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New FDA rule will ensure all women have more information after cancer screenings

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theconversation.com – Nancy Kressin, Emeritus Professor of Medicine, Boston University – 2024-09-09 07:24:09

New FDA rule will ensure all women have more information after cancer screenings
Breast density raises the risk of breast cancer and can also make it more difficult for breast cancer to be detected.
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Nancy Kressin, Boston University; Christine M. Gunn, Dartmouth College; Priscilla J. Slanetz, Boston University, and Tracy A. Battaglia, Yale University

The Food and Drug Administration implemented a rule to go into effect on Sept. 10, 2024, requiring mammography facilities to notify women about their breast density. The goal is to ensure that women nationwide are informed about the risks of breast density, advised that other imaging tests might help find cancers and urged to talk with their about next steps based on their individual situation.

The FDA originally issued the rule on March 10, 2023, but extended the implementation date to give mammography facilities additional time to adhere.

U.S. asked a team of experts in social science and patients’ health behaviors, health policy, radiology and primary care and health services research to explain the FDA’s new regulations about these health communications and what women should consider as they decide whether to pursue additional imaging tests, often called supplemental screening.

What is breast density and why does it matter?

Breast density is categorized into four categories: fatty, scattered tissue, heterogeneously dense or extremely dense.

Dense breasts are composed of more fibrous, connective tissue and glandular tissue โ€“ meaning glands that produce milk and tubes that carry it to the nipple โ€“ than fatty tissue. Because fibroglandular tissue and breast masses both look white on mammographic images, greater breast density makes it more difficult to detect cancer. Nearly half of all American women are categorized as dense breasts.

Having dense breasts also increases the risk of getting breast cancer, though the reason for this is unknown.

Because of this, decisions about breast cancer screening get more complicated. While evidence is clear that regular mammograms save lives, additional testing such as ultrasound, MRI or contrast-enhanced mammography may be warranted for women with dense breasts.

What does the new FDA rule say?

The FDA now requires specific language to ensure that all women receive the same โ€œaccurate, complete and understandable breast density information.โ€ After a mammogram, women must be informed:

โ€“ Whether their breasts are dense or not dense

โ€“ That having dense breasts increases the risk of breast cancer

โ€“ That having dense breasts makes it harder to find breast cancer on mammograms

โ€“ That for those with dense breasts, additional imaging tests might help find cancer

They must also be advised to discuss their individual situation with their provider, to determine which, if any, additional screening might be indicated.

A female doctor holds a breast model up, explaining it to her patient, with a mammogram image in the background.
Conversations between patients and doctors are crucial for determining whether supplemental screening would be beneficial.
PonyWang/E+ via Getty Images

Why did the FDA issue the new rule?

Prior to the federal rule, 38 U.S. states required some form of breast density notification. But some states had no notification requirements, and among the others there were many inconsistencies that raised concerns by advocates, women with dense breasts whose advanced cancer had not been detected on a mammogram.

The FDA standardized the information women must receive. It is written at an eighth grade reading level and may address racial and literacy-level differences in women’s knowledge about breast density and reactions to written notifications.

For instance, our research team found disproportionately more confusion and anxiety among women of color, those with low literacy and women for whom English was not their first language. And some women with low literacy reported decreased future intentions to undergo mammographic screening.

What is the value of additional screening?

Standard mammograms use X-rays to produce two-dimensional images of the breast. A newer type of mammography imaging called tomosynthesis produces 3D images, which find more cancers among women with dense breasts. So, researchers and doctors generally agree that women with dense breasts should undergo tomosynthesis screening when available.

There is still limited scientific evidence to guide recommendations for supplemental breast screening beyond standard mammography or tomosynthesis for women with dense breast tissue. Data shows that supplemental screening with ultrasound, MRI or contrast-enhanced mammography may detect additional cancers, but there are no prospective studies confirming that such additional screening saves more lives.

