Walgreens is on a mission to attain provider status for its pharmacists.
An abundanceofresearch has concluded that patients crave and care improves with broader scopes of practice for pharmacists. It’s an uphill battle though as some organizations lobby against scope expansions.
Walgreens, the nation’s second largest pharmacy company (behind CVS), is going full steam ahead to grow job descriptions for its 26,000-some pharmacists.
Mary Langowski, Walgreens Boots Alliance’s executive vice president and U.S. healthcare president, said pharmacists are well positioned to take on extra duties and tackle obstacles made by workforce shortages.
She raised the example of blood pressure screenings, reasoning that it makes more sense for pharmacists to take on this role than primary care physicians, who are already burnt out.
“To the extent we can create better, faster, cheaper pharmacy operations, so that our pharmacists can do more and more and more, that’s the ideal state,” Ms. Langowski said at AHIP’s 2024 conference in Las Vegas.
Before this “ideal state” can come alive, advocates for expanding pharmacist scopes of practice have to first contend with regulatory and reimbursement constraints. Some organizations argue that physicians have more training in clinical settings than pharmacists, but Ms. Langowski said it isn’t an either/or, but a both/and.
“We want to partner with physicians,” she said. “This is all totally complimentary to the rest of the activity that’s going on in the healthcare system.”
“There’s a lot of old paradigms out there, and a lot of old regulatory regimes and a lot of entrenched interests that are making it difficult for us to make progress on that, but we’re gonna keep fighting on it,” Ms. Langowski said. “It’s so important for us to kind of crack that open for pharmacists.”
Citing financial challenges, Cleveland-based University Hospitals is reducing its leadership structure by more than 10% as part of more than 300 layoffs.
Rising costs of supplies, labor and purchase services, and reduced Medicare reimbursement rates, have affected UH and various other systems, according to COO Paul Hinchey, MD.
“All of that’s creating significant downward pressure on our revenue,” Dr. Hinchey told Becker’s.
The news from UH follows a national trend of hospitals facing significant headwinds. Kaufman Hall found in early June that 40% of hospitals in the U.S. are still losing money.
At UH, revenue has increased nearly 9% year over year due to various changes, such as increased access for patients and implementing a new EHR system, according to UH.
“[However], in spite of our efforts and being successful in growth, that downward pressure on revenue and the increasing prices is pinching our margin,” said Dr. Hinchey.
Dr. Hinchey said the health system has been optimizing operations since the end of the pandemic.
“We took a look at our cost structure and recognized we needed to get our cost structure down,” he said. “We’ve done a couple initiatives that we put under the auspices of a Medicare break-even initiative to try to drive down our cost structure.”
Some actions already taken have included increasing efficiency, consolidating service lines and closing hospitals in Bedford and Richmond Heights, according to UH.
Most recently, the health system identified an opportunity to make cuts to leadership. Dr. Hinchey said C-suite level leaders and vice presidents were included in the cuts.
“These decisions are never easy,” Cliff Megerian, MD, CEO and Jane and Henry Meyer Chief Executive Officer Distinguished Chair, said in a news release. “The important thing is that we make these strategic moves now so we can continue to serve our community and fulfill our mission for decades to come. We are thankful for our hometown team that delivers lifesaving care to our neighbors, friends and relatives each and every day.”
Dr. Hinchey said UH began notifying employees of the layoffs on June 17. Affected workers will receive a severance package aligned with their roles and tenure.
In 46 states, once you choose Medicare Advantage at 65, you can almost never leave.
Medicare was founded in 1965 to end the crisis of medical care being denied to senior citizens in America, but private insurers have been able to progressively expand their presence in Medicare.
One of the biggest selling points of Obamacare was that it would finally end discrimination against patients on the basis of pre-existing conditions.
But for one vulnerable sector of the population, that discrimination never ended. Insurers are still able to deny coverage to some Americans with pre-existing conditions. And it’s all perfectly legal.
Sixty-five million seniors are in Medicare open enrollment from October 15 until December 7. Nearly 32 million of those patients are enrolled in Medicare Advantage, a set of privately run plans that have come under fire for denying treatment and overbilling the government.
Medicare Advantage patients theoretically have the option to return to traditional Medicare. But in 46 states, it is nearly impossible for those people to do so without exposing themselves to great financial risk.
