Tagged Cost and Quality

Viewpoints: Applause For Push To Rescue Mo.’s In-Home, Nursing Care For Senior Citizens, Disabled People; Moving Toward Medical Quality

Here’s a review of editorials and opinions on a range of public health issues.

The Kansas City Star: Don’t Give Up On Restoring In-Home And Nursing Care In Missouri
Kudos to those Democratic Missouri lawmakers who still have not given up on trying to stop Gov. Eric Greitens from single-handedly taking in-home and nursing care away from 8,300 seniors and disabled people. On Monday, several legislators asked the state to drop plans to request a federal waiver from the Centers for Medicare and Medicaid Services that would allow them to cut the program. (7/25)

KevinMD: 5 Steps To Create Medical Quality Without Trying
The need for what we are calling medical “quality” is acute, yet the strategies employed to obtain it are destroying medicine. Patient outcomes are inconsistent, care varies depending on many factors outside of disease state, and the cost of our medical system is not sustainable. But to fix this, most health systems employ non-clinicians to audit charts while checking boxes such as “A1C<8%?” and “DVT prophylaxis ordered within 24 hours?” These non-providers then send threatening letters and cut salaries with “pay-for-performance.” Unsurprisingly, such efforts are not working, and only end up creating distorted physician-patient relationships. Yet, obtaining improved quality requires only a few key steps. (Kjell Benson, 7/25)

Stat: Doctors Have The Power To Help Their Patients Thrive Financially
StreetCred’s formula is simple. It takes advantage of the trusting relationships that families have with their pediatricians and makes productive use of the time typically wasted in doctors’ waiting rooms. In partnership with the IRS-sponsored Volunteer Income Tax Assistance program and other government agencies, StreetCred uses trained volunteers and staff to help families file taxes, attain tax refunds, and apply for anti-poverty government programs. (Andrea Levere, 7/25)

Stat: Human Trafficking Must Be Officially Recognized As A Medical Diagnosis
Early this week, nearly 100 people were found trapped in a sweltering tractor-trailer in San Antonio, Texas. Ten have died and others are in critical condition. Many were sent to local hospitals for treatment of severe dehydration and shock, medical conditions that are common in the emergency department. What may not be as obvious to emergency physicians is that these people are possibly victims of human trafficking. As physicians who have treated victims of human trafficking and research this scourge, we believe that this form of severe exploitation is under-recognized in health care settings and live are being lost because of that. (Abraar Karan and Hanni Stoklosa, 7/25)

Los Angeles Times: The ‘it’s All In Your Head’ Diagnosis Is Still A Danger To Women’s Health
TV personality Maria Menounos stunned fans when she announced this month that she was in recovery from surgery for a nonmalignant brain tumor, which she discovered while her mother was battling brain cancer. Perhaps most surprising was how quickly Menounos was treated. She explained to People magazine that when she told her mother’s doctor about her symptoms — headaches, dizziness, slurred speech — he immediately investigated what was wrong. (Emily Dwass, 7/26)

The Des Moines Register: Attorney General Sessions Should Not Re-Escalate War On Drugs
Attorney General Jeff Sessions has apparently learned nothing regarding the War on Drugs. He wants to re-escalate this failed policy at a time when many states are realizing its futility and trying to move in different directions. Drug treatment doesn’t work 100 percent of the time, but it is certainly more effective (and less costly) than incarcerating people with this illness. And as long as there are addicts, there will always be dealers, so incarcerating dealers has little long-term impact on the drug problem. (Allen Hays, 7/25)

Boston Globe: Mass. Should Pass Gun Restraining Order Bill
Representative David P. Linsky, a Natick Democrat, has filed legislation that would allow family and household members, police, district attorneys, and health care providers to go to court and seek “extreme risk protective orders” for individuals who pose a significant danger to themselves or others. The bill, which has raised the hackles of gun rights groups, stands up to constitutional scrutiny and builds in an important hearing mechanism before long-term restrictions can be imposed. (7/26)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Perspectives: Too Often In U.S. Profit Comes Before Public Interest

Read recent commentaries about drug-cost issues.

