Appealing an Insurance Company’s Decision

triage-cancer-blog-appealsOne of the more frustrating aspects of cancer treatment is dealing with the insurance industry.  We pay our monthly premiums with the expectation that when and if the time comes, we will receive coverage for our medical care.  Sadly, it’s not always as turn-key as that.  Sometimes, claims are denied or we are charged more than we think we should be paying under our policies.  At that point we have to fight for our coverage.  This process is called an appeal (note: some companies call this a grievance).  There is an internal appeals process and an external appeals process.

Internal Appeals

Your insurer must notify you in writing if they deny your claim for coverage:

  • Within 15 days if you are seeking prior authorization for a treatment
  • Within 30 days for medical services already received
  • Within 72 hours for urgent care that you have not yet received

If you disagree with a decision your health plan has made, you have the right to file one of two types of internal appeals:

  1. Expedited Appeal

An expedited, or urgent appeal is filed if you have not received any treatment yet, or if you are in the middle of treatment and you or your doctor believe that your condition could involve imminent or serious threat to your health.  Obviously, this is an urgent matter, so your health plan should respond to your appeal within 72 hours of getting a qualifying appeal.  They will notify you by phone, as well as in writing.

  1. Standard Appeal

If your situation does not meet the standard for an expedited appeal, you still have the right to an appeal.  This process is longer, as your health plan will inform you of their decision, in writing, within 30 calendar days from the date they receive an appeal.

In both cases, your appeal will be reviewed by the appropriate administrative and/or clinical specialist.  These specialists will not have been involved in the initial decision or a subordinate of the person who made the initial decision.

What to Include in Your Appeal?

When preparing your appeal, but sure to include all the necessary information.  This means the member name and ID number, the name of the provider who will or has provided the care, the dates of service, the claim reference number for the specific decision you are appealing, and the precise reason you disagree with the initial decision.  You have the right to include any documents, comments or other materials that are relevant to your appeal.

You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external appeal at the same time as your internal appeal.

If your insurance company denies your internal appeal, you can file for an external appeal.

External Appeals

Under the Affordable Care Act (ACA) and some state laws, you not only have the right to appeal a decision within your insurance plan, but you also have the right to ask for an external review.  This means that an external, independent, specialist will review your appeal and the insurance plan no longer has final say over whether to pay a claim.  Keep in mind, you can ask for an external review if your internal appeal was denied or was not satisfactorily resolved within the 30 days or 72 hours, in cases of an expedited appeal.

All states are required to participate in an external review process that meets the consumer protection standards of the ACA. Your state may also have an external review process that is more protective. In California, which has some the strongest consumer protections in the county, this means going to http://hmohelp.ca.gov.  To find out about the external review process in your state, visit: http://triagecancer.org/resources/stateresources/.

If your state doesn’t have an external review process that meets the minimum consumer protection standards, the U.S. Department of Health and Human Services (HHS) will oversee your state’s external review process for health insurance companies. If your state relies on an HSA-administered external review, you can begin that process in four ways:

  1. Call 1-888-866-6205 to request an external review request form. Then fax an external review request to: 1-888-866-6190.
  2. Mail an external review request form to: MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534
  3. Submit a request via email: is ferp@maximus.com
  4. At some point in the near future you will be able to request an external review online at externalappeal.com

Ideally, you will not need any of this information.  However, if you do, take heart.  Thanks to the ACA, there are strong consumer protections available in every state and we see an average of approximately 50% of external appeals of denials get successfully overturned.

The Food & Drug Administration & Compassionate Use

The U.S. Food & Drug Administration (FDA) is the federal agency that is responsible for fda-logoprotecting the public health by assuring the safety, efficacy and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation.

The FDA recently implemented new developments in their compassionate use (“expanded access”) program in hopes of solving problems that have been created by state efforts to pass legislation making it easier for patients to access drugs that are still in clinical trials. These state laws are often called “Right to Try” laws.