Traditional Medicare has no out-of-pocket cap and covers 80 percent of medical expenses. Unlike Medicare Advantage plans, in traditional Medicare, seniors can choose whatever provider they want, and coverage limitations are far less stringent. Consequently, there’s a huge upside to going with traditional Medicare, and the downside is mitigated by the purchase of a Medigap plan, which covers the other 20 percent that Medicare doesn’t pay.
While this coverage is more expensive than most Medicare Advantage plans, nearly everybody in their old age would like to be able to choose their doctor and their hospitals, and everybody would want the security of knowing that they won’t be denied critical treatments. In 46 states, however, Medigap plans are allowed to engage in what’s called underwriting, or medical health screening, after seniors have already chosen a Medicare Advantage plan at age 65.
Only four states—New York, Connecticut, Maine, and Massachusetts—prevent Medigap underwriting for Medicare Advantage patients trying to switch back to traditional Medicare. The millions of Americans not living in those states are trapped in Medicare Advantage, because Medigap plans are legally able to deny them insurance coverage.
Medicare Advantage little resembles Medicare as it was traditionally intended, with tight networks and exorbitant costs that threaten to bankrupt the Medicare trust fund. (A recent estimate from Physicians for a National Health Program found that the program costs Medicare $140 billion annually.)
Jenn Coffey, a former EMT in New Hampshire who has been a vocal critic of her Medicare Advantage insurers’ attempts to deny her needed care, told the Prospect that she would jump back to traditional Medicare in a second. But because she became eligible prior to turning 65 due to a disability, she never had the option to pursue traditional Medicare with a Medigap plan. Instead, she pays premiums for a Medicare Advantage plan that nearly mirror what the cost of Medigap would be. But New Hampshire, like most other states, allows Medigap plans to reject her.
“I tried to find out if I could switch to traditional Medicare,” said Coffey. “When I talked to an insurance broker they said that I could. I made an appointment with an insurance agent, who then started looking at my pre-existing conditions, and they said, ‘We’re never going to get somebody to underwrite you.’”
Coffey was stunned by the agent’s words. “I honestly thought that we were completely done with pre-existing conditions” as a determinant for insurance coverage, she said. “Medigap plans are the only place where they are allowed to discriminate against us.”
Medicare Advantage now covers a majority of Medicare participants, thanks to extremely aggressive marketing and perks for healthier seniors like gym memberships.
In the 46 states that lack protections for people with pre-existing conditions, “lots of people don’t know that they may not be able to buy a Medigap plan if they go back to traditional Medicare from Medicare Advantage,” said Tricia Neuman, a senior vice president at KFF who has studied this particular issue.
Technically speaking, they can still go back to traditional Medicare if they don’t like their Medicare Advantage options, Neuman explained. But without access to a Medigap plan, they would be on the hook for 20 percent of their medical costs, which is unaffordable for most seniors.
Neuman told the Prospect about “cases where people have serious medical problems, and wanted to see a specialist,” but were blocked by their Medicare Advantage plan. Those same people had no ability to switch to traditional Medicare with a Medigap plan at precisely the time they need it the most, in nearly every state in the U.S.
“Medigap wasn’t a part of the ACA discussion on pre-existing conditions,” Neuman added. “A lot of people have no idea about this restriction on Medicare coverage, until they find themselves in a position that they want to go back and then it could be too late.”
Academic research shows that seniors often seek to return to traditional Medicare when they become sick.
The critical component that both Medigap and Medicare Advantage plans offer, which traditional Medicare does not, is out-of-pocket caps, said Cristina Boccuti, a director at the West Health Policy Center. “People who want to leave their Medicare Advantage plan, maybe because they are experiencing problems in their plan’s network, decide to disenroll and can’t obtain an out-of-pocket limit which they had previously had in Medicare Advantage,” Boccuti said.
That’s exactly the problem facing Rick Timmins, a retired veterinarian in Washington state. When Timmins was continually delayed care for melanoma, he explored getting out of his Medicare Advantage plan. “I wanted out of Medicare Advantage big-time,” said Timmins. But when he began to look at Medigap plans, he was told that he wouldn’t be guaranteed to get a plan, and that the insurance company could raise premiums based on a pre-existing condition.