So far, there is no data from randomized clinical trials showing that supplemental breast MRIs, the most often-recommended supplemental screening, reduce from breast cancer.

However, more early stage โ€“ but not late-stage โ€“ cancers are found with MRIs, which may require less extensive surgery and less chemotherapy.

Various professional organizations and experts interpret the available data about supplemental screening differently, arriving at different conclusions and recommendations. An important consideration is the woman’s individual level of risk, since emerging evidence suggests that women whose personal risk of developing breast cancer is high are most likely to benefit from supplemental screening.

Some organizations have concluded that current evidence is too limited to make a recommendation for supplemental screening, or they do not recommend routine use of supplemental screening for women based solely on breast density. Others recommend additional screening for women with extremely or heterogeneously dense breasts, even when their risk is at the intermediate level.

What should women consider about added screening?

Because personal risk of breast cancer is a crucial consideration in deciding whether to undergo supplemental screening, women should understand their own risk.

The American College of Radiology recommends that all women undergo risk assessment by age 25. Women and their providers can use risk calculators such as Tyrer-Cuzick, which is free and available online.

Women should also understand that breast density is only one of several risks for breast cancer, and some of the others can be modified. Engaging in regular physical activity, maintaining a healthy weight, limiting alcohol use and eating a healthy diet rich in vegetables can all decrease breast cancer risk.

Are there potential harms?

Amid the debate about the benefits of supplemental breast screening, there is less discussion about its possible harms. Most common are false alarms: results that suggest a finding of cancer that require follow-up testing. Less commonly, a biopsy is needed, which may lead to short-term fear and anxiety, medical bills or potential complications from interventions.

Supplemental screening can also lead to overdiagnosis and overtreatment โ€“ the small risk of identifying and treating a cancer that would have never posed a problem.

MRI screening also involves use of a chemical substance called gadolinium to improve imaging. Although tiny amounts of gadolinium are retained in the body, the FDA considers the contrast agent to be safe when given to patients with normal kidney function.

MRIs may also identify incidental findings outside the breast โ€“ such as in the lungs โ€“ that warrant additional concern, testing and cost. Women should consider their tolerance for such risks, relative to their desire for the of additional screening.

The out-of-pocket cost of additional screening beyond a mammogram is also a consideration; only 29 states plus the District of Columbia require insurance coverage for supplemental breast cancer screening, and only three states โ€“ New York, Connecticut and Illinois โ€“ mandate insurance coverage with no copays.

How can you learn more?

Though the FDA urges women to talk with their providers, our research found that few women have such conversations and that many providers lack sufficient knowledge about breast density and current guidelines for breast screening.

It’s not yet clear why, but providers receive little or no about breast density and little confidence in their ability to counsel patients on this topic.

To address this knowledge deficit in some health care settings, radiologists, whose screening guidelines are more stringent than some other organizations, sometimes provide a recommendation for supplemental screening as part of their mammography report to the provider who ordered the mammogram.

Learning more about the topic in advance of a discussion with a provider can help a woman better understand her options.

Numerous online resources can provide more information, including the American Cancer Society, the website Dense Breast-info and the American College of Radiology.

Armed with information about the complexities of breast density and its impact on breast cancer screening, women can discuss their personal risk with their providers and evaluate the options for supplemental screening, with consideration of how they value the benefits and harms associated with different tests.The Conversation

Nancy Kressin, Emeritus Professor of Medicine, Boston University; Christine M. Gunn, Assistant Professor of Health Policy and Clinical Practice, Dartmouth College; Priscilla J. Slanetz, Professor of Radiology, Boston University, and Tracy A. Battaglia, Associate Director of Cancer Care Equity, Yale Cancer Center, Yale University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Comet Tsuchinshan-ATLAS is a Halloween visitor from the spooky Oort Cloud โˆ’ the invisible bubble thatโ€™s home to countless space objects

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theconversation.com – James Wray, Professor of Earth and Atmospheric Sciences, Georgia Institute of Technology – 2024-10-11 12:36:00

The human mind may find it difficult to conceptualize: a cosmic cloud so colossal it surrounds the Sun and eight planets as it extends trillions of miles into deep .