The FDA’s expanded access program essentially allows terminal patients with no other medical alternatives to access investigational drugs (i.e. medical products that have not yet been approved by the FDA).

Many in the patient advocacy community have argued that the expanded access program isn’t effective enough and advocated for state legislation that would permit terminally ill patients the “right to try” investigational drugs.

There are three main problems with the “right to try” laws, however:

  1. The FDA still has complete control of programs more extensive than its expanded access program. In other words, no matter how many state laws are passed, nothing happens unless the FDA approves it.
  2. Manufacturers are constantly threatened with liability, meaning that if someone is harmed by a drug the manufacturer is going to be held liable, even though the drug is still being tested.
  3. The process to provide investigational drugs is simply too precarious for manufacturers. If a very ill patient dies after taking an investigational drug (which maybe more likely given the patient’s health), the adverse event is then reported to the FDA. These adverse events make it harder for manufacturers to get approval from the FDA.

The FDA has attempted to alleviate some of these issues by adopting two new guidelines:

These guidelines include “expanded access protocol,” “new treatment IND,” and the use of institutional review board review. In addition, only a year’s worth of the drug can be charged without the FDA reevaluating and in the case where a manufacturer does not have an active IND, a physician can submit an expanded access IND instead.

The FDA’s new program is also voluntary, and thus cannot compel a manufacturer to supply investigational drugs. More importantly, the FDA’s guidelines still do not grant immunity for participants, as the FDA can still use adverse events against manufacturers in determining whether or not to grant approval of the drug.

There is legislative pending in Congress, the Trickett Wendler Right to Try Act of 2016, which if passed, would prohibit the use of adverse events from negatively affecting possible FDA approval and would not hold a manufacturer liable if there is an adverse event.

It is still unclear how much effect the states can have if the FDA is not in complete accordance with them. Nevertheless, only time will tell how successful these recent developments will be.

For more information about the expanded access program, visit: www.fda.gov/NewsEvents/PublicHealthFocus/ExpandedAccessCompassionateUse/default.htm.

How to Support Someone with Cancer

Do you have a family member or a friend who has been diagnosed with cancer?

Have you been wondering how you might be able to provide support or do anything to help?

Often we don’t know what to say other than, “Let me know if there is anything that I can Triage Cancer Blog Supporting a Friend with Cancerdo.” While well-intentioned, an open-ended offer of support is unlikely to be followed up on. It can be more helpful to offer to do specific things for your family member or friend.

There are a number of helpful lists of suggestions available in the resources listed below, and we offer a few additional ways to offer practical help, here:

  • Practical help
    • Attend medical appointments and take notes
    • Sort mail
    • Sort medical bills, insurance company paperwork, and medical records
    • Make follow up calls to providers and insurance companies
    • Complete appeals paperwork
    • Apply for financial assistance programs
    • Pay bills
    • Create a spreadsheet of tax deductible medical and dental expenses (http://triagecancer.org/blog/tax-time-is-coming) to make tax time easier
    • Research clinical trials or treatment options
    • Schedule appointments
  • Errands
    • Provide transportation to medical appointments
    • Go grocery shopping
    • Drop off prepared meals
    • Pick up prescriptions
    • Pick up/send mail/buy stamps
    • Pick up dry cleaning
    • Pick up thank you cards (for your loved one to send to others who have helped)
  • Babysit
    • Pick up children from school
    • Take them to extracurricular activities
  • Household chores
    • Cook
    • Wash dishes
    • Do laundry
    • Vacuum
    • Dust
    • Change bedsheets
    • Change lightbulbs
    • Organize a closet
    • Rake leaves
    • Mow the law
    • Water plants
    • Feed/take care of pets

Resources

Supporting a Friend Who Has Cancer: www.cancer.net/coping-with-cancer/talking-with-family-and-friends/supporting-friend-who-has-cancer

Helping a Loved One with Cancer Long Distance: www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/long_distance.aspx

These websites also have tips on how to help family members and friends and have great tools like calendars to schedule meal delivery, transportation to treatment, and more:

www.MyLifeline.org
www.CaringBridge.org
www.Lotsahelpinghands.com
www.foodtidings.com
www.takethemameal.com

Don’t be hurt or offended if your friend or family member doesn’t ask for your help or declines your help when you offer. Even if your friend or family member doesn’t need help, your willingness to be supportive will be appreciated.

