Why Medicare Doesn’t Pay for Rapid At-Home Covid Tests

Yves here. This post describes how rigidities in Medicare, as in “home tests not allowed,” prevent the program from reimbursing Covid tests.

One must ask why no one in the Biden administration has tried to fudge a rule reinterpretation and get that through the regulatory approval process. That would take some months but is better than doing nothing and letting seniors suffer….unless, as cynics allege, that is part of the plan.

After the way Team Biden imposed its vax mandate rule on OSHA after OSHA had drafted a far-reaching set of workplace provisions that included a mask mandate, ventilation, and separation, one would think they could try an easier lift….particularly since it’s hard to see who if anyone would find it in their interest to challenge it.

Oh, but wash my mouth out. All of the private insurer providing Medicare Advantage plans would be upset about giving more benefits at the same cost. Fine. If the Biden Administration had any balls (clearly not, but that’s the point of going on), officials could make clear they made sure the press knew damned well which Medicare Advantage plans were out to harm senior by fighting access to tests that everyone else could get.

Forgive me if I engage in a mini-rant about Medicare. While if you’ve been on overpriced, high deductible Obamacare plans, Medicare looks like a big step up, it’s thin gruel for pretty much everyone else.

Let’s start with the scam called Medicare Advantage, where to get in theory lower premiums (my mother didn’t), you are in a narrow network and subject to HMO gatekeeping. Or Medicare Part D, which as Medicare.gov blandly warns, “Each plan can vary in cost and specific drugs covered.” As I infer from the comments of readers who need expensive meds, one has to research carefully to see if the needed Rx is included. And you have to recheck every year! 1

On top of that, consistent with the Covid home est example, Medicare not only is poor on workarounds, it actually impedes them. Two of many idiocies from my caring for my mother:

1. During a Covid wave, she was due for an annual exam. Her doctor could do a telemedicine visit but, not unreasonably, wanted a blood workup.

She had COPD, so Covid would be an even more certain death sentence for her than most old people. I did not want her to go into the huge outpatient clinic (remember in Alabama where even medical professionals in hospitals don’t mask well/at all) and get a blood draw (she could not wear a high quality mask; “normal” blood ox for her was 92 and that place always makes patients wait, so there was no possibility of a fast in and out).

But despite working on it for the better part of two months, including calling multiple home health agencies if they had any aides who were also licensed phlebotomists who could do the job, I got nowhere. Medicare does not allow home visits just for a blood draw, and the MD was unwilling to add other service needs to set up a limited course of nursing visits. Literally every agency that had nurses would not allow me to hire a nurse for just a blood draw, even though that was not a Medicare-covered service. They simply were not willing to see a Medicare patient unless they could bill to Medicare.

2. I had a variant of this problem when I tried hiring a physical therapist, not as a formal PT (as in working under an MD Rx) but to do some at home strength and basic balance work2 The reason for preferring a PT was trainers seldom deal with super feeble old people and would likely be unable to come up with a sufficiently basic regime (and yes, we needed an outside human; it was hard enough to get my mother to cooperate even then).

Again without belaboring details, despite considerable effort, it was pretty much impossible to get someone to train her at home. I did find a licensed PT who advertised himself at the local Jewish community center as doing at home programs…and as I feared, he couldn’t gear down to something basic enough. Everyone else was Medicare connected and would not take a patient outside the Medicare regime….even though there was no physician Rx and therefore no providing of a Medicare service.

After by sheer accident getting a very good set of PTs for my post surgery rehab, I embarrassed my mother’s physician into writing an Rx for physical therapy and getting the same team for her. But that took over a year.

Mind you, we were in the high class position of being able to throw some money at these problems, which is not the case for many Medicare patients.

But it appears the only solution to problems like that is to opt out of Medicare B via enrolling in a “concierge” practice. Here the price is $3000 a year, which included as many MD visits as you need, and unlimited nurse house calls, but not specialists not in their practice and not test. 75% of their patients were elderly, so it was a de facto gerontology practice. Since my mother even in her very aged condition had needed only 3 MD visits a year, this seemed like an awfully high cost just to get access to a nurse.

Outside a low labor cost state like Alabama, the rate or an old person to join a concierge practice in the rest of the US is likely to be higher.

And do not let me get started on how few MDs take Medicare in high cost locales. A friend who recently left NYC had none of his NYC doctors accepting Medicare, and none of my smaller roster do either.

By Michelle Andrews. Originally published at Kaiser Health News

What group is especially vulnerable to the ravages of covid-19 even if fully vaccinated and boosted? Seniors. And who will have an especially tough time getting free at-home covid tests under the Biden administration’s plan? Yes, seniors.

As of Jan. 15, private insurers will cover the cost of eight at-home rapid covid tests each month for their members — for as long as the public health emergency lasts.

Finding the tests will be hard enough, but Medicare beneficiaries face an even bigger hurdle: The administration’s new rule doesn’t apply to them.

It turns out that the laws governing traditional Medicare don’t provide for coverage of self-administered diagnostic tests, which is precisely what the rapid antigen tests are and why they are an important tool for containing the pandemic.