“I doubt that I’ll be able to switch over to traditional Medicare, as I can’t afford high premiums,” Timmins said. “I’m still paying off some old medical debt, so it adds to my medical expenses.”
Medicare was founded in 1965 to end the crisis of medical care being denied to senior citizens in America. “No longer will older Americans be denied the healing miracle of modern medicine,” Lyndon Johnson said at the time. “No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years. No longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations to their parents, and to their uncles, and their aunts.”
But slowly, private insurers were able to progressively expand their presence in Medicare, with a colossal advance made through George W. Bush’s Medicare prescription drug program in 2003. Now, Medicare Advantage covers a majority of Medicare participants, thanks to extremely aggressive marketing and perks for healthier seniors like gym memberships.
Numerous recent studies have shown Medicare Advantage plans to deny care while boosting the profits of private insurance companies. Defenders of Medicare Advantage argue that managed care—which practically speaking means insurance employees denying care to seniors—improves our health care system.
Denial-of-care issues,
combined with the aforementioned $140 billion drain on the trust fund, have attracted far more scrutiny of the program than in years past. Community organizations like People’s Action, along with other groups like Be A Hero, have stepped up their criticism of the program. The Biden administration proposed new rules this year to curb overbilling through the use of medical codes, but a furious multimillion-dollar lobbying campaign from the health insurance industry led to the rules being implemented gradually.
Still, members of Congress have become more emboldened to speak out against abuses in Medicare Advantage. A recent Senate Finance Committee hearing featured bipartisan complaints about denying access to care. And House Democrats have urged the Centers for Medicare & Medicaid Services to crack down on increases in prior authorizations for certain medical procedures, as well as the use of artificial-intelligence programs to drive denials.
Megan Essaheb, People’s Action’s director of federal affairs, said that Medicare Advantage has become a drain on the federal trust fund. “These private companies are making tons of money,” Essaheb said. “The plans offer benefits on the front end without people understanding that they will not get the benefits of traditional Medicare, like being able to choose your doctor.”
Despite the growing scrutiny, the trapping of patients who want to get out of Medicare Advantage hasn’t gotten as much attention from either Congress or state legislatures that could end the practice.
Coffey, the retired EMT from New Hampshire, told the Prospect that she has paid $6,000 in out-of-pocket expenses this year under a Medicare Advantage program. “If I could go to Medigap, I would have better access to care, I wouldn’t be forced to give up Boston doctors,” she said.
“These insurance companies are allowed to reap as much profit as possible for as little service as they can get away with. They pocket all of our money and they don’t pay for anything, they sit there and deny and delay.”
Generative AI tools have made remarkable strides in medicine since the launch of ChatGPT in late 2022. Research has shown that AI, with expert clinician oversight, can significantly enhance diagnostic accuracy, treatment recommendations, and patient monitoring and analysis.
And yet, despite its impressive capabilities and buzz, generative AI is still in the early stages of adoption—both in U.S. healthcare and society.
In demos released during its spring update, OpenAI showed users engaged in natural, human-like conversations with GPT-4o. The AI interacted with people on their smartphones across video, audio and text, offering real-time spoken responses that sounded eerily human.
In the demo above, AI’s instant answers and friendly voice closely mimic the pace and inflection of normal dialogue. Not coincidently, GPT-4o’s voice sounded remarkably like Scarlett Johansson’s AI character in the movie Her (a decision OpenAI later walked back “out of respect”).
Regardless of the voice coming out of it, GPT-4o is at once awe-inspiring and unsettling. It also represents a significant departure from tech-industry norms. Most tech companies have long avoided creating AI “companions” because of ethical concerns, fearing people could form addictions that exacerbate isolation and loneliness.
What Will GPT-4o’s Rule-Breaking Mean For Medicine?
Critics point out that OpenAI and its peers have yet to resolve a host of major “trust” issues. These include accuracy, privacy, security, bias and misinformation. Of course, these will need to be resolved.
But by creating an AI experience that feels more like talking to a friend, or potentially a doctor, OpenAI has already leapt the tallest hurdle to mass acceptance and adoption. The company understands that humanizing GPT-4o—making it easier and more enjoyable to use—is essential for attracting a wide array of users, including the “late majority” and “laggards” described in Geoffrey Moore’s seminal 1991 book Crossing the Chasm.
They also make up the overwhelming majority of Americans with chronic diseases like diabetes, heart failure and cancer.