Buying Supplemental Insurance Can Be Hard For Younger Medicare Beneficiaries

by, Kasier Health News

Danny Thompson’s kidneys have failed and he needs a transplant but in some ways, he’s lucky: Both of his sons want to give him one of theirs, and his Medicare coverage will take care of most of his expenses.

Yet the 53-year-old Californian is facing another daunting obstacle: He doesn’t have the money for his share of the medical bills and follow-up drugs, and he can’t buy supplemental insurance to help cover his costs.

“It’s frustrating to be in the shape I’m in,” said Thompson, who depends on dialysis instead of his kidneys to cleanse his blood. “My plan is to get a transplant so I can go back to work.”

Almost one in four Medicare beneficiaries has such a policy, known as Medigap, which is sold by private insurance companies. It can help pay for costs Medicare doesn’t cover, including the 20 percent coinsurance required for medical expenses, including certain drugs, plus deductibles and co-payments. Those expenses have no out-of-pocket limit for beneficiaries.

Federal law requires companies to sell Medigap plans to any Medicare beneficiary aged 65 or older within six months of signing up for Part B, which covers doctor visits and other outpatient services. If they sign up during this guaranteed open enrollment, they cannot be charged higher premiums due to their medical conditions.

But Congress left it to states to determine whether Medigap plans are sold to the more than 9 million people younger than 65 years old who qualify for Medicare because of a disability.

In 20 states and the District of Columbia, home to more than 2 million disabled Medicare beneficiaries, insurers are not required to sell Medigap policies to customers under 65. In other states, insurers cannot reject applicants if they enroll when they first join Medicare. Companies in some states, including Virginia, can still charge higher premiums to younger beneficiaries or those with kidney disease, often making policies unaffordable.

In California, Massachusetts and Vermont. insurers are required to sell Medigap policies to anyone with Medicare, except to people like Thompson who are under 65 and have end stage renal disease.

“If it was the reverse — if you were discriminating against somebody because they were 65 or older as opposed to younger — people would be outraged,” said Bonnie Burns, policy specialist for the consumer group California Health Advocates and a member of the National Association of Insurance Commissioners’ Medigap committee.

The federal health law provides no relief for these younger Medicare beneficiaries. One of its most popular provisions prohibits discrimination by insurance companies in the non-Medicare market based on pre-existing conditions or age, but the law is silent on Medigap.

Thompson, who lives in Menlo Park, near San Francisco, said 12 Medigap insurers have turned him down. Buying a health plan through Covered California, the state’s health insurance exchange, is not an option since he has primary insurance through Medicare. “That is for people who don’t have insurance, and I have insurance,” he said. “But it is as if I don’t.”

The transplant costs are substantial, and Thompson said he does not have the resources to cover his share. Kidney transplant patients can expect the preparation, surgery, tests and treatment for the first year to run more than $262,000, according to the American Kidney Fund. The immunosuppressant drugs, which patients will need for the rest of lives to ensure their body does not reject the new kidney, cost another $2,000 to $4,000 a month.

No Hospital Mandate

Hospitals and doctors are not required to provide care for Medicare patients unless it’s a medical emergency, a Medicare official said.

Joe Baker, president of the Medicare Rights Center, said that they can turn away Medicare patients for any number of reasons, including inability to pay their share of the bills or because providers are not taking new patients.

“Medicare beneficiaries under 65 with end stage renal disease get an organ transplant if they agree to pay their share of the costs Medicare doesn’t cover,” said Lisa Kim, a spokeswoman for Stanford Hospital, where Thompson has sought treatment.