The spherical shell known as the Oort Cloud is, for all practical purposes, invisible. Its constituent particles are spread so thinly, and so far from the light of any star, the Sun, that astronomers simply cannot see the cloud, even though it envelops us like a blanket.

It is also theoretical. Astronomers infer the Oort Cloud is there because it’s the only logical explanation for the arrival of a certain class of comets that sporadically visit our solar system. The cloud, it turns out, is basically a gigantic reservoir that may hold billions of icy celestial bodies.

Two of those bodies will pass by Earth in the days leading up to Halloween. Tsuchinshan-ATLAS, also known as Comet C/2023 A3, will be at its brightest, and likely visible to the naked eye, for a or two after Oct. 12, the day it’s closest to Earth โ€“ just look to the western sky shortly after sunset. As the days pass, the comet will get fainter and move to a higher part of the sky.

A view of comet Tsuchinshan-ATLAS from the International Space Station.

The second comet, C/2024 S1 (ATLAS), just discovered on Sept. 27, should be visible around the end of October. The comet will pass closest to Earth on Oct. 24 โ€“ look low in the eastern sky just before sunrise. Then, after swinging around the Sun, the comet may reappear in the western night sky right around Halloween. It’s possible, however, that it could disintegrate, in part or in whole, as sometimes happens when comets pass by the Sun โ€“ and this one will within 1 million miles (1.6 million kilometers) of our star.

As a planetary astronomer, I’m particularly curious about the Oort Cloud and the icy bodies inhabiting it. The Cloud’s residents may be a reason why ignited on Earth; crashing on our planet eons ago, these ice bodies may have supplied at least some of the water that all life requires. At the same time, these same objects pose an ever-present threat to Earth’s continuation โ€“ and our survival.

Billions of comets

If an Oort Cloud object finds its way to the inner solar system, its ices vaporize. That produces a tail of debris that becomes visible as a comet.

Some of these bodies, known as long-period comets, have orbits of hundreds, thousands or even millions of years, like Tsuchinshan-ATLAS. This is unlike the so-called short-period comets, which do not visit the Oort Cloud and have comparatively quick orbits. Halley’s comet, which cuts a path through the solar system and orbits the Sun every 76 years or so, is one of them.

The 20th-century Dutch astronomer Jan Oort, intrigued by the long-period comets, wrote a paper on them in 1950. He noted about 20 of the comets had an average distance from the Sun that was more than 10,000 astronomical units. This was astounding; just one AU is the distance of the Earth from the Sun, which is about 93 million miles. Multiply 93 million by 10,000, and you’ll find these comets come from over a trillion miles away. What’s more, Oort suggested, they were not necessarily the cloud’s outermost objects.

Nearly 75 years after Oort’s paper, astronomers still can’t directly image this part of space. But they do estimate the Oort Cloud spans up to 10 trillion miles from the Sun, which is almost halfway to Proxima Centauri, the next closest star.

The long-period comets spend most of their time at those vast distances, making only brief and rapid visits close to the Sun as they come in from all directions. Oort speculated the cloud contained 100 of these icy objects. That may be as numerous as the number of stars in our galaxy.

How did they get there? Oort suggested, and modern simulations have confirmed, that these icy bodies could have initially formed near Jupiter, the solar system’s largest planet. Perhaps these objects had their orbits around the Sun disturbed by Jupiter โ€“ similar to how NASA spacecraft bound for destinations from Saturn to Pluto have typically swung by the giant planet to accelerate their journeys outward.

Some of these objects would have escaped the solar system permanently, becoming interstellar objects. But others would have ended up with orbits like those of the long-period comets.

An artistic illustration of the solar system and the Oort Cloud.