“While at this time original Medicare cannot pay for at-home tests, testing remains a critical tool to help mitigate the spread of covid,” a statement from the federal Centers for Medicare & Medicaid Services said. Medicaid and CHIP cover at-home covid tests, with no cost to beneficiaries, based on a 2021 Biden administration mandate.

Medicare patients are left to seek free tests other ways, including through the administration’s new website, covidtests.gov, and at community centers. The Medicare program does cover rapid antigen or PCR testing done by a lab without charging beneficiaries, but there’s a hitch: It’s limited to one test per year unless someone has a doctor’s order.

More needs to be done, advocates say.

The administration has changed some Medicare rules during the pandemic, including improving access to telehealth services and nursing home care, said David Lipschutz, associate director and senior policy attorney at the Center for Medicare Advocacy.

“We know that the Medicare program has significant flexibility relative to the public health emergency, and it has demonstrated it has the ability to alter the rules,” Lipschutz said. “We think they should find the flexibility to offer the covid at-home tests for free.”

Q: Why can’t the Medicare program reimburse beneficiaries for the over-the-counter tests or pick up the tab at the pharmacy as commercial health plans will do?

The services the Medicare program pays for are spelled out in federal law.

“It generally excludes over-the-counter things,” said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.

The public health emergency was recently extended 90 days, through mid-April, and the administration could yet decide to expand coverage. Some lawmakers in Congress are urging the administration to cover the tests.

“Demanding Medicare recipients — nearly one-fifth the population of the United States — to foot the bill out-of-pocket for at-home tests is unfair, inefficient, and will cost lives,” said Rep. Bill Pascrell Jr. (D-N.Y.), who has urged the Biden administration to expand Medicare coverage to include them.

It may not be a simple change, as these tests appear to fall into coverage gaps. Medicare Part A covers hospitalization, and Part B generally covers provider-based services like doctor visits and lab tests. Part D covers drugs.

“So there’s a little bit of a question of where this type of benefit would fit,” Schwarz said.

People in private plans sometimes pay upfront for services and then are reimbursed by their health plan. But that’s not how Medicare works. The program pays providers, not beneficiaries. So that’s another wrinkle that would have to be ironed out.

Q: So how can a Medicare beneficiary get free at-home covid tests?

There are a couple of options. This week, the Biden administration launched a website, covidtests.gov, where anyone, including Medicare beneficiaries, can order free at-home covid tests. One billion tests eventually will be available. Each residence initially can receive four tests.

Four tests is a far cry from the eight monthly tests that people with private insurance can be reimbursed for. But it’s better than nothing, experts say, especially when preventing the spread of covid requires repeated testing over a period of days.

“Four tests is not a lot of tests,” said Juliette Cubanski, deputy director of the program on Medicare policy at KFF. “This is one of the most at-risk populations, and to not have the opportunity to buy at-home tests and get reimbursed puts this whole population on their back foot.”

The Biden administration is also providing up to 50 million additional free at-home tests to community health centers and Medicare-certified health clinics.

But 50 million tests won’t even provide one test apiece to the 62 million Medicare beneficiaries, Lipschutz said.

About 4 in 10 Medicare beneficiaries are in Medicare Advantage managed-care plans. These private plans may offer free at-home tests to members, but it’s not required. Enrollees should check with their plans to see whether that’s an option.

Q: What other free covid testing options are available to Medicare beneficiaries?

In traditional Medicare, beneficiaries can get rapid antigen or PCR diagnostic tests without paying anything out-of-pocket if the test is ordered by a doctor or other health care provider and performed by a lab.

The federal government has set up more than 10,000 free pharmacy testing sites across the country that Medicare beneficiaries can visit as well.

With the recent extension of the public health emergency, the situation is fluid, and Medicare beneficiaries may yet get coverage for at-home covid tests that’s comparable to what privately insured people now have.

“This is all a moving target,” Lipschutz said.



From EHealth:

Medicare plans providing prescription drug coverage can select medications to include in their list of covered prescription drugs (called the formulary) and, with certain restrictions set by Medicare, change the formulary. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.

Plans often change their formularies each year. Although the plan notifies you of changes, it’s generally a good idea to review your plan’s Annual Notice of Change mailed in early fall each year to see if your medications are on the formulary for the coming year and compare your current plan to others available where you live.

If you find out your stand-alone Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan is planning to stop covering your prescription drug, then it may be a good idea to switch to another Medicare plan with prescription drug coverage. Remember that even though all Medicare plans with prescription drug coverage must cover the same drug categories or classes, each plan can choose which specific medications to include in each category, so a different plan may offer the prescription drug you take.

2 Going within her plan would have required an orthopedist visit and imaging, which = Covid risk, plus her HMO would have resisted at home therapy and instead wanted her to use their outpatient facility. Aside from yet more Covid risk, I had seen the programs she had gotten there is the past. They were cookie cutter with at best 40% of what they gave her suited to her needs…and some exercises actually counterproductive.

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  1. Larry

    Thanks for sharing your personal story Yves. The cruelty of bureaucratic profit seeking rears it’s ugly head. Complicated policies that change every year are basically to insure that eventually Medicare patients stop using services. They can’t kill the program outright (yet), but try to bleed it to death. Given it’s nearly $1 trillion dollar annual spend, one would think there are providers who don’t wish to see this ridiculous rule making, but I guess they get paid either way eventually regardless of burden or outcomes on the patients.