To help Thompson find financial assistance, a Stanford social worker referred him to Christina Dimas-Kahn, who heads the San Mateo County office of the California Department of Aging’s Health Insurance Counseling and Advocacy Program (HICAP). She said he is one of several clients with end stage renal disease that HICAP counselors have tried to help in the past few years, “But people with the disease don’t have whole lot of options if they are under 65,” she said.

Danny Thompson, 53, needs a kidney transplant and both of his sons want to give him one of theirs (Heidi de Marco/KHN).

Thompson needs a kidney transplant and both of his sons want to give him one of theirs. (Heidi de Marco/KHN)

Thompson recently learned that he could qualify for Medi-Cal, California’s Medicaid program for low-income people, which Dimas-Kahn said would cover his transplant expenses. But Thompson said that coverage would kick in only after he paid a $2,500 deductible every month, which he cannot afford.

If Thompson divorced his wife of 30 years, her income wouldn’t be counted along with his Social Security disability benefits and it’s possible he wouldn’t have to pay the deductible. That’s not a good alternative, he said. “We made vows — rich or poor, in sickness or in health — you stay married.”

‘Crazy Patchwork’ Of Regulations

Another solution could be moving to another state, such as Delaware. That’s where Heather Block, a politically savvy project manager for federal and international organizations, took on her state legislature after she was diagnosed with advanced breast cancer.

“I considered myself lucky when I became eligible for Medicare but that 20 percent co-pay with no out-of-pocket maximum is exorbitant for anyone let alone someone with a serious illness,” she said.

Block could get Medicare before turning 65 because she qualified for disability benefits, but she couldn’t get Medigap coverage. Two years ago, she spearheaded a successful campaign to change state law, forcing insurers to sell Medigap policies to anyone when they first enroll in Medicare regardless of age, without basing rates on their health conditions.

“It is insane that we have to go through this crazy patchwork of state regulations,” said Block, whose monthly charges for cancer drugs alone range as high as $9,800. Without Medigap, medical bills would eventually deplete her savings.

Prospects for a nationwide solution are dim because expanding Medigap coverage could lead to these beneficiaries with disabilities receiving more care and raising costs for the Medicare program. Congress is looking for strategies to curb Medicare spending, not increase it, Burns said.

The health insurance industry’s trade association opposes expanding Medigap to include all Medicare beneficiaries younger than 65 with end stage renal kidney disease. Since treatment for those patients can be so expensive, adding them could increase Medigap premiums for everyone, said Cindy Goff, a vice president at America’s Health Insurance Plans. She pointed to Medicare statistics that show when the program covers patients over 65 with end-stage renal disease, their care averages nearly nine times more than other Medicare beneficiaries.

Older adults are “super price-sensitive” and raising premiums “would basically price them out of being able to get the Medigap protection they want,” said Goff.

“The insurance company knows that these patients coming through the door are going to use services,” said LaVarne Burton, president of the American Kidney Fund. “In most instances, if they don’t get treatment, they will die.”

This post originally appeared at Kaiser Health News on February 3, 2016.

Cancer-Related Fatigue – Fighting Those Zzzzzs

Triage Cancer FatigueHas your treatment left you feeling unusually tired? If yes, you be experiencing cancer-related fatigue.

What is cancer-related fatigue?

Cancer-related fatigue is a persistent feeling of physical, emotional, or mental tiredness or exhaustion related to cancer and/or its treatment. Some of the symptoms include:

  • Feeling tired and it not getting better, it constantly returning, or it becoming severe
  • Being more tired than usual during or after an activity
  • Feeling tired with no relation to any activity
  • Putting less effort into your appearance because you’re too tired
  • Being too tired to do the things you normally do
  • Having no energy and/or feeling weak
  • Feeling tired even with sufficient rest and sleep
  • Spending more time in bed and/or sleeping more
  • Staying in bed for more than 24 hours
  • Not being able to concentrate or focus your thoughts
  • Having trouble remembering things
  • Becoming confused
  • Feeling tired and it disrupting your work, social life, or daily routine
  • Feeling sad, depressed, or irritable
  • Feeling frustrated, irritable, and upset about the fatigue and its effects on your life

What causes cancer-related fatigue?