The New York Times: The Tasmanian Hep C Buyers’ Club
In 2014, when Greg Jefferys’s urine started smelling like dead meat, he knew there was something seriously wrong. For weeks, Jefferys, an Australian then 60 years old, had felt fatigued and noticed that just a slight bump would leave a dark purple bruise on his skin. Blood tests revealed to Jefferys that he had chronic hepatitis C – a disease he’d never heard of. (Sophie Cousins, 7/25)

Forbes: When It Comes To Abusive Drug Pricing, Don’t Confuse Shkreli With Hep C Drugs
Drug pricing is a topic commanding a lot of attention these days, particularly as healthcare in the U.S. is a national focus. The debate isn’t simple. The ways that drugs are distributed and paid for in this country can be best described as convoluted. Froma Harrop, a nationally syndicated, award-winning columnist who focuses on the financial world, has recently weighed in on this discussion with her op-ed “America’s addiction to abusive drug pricing.” Given her reputation, one would expect that her views would add substance to the debate. Instead, her op-ed is fraught with inaccuracies. (John LaMattina, 7/19)

Los Angeles Times: Shining A Light On Prescription Drug Pricing
After years of failed efforts, the California Legislature may finally pass a bill that responds to the problem of rising prescription drug costs. But temper your enthusiasm: Though this measure (SB 17) has been fiercely resisted by the pharmaceutical industry, it wouldn’t actually stop manufacturers from raising their prices as high as they think the market will bear. It would just make them reveal more about the cost and value of their drugs as they do so. (7/24)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Democrats Announce Three-Pronged Plan To Tackle High Drug Prices

News outlets report on stories related to pharmaceutical pricing.

Politico: Democrats’ ‘Better Deal’ Would Penalize Drug Price Hikes
Democrats are going straight at one of the top concerns of voters, using the rising cost of drugs to strike a more populist tone and counter President Donald Trump, who campaigned hard against the power of the drug industry, but took a friendlier stance after taking office. Congressional Democrats [on Monday] laid out a three-pronged approach to lower the cost of prescription drugs in the United States that aims to stop large price increases and give the federal government more power to influence what Medicare pays for medicines. (Karlin-Smith, 7/24)

CNBC: Democrats Take Aim At Big Business, Drug Prices, In Economic Campaign
Democrats are proposing an independent agency to tackle the high cost of prescription drugs. The director would be appointed by the president and confirmed by the Senate, charged with investigating drug manufacturers and able to slap fines on companies with exorbitant rate hikes. Pharmaceutical companies would also be required to notify the government of substantial price increases. (Mui, 7/23)

Stat: How Pricey Is Your Drug? These 10 Sold The Most In The U.S. Last Year
Awhopping $450 billion was spent in the United States on prescription drugs last year. Topping the list, perhaps unsurprisingly, are medications whose patents were still in force or had recently expired. When a patent expires, generic versions — or biosimilar versions of biologic drugs — can become available, driving down costs that in turn make them accessible to more patients. (Blau, 7/25)

Stat: FDA May Publicly Shame Drug Makers For Thwarting Generic Rivals
The idea is to break a logjam caused by an FDA program that is designed to boost safety. Typically such a program, known as a Risk Evaluation and Mitigation Strategy, requires drug makers to develop a plan to educate doctors and monitor distribution. But generic companies claim they have been denied samples of brand-name drugs needed to conduct product testing in order to win FDA approval. Brand-name companies argue that REMS programs do not permit such sharing. (Silverman, 7/19)

FierceHealthcare: Democrats Revive Calls For Medicare To Negotiate Drug Prices
As part of their newly unveiled “Better Deal” agenda, congressional Democrats are pledging to tackle one of healthcare’s thorniest issues—the high cost of prescription drugs. “Right now, there’s nothing to stop vulture capitalists from egregiously raising the price of life-saving drugs without any justification,” Senate Minority Leader Chuck Schumer, D-N.Y., said during a press conference Monday. (Small, 7/25)

Stat: Ohio Places Drug Pricing Measure On Its November Ballot
In a blow to the pharmaceutical industry, Ohio state officials have approved a controversial initiative designed to lower drug prices for the November ballot. Known as the Ohio Drug Price Relief Act, the ballot measure would require state agencies to pay no more for medicines than the Department of Veterans Affairs. The agency currently gets a 24 percent federally mandated discount off average manufacturer prices. (Silverman, 7/21)

The Blade: Television Ads Clash Over Ohio Drug Price Relief Act
The conflicting claims in the prescription drug issue that will be on the Ohio ballot in November are enough to cause a headache. Or even something requiring a prescription. The most recent flurry of ads last week on broadcast television attacked the previous flurry of TV ads, each accusing the other of deceptive tactics to manipulate Ohio voters. What to believe? (Troy, 7/24)

The Associated Press: ‘Pharma Bro’ Won’t Stop Talking, Except To Jury In Trial
“Pharma Bro” Martin Shkreli has kept up his trademark trolling on social media during his securities fraud trial — calling the case “bogus” — but the jury won’t hear him defend himself in court. The government’s last witness testified on Tuesday, a day after a lawyer for the former biotech CEO told the court that his client had chosen not to take the witness stand. Closing arguments are expected later this week. (Hays, 7/26)