An illustration of the solar system and the Oort Cloud. The numbers on the graph depict AUs, or astronomical units. Note the location of Voyager 2, which will take another 30,000 years to fly out of the Cloud.
NASA

Threats to Earth

Long-period comets present a particular potential danger to Earth. Because they are so far from our Sun, their orbits are readily altered by the gravity of other . That means scientists have no idea when or where one will appear, until it does, suddenly. By then, it’s typically closer than Jupiter and moving rapidly, at tens of thousands of miles per hour. Indeed, the fictional comet that doomed Earth in the film โ€œDon’t Look Upโ€ came from the Oort Cloud.

New Oort Cloud comets are discovered all the time, a dozen or so per year in recent years. The odds of any of them colliding with Earth are extremely low. But it is possible. The recent success of NASA’s DART mission, which altered the orbit of a small asteroid, demonstrates one plausible approach to fending off these small bodies. But that mission was developed after years of studying its target. A comet from the Oort Cloud may not offer that much time โ€“ maybe just months, weeks or even days.

Or no time at all. ‘Oumuamua, the odd little object that visited our solar system in 2017, was discovered not before but after its closest approach to Earth. Although ‘Oumuamua is an interstellar object, and not from the Oort Cloud, the proposition still applies; one of these objects could sneak up on us, and the Earth would be defenseless.

One way to prepare for these objects is to better understand their basic properties, including their size and composition. Toward this end, my colleagues and I work to characterize new long-period comets. The largest known one, Bernardinelliโ€“Bernstein, discovered just three years ago, is roughly 75 miles (120 kilometers) across. Most known comets are much smaller, from one to a few miles, and some smaller ones are too faint for us to see. But newer telescopes are helping. In particular, the Rubin Observatory’s decade-long Legacy Survey of Space and Time, starting up in 2025, may double the list of known Oort Cloud comets, which now stands at about 4,500.

The unpredictability of these objects makes them a challenging target for spacecraft, but the European Space Agency is preparing a mission to do just that: Comet Interceptor. With a launch planned for 2029, the probe will park in space until a suitable target from the Oort Cloud appears. Studying one of these ancient and pristine objects could offer scientists clues about the origins of the solar system.

As for the comets now in Earth’s vicinity, it’s OK to look up. Unlike the comet in the DiCaprio , these two will not crash into the Earth. The nearest Tsuchinshan-ATLAS will get to us is about 44 million miles (70 million kilometers); C/2024 S1 (ATLAS), about 80 million miles (130 million kilometers). Sounds like a long way, but in space, that’s a near miss.

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Happiness class is helping clinically depressed school teachers become emotionally healthy โˆ’ with a cheery assist from Aristotle

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theconversation.com – John Sommers-Flanagan, Clinical Psychologist and Professor of Counseling, of Montana – 2024-10-11 07:32:00

Text saying: Uncommon Courses, from The Conversation

Uncommon Courses is an occasional series from U.S. highlighting unconventional approaches to teaching.

Title of Course

Evidence-Based Happiness for Teachers

What prompted the idea for the course?

I was discouraged. For nearly three decades, as a clinical psychologist, I trained mental health professionals on suicide assessment. The work was good but difficult.

All the while, I watched in dismay as U.S. suicide rates relentlessly increased for 20 consecutive years, from 1999 to 2018, followed by a slight dip during the COVID-19 pandemic, and then a rise in 2021 and 2022 โ€“ this despite more local, and national suicide prevention programming than ever.

I consulted my wife, Rita, who also happens to be my favorite clinical psychologist. We decided to explore the science of happiness. Together, we established the Montana Happiness Project and began offering evidence-based happiness workshops to complement our suicide prevention work.

In 2021, the Arthur M. Blank Family Foundation, through the University of Montana, awarded us a US$150,000 grant to the state’s K-12 public school teachers, counselors and staff. We’re using the funds to offer these educators low-cost, online graduate courses on happiness. In spring 2023, the foundation awarded us another $150,000 so we could extend the program through December 2025.