There are several factors that can contribute to cancer-related fatigue. Some of the causes include:

  • Cancer treatment
  • Anemia
  • High/low hormone levels
  • Loss of appetite
  • Dehydration
  • Lack of exercise
  • Anxiety
  • Depression

 How is cancer-related fatigue treated?

The first step in treating fatigue is to identify the cause. If the cause is not known, you may need to try several different methods in order to figure out which one works for you. Staying physically active can help both manage fatigue and improve strength. Over time, try to build up to 150 minutes of moderate activity (walking, cycling, swimming) per week. You can also add in strength training exercises. Make sure that you are staying hydrated, by drinking enough water.

A psychosocial care professional (e.g., therapist, counselor, social workers, psychologist, psychiatrist, etc.) can help provide you with emotional support, which may alleviate your fatigue. Many patients have also found that acupuncture and yoga can help. Cancer-related fatigue can persist months or years after treatment, so it’s important to receive both short-term and long-term care.

Although common among cancer patients, cancer-related fatigue is not something that should be taken lightly. It is important that you talk with your doctor, or other members of your health care team, if your fatigue is affecting your health and well-being.

For more information on cancer-related fatigue, click here.

FDA Updates the Nutrition Label

Individuals across the country have heavily relied on the nutrition facts label to speak the ChooseMyPlatetruth about their food choices. On May 20, 2016, the FDA released a new and updated nutrition facts label to help individuals make better informed decisions about the foods they consume.

The new nutrition facts label includes:

  • A design that better emphasizes the amount of “calories” and the number of “servings” in a package
  • “Dual column” labels to indicate both “per serving” and “per package” calorie and nutrition information.
  • A declaration of grams and a percent daily value (%DV) for “added sugars” to differentiate the amount of added sugars from the natural sugars.
  • Updated daily values for nutrients like sodium, dietary fiber and vitamin D that are consistent with the Institute of Medicine recommendations and the 2015-2020 Dietary Guidelines for Americans.
  • A declaration of grams and a %DV of vitamin D and potassium for consumers who are deficient in these nutrients and are, thus, at greater risk for chronic disease. The %DV and actual gram count for calcium and iron will continue to be required, whereas the %DV and actual gram count for Vitamins A and C will no longer be a requirement.
  • A removal of “Calories from Fat” because research shows that the type of fat is more important than the amount of fat. “Total Fat,” “Saturated Fat,” and “Trans Fat” will continue to be required.
  • An abbreviated footnote to better explain the %DV.

New Nutrition Label

Don’t expect to see these changes right away.  Most food manufacturers will be required to use the new label by July 26,2018. Manufacturers with annual food sales of less than $10 million will have an additional year to adjust to the change.

However, the new label is a big step towards helping individuals be more conscious of the products they are eating. For more nutritional tools, visit: https://www.supertracker.usda.gov.

Take another step by watching the recording of our free webinar on nutrition and plant-based diets.

Are You a Veteran & Applying for Disability?

Then you should know about the ABA Veterans Claims Assistance Network . . .

The American Bar Association Veterans’ Claims Assistance Network (ABA VCAN), along VCANwith the U.S. Department of Veterans Affairs (VA), is providing a program where volunteer lawyers work with unrepresented veterans with pending disability claims.

With the help of legal assistance, veterans will complete their claim packages for expedited review by the VA and will receive disability compensation.

The ABA’s goal is to help address the VA claims backlog and get veterans the disability benefits to which they are entitled.

For more information about ABA VCAN, click here.