    1. Yves Smith Post author

      I give these stories in the hopes that readers will share their accounts, particularly if they have found ways to work around obstacles that could be good pointers to others. But yes, it’s amazing how they make it hard and costly to do the right thing. Just sending a nurse out for a blood draw would have been way cheaper than any of the permitted alternatives.

      1. Not_a_nurse

        As to periodic blood draw, Life Extension has locations all over the US and it is not even necessary to make appt online, one can simply walk-in and they do blood draw and results are in email couple days later, Quest or Labcorp typically processed. Very small cost for typical CBC, Lipid panel, Vit D, etc.

        No doctor visit needed.

        If LEF is not in your location, there are several alternatives that are similar

        1. Mtnwoman

          To clarify, Life Extension is an online business that has partnered with Labcorp who does the labs.
          You chose the labs you want, pay online and Life Extension mails you the lab order that you take to Labcorp.

          1. Yves Smith Post author

            Did you not read the post?

            Did you not understand that the boundary condition was my mother not leaving the house?

            You seriously think we’re doing blood draws at home? With my mother having terrible veins and bruising like crazy even when using a butterfly needle? What planet are you from?

            There’s a Labcorp a one minute drive from here. We could walk in and lie and cash pay there. That’s not the issue. It’s sitting in the waiting area and exam rooms with people who mask badly (including at the Labcorp, I’ve seen two tech there with procedure masks below their noses) and risking my mother getting Covid. This is Alabama, with the highest per capita death rate and Covid case rate.

            I don’t think it’s legal, let alone prudent, to have someone other than a trained and licensed phlebotomist draw blood.

        2. Yves Smith Post author

          Reading comprehension fail, big time.

          What about “my mother is wheelchair bound and not leaving the house to take Covid risk when she can’t wear a respirator” don’t you understand?

          The entire point was to have her deal ONLY with a single nurse who’d wear at a N95 (I provided them as a condition of coming into the house) for only 10-15 mins, and not sit in a waiting and treatment room exposed to all sorts of unmasked or improperly masked people when she could not wear a protective mask?

          And the only Life Extension I find when I search its name + Alabama is a dietary supplements company.

  2. LAS

    If I could find a concierge program at $3,000 per year, that would be marvelous. That’s less than the Medicare Part B premiums!

    1. Yves Smith Post author

      But you missed the tests are all on you, as well as ANY AND ALL specialists outside the concierge practice, which are GPs The annual EKG. The annual bloodwork. A strep test if you have a bad sore throat. If you have a fall, the Xrays to make sure you didn’t get a hairline fracture. Physical therapists if you need that after an injury or period of immobility. Any assistive devices that would be covered by Medicare, from a walker to a wheelchair, are all on you. One of my mother’s 3 doctor visits a year was to a pulmonologist. That would be extra and at a full rack rate, no insurance negotiated discount. Ditto if you had to see an orthopedist, an oncologist, a urologist…

      Trust me, all in it it will cost at least double the $3000. That entry cost is really deceptive. And that’s before getting to the fact that the doctors may run some tests in house (certainly EKGs) and overprescribe them…..

      And would you actually give up the Medicare B? Let’s say for some reason you move. You become feeble or a spouse dies and your kids decide to take you in. Concierge plans where they are are $7000. Then you have to pay that or eat the increase in Medicare B, which is 10% more for every year you didn’t take it.

      1. LAS

        Yes, I do appreciate that it is not quite so simple a decision. But the Medicare premiums increase with income and on top of them are the medigap and drug coverage premiums.

        It’s upsetting to juggle all the what if scenarios b/c it is a complicated risk assessment that most of us are not equipped to calculate. Vanguard produced a paper a few years ago that suggested about $300,000 in premiums and out of pocket costs is what we’ll need to cover health costs in a typical retirement whatever we choose. For most, that’s a big chunk of retirement savings. If it comes from tax deferred savings, it is probably more like $400,000.

        When my parents retired, about 15-20 years ago, Medicare was a much clearer major benefit than it is today.

        1. Arizona Slim

          So, Vanguard produced a paper. I’m guessing that the conclusion would be to invest with Vanguard so you have that $300k for premiums and out of pocket costs.

          Not that I’m cynical or anything.