GenAI: From Mass Adoption To Mass Empowerment
Once consumers in their 50s, 60s and 70s become comfortable using GPT-4o for everyday tasks, they will then start to rely on it for medical inquiries, too. In a healthcare context, using GPT-4o will closely resemble a video visit or a phone call with a medical professional—two modalities that satisfy the majority of older patients. In fact, 93% of adults over age 70 say they value having telehealth as an option.
With broad adoption, GPT-4o (which will be embedded in next generations of ChatGPT) will empower the sickest Americans to take greater control of their own health, preventing up to hundreds of thousands of premature deaths each year from the complications of chronic disease: heart attacks, strokes, cancer and kidney failure. According to the Centers for Disease Control and Prevention, the effective management of chronic illness would reduce these complications by 30% to 50%, with a similar reduction in mortality.
Generative AI technology contains both the knowledge and ability to help accomplish this:
Knowledge. ChatGPT houses an extensive corpus of scientific literature, which includes a diverse and extensive dataset of clinical studies, guidelines from professional medical organizations and research published in top-tier medical journals. In the future, it will be updated with real-time data from medical conferences, health records and up-to-the-minute research, ensuring the AI’s knowledgebase remains both comprehensive and current.
Ability. To assist overburdened clinicians, genAI can provide patients with round-the-clock monitoring, insights and advice—empowering them to better diagnose and manage their own health problems. Future generations of these tools will connect with monitoring devices, informing patients about their health status and suggesting medication adjustments or lifestyle changes in clear and friendly terms. These tools will also remind people about preventive screenings and even facilitate testing appointments and transportation. These proactive approaches can reduce complications and improve health outcomes for the 130 million Americans living with chronic diseases.
Combatting Chronic Disease With GPT-4o
To dive deeper into genAI’s difference-making potential, let’s look at two major gaps in chronic disease management: diabetes and hypertension.
Diabetes is the leading cause of kidney failure, a major contributor to heart attacks and responsible for 80% of lower limb amputations. Effective management is possible for nearly all patients and would prevent many of these complications. Yet diabetes is well controlled in only 30% of cases across the United States.
Similarly, effective control of high blood pressure—the leading cause of strokes and a major contributor to kidney failure and heart attacks—is achieved only 55% to 60% of the time. Although some health systems achieve control levels above 90%, the best-available tools and approaches are inconsistently deployed throughout medical practices.
Medical monitoring devices plus AI could play a crucial role in managing hypertension. Imagine a scenario in which a doctor prescribes medication for hypertension and sends the patient home with a wearable device to monitor progress. After a month, the patient has 100 readings—90 normal and 10 elevated. The patient is unsure whether the 90 normal readings indicate all is well or if the 10 elevated ones signal a major problem. The doctor doesn’t have time to review all 100 readings and prefers not to clutter the electronic health record with this data. Instead of the patient waiting four months for the next visit to find out if all is well or not, a generative AI tool could quickly analyze the data (using the doctor’s instructions) and advise whether a medication adjustment is needed or to continue as is.
Today’s generative AI tools aren’t ready to transform medical monitoring or care delivery, but their time is coming. With the technology doubling in power each year, these tools will be 32 times more capable in five years.
Overcoming Barriers To Mass Adoption
Concerns about AI privacy, security and misinformation need to be solved before the majority of Americans will buy in to an AI-empowered future. Progress is being made on those fronts. For example, the leap from GPT-3.5 to GPT-4 saw an 82% reduction in hallucinations, a larger context window and better safety mechanisms.
In addition, clinicians worry about potential income loss if AI leads to healthier patients and reduced demand for medical services. The best solution is to shift from the current fee-for-service reimbursement model (which rewards the volume of medical services) to a value-based, capitated model. This system rewards doctors for preventing chronic diseases and avoiding their most serious complications, rather than simply treating life-threatening medical problems when they arise.
By adopting a pay-for-value approach, medical professionals will embrace genAI as a tool to help prevent and manage diseases (rather than seeing it as a threat to their livelihoods).
The release of GPT-4o shattered the industry norm against creating human-like AI, introducing ethical risks that must be carefully managed. However, the potential for genAI to save thousands of lives each year makes this risk worth taking.