What kind of water should I drink?

by Julie Lanford, MPH, RD, CSO, LDN
Infused-Water-in-Jars-landscape-reshoot-Photo-by-Vanessa-Greaves-e1434731790958
First off, it’s important to remember that we need to drink fluids to keep our bodies hydrated. In general, our bodies simply need plain water. It’s our taste buds (and sometimes our emotions!) that want something different!
 
Just because your water is clear, does not mean it is healthy! The majority of flavored waters that are available, such as vitamin or sparking waters, are filled with sugar and artificial sweeteners. The best way to know is to simply read the ingredient list. 
 
Unfortunately, even the “vitamin water” brand is not just water with added vitamins. There are many ingredients in these beverages that have no benefit to your health. To see a full list of these ingredients, check out my post “Is Vitamin Water Healthy? Plus a Recipe to Make Your Own” (link here: http://www.cancerdietitian.com/2011/07/is-vitamin-water-healthy-plus-a-recipe-to-make-your-own.html). Most of the added vitamins in these drinks come from synthetic forms and do not provide you the same benefit as you would by eating food. 
 
Remember that drinking any form of plain water is better than choosing a soda or other sweetened beverage! Luckily, there is a way to drink delicious flavored water without being at risk of consuming unnecessary additives.
 
Make your own infused water!
 
Here are a few tips to get you started making your own infused water. Not only is it nutritious, it’s also really pretty!!
 
First, you choose the flavor. There are limitless possibilities! You can choose fresh fruit flavors such as strawberry, orange, or blueberry or you can choose a vegetable-based flavored water by adding cucumber, beets, or celery. 
 
Herbs and spices such as basil, rosemary, and cinnamon can also be used to add some extra flavor. I think the best flavored water comes from a combination of all of the above! Making your own infused water gives you the opportunity to select the flavors that you like best and allows you to individually customize each beverage you make.
 
The directions for making your own “vitamin water” are very simple. 
1.     Choose your fresh fruits, vegetables, or herbs. 
2.     Make sure you thoroughly wash your produce.
3.     Slice or cut your produce however you like it. The more surface area of the produce that touches the water, the better!
4.     Add all the ingredients into a pitcher filled with water.
5.     Let it soak in the refrigerator overnight. 
6.     Enjoy!
You also want to make sure to use cold water. Hot water can make produce fall apart and compromise some of the nutrients. Also if you want an extra “vitamin boost”, feel free to eat the produce!

Unflavored sparkling water is equivalent to flat water. One of my favorite ways to have a “special drink” is to mix 1 part juice to 2 parts sparkling water. Have it over ice, with a slice of lime and an umbrella and you’re really feeling good!!

The Cancer Dietitian BOTTOM LINE: Drink water without added sweeteners (artificial or natural) most of the time. Have processed water drinks (sodas, diet sodas, “vitamin waters”, etc) 2 times a week or less. If you like a little flavor to your water, find ways to add flavor with fruits or vegetables!

Julie Lanford MPH, RD, CSO, LDN, is a member of Triage Cancer’s Speakers Bureau and wellness director for Cancer Services, a non-profit in Winston-Salem, NC. She is a registered dietitian, licensed nutritionist and a board certified specialist in oncology nutrition. Lanford developed www.CancerDietitian.com a healthy living web site for Cancer Services that translates evidence based nutrition guidelines into consumer friendly messages for everyday life.

Medical Marijuana: A Guide to Navigating Employment

A few months ago, we posted a blog about the legal and practical issues of medical Triage Cancer Blog Medical Marijuanamarijuana. This blog follows up on the challenges facing employees who are using medical marijuana to address their side effects from cancer treatment.

Legal Cases, Updated Laws, and Employment Issues

Currently, 25 states and the District of Columbia allow for the use of medical marijuana. In an article written by Jon Woodruff, a legislative attorney for the National Alliance for Model State Drug Laws, it is estimated that about 70-80% patients using marijuana are between the ages of 18 and 60. These numbers indicate that many of those patients are currently in the workforce. With more and more state laws increasing the availability of medical marijuana and recreational marijuana, new legal issues are occurring at the workplace between employers and employees.