What does the course explore?

Using the word โ€œhappinessโ€ can be off-putting. Sometimes, people associate happiness with recommendations to just smile, cheer up and suppress negative emotions โ€“ which can lead to toxic positivity.

As mental health professionals, my wife and I reject that definition. Instead, we embrace Aristotle’s concept of โ€œeudaimonic happinessโ€: the pursuit of meaning, mutually supportive relationships and becoming the best possible version of yourself.

The heart of the course is an academic, personal and experiential exploration of evidence-based positive psychology interventions. These are intentional practices that can improve mood, optimism, relationships and physical wellness and offer a sense of purpose. Examples include gratitude, acts of kindness, savoring, mindfulness, mood music, practicing forgiveness and journaling about your best possible future self.

are required to implement at least 10 of 14 positive psychology interventions, and then to talk and write about their experiences on implementing them.

Why is this course relevant now?

Teachers are more distressed than ever before. They’re anxious, depressed and discouraged in ways that adversely affect their ability to teach effectively, which is one reason why so many of them leave the profession after a short period of time. It’s not just the low pay โ€“ educators need support, appreciation and coping tools; they also need to know they’re not alone.

This exercise helps you focus on what goes right, rather than the things that go wrong.

What’s a critical lesson from the course?

The lesson on sleep is especially powerful for educators. A review of 33 studies from 15 countries reported that 36% to 61% of K-12 teachers suffered from insomnia. Although the rates varied across studies, sleep problems were generally worse when teachers were exposed to classroom violence, had low job satisfaction and were experiencing depressive symptoms.

The sleep lesson includes, along with sleep hygiene strategies, a happiness practice and insomnia intervention called Three Good Things, developed by the renowned positive psychologist Martin Seligman.

I describe the technique, in Seligman’s words: โ€œWrite down, for one week, before you go to sleep, three things that went well for you during the day, and then reflect on why they went well.โ€

Next, I make light of the concept: โ€œI’ve always thought Three Good Things was hokey, simplistic and silly.โ€ I show a of Seligman saying, โ€œI don’t need to recommend beyond a week, typically โ€ฆ because when you do this, you find you like it so much, most people just keep doing it.โ€ At that point, I roll my eyes and say, โ€œMaybe.โ€

Then I share that I often awakened for years at 4 a.m. with terribly dark . Then โ€“ funny thing โ€“ I tried using Three Good Things in the middle of the night. It wasn’t a perfect solution, but it was a vast improvement over lying helplessly in bed while negative thoughts pummeled me.

The Three Good Things lesson is emblematic of how we encourage teachers in our course โ€“ using science, playful cynicism and an open and experimental mindset to apply the evidence-based happiness practices in ways that work for them.

I also encourage students to understand that the strategies I offer are not universally effective. What works for others may not work for them, which is why they should experiment with many different approaches.

What will the course prepare students to do?

The educators leave the course with a written lesson plan they can implement at their school, if they wish. As they deepen their happiness practice, they can also share it with other teachers, their students and their families.

Over the past 16 months, we’ve taught this course to 156 K-12 educators and other school personnel. In a not-yet-published survey that we carried out, more than 30% of the participants scored as clinically depressed prior to starting the class, with just under 13% immediately after the class.

This improvement is similar to the results obtained by antidepressant medications and psychotherapy.

The educators also reported overall better health after taking the class. Along with improved sleep, they took fewer sick days, experienced fewer headaches and reported reductions in cold, flu and stomach symptoms.

As resources allow, we plan to tailor these courses to other people with high-stress jobs. Already, we are receiving requests from police , health care providers, veterinarians and construction workers.

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sales pitches are often from biased sources, the choices can be overwhelming and impartial help is not equally available to all

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theconversation.com – Grace McCormack, Postdoctoral researcher of Health Policy and Economics, University of Southern California – 2024-10-10 07:32:00

It can take a lot of effort to understand the many different Medicare choices.

