesbians, gay men, and people with HIV and AIDS, sent letters in mid-November to 12 of the top health insurance companies, asking for copies of their policies for people with HIV. The companies include Assurant, Aetna, Aflac, Anthem, BlueCare, Cigna, Healthnet, Humana, PacifiCare, United Health, Wellpoint and Wellchoice. None had responding with existing or new policies when the press release was issued on November 30.

'HIV itself isn't necessarily a death sentence any more-but it becomes one when health insurance companies refuse to let people have the transplants they need,' said Kevin Cathcart, executive director of Lambda Legal.

Cathcart cited the case of a 46-year-old Pennsylvania man with HIV and Hepatitis C who was denied a transplant even thought he had been accepted as a candidate by the Thomas E. Starzl Transplant Institute in Pittsburgh. William Gene Gough's transplant request for coverage was denied because Medicaid said the transplant was not 'necessary.'

Lambda appealed on Gough's behalf and an administrative law judge reversed the decision within days. 'William Jean Gough got a new liver 8 months ago, and he might not be alive today without it,' Cathcart said.

Prior to winning Gough's appeal, Lambda Legal had been successful in persuading Kaiser Permanente to overturn its decision to deny a kidney transplant to John Carl, a Colorado man with HIV.

'We have no idea exactly how many other people with HIV are in William and John's situation, but we know that these insurance companies have millions of customers,' Cathcart said. 'We are determined to get these insurance companies on record so that people with HIV know whether they'll be covered when their lives depend on it-and so that the public knows just where these companies stand.'

NONAPPROPRIATED FUND EMPLOYEES ELIGIBLE FOR NEW HEALTH INCENTIVE CREDIT - US Fed News Service, Including US State News

SAN ANTONIO, Feb. 25 -- The U.

S. Air Force issued the following press release:

Nonappropriated fund federal employees who participate in the NAF Department of Defense Health Benefits Program are now eligible to earn a health incentive credit.

Beginning Jan. 1, health plan participants may earn a $100 health incentive credit when they complete the Simple Steps to a Healthier Life online health assessment or complete a routine physical exam. Participating family members may also earn the credit.

For a family of two the maximum credit is $200, and for a family of three or more, the maximum credit is $300. The credit will be automatically applied to the next deductible or co-insurance expense. Co-insurance is the percentage of the covered expenses paid after the calendar year deductibles are met.

The incentive does not apply to co-pays. Any credit remaining at the end of the health plan year will roll over to the next year, for up to three years.

To access the health assessment, visit www.aetna.com and log in to the Aetna Navigator by selecting 'Member Log In.' More details are available in the 'Your Life, Your Health 2011 Health Benefits Program' open enrollment booklet.

More information about NAF employee benefits can be found at http://www.cpms.osd.mil/nafppo or through a local human resource office. To apply for a NAF job, visit www.

US Medicare HMO/PBM political funds slammed.(health maintenance organizations)(pharmacy benefit managers) - Pharma Marketletter

The 10 health maintenance organizations and pharmacy benefit managers approved by the Bush Administration to receive US Medicare prescription drug contracts contributed $6.5 million to federal lawmakers since 2000, claims consumer advocacy group the Foundation for Taxpayer and Consumer Rights. Members of the House of Representatives received over half this total, at $3.4 million, 80% going to Republicans, it adds.

The 10 firms awarded national contracts will likely keep 15%-20% ($90.0-$120.0 billion) of the $600.0 billion earmarked for the Medicare drug program over the next 10 years for overheads, advertising, executive salaries and profit and, as a result, seniors and taxpayers will pay more for prescription drugs, the group claims. In contrast, Medicare's overhead costs are roughly 3%, it adds.

Wyden 'has enough Senate votes to pass govt Rx price negotiation powers'

Recently, Democratic Senator Ron Wyden said he had enough votes in the Senate for a measure to allow Medicare to use its bargaining power to negotiate discounts, thus bypassing HMOs and PBMs and lowering costs of prescription drugs, the FTCR points out. It adds that most of the private companies offering Medicare drug coverage will negotiate volume discounts with firms but charge Medicare for overheads and profit.