Despite the state-by-state legalization, the fact remains that marijuana is still illegal under federal law. This makes treading the employment waters very tricky for both employers and employees.

This leads to the biggest question, can an employee be terminated or have a job offer rescinded based on their use of medical marijuana? The answer is . . . it depends. Under most state laws, an employer is not required to accommodate an employee’s use of medical marijuana, but there are some exceptions to this.

Breakdown of Requirements for Employers to Accommodate Employee Use of Medical Marijuana by State

  States
State law does not explicitly address employer accommodation Hawaii, Louisiana, Maryland, New Mexico, Vermont, and the District of Columbia
Employers are NOT required to accommodate Alaska, California, Colorado, Maine, Massachusetts, Michigan, Montana, New Jersey, New Hampshire, Oregon, Pennsylvania, Rhode Island, and Washington
Employers cannot discriminate against or terminate a registered patient (other than a federal employee) Arizona, Delaware, Minnesota, and Connecticut*
Employers are required to make attempt to accommodate use Nevada, New York, and Illinois
Pending bills requiring more employer accommodation Hawaii, Michigan, New Jersey, and Rhode Island

*Connecticut statute does not address accommodation, but states that employer cannot refuse to hire based on status as a “patient.”

Court cases in New Mexico, Colorado, and Oregon aren’t making it any easier to understand when and where it is acceptable to work as an employee using medical marijuana. In New Mexico, a court ruled that it would not require employers to accommodate the use of “a drug that is still illegal under federal law” (Garcia v. Tractor Supply Co.). Meanwhile, in Colorado, one of the states that has legalized marijuana for recreational use, a court ruled that termination of an employee is valid because marijuana is still classified as illegal under the federal Controlled Substances Act (Coats v. Dish Network). Brandon Coats, a quadriplegic, licensed to use medical marijuana after his painkillers used to treat muscle spasms had lost effectiveness, was terminated from his job when failing a mandatory drug test. The termination was deemed valid in Colorado’s Supreme Court. Finally, in a court case in Oregon, a state that does not require employers to accommodate medical marijuana use, an arbitrator reinstated a Lane county employee that was fired for medical marijuana use outside of the workplace, while off-duty.

A Lack of Research Findings

Medical marijuana has become a hot topic for legalization for a number of different reasons. The reported ability to help reduce pain and nausea and to increase appetite are the major contributing factors to its promotion, particularly in the cancer community. However, despite the attention, the research on marijuana’s ability to control pain, nausea, and stimulate appetite is severely lacking. In an article published in Cure Magazine, the author summarizes what studies have been conducted and why it has been so difficult to develop better studies in recent years. The major issue facing medical marijuana research is the classification of marijuana as a Schedule I substance with “no medical uses,” under the Controlled Substances Act. This makes it difficult to get funding or materials to conduct research or a clinical trial. The Journal of the American Medical Association (JAMA) and CA: A Cancer Journal for Clinicians have both published articles attempting to summarize the research that has been done, but combined found a total of nine studies that looked into the use of inhaled cannabis for pain and even less (only two) met inclusion criteria for studying the effect of inhaled cannabis on chemotherapy induced nausea and vomiting. While each of these studies did find that marijuana use decreased the effects of pain, the study size and duration leaves much to be desired in terms of power. Outside of established medical journals, trials have found that smoking cannabis does help chemotherapy patients with controlling nausea and vomiting better than a “no treatment” test group and the ingestion of a purified active ingredient of cannabis.

There are other concerns about the use of medical marijuana, including a lack of regulation of quality, dosage, and a lack of understanding of how it may interact with other treatments, such as chemotherapy.  Testing of available medical marijuana has found fungus, bacteria, and other ingredients which could be unhealthy.