      2. Amfortas the hippie

        standing behind a guy in the local pharmacy..told him bill was almost $500, and he’s like “s’posed to be $120…medicare, etc…”
        they say gobbldygook about new year, and deductables…and he hands over his plastic.
        then i took mom for a “routine” visit to her Doc, hour away(she rarely goes to doc, doesn’t trust medicine, and is probably the worst patient ever).
        they drew blood after a 1 1/2 hour wait, and she did her usual squirrelly vagus nerve thing and fainted and puked(very exciting day)….so Doc comes to find me in the parking lot…and i’m hanging around in there while she’s recovering enough for the hour’s drive home, and picking his and his nurse’s brains.
        covid all over the place…and all day(noon til 5pm closing) there was a steady stream of cars with old folks to get their noses swabbed under the drive in drop off….due to the topic of this post, medicare’s failure to do tests.
        doc…out of his depth in emergency medicine… wanted to send mom to the er, but after inquiring about wait time and covid, it sounded too much like Raccoon City, and i talked them into giving her Zofran and driving real fast home.
        scuttlebutt during the wait was that…aside from the rampant ItAintRealism hereabouts, the System is totally frelled…medicare and private insurance are being even more weird about payments and rules and what they will cover…they’re all shorthanded and exhausted…and are having financial troubles that are threatening to shut down the little clinic. It was surprising how open they were about these in-house things…as usually, i can only talk about such things with my regular doctor friend of 20+ years.
        Doc said the big regional hospital was in dire straights, too…but not to quote him on that.
        sending more and more routine patients on to big medical center in san antonio, because they don’t have enough plastic goods or ordinary drugs(analogous to our little mom and pop hardware store being at the end of the supply chain and having to sell studs with a freight markup)….helicopter and ambulance companies making a killing.

        this is in a rich hill country area…lots of winery investments and the like…not some poor backwater.

        myself, i long ago realised that i will just never have the medical care my parents have enjoyed…and my life will be necessarily shortened as a result.
        i reckon a lot of people will learn what it’s like to just not have healthcare in the near future.
        it’s gonna be a hard realisation.
        Boss class is playing with fire.

        1. WobblyTelomeres

          Medicare is a creature of Congress. What you and Yves describe is a direct result of our
          putting our country into the hands of corrupt mediocrities. I have no peaceful solution.

          1. Louis Fyne

            peaceful step 1: is stop focusing on the petty ID politics baloney sausage that the media and a certain cohort of elites and activists push.

            ID politics is the nail on the coffin of bottom 99.5% class unity.

            IMO. Ymmv.

            1. JTMcPhee

              Yes, most of us know that, but how to force the PTB to do anything different, or supplant the PTB? How to instill class consciousness in Anomie Space ™?

              1. Amfortas the hippie

                Prime Directive #1: stop believing in all their bullshit.

                everything flows from this first thing that you stand on.

                Boss Class is Full of Shit.

                Everything they tell you is Bullshit.

                Ergo, investigate the Opposite of Boss Bullshit.

                Arrive at something akin to marxism,hopefully leavened with a bit of Bookchin,,,, modified for your….and your community’s….needs

          2. Carla

            I highly recommend the documentary film,
            “The Power to Heal: Civil Rights, Medicare and the Struggle to Transform America’s Health Care System.” I just learned that it is actually based on a book of the same name, which I’m going to try to order.

            Medicare actually was the creation of Lyndon B. Johnson. The film illustrates a functional federal government. It was shocking to see, and realize how very much we have lost.

      3. Stillfeelinthebern

        Sounds like dental insurance. You get a limited amount of services but are locked in for the expensive ones so the net is a higher cost. And what if you have difficulties with a diagnosis? No option for a second opinion.

        I’m new to Medicare. Went for a intro visit with my NP and she recommended getting a cologuard instead of colonoscopy, but she didn’t know if it was covered by Medicare. I called Medicare and the person I got said “it’s a test, Medicare doesn’t cover tests.” Cologuard’s website says it’s covered by Medicare.

        It’s all about the confusion and a huge tax on our time. I’m sorry but no “great” county does this to it’s citizens.

        Top this off with a letter I got from the IRS telling me, call this number, or else ….. I’ve been calling that number every day for over a week and I get through the menu and then it says “our call volume is too high, call back tomorrow,” and it hangs up. I called my senator’s office about it last week and they told me to call early in the day (didn’t work) and said someone from their office would call back. Of course, that hasn’t happened.

        We are so screwed.

        1. John Zelnicker

          Stillfeelinthebern – Try calling the IRS near the end of their open hours, but never on Mondays. Sometimes that works. Try a Friday. Filing season started yesterday, so it’s going to be tough no matter what.

          Last year less than 24% of calls to the IRS were answered, so you’re not alone.

          You should also write to them at the address on the letter and include a copy. It will take awhile for them to get to your letter, but they will date any actions from the time you sent it. Use Priority Mail or Certified Mail so you have a tracking number. Then they will have a response from you even if you can’t reach them by phone.

        2. Yves Smith Post author

          Re Cologuard, it looks to be another at home test, so presumably not covered by Medicare.


          I suggest you read that post.

          You may be too old for this to be a reasonable alternative (as in you haven’t been tested regularly) but if you are not in a cancer/colon cancer risk category (no family history of cancer, never smoked, never ate much red meat, particularly undercooked red meat) an alternative in a fecal occult blood stool test. But you have to be religious and do it annually. And you may be starting too old for that to be a good idea.

          1. John Zelnicker

            Yves – Would it be too much trouble for you to provide a link or reference explaining why starting colon cancer tests at Medicare age would be a bad idea?

            Thank you.

            1. Yves Smith Post author

              I NEVER NEVER NEVER said that.

              What is wrong with readers? We are having massive reading comprehension fails.

              I said using an annual fecal occult stool test (as in for occult blood) was an ALTERNATIVE to a colonoscopy. Canada among other advanced economies uses this as opposed to colonoscopies for patients who are not in high risk categories. They don’t see colonscopies as warranted (and that’s before getting to not trivial contamination and colon perforation risk, 15% of colonoscopy tools are not cleaned properly).