Halfpoint Images/Moment via Getty Images

Grace McCormack, University of Southern California and Melissa Garrido, Boston University

The 67 million Americans eligible for Medicare make an important decision every October: Should they make changes in their Medicare health insurance plans for the next calendar year?

The decision is complicated. Medicare has an enormous variety of coverage options, with large and varying implications for people’s health and finances, both as beneficiaries and taxpayers. And the decision is consequential โ€“ some choices lock beneficiaries out of traditional Medicare.

Beneficiaries choose an insurance plan when they turn 65 or become eligible based on qualifying chronic conditions or disabilities. After the initial sign-up, most beneficiaries can make changes only during the open enrollment period each fall.

The 2024 open enrollment period, which runs from Oct. 15 to Dec. 7, marks an opportunity to reassess options. Given the complicated nature of Medicare and the scarcity of unbiased advisers, however, finding reliable information and understanding the options available can be challenging.

We are health care policy experts who study Medicare, and even we find it complicated. One of us recently helped a relative enroll in Medicare for the first time. She’s healthy, has access to health insurance through her employer and doesn’t regularly take prescription . Even in this straightforward scenario, the number of choices were overwhelming.

The stakes of these choices are even higher for people managing multiple chronic conditions. There is help available for beneficiaries, but we have found that there is considerable room for improvement โ€“ especially in making help available for everyone who needs it.

The choice is complex, especially when you are signing up for the first time and if you are eligible for both Medicare and Medicaid. Insurers often engage in aggressive and sometimes deceptive advertising and outreach through brokers and agents. Choose unbiased resources to guide you through the process, like www.shiphelp.org. Make sure to start before your 65th birthday for initial sign-up, look out for yearly plan changes, and start well before the Dec. 7 deadline for any plan changes.

2 paths with many decisions

Within Medicare, beneficiaries have a choice between two very different programs. They can enroll in either traditional Medicare, which is administered by the , or one of the Medicare Advantage plans offered by private insurance companies.

Within each program are dozens of further choices.

Traditional Medicare is a nationally uniform cost-sharing plan for medical services that allows people to choose their providers for most types of medical care, usually without prior authorization. Deductibles for 2024 are US$1,632 for hospital costs and $240 for outpatient and medical costs. Patients also have to chip in starting on Day 61 for a hospital stay and Day 21 for a skilled nursing facility stay. This percentage is known as coinsurance. After the yearly deductible, Medicare pays 80% of outpatient and medical costs, leaving the person with a 20% copayment. Traditional Medicare’s basic plan, known as Part A and Part B, also has no out-of-pocket maximum.

Pen, glasses and medicare health insurance card

Traditional Medicare starts with Medicare parts A and B.

Bill Oxford/iStock via Getty Images

People enrolled in traditional Medicare can also purchase supplemental coverage from a private insurance company, known as Part D, for drugs. And they can purchase supplemental coverage, known as Medigap, to lower or eliminate their deductibles, coinsurance and copayments, cap costs for Parts A and B, and add an emergency foreign travel benefit.

Part D plans prescription drug costs for about $0 to $100 a month. People with lower incomes may get extra financial help by signing up for the Medicare program Part D Extra Help or state-sponsored pharmaceutical assistance programs.

There are 10 standardized Medigap plans, also known as Medicare supplement plans. Depending on the plan, and the person’s gender, location and smoking status, Medigap typically costs from about $30 to $400 a month when a beneficiary first enrolls in Medicare.

The Medicare Advantage program allows private insurers to bundle everything together and offers many enrollment options. with traditional Medicare, Medicare Advantage plans typically offer lower out-of-pocket costs. They often bundle supplemental coverage for hearing, vision and dental, which is not part of traditional Medicare.

But Medicare Advantage plans also limit provider networks, meaning that people who are enrolled in them can see only certain providers without paying extra. In comparison to traditional Medicare, Medicare Advantage enrollees on average go to lower-quality hospitals, nursing facilities, and home health agencies but see higher-quality primary care doctors.