The minimal research that has been done so far does show promising results with data concluding that inhaled cannabis helps with pain, nausea and vomiting, and increased appetite in chemotherapy and AIDS patients. Current FDA approval exists for pill forms of medical marijuana in Marinol (dronabinol) and Cesamet (nabilone), for the treatment of nausea and vomiting in patients with AIDS or who are undergoing chemotherapy, respectively. However, we now need higher quality studies of medical marijuana to fully understand its benefits and determine whether the benefits do outweigh the risks, such as paranoia, anxiety, irritability, lethargy, acute increase in blood pressure, cognitive impairment, and other possible side effects.

What Does This Mean for Employees and Patients?

As an employee, it is important to make sure that you know your employer’s policies on drug use. Some employers have a “zero tolerance” policy, because it makes managing employees simple or it may be a company that is in multiple states. Other companies take a more relaxed approach, by delegating certain “safety-sensitive” positions that do allow for termination if an employee is found under the influence. For example, you probably wouldn’t want your school bus drivers or your airline pilots to come to work under the influence.  Employers also need to know their legal responsibilities under relevant state laws or they may find themselves in violation of disability laws for not reasonably accommodating their employees. As always, if you have any questions, it is best to seek legal advice from a professional in your area.

The Danger of Fixed Indemnity Plans: But Not in the Eyes of the Court

A recent court ruling declared that consumers must have the option of buying certain types of health insurance that do not meet the standards of the Patient Protection & Affordable Care Act (ACA).

One of the many ways in which the ACA tried to protect consumers, was by not allowing Cautioninsurance companies to sell “fixed indemnity” health insurance plans as a stand-alone product. A fixed indemnity plan is a type of health insurance that pays consumers a fixed amount for each service, regardless of the actual cost of the medical care received. For someone received treatment for a cancer diagnosis, these plans can prove to be very dangerous, leaving patients with huge out-of-pocket costs. However, these plans do give people the freedom to visit their preferred doctor or hospital, without having to stay within a defined “network” of providers.

In 2014, the Obama Administration enforced rules that such insurance could only be sold to those with more extensive coverage; where the fixed indemnity plan was meant as a supplemental policy, not as a “substitute for major medical coverage.” The Administration was concerned that allowing consumers to buy fixed indemnity insurance plans as a stand-alone product gives people “the mistaken belief that it provides comprehensive coverage.”

And we have certainly seen that to be true. Marketing of these plans can be deceptive, and many people do not realize that the policy they have bought will not cover much of their medical expenses, leaving them with enormous medical bills, and only bankruptcy ahead of them. In some circumstances, people have not been able to get the medical care they need because they cannot afford it. In addition, because these are limited policies, hey do not meet the requirement that most people in the United States have health insurance coverage, leaving people with an additional penalty to pay come tax time.

Despite these issues, the Court disagreed, ruling that the Obama administration could not restrict the sale of these plans. The Court agreed with the plaintiffs in the case, who felt that because fixed indemnity plans are a branch under catastrophic health insurance (policies that are intended to protect you from unexpected health costs), these plans could be a valuable option for those who have incomes that fall in the coverage gap: they make too much for Medicaid, but too little for financial assistance in the Health Insurance Marketplace.

Although the court ruling may provide more health insurance options for consumers, it poses hidden risks. Consumers with fixed indemnity insurance generally have fewer protections, meaning that they can still have pre-existing condition exclusions, caps on benefits, no access to free preventive services, and the policy does not have to cover a certain percentage of medical costs. In addition, because the stand-alone insurance has a fixed amount for each service, it may leave consumers with a large bill to cover the difference, depending on their health needs. And, despite the lower monthly costs, there is usually a higher annual deductible. Thus, it’s imperative that consumers are not only aware of the costs, but also the protections each respective plan provides for them.

Triage Cancer is hosting a webinar on October 18, 2016, on “Choosing Wisely: How to Pick Health Insurance Plans.”  Register Here. In the meantime, there are other webinars available for watching at any time here.