              My surmise is starting the annual fecal occult stool test at 65 is too old for that to be an adequate substitute. But I don’t know either way.

              1. Vthestate

                I have used that alternative….due to less invasive & my own good health.I think it would work well as an easy pre colonoscopy test. Just open kit use paint brush to swab do do and swab on absorbent card , seal and send. 3 weeks test results. I am so blessed …vow of poverty and tax avoidance has given max coverage for health care here in CT…. now Medicare …eroded benefits , still working pretty good. The real challenge we have is Congress critters, until we get organized and up in arms….this is what we get. Biggest blockades are election $ and profit from public good/defense. Solve these it would make room for democracy.

              2. John Zelnicker

                Yves – I may indeed have miscomprehended what you said.

                Or perhaps my comment was poorly worded, it was late, and I was trying to be brief.

                I was referring to this “You may be too old for this to be a reasonable alternative (as in you haven’t been tested regularly)”

                And this: “And you may be starting too old for that to be a good idea.”

                So, please forgive my poor wording or miscomprehension, whichever it was. I was only trying to understand the phrases I quoted since I’m almost 72 and have never had either a colonoscopy or fecal occult stool test.

                I have no reason to believe I’m at very high risk. Although I am a lifetime smoker, I seem to be in pretty good health so far (fingers crossed).

                Nevertheless, your last paragraph answers my original question.

                Thank you.

      4. Bridget

        Are you saying that if you have Medicare coverage and also choose to see a concierge primary care physician that none of the tests or labs or specialist referrals ordered by that physician are covered by Medicare? What if those labs and tests are provided by third parties that do accept Medicare? Asking for a friend who is considering following her primary care physician who has just gone into a concierge practice. :)
        I would expect that the unfortunates stuck in Medicare Advantage would not be able to work around this, but it seems that there must be ways to get original Medicare to pay for third party labs and tests and specialists no matter if the primary care physician takes Medicare or not. In the case of specialists, I do know that my husband (in original Medicare) has no primary care physician, but he sees a urologist and a cardiologist annually. Medicare pays for those visits and for any tests or labs they order. But I am now very curious about labs and tests ordered by concierge primary care physicians from national labs like Quest, or third party radiology practices, etc. would be covered or not. Interesting.

        1. Pat

          Check with the service.
          one of my former doctors and her colleagues from a great program of a local major hospital that got cancelled have what I call a modified concierge service. You pay a monthly fee, but they accept your insurance. The difference is they manage to see you with less than a month’s notice. And if they have really managed to recreate the hospital’s set up most of the family could see their basic healthcare needs met in the practice. I just haven’t been able to jump to paying:

          Membership in name of practice costs $100/month for the first family member or registered domestic partner, $100/month for the second, $25/month for the third, $25/month for the fourth, and the fifth plus is free, because you’ve got enough to deal with. Pay yearly and we’ll waive 2 month’s fee, as well.

          IOW a minimum of $1000/year just to have access.

          Not saying this is what their doctor is doing, but it is one of the wrinkles I am finding in my hunt for a doctor who is accepting new medicare patients in my area. The only way they will know is to ask. But a full on concierge system doesn’t deal with insurance at all.

        2. Yves Smith Post author

          Medicare B is not free. You only get Medicare A for free and you still have to opt in.

          You need to either get Medicare B (oh, and D for drugs) both of which have annual fees, or get a Medicare Advantage plan (which might be no fee but wasn’t for my mother) which locks you into a narrow network. You might be able to get tests done but you’d have to go to third party labs in that Medicare Advantage plan (as in your MD could not draw blood and send it anywhere, it would have to go to an in-network lab). And any tests they did there like an EKG would definitely not be covered since they have opted out of Medicare to take the concierge practice fee.

          The concierge practice might not be willing to inconvenience themselves that way.

  3. LAS

    Medicare recently sent out notice to its beneficiaries on how … “Each household in the U.S. can now have four free COVID-19 at-home tests shipped directly to their home at no cost! All you need to do is visit COVIDtests.gov and enter your contact information and mailing address.” To me, that showed some coordination and intelligence.

    I rather appreciate traditional Medicare, except for the 20% gap that needs filling with medi-gap insurance and the separate drug coverage. The root problem is that too many congress people still believe in private markets as a sol’n for health care and likely get campaign contributions to say and act just so. This is not the fault of Medicare.

    1. JTMcPhee

      I doubt Congress people “believe in” markets. They are just wholly owned subsidiaries of the Business Class.

      And Medicare does not exist sui generis, it is a creation of the lawmakers, and it is getting worse as the regulatory capture insinuates itself and empties any decency reservoirs from the structure…

    2. antidlc

      ” The root problem is that too many congress people still believe in private markets as a sol’n for health care and likely get campaign contributions to say and act just so. T”

      imo, part of the problem is that Congress gets its own Office of the Attending Physician, specialists, and treatment at military hospitals.