Using data from the Federal Elections Commission, the FTCR estimates that the six HMOs - Aetna, Cigna Coventry Health, PacifiCare, WellPoint/UniCare, UnitedHealth and WellCare - and four PBMs - Medco Health Solutions, MemberHealth, SilverScript/Caremark and MedCo - approved for US-wide contracts, had contributed, during the period:

- $6.5 million to Congressional candidates and political action committees since 2000, including $988,135 in first-half 2005, with 75% of this total being provided to Republican candidates and Republican-affiliated PACs, 25% to Democratic candidates and Democratic-affiliated PACs;

- 50% more to Congressional candidates and PACs during the time the Medicare prescription drug law was written (2004 election cycle) compared to the previous two-year period; and

- $2.5 million (38% of the six-year total) to Congressional candidates and PACs during the 2004 election cycle.

The largest annual expenditures during 2003-4 were: Cigna $585,556; WellPoint $390,400; UnitedHealth $268,125; Aetna $253,600; and PacifiCare $204,500. In addition to the 10 national plans, further PBMs and other companies will provide drug plans at the state and regional level, it says.

Baldacci: No higher premiums ; State House: He backs a bill that would prevent higher health insurance rates to help fund Dirigo. - Portland Press Herald (Portland, ME)

SUSAN M. COVER Blethen Maine News Service
Portland Press Herald (Maine)
11-24-2005
Baldacci: No higher premiums ; State House: He backs a bill that would prevent higher health insurance rates to help fund Dirigo.
Byline: SUSAN M. COVER Blethen Maine News Service
Edition: HOLIDAY
Section: Local & State

AUGUSTA --

Gov. John Baldacci said Wednesday he will support legislation to prevent insurance companies from increasing premiums to help pay for a state health insurance program. One day after the Dirigo Health board voted to require insurance companies to pay $43.7 million to support Dirigo Health, Baldacci on Wednesday said health insurers shouldn't pass that cost along to consumers.

'It does not go to the bottom line of insurance companies and shareholders,' Baldacci said. 'It goes to Maine people. It's their money.'
The amount is what the state superintendent of insurance believes insurance companies saved last year as a result of cost-saving measures in the program.

Sen. John Martin, D-Eagle Lake, is sponsoring a bill that would prevent insurers from increasing premiums to cover the cost of Dirigo.

Martin said the understanding between the state and health insurance companies all along was that Dirigo costs would not be passed along to policy holders.

'The original intent was certainly it would not be passed along,' he said. 'It was a savings.'

Baldacci said the state went through a thorough process to determine the amount of savings in the health care system that can be attributed to Dirigo. The intent, he said, was that insurance companies would use the money they had saved because of Dirigo to support the program moving forward.

'If, in fact, that's not followed, I'll support legislation that's already introduced that will make sure they cannot pass that on in terms of a premium increase to premium payers,' he said. 'If need be, it should be retroactive.'

Some insurance companies that serve Maine consumers have said they would be forced to pass along the cost to customers because Dirigo hasn't saved them nearly as much as the state estimated. Some are even considering challenging the assessment.

Anthem Blue Cross Blue Shield spokesman Mark Ishkanian said Anthem wants to pass along savings to consumers, but that inflation in health care costs means smaller increases, not reductions.

'This is the first we've heard of the governor's position,' he said. 'If it's true, this news is disconcerting to us.'

Anthem, the state's largest health insurance company, administers DirigoChoice health insurance for the state.

Katherine Pelletreau, executive director for the Maine Association of Health Plans, which represents Anthem, Aetna, Cigna and Harvard Pilgrim, said insurers strive to reduce rates, when possible, to remain competitive. 'Our issue is, look, until you see savings in the marketplace on the ground, they don't really exist,' Pelletreau said.

Rep. Kevin Glynn, R-South Portland and a member of the legislative committee that will hear Martin's bill, said the measure is unnecessary because the state Bureau of Insurance already reviews rate increases to protect consumers against price gouging or other unreasonable premium hikes.

The Legislature passed the landmark Dirigo Health legislation in June 2003, with broad, bipartisan support. The measure passed the House 105-38 and the Senate 25-8. About 7,300 people are currently enrolled in Dirigo.