Healthcare leaders are grappling with a daunting healthcare challenge that persists quietly. Day-to-day, it doesn’t trigger loud alarms, emergency press conferences, or AI pilots, but addressing it will take immense collective effort.
As of 2022, there were 52 million Americans over the age of 65, a population that grows by 10,000 each day. By 2034, older Americans will outnumber younger ones. An estimated 50% of babies born in 2020 are expected to live beyond 100 years.
Behind these statistics lies a diverse population: 90-year-olds running marathons and 65-year-olds incapacitated by strokes. Biological age is distinct from numerical age, after all.
The intensifying demands of an aging population on the U.S. healthcare system represent a challenge of a lifetime, yet one often downplayed or overlooked in the day to day. This aligns with the history of geriatric medicine. The specialty focused on medical care for older adults and the promotion of healthy aging was not widely accepted in the U.S. even in the 1980s.
“About 25 years ago, if you were in most health systems and you talked about geriatric medicine, most clinicians would tell you there was no such thing,” said Michael Dowling, president and CEO of Northwell Health. “There was a denial about the fact that there was geriatric medicine. The idea was that people were older adults that were just getting older.”
Mr. Dowling is a co-author of “The Aging Revolution.” The book, released in June 2024, highlights the revolutionaries who rejected the status quo in elder care and pioneered new methods to improve aging adults’ quality and longevity of life.
Much of the geriatric medicine specialty originates in Northwell’s home base: New York City. There, Robert Butler, MD, earned his medical degree in 1953 and not long after began to notice gaps in his education when caring for older adults. Their health needs were more complex, interrelated, and varied, yet they were treated as no different from younger adults. Driven to know more, he joined the National Institute of Mental Health in Washington, D.C., to explore healthy aging, embarking on an irreversible journey.
Through the 1960s and early 1970s, Dr. Butler grew more impatient with the status quo healthcare treatment of older adults in America. He observed prevailing attitudes of paternalism, infantilism, avoidance or mere caretaking rather than meaningful treatment.
Dr. Butler made no effort to hide his frustration with the title of his 1975 book, “Why Survive? Being Old in America.” In it, he argued that healthcare professionals were not adequately trained to meet the needs of older patients. Their medical conditions were considered uninteresting by teaching institutions and stereotyped as cantankerous and bothersome. The book won the Pulitzer Prize for General Non-Fiction and resonated with other physicians, expanding the circle of healthcare professionals seeking specialization in the care of older patients.
In 1982, Dr. Butler established the Department of Geriatrics and Adult Development at Mount Sinai Medical Center in New York City, creating the first department of its kind in a U.S. medical school. He continued to promote the specialty and the pursuit of knowledge in geriatric medicine, a field in which he had no formal education because it did not exist during his training. Dr. Butler passed away in 2010 at the age of 83.
“He was a powerhouse. It was [Dr. Butler] who basically pushed the issue,” said Mr. Dowling. “It doesn’t mean it wasn’t discussed prior, but he actually took it upon himself to make a difference. That’s amazing.”
Mr. Dowling said the book, co-authored with Maria Torroella Carney, MD, chief of geriatric and palliative medicine for Northwell, and author Charles Kenney, aims to raise awareness about the relatively recent development of geriatric medicine. It highlights how a dedicated group of individuals transformed this field from a notable shortcoming into a reality not that long ago.
The book includes real patient stories and took two years to write, aiming to help readers understand healthcare for older adults vividly and not merely in theory. It covers the rise of palliative medicine in the 1990s, the return of home care and pioneers’ work to address the toughest geriatric syndromes, like falls and delirium.
The questions and shortcomings that Dr. Butler forcefully highlighted in the 1970s and 1980s remain relevant today.
Geriatricians provide comprehensive care for adults ages 65 through the end of their life. While this age group consumes more healthcare than any other,
there are fewer than 7,300 physicians that are board-certified geriatricians, which is fewer than 1% of all physicians.
This deficit places greater demands on entire systems, then, to better meet the needs of the aging population. Demand for services will increase, necessitating the evolution and expansion of skill sets, cultural competencies, access points and care settings.
This work makes the practice of geriatric medicine and the advancements made for older patients relevant to far more than the physicians earning certifications in the specialty. Health systems today face questions about what it means to be an age-friendly health system, which requires more than medical care. Age-friendly care is a specific model from the Institute for Healthcare Improvement and The John A. Hartford Foundation that rests on four M’s: What Matters Most, Medication, Mentation and Mobility.