      Services offered by the Office of the Attending Physician include physicals and routine examinations, on-site X-rays and lab work, physical therapy and referrals to medical specialists from military hospitals and private medical practices. According to congressional budget records, the office is staffed by at least four Navy doctors as well as at least a dozen medical and X-ray technicians, nurses and a pharmacist.

      Sources said when specialists are needed, they are brought to the Capitol, often at no charge to members of Congress.

      “If you had, for example, prostate cancer, you would go to one of the centers of excellence for the country, which would be Johns Hopkins. If you had coronary artery disease, we would engage specialists at the Cleveland Clinic. You would go to the best care in the country. And, for the most part, nobody asked what your insurance was,” Balbona said.

      Congress gets gold-plated medical treatment. The fee is around $500 per year.

  4. Louis Fyne

    — Or Medicare Part D, which as Medicare.gov blandly warns, “Each plan can vary in cost and specific drugs covered.—

    Not just Covid tests….my mother got her shingles vaccine. She thought that it was a 1x shot and as such was willing to pay out of her own pocket ($180 I think) with her current plan.

    She then learned that it is a 2-shot vaccine ($180 x2) after it was too late to shop around and perhaps change her plan.

    As I am not familiar w/Medicare, gobsmacked that the shingles vaccine is not required coverage.

    1. Oh

      Shingles vaccine is not really a vaccine if you have have a booster every so many years. At least the flu virus type changes every year requiring a shot but does shingles do that?

      To me, the shingles vaccine is another rip off.

  5. LAS

    I’m back … to provide a link to a new Congressional Budget Office report on health care prices in the US using data on cost of services through about 2018:


    If anyone has an interest in healthcare economics, this would be a good read. There is one curious chart that suggests Alabama could be a genuine outlier with respect to physician services costs for payers, as the only state where Medicare FFS plans pay physician services at a higher rate than commercial payers. Weird.

  6. artemis

    My local newspaper this morning had an article on how to get your free tests that was pretty detailed and helpful, and ended up with this information for Medicare patients:

    GETTING YOUR TESTS COVERED: MEDICARE If you are insured under Medicare, you are not eligible to have at-home, over-the-counter COVID tests covered at the point of sale or through reimbursement. The federal Department of Health and Human Services is instead providing 50 million free, at-home tests to community health centers and Medicare-certified health clinics for distribution at no cost to patients and community members. Find out more about the federal DHHS program at hrsa.gov/coronavirus/testing-supplies.

    1. Anthony G Stegman

      As perhaps Yves may have said there are 62 million Medicare recipients. 50 million tests are a tiny fraction of the real need. A complete joke.

  7. Carolinian

    Medicare is controlled by a highly lobbied Congress which is always mindful of those lobbies’ financial interests. That’s why we don’t have prescription drug price negotiations and our medical care is focused on doctor visits rather than home care.

    In traditional Medicare, beneficiaries can get rapid antigen or PCR diagnostic tests without paying anything out-of-pocket if the test is ordered by a doctor or other health care provider and performed by a lab.

    And to get that prescription they will want you to come to their office where they can bill for an office visit. They will want that even if it means putting the non ambulatory elderly in a transport ambulance to get them to their office to undergo tests that could just as well be administered at home. In many ways the old country doctor medicine of house calls was more humane and likely better medicine if not nearly so high tech and scientific. Not all medical problems require heroic scientific intervention.

    IMO American medicine isn’t well set up for elder care. Capitalism and medicine are a poor mix.

    1. Pat

      IMO opinion America is not set up for healthcare period. This does not mean that a lucky percentage won’t find care, they will. But with every passing year that percentage gets smaller and smaller, and even for the wealthiest among us getting real informed care based on the person and their needs rather than a cookie cutter regimen meant to cost the most and provide the least health care but plenty of distracting perks is getting less and less possible.

      Greed is good as an ethical system has produced massive systemic rot, but our failing healthcare system may be the most heartbreaking. (I recognize that the Gekkos of the world don’t think our healthcare system is failing except for things like Medicare, Medicaid, and the VA, but give them time to realize their care will not be the exception.)

    2. PHLDenizen

      I agree with the bulk of your sentiments.

      I have a dad who’s a specialist physician in a major metro area and his practice has a large population of medicare/medicaid patients. I get to pick his brain regularly about these issues. His practice may be in the minority, but one of their philosophies is to minimize diagnostics because a) they’re expensive depending on how shitty your insurance is and b) it often sends you down needless rabbit holes, often scaring the patient into procedures they simply don’t need.

      His treatment regimens are deliberately conservative because his patients come first. Sure, I guess he could find any number of reasons to get them in for echocardiograms or cath studies or cardiac MRIs (I know the hospital would love the revenue stream), but since he’s a chief and highly regarded in the area, the MBAs back down. The amount of money he spends on the backend of the office just to deal with the government programs and private gap insurers is insane. So, while I’m familiar of revenue maximization practices, they aren’t all that way. His outcomes are always very, very good and he tackles a lot of difficult cases no one will touch.

      The drugs reps hate him because he looks at me-too drugs says “Uh…no. This is expensive and there’s no clinical difference. GFY.” Same thing with the “miracle” pharma wonders that keep parading around on TV. But my dad is also old school and he’s incredibly aggravated by the EBM-fixated young docs who exhibit zero critical thinking skills. And who spend way too much money on McMansions, BMWs, etc.