But since its launch a year ago, many Republicans have been critical of the program, saying it hasn't covered as many people as expected, that coverage is too expensive, and that it hasn't reduced health care costs for all Mainers.

Supporters say the program, which is designed to offer health insurance to the estimated 130,000 Maine people who don't have it, is working. Now that $53 million in one-time startup money is nearly gone, the state is looking for a way to fund the program.

That's why insurance companies are being told to pay into the program, which is also supported by employer and employee payments, and federal Medicaid money. The additional $43.7 million is expected to help 3,000 people who are on a waiting list get coverage next year.

Copyright 2005 Blethen Maine Newspapers Inc.

Florida HMO Industry Weakens as Health Costs Rise, Medicare Funds Drop. - Knight Ridder/Tribune Business News

By James McNair, The Miami Herald Knight Ridder/Tribune Business News

Apr. 8--Health maintenance organizations, which insure nearly four of every 10 Floridians, could use some health care themselves.

Last year, the 33 HMOs still doing business in Florida lost a total of $115 million, according to the Florida Department of Insurance. Had it not been for the profitability of providing care to Medicare and Medicaid patients, HMOs would have lost $291 million in the state.

Florida might be paradise to the elderly and infirm, but to HMOs it's a bloodbath. Especially when the coverage doesn't entail federal benefits.

'A lot of HMOs are not able to cover their costs on the commercial side,' said Glennda Newman, a financial analyst with the state's Agency for Health Care Administration in Tallahassee. 'They're in the hole covering their medical costs before they cover their overhead.'

HMOs provided health insurance to 4.9 million Florida residents in 2000, a fourth of them using HMOs as a pass-through for Medicare and Medicaid benefits. The number of HMOs in Florida fell to 33 from 35 by the end of 2000, yet total HMO enrollment remained steady at 4.9 million.

'What you're seeing is that some of the smaller plans, for whatever reason, are not able to make it and are currently winding down. But the people are finding other coverage,' said Jim Brocker, who monitors the solvency of health and life insurance companies for the Florida Department of Insurance.

The industry's dismal performance in 2000 has a few bright spots. For one, the $115 million loss represented a 35 percent improvement over the $176 million in red ink in 1999. Moreover, $103 million of last year's loss was incurred by a single company, Prudential Health Care Plan.

Aetna U.S. Healthcare acquired the Prudential HMO in 1999 and is in the process of assimilating its organization, products and brand name, said Aetna spokeswoman Marlene Baltar. She added that the combined company pulled the plug on its money-losing Medicare unit in January.

'The conversion [of Prudential] is taking place now, and we hope to complete it sometime in 2002,' Baltar said. 'It is our goal to improve profitability.'

Aetna, now neck-and-neck with United HealthCare of Florida as the second-biggest HMO in the state, turned a $14.9 million profit in 2000. The market leader, Health Options, generated more profit than any other in the state -- $29.9 million.

Of the 33 HMOs operating at the end of last year, 16 lost money. The losers included HIP Health Plan of Florida, ranked sixth in state enrollment; Foundation Health, ranked 11th; and Preferred Choice.

Gil Weber, a health care business consultant in Davie, ventured that HMOs lost money in Florida for myriad reasons. Among them, he said, are high prescription costs, higher-than-expected medical costs, a large immigrant population with unpredictable medical risks, and a history of price discounting by HMOs to win market share.

'The HMOs estimate what they expect their claims exposure is going to be -- how many cataract surgeries, how many open-heart surgeries, how many premature babies they're going to have in the next year,' Weber said. 'Based on that projected exposure and their belief that they can negotiate reasonable rates, they set prices to cover their costs and put money in the bank.'

As the last four years have shown, HMOs have done a miserable job of keeping up with costs -- on the commercial side of their business, anyway. According to a breakdown by the Agency for Health Care Administration, the 14 HMOs that handle Medicaid clients lost $291 million in the 1997-2000 period. During the same period, those companies netted $121 million from their Medicaid practice, $164 million from Medicare.

That gravy train, however, is drying up, thanks mainly to fee increase caps imposed on Medicare by the Balanced Budget Act in 1997. According to AHCA, HMOs lost $3.1 million combined last year, compared with $94.1 million in profit in 1999.