Northwell is one of the largest systems to adopt the framework in all adult acute care settings, primary care ambulatory sites, and post-acute care locations. The effort requires staff training, evidence-based assessment tools and metrics, governance and partnerships with outside institutions. Nationwide, more than 4,000 sites of care have been recognized as age-friendly organizations.
Mr. Dowling’s focus on the topic is a steady one, with more initiatives to come. Aging presents a dual challenge: as people live longer, they place increasing demands on health systems and support infrastructures, compounded by declining birth rates.
“When the older population is growing by about 10,000 a day, and the population of children is declining, you have this massive imbalance, which is not just a healthcare issue. It’s a huge economic issue,” Mr. Dowling said. The book does not shy away from the challenge, including a chapter with seven experts addressing the question: How will we as a society deliver and pay for care needed by an aging population where every day 10,000 people turn 65?
“The Aging Revolution” celebrates the strides made in geriatric medicine and honors the pioneers who led the way, helping our elders avoid unnecessary suffering in the pursuit of longer, fulfilling lives. It also serves as a reminder that the aging of our society demands rigorous problem-solving today and in the years ahead, requiring a spirit of innovation equal to, if not greater than, that which drove its inception.
The rebates that will be issued later this year will be larger than those issued in most prior years, the analysis found.
Health insurers are projected to pay about $1.1 billion in Affordable Care Act medical loss ratio rebates this year, a new KFF report finds.
The medical loss ratio (MLR) provision of the ACA limits the amount of premium income that insurers can keep for administration, marketing and profits. Insurers that fail to meet the applicable MLR threshold are required to pay back excess profits or margins in the form of rebates to individuals and employers that purchased coverage.
The $1.1 billion in estimated total rebates across commercial markets are similar to the $1 billion in total rebates issued in 2022, and the $950 million issued in 2023. Last year, rebates were issued to 1.7 million people with individual coverage and 4.1 million people with employer coverage. In the individual market, the 2023 average rebate per person was $196, while the average rebates per person for the small group market and the large group market were $201 and $104, respectively.
The rebates, to be issued later this year, will be larger than those issued in most prior years, the analysis found, but they’ll fall short of the recent rebate totals of $2.5 billion issued in 2020 and $2 billion issued in 2021, which coincided with the onset of the COVID-19 pandemic.
WHAT’S THE IMPACT?
In the individual and small group markets, insurers are required to spend at least 80% of their premium income on healthcare claims and quality improvement efforts, leaving the remaining 20% for administration, marketing expenses and profit.
The MLR threshold is higher for large group insurers, which have to spend at least 85% of their premium income on healthcare claims and quality-improvement efforts.
MLR rebates are based on a three-year average, meaning that rebates issued in 2024 will be calculated using insurers’ financial data in 2021, 2022 and 2023, and will go to people and businesses who bought health coverage in 2023.
In 2023, the average individual market simple loss ratio – meaning there’s no adjustment for quality improvement expenses or taxes, and doesn’t align perfectly with ACA MLR thresholds – was 84%. That shows insurers spent an average of 84% of their premium income in the form of health claims in 2023, according to KFF data.
However, rebates issued in 2024 are based on a three-year average of insurers’ experience in 2021-2023. Consequently, even insurers with high loss ratios in 2023 may expect to owe rebates if they were highly profitable in the prior two years.
In the small and large group markets, 2023 average simple loss ratios were 84% and 88%, respectively. Only fully insured group plans are subject to the ACA MLR rule, while roughly two-thirds of covered workers are in self-funded plans, to which the MLR threshold doesn’t apply.
THE LARGER TREND
KFF cautioned that the rebate amounts are still preliminary. Rebates and notices are mailed out by the end of September, and the federal government will post a summary of the total amount owed by each issuer in each state later in the year.
Insurers in the individual market can either issue rebates in the form of a check or premium credit. For people with employer coverage, the rebate can be shared between the employer and the employee, depending on the way in which they share premium costs.
If the amount of the rebate is exceptionally small – less than $5 for individual rebates and less than $20 for group rebates – insurers are not required to process the rebate, as it may not warrant the administrative burden required to do so, KFF said.
HENRY KOTULA 