      Elder care is as much of a cultural issue as it is rapacious capitalism. Narcissistic children and structural barriers to keeping parents in their home for as long as possible are the primary issues. An alarming number of people I’ve crossed paths with buy into capitalism’s promise to send your parents into the grave in a splendorous, pampered last hurrah. The elderly are commodities and the disposal of them via LTC appeals to a guilty conscience and, for the selfish, a means to maximize leisure time. It’s cruel, neglectful, and wholly unloving in most cases — some mental calculus by which assets become liabilities. The Japanese, at least, value the elderly as part of their culture. No such thing exists here. Certainly not in the large urban areas.

      My mother and I have had experiences similar to Yves, taking care of her mother. Whom I miss very much. We made the decision to keep her in her house as long as possible. Fortunately, when my dad finished his fellowship, my mom was adamant they move back here. My grandmother lived a few blocks away and his income meant they could subsidize her as needed, e.g. property taxes, home repairs, etc. I ended up doing a lot of the work to install shower rails, replacing the sump pump, demolition of water damage, replacing windows, etc. myself because I enjoyed it and I also got to hang out with my grandma. Even toward the end, after a series of mini-strokes that gradually deprived her of her sense of self, I knew she never felt abandoned or burdensome.

      Ugh. But even with dad’s BSD at the hospital, dealing with doctors was a full-time, pain-in-the-ass job. Often times, they’d be dismissive, stubborn, insist on interventions that made absolutely no clinical sense, deprioritized hospice care, insisted everything could be solved with the right drug cocktail, would ignore the facts as my mother and I presented them, insisted what we observed couldn’t possibly be right, and so on. We tried as best we could not to escalate, but being able to name drop was a huge advantage that few other people had.

      Yes. Taking care of your aging parents at home is a tax on your time, often maddening (almost always when dealing with third parties), requires some financial outlay. But don’t they deserve that? I think they do. And it’s criminal not to do so. Like Yves’ mom, my grandparents were lucky to have offspring that gave enough of a shit to keep her in the place she knew, keeping her away from underpaid, overworked, disinvested staff in a PE horror show LTC facility, and had the financial means to do so. All in all, it was LESS expensive to keep her at home and, even at her most cantankerous, I was glad to have the time with her I did. She was awesome.

      At the end, she fell off the bottom porch steps, hit her head enough to cause some bleeding on the brain, and we decided that it was time to let her go. Rather than subject her to surgery and recovery that would in no way markedly improve her quality of life, we held vigil around her hospital bed, watching her peacefully fade away on a morphine drip. It took years before I really got to process it. The aftermath of readying her house for sale was its own special hell.

      She was cremated, as per her wishes. I remember going with my mom to the funeral home to pick up her ashes. I sat down, staring at this small box in my lap, wondering if it was really possible that an entire life could occupy so small a space. But she had a good long run. And she was probably standing behind me, thinking I was a complete moron to even ponder such silliness.

      1. Pat

        Your grandmother was a lucky woman, and she done good with your mother. As your father and mother have with you. All of you are lucky to have each other.

        I envy your father’s patients, just as I envy IM Doc’s. I was lucky enough to have a similar doctor until he retired. Wisdom coupled with experience and compassion is rarer every year, even as we need this more than ever.

        I hope the younger physicians capable of this survive a system designed to destroy that so that somewhere down the line their children can also sing their praises.

      2. LAS

        It is always difficult to experience this portion of life and relationships, however it unfolds, b/c our culture does not embrace it and kind of lies to us about it. I think it takes multiple experiences of death to understand a good death versus an unfortunate one. There are many elderly without children to care for them who valiently keep themselves, maybe, a little less than optimal.

        When I was care giving my father, it felt to me at the time like we were a Muff and Jeff comedy team, and not b/c we were cracking jokes. It’s just that nothing unfolded according to plan, and nothing went according to advertisement, and one had always to keep re-evaluating what was possible and/or desire-able. On the other hand, there were many intimate and funny occasions. My father once remarked that he was helping me grow up. In fact, he was.

    3. Amfortas the hippie

      “In many ways the old country doctor medicine of house calls was more humane and likely better medicine if not nearly so high tech and scientific. Not all medical problems require heroic scientific intervention.”

      is there a legal and/or regulatory and/or licensing reason that this isn’t a thing?

      my doctor/friend has often said that that was the sort of juvenile dreamer ideal he had in mind as a child when he figured out that he wanted to be in medicine.
      says he knew even then that that isn’t how it’s done…but i never thought to ask, until right now, if there’s something standing in the way of someone wanting to be a housecall doctor like in mayberry.
      analogous to how i am with farming…and even having a one night a week chef’s supper club out here….not everyone is all about the big bucks.
      in my county, i would bet that such an itinerant doctor would be in high demand…perhaps combined with a boutique/subscription model(which my doc has moved to, and which reminds me of community supported agriculture farming models(CSA’s).