Medicare's diminished profitability has many HMOs rethinking that segment of the market. Humana Medical Plan, for instance, made $52.1 million off Medicare last year, but on Jan. 1 ceased doing Medicare business in six counties in Southwest and Northeast Florida.

'We're trying to stay with it and lessen the markets we leave,' said Harry Spring, director of government affairs for Humana in Florida, 'but the government is not keeping pace with the cost of our care. We're encouraging the government to reform the market.'

United HealthCare, a Minnesota HMO with a Florida headquarters in Sunrise, likewise is looking more and more to commercial accounts to boost growth. The company recently added the University of Miami, with 18,000 people, and Orange County government. United, which lost $17.4 million last year as a Medicare contractor, said Medicare reimbursements have fallen to 30 to 35 percent of its revenue.

'It's becoming increasingly difficult to provide the kind of benefits people expect at the rates the government's paying,' said Gary Schultz, president of United HealthCare's Florida division.

The squeeze is on in Medicaid contracting, too. A number of proposals are pending in the Florida Legislature that would cut Medicaid fees to HMOs. The working estimate is a 5 percent cut.

Against the backdrop of rising medical costs and falling fees from government, the $29.9 million in profit posted by Health Options stood out all the more. The largest subsidiary of Blue Cross/Blue Shield showed that it is possible to make money and stay in good standing with customers and health care providers.

'We truly believe that we are a customer-oriented organization,' said Chris Doerr, chief financial officer at Health Options. 'We try to provide customers with products and services they want, and if you have happy customers, you have a much better opportunity to earn a profit.'

Doerr said Health Options continues to grow in an industry marked by high customer turnover. Membership, he said, grew 15 percent last year to more than 1 million policyholders.

'Another important factor [in profitability] is pricing discipline,' Doerr added. 'This is a business that has very, very low profit margins. Our $30 million is a little less than 2 percent. If a company doesn't maintain strong pricing and underwriting discipline, you can get yourself into trouble quickly because the margins are so thin.'

To see more of The Miami Herald, or to subscribe to the newspaper, go to http://www.herald.com

(c) 2001, The Miami Herald. Distributed by Knight Ridder/Tribune Business News.

Aetna (Atlanta) reported that it has awarded a $40,000 grant to the Ryan Cameron Foundation (Atlanta) to help fund a diabetes screening day, for which Aetna will be the title sponsor this fall.(Grants/contracts) - Diagnostics & Imaging Week

Aetna (Atlanta) reported that it has awarded a $40,000 grant to the Ryan Cameron Foundation (Atlanta) to help fund a diabetes screening day, for which Aetna will be the title sponsor this fall.

Aetna representatives will share information about the risk factors connected with diabetes and what people can do to help manage the disease.

'A significant portion of Aetna's philanthropic donations has been used to target diabetes and childhood obesity, which present tremendous health challenges in the Atlanta area,' said Cynthia Follmer, president of Aetna's Georgia market. 'Working with organizations like the Ryan Cameron Foundation, we hope to raise awareness of this growing problem and help people in this community learn to live healthier, more productive lives.'

Aetna provides health benefits to more than 500,000 people in Georgia.

The Ryan Cameron Foundation provides Atlanta's youth with tools of empowerment, preparing them for their future roles as leaders. Some of these tools include: mentoring, tutoring, volunteering, business etiquette, self-reflection, leadership instruction and life skills.

THE INFLUENCE GAME: Health interests fund senators - AP Online

Sen. Max Baucus, a leader in the troubled effort in Congress to write a health care overhaul bill, has received more campaign donations from the health industry than any elected federal official except President Barack Obama and three other senators.

The Montana Democrat is enjoying this largesse _ some $3.9 million in contributions from the health care industry since 1989 _ principally because of his place as chairman of the Senate Finance Committee. The panel is at the center of this year's health care debate, and on Wednesday Baucus released his view of how the medical system should be reshaped: an $856 billion, 10-year package of changes.

The stream of generous campaign contributions from doctors, drug makers, hospitals and other medical interests didn't stop at the chairman's door. It extends to the other members of the so-called Gang of Six, the two Democratic and three Republican senators who labored with Baucus since June to produce what he hoped would be a bipartisan bill. All have received above-average donations from the health-care world.