Medicare Advantage plans also often require prior authorization โ€“ often for important services such as stays at skilled nursing facilities, home health services and dialysis.

Choice overload

Understanding the tradeoffs between premiums, health care access and out-of-pocket health care costs can be overwhelming.

Graphic of a person flow lines pointing to text boxes on either side that have smaller arrows to more text boxes holding plan choice descriptions.

Turning 65 begins the process of taking one of two major paths, which each have a thicket of health care choices.

Rika Kanaoka/USC Schaeffer Center for Health Policy & Economics

Though options vary by county, the typical Medicare beneficiary can choose between as many as 10 Medigap plans and 21 standalone Part D plans, or an average of 43 Medicare Advantage plans. People who are eligible for both Medicare and Medicaid, or have certain chronic conditions, or are in a long-term care facility have additional types of Medicare Advantage plans known as Special Needs Plans to choose among.

Medicare Advantage plans can vary in terms of networks, benefits and use of prior authorization.

Different Medicare Advantage plans have varying and large impacts on enrollee health, dramatic differences in mortality rates. Researchers found a 16% difference per year between the best and worst Medicare Advantage plans, meaning that for every 100 people in the worst plans who die within a year, they would expect only 84 people to die within that year if all had been enrolled in the best plans instead. They also found plans that cost more had lower mortality rates, but plans that had higher federal quality ratings โ€“ known as โ€œstar ratingsโ€ โ€“ did not necessarily have lower mortality rates.

The quality of different Medicare Advantage plans, however, can be difficult for potential enrollees to assess. The federal plan finder website lists available plans and publishes a quality rating of one to five for each plan. But in practice, these star ratings don’t necessarily correspond to better enrollee experiences or meaningful differences in quality.

Online provider networks can also contain errors or include providers who are no longer seeing new patients, making it hard for people to choose plans that give them access to the providers they prefer.

While many Medicare Advantage plans boast about their supplemental benefits , such as vision and dental coverage, it’s often difficult to understand how generous this supplemental coverage is. For instance, while most Medicare Advantage plans offer supplemental dental benefits, cost-sharing and coverage can vary. Some plans don’t cover services such as extractions and endodontics, which includes root canals. Most plans that cover these more extensive dental services require some combination of coinsurance, copayments and annual limits.

Even when information is fully available, mistakes are likely.

Part D beneficiaries often fail to accurately evaluate premiums and expected out-of-pocket costs when making their enrollment decisions. Past work suggests that many beneficiaries have difficulty processing the proliferation of options. A person’s relationship with health care providers, financial situation and preferences are key considerations. The consequences of enrolling in one plan or another can be difficult to determine.

The trap: Locked out

At 65, when most beneficiaries first enroll in Medicare, federal regulations guarantee that anyone can get Medigap coverage. During this initial sign-up, beneficiaries can’t be charged a higher premium based on their health.

Older Americans who enroll in a Medicare Advantage plan but then want to switch back to traditional Medicare after more than a year has passed lose that guarantee. This can effectively lock them out of enrolling in supplemental Medigap insurance, making the initial decision a one-way street.

For the initial sign-up, Medigap plans are โ€œguaranteed issue,โ€ meaning the plan must cover preexisting health conditions without a waiting period and must allow anyone to enroll, regardless of health. They also must be โ€œcommunity rated,โ€ meaning that the cost of a plan can’t rise because of age or illness, although it can go up due to other factors such as .

People who enroll in traditional Medicare and a supplemental Medigap plan at 65 can expect to continue paying community-rated premiums as long as they remain enrolled, regardless of what happens to their health.

In most states, however, people who switch from Medicare Advantage to traditional Medicare don’t have as many protections. Most state regulations permit plans to deny coverage, impose waiting periods or charge higher Medigap premiums based on their expected health costs. Only Connecticut, Maine, Massachusetts and New York guarantee that people can get Medigap plans after the initial sign-up period.