      90% of the time we go to the doctor(aside from wife’s cancer stuff, which DOES require heroic scientific interventions), it’s for stuff that can be diagnosed with things that would fit into a patent leather bag or a tackle box.
      (sinus infections, bad cuts(beyond duct tape), spider bites, and even things like strep)

          1. thymia17

            My husband was the only Cornell Med graduate I’ve known who fit much of your description. He was a board certified radiologist but hated the medical business model so much, he worked later as a locum tenens (temp doc). He once went to work w the farmworkers in the San Joaquin Valley in the Chavez era, and told me he learned you can practice medicine with a chair (the basic health maintenance type of medicine you describe). Never became “successful,” but maybe he was happier gardening & hiking.

  8. antidlc

    In the midst of a pandemic, I found out that Medicare won’t cover a Vitamin D test. (So I was told by the doctor’s office.)

    1. Yves Smith Post author

      Insurers stopped covering Vitamin D tests a while back. I used to get this as part of my annual workup and stopped. At Labcorp, paying at time of service, which = their best rate, the price was $80. Probably more now.

    2. Mtnwoman

      LIfe Extension Foundation has been mentioned above.
      Go online to their lab section and you can order a Vit D for $47. A decent price.
      They send you the requisition and you take it to your local Labcorp.

      Medicare is very odd about which testst they wont pay for.

      Considering research indicates that a Vit D level> 50 looks like a buffer against covid hospitalization, and all the other good benefits of Vit D, they are shooting themselves in the foot for not checking it and optimizing the levels in their patients.

      1. Yves Smith Post author

        You have this wrong. You have to pay for the phlebotomy too, which at Labcorp can be anywhere from $10 to $28.

        And now that I finally found it, it’s outlawed in New York, New Jersey, Rhode Island, and Massachusetts.

        Stop misleading readers.

    3. grayslady

      My Vitamin D test at Quest was covered by Medicare–December 2, 2021. Don’t know if things changed at the beginning of 2022. The test just has to be coded correctly by the doctor as necessary for a condition. About 7 years ago, I really did have a Vitamin D deficiency, so all the doctor needs to say is that they are continuing to monitor that condition.

  9. delaney2

    I’m one of the schlubs who’s delighted with Medicare, after living with the narrow networks and the nuisance of referrals of most Obamacare policies.

    There’s been no difficulty finding board certified specialists in UWS/UES Manhattan, but if the idea is that a good insurance would be prepared to pay 80% of “full cost’, how would this work without a massive increase in premiums, well beyond the means of most SS recipients, or equally dramatic reduction in doctors’ income?

    1. Yves Smith Post author

      My current insurance pays that. Low premium, low deductible, and it has better drug benefits than Medicare D. Covers any med anywhere in the world and lets me use discount coupons first (not a pharmacy plan so I do have to lay out the cash but the net result is cheap). And I am not limited to a network. It does force network prices on network doctors but pays 80% of the billed rate for any out of network MD.

      You are in a network with Medicare. Plenty of doctors including all of mine and all of my friend’s, do not take Medicare. When I returned from Oz in 2004 and my former excellent GP had become a director at a biotech company, I must have seen a half dozen GPs over 4 years before I found one that was OK. For a few years I used an endocrinologist as a GP proxy when I didn’t have a GP, they could order all sorts of bloodwork, which is the most important part of an annual exam.

      So don’t tell me there are all sorts of great doctors floating around and you can just pick from a list. My experience in Manhattan has not been that. Even more true with specialists like orthopedists and OB/gyns. For instance, when I had plantar fasciitis, a very common problem, it took a year of going through seven orthopedists in Manhattan before one told me what to do: “Get in a low heel and get an orthotic.” Oh, and the good OB/gyn, found after years of despairing at the lousy ones I’d seen? Referred by a Manhattan friend and warned me she does not take Medicare.

      1. Angie Neer

        Yves, you’ve often mentioned your outstanding grandfathered health insurance which seems to be radically different from the current norm. Are such policies even available now?

      2. delaney2

        I make relatively little of use health care services, so I won’t argue with you about the availability of specialists in the Medicare network. Oddly, the 5th Avenue Moh surgeon I had been seeing dropped all other insurance, but still takes Medicare. And I just looked up a well-reputed Lenox Hill orthopedic surgeon who treated a broken bone a few years ago. Medicare says he’s still with them. In any event, I’ve had no difficulty, so far.

        But I’m puzzled about your insurance. *Somebody’s* got to pay for that 80% out of network, but you seem to be saying that you don’t, in premiums.

        I’ve lived in Europe, but it’s difficult see how that system would operate here, without a dramatic cut in MD and provider pay. And health care as a utility service might not go over so well here. Your own experience suggests as much.

  10. Alice X

    I am on traditional Medicare and am dual eligible with Medicaid and QMB. After a heart attack two years ago I have high blood pressure meds, amplified since then. They are expensive but with Medicare part D special help, all I pay is $1.30 per refill. Except for the hospital with my cardiologist, my healthcare resides with the UofMichigan Health System. I have a host of issues but they take care of me. I never pay anything. Everything is great except, of course, that every month I get to the last week and wonder if I will have enough food till the new month. I certainly would qualify for food stamps. I may yet have to do that, though it is quite a hassle. On the bright side, I am only 72 and not yet in my droolidge. My heirs will have a headache with Medicaids estate capture protocals. I’ll be dead but still I am concerned.

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