At least initially, no Republicans were supporting Baucus' bill. Yet the work of the Gang of Six is important because Baucus' measure comes closer than any of Congress' health overhaul bills to what the health industry and many Republicans want. It has no government-run insurance option, would require individuals to get coverage and sets up experiments in limiting medical malpractice suits.

The Baucus legislation is also seen as the likeliest to win Senate passage with some GOP support. Four other congressional committees have produced bills that tilt heavily toward Democratic priorities.

Among them, the six senators have raised $10.7 million since 1989 from the industries and people with the most at stake financially in the overhaul effort. That's an average of nearly $1.8 million apiece over that period, more than triple the roughly $560,000 average for all other senators and representatives.

The figures are based on data compiled by the nonpartisan Center for Responsive Politics, which studies political spending, and actually understate health-related contributions. The center's researchers include only some campaign donations from health insurers in the health category because they lump many health insurers' donations into a separate category for insurance, real estate and financial firms.

Even so, the data spotlight the financial clout health interests wield on Capitol Hill.

Corporate and individual contributions from the health sector to current officeholders have totaled $328 million over the past two decades. The leaders are Obama, with $20 million, mostly during his presidential run last year, and Sen. John McCain of Arizona, his GOP opponent, with $9 million.

Health insurers alone have donated at least $42 million to lawmakers, including nearly $2 million to the six senators working on the health legislation.

In the first six months of this year, health interests have made campaign contributions of $23 million. By comparison, the biggest 2009 donors so far _ finance, real estate and insurance interests _ have given $50 million.

Since 1989, five of Baucus' top 20 campaign contributors have been from the health care world: drug makers Schering-Plough Corp. and Amgen Inc., insurers Blue Cross/Blue Shield and Aetna Inc., and DaVita Inc., which provides dialysis services. From 2005 through this year, 18 percent of his campaign funds have come from the health sector, though he has also relied heavily on donations from insurance, finance, real estate and law interests _ all with key interests before his tax-writing panel.

Baucus spokesman Tyler Matsdorf said the senator was too busy to be interviewed. His office said Baucus has clashed with health insurers and pharmaceutical companies.

"I resent any implication that any of my actions or decisions are a result of contributions," Baucus told the Independent Record newspaper of Helena, Mont., last month. "I resent that because that is totally inaccurate. I do what I think is right, period."

Critics say campaign funds inevitably have impact.

"Companies like the health care industry don't spend money on members of Congress because they think it's like burning their money and throwing it away. They spend money on members of Congress because they believe it gets them results," said Lawrence Lessig, a Harvard Law School professor and co-founder of Change-Congress.org, an advocacy group seeking to end large private political donations.

Of the six senators, Charles Grassley of Iowa comes closest to Baucus' health donations _ $2.7 million, ranking him 14th among officeholders.

The Finance Committee's top Republican, Grassley is the only one of the six who faces re-election next year, and his $227,000 in contributions from health interests in the first half of 2009 places him eighth among lawmakers for the period. Twenty-six percent of his campaign contributions since 2005 have come from health interests, the highest proportion in the Gang of Six, including large amounts from Blue Cross/Blue Shield, Amgen and the insurer AFLAC Inc.

"Senator Grassley accepts campaign contributions that are legal and come with no strings attached," said spokeswoman Jill Kozeny.

Even the Gang of Six member with the smallest take from health interests, Sen. Olympia Snowe, R-Maine, has tallied $756,000 from the health sector. That ranks her 122nd of 533 current members of Congress.

Snowe could be a critical actor in this year's health care drama because she is considered the likeliest Republican to back a Democratic bill. She doesn't face the voters again until 2012.

Of the other senators in the Gang of Six:

_Kent Conrad, D-N.D., has received $1.6 million in health contributions since 1989, 35th among lawmakers.

_Jeff Bingaman, D-N.M., has accumulated $865,000, ranking him 102nd.

_Mike Enzi, R-Wyo., has gotten $844,000, ranking him 104th.

Besides Obama and McCain, only Sens. John Kerry, D-Mass., and Arlen Specter, D-Pa., have received more health contributions than Baucus, $8.3 million and $4.5 million, respectively.

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