Deceptive advertising

Information about Medicare coverage and assistance choosing a plan is available but varies in quality and completeness. Older Americans are bombarded with ads for Medicare Advantage plans that they may not be eligible for and that include misleading statements about benefits.

A November 2022 report from the U.S. Senate Committee on Finance found deceptive and aggressive sales and marketing tactics, including mailed brochures that implied government endorsement, telemarketers who called up to 20 times a day, and salespeople who approached older adults in the grocery store to ask about their insurance coverage.

The Department of Health and Human Services tightened rules for 2024, requiring third-party marketers to include federal resources about Medicare, including the website and toll- phone number, and limiting the number of contacts from marketers.

Although the government has the authority to marketing materials, enforcement is partially dependent on whether complaints are filed. Complaints can be filed with the federal government’s Senior Medicare Patrol, a federally funded program that prevents and addresses unethical Medicare activities.

Meanwhile, the number of people enrolled in Medicare Advantage plans has grown rapidly, doubling since 2010 and accounting for more than half of all Medicare beneficiaries by 2023.

Nearly one-third of Medicare beneficiaries seek information from an insurance broker. Brokers sell health insurance plans from multiple companies. However, because they receive payment from plans in exchange for sales, and because they are unlikely to sell every option, a plan recommended by a broker may not meet a person’s needs.

Help is out there โˆ’ but falls short

An alternative source of information is the federal government. It offers three sources of information to assist people with choosing one of these plans: 1-800-Medicare, medicare.gov and the State Health Insurance Assistance Program, also known as SHIP.

The SHIP program combats misleading Medicare advertising and deceptive brokers by connecting eligible Americans with counselors by phone or in person to help them choose plans. Many people say they prefer meeting in person with a counselor over phone or internet support. SHIP staff say they often help people understand what’s in Medicare Advantage ads and disenroll from plans they were directed to by brokers.

Telephone SHIP services are available nationally, but one of us and our colleagues have found that in-person SHIP services are not available in some areas. We tabulated areas by ZIP code in 27 states and found that although more than half of the locations had a SHIP site within the county, areas without a SHIP site included a larger proportion of people with low incomes.

Virtual services are an option that’s particularly useful in rural areas and for people with limited mobility or little access to transportation, but they require online access. Virtual and in-person services, where both a beneficiary and a counselor can look at the same computer screen, are especially useful for looking through complex coverage options.

We also interviewed SHIP counselors and coordinators from across the U.S.

As one SHIP coordinator noted, many people are not aware of all their coverage options. For instance, one beneficiary told a coordinator, โ€œI’ve been on Medicaid and I’m aging out of Medicaid. And I don’t have a lot of money. And now I have to pay for my insurance?โ€ As it turned out, the beneficiary was eligible for both Medicaid and Medicare because of their income, and so had to pay less than they thought.

The interviews made clear that many people are not aware that Medicare Advantage ads and insurance brokers may be biased. One counselor said, โ€œThere’s a lot of backing (beneficiaries) off the ledge, if you will, thanks to those TV commercials.โ€

Many SHIP staff counselors said they would benefit from additional training on coverage options, including for people who are eligible for both Medicare and Medicaid. The SHIP program relies heavily on volunteers, and there is often greater demand for services than the available volunteers can offer. Additional counselors would help meet needs for complex coverage decisions.

The key to making a good Medicare coverage decision is to use the help available and weigh your costs, access to health providers, current health and medication needs, and also consider how your health and medication needs might change as time goes on.

This article is part of an occasional series examining the U.S. Medicare system.

This story has been updated to remove a graphic that contained incorrect information about SHIP locations, and to correct the date of the open enrollment period.The Conversation

Grace McCormack, Postdoctoral researcher of Health Policy and Economics, University of Southern California and Melissa GarridoBoston University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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