Stat: Proposed Rule To Bolster Safety Data On Generic Drug Labels May Be Dead
Once again, a controversial rule for updating generic drug labeling is being postponed, but this time, its chances of being implemented appear slimmer than ever, according to consumer advocates. The rule was proposed four years ago by the Food and Drug Administration in an effort to bolster patient safety. Specifically, the rule would allow generic drug makers to independently update safety warnings, something only brand-name drug makers can currently do before receiving FDA permission. (Silverman, 7/24)

Marketplace: Drug Prices: How Generics Changed The Game
For a time, high drug prices made headlines, and it looked like the issue could be tackled by the Trump administration. But as we all know, efforts to repeal Obamacare have consumed Republicans much of this year. The drug problem hasn’t gone away; it’s just lingering in the background. Even the cost of some generic drugs are rising. (Gornstein, 7/25)

CQ Roll Call: FDA Notice Buys Senate More Time On User Fee Bill
The Food and Drug Administration will delay issuing furlough notices to employees whose salaries depend on congressional action renewing the agency’s fee-collection authority, FDA Commissioner Scott Gottlieb announced Monday in an email obtained by CQ. Gottlieb’s announcement effectively gives Congress until Sept. 30 to pass a bill that would provide the agency with about $1.4 billion in annual funding through fiscal 2022 from the prescription drug and medical device industries. That money mostly goes to the salaries of employees who review medical product applications. Lawmakers previously believed the agency would begin issuing furlough notices 60 days before funding lapsed on Sept. 30, and were aiming to finish work on the bill by late July. (Siddons, 7/24)

Stat: How Do You Measure Value In A Drug — Or Anything Else In Medicine?
At a swanky hotel in the Theatre District, about a dozen health policy experts and drug development academics gathered Wednesday to talk drug pricing. Speakers on the Manhattan Institute-curated panel see a future where the amount of money people pay for pharmaceuticals has something to do with how much “value” they provide — but seemed to have more questions than answers about what that actually means. (Swetlitz, 7/19)

The New York Times: Celgene To Pay $280 Million To Settle Fraud Suit Over Cancer Drugs
The pharmaceutical company Celgene has agreed to pay $280 million to settle claims that it marketed the cancer drugs Thalomid and Revlimid for unapproved uses, the company said on Tuesday. Under the terms of the settlement, which resulted from a lawsuit filed by a whistle-blower — a former sales representative at Celgene — the company will pay $259.3 million to the United States and $20.7 million to 28 states and the District of Columbia. (Thomas, 7/25)

Stat: A New HIV Drug’s Strong Results Give A Big Boost To Gilead Sciences
An experimental HIV pill from Gilead Sciences suppressed the virus in newly diagnosed patients at a rate statistically equivalent to that of a similar, rival drug from GlaxoSmithKline, according to results from a late-stage clinical trial presented Monday. The positive data supporting Gilead’s new HIV pill, a second-generation integrase inhibitor called bictegravir, are vitally important to the Foster City, Calif.-based biotech company. Sales of Gilead’s hepatitis C drugs are falling and its oncology pipeline has largely disappointed, so the company is once again reliant on its HIV business for the majority of its profits. (Feuerstein, 7/24)

Stat: AbbVie Must Pay $150 Million For Misleading AndroGel Marketing
In a split decision, a federal jury in Chicago ordered AbbVie to pay $150 million in punitive damages for fraudulently misrepresenting the risks of its AndroGel testosterone replacement drug. But at the same time, the jury decided the drug maker was not liable for a heart attack that the plaintiff, Jesse Mitchell, suffered after taking the medication. The trial was the first in an estimated 6,000 lawsuits that the drug maker faces over its controversial marketing, which warned that low testosterone can interfere with sex drive, moods, and energy levels. However, the increased usage was accompanied by dueling medical studies — and subsequent debate — over the extent to which AndroGel and other such drugs could increase cardiovascular risks. (Silverman, 7/24)

Boston Globe: Vertex Reports Strong Findings From Cystic Fibrosis Drug Trials
Vertex Pharmaceuticals Inc. on Tuesday released clinical findings showing its new approach to combating cystic fibrosis substantially improved lung function in patients, lifting hopes for a treatment that could be used by about 68,000 people worldwide — including 24,000 who don’t respond to any existing medicines. The results prompted Boston-based Vertex to say it plans to launch one or two late-stage clinical trials of the biotech’s three-drug combination in the first half of next year. (Weisman, 7/18)

Stat: Merck: Keytruda Trial Comes Up Short In Head And Neck Cancer, But FDA Approval Stays
Merck’s checkpoint inhibitor Keytruda doesn’t help patients with advanced head and neck cancer live longer, but the failed phase 3 clinical trial, announced Monday night, won’t compel the FDA to rescind the drug’s conditional approval, the company said. And with that, the pile of evidence pointing towards FDA’s extreme flexibility when it comes to easy drug approvals grows even larger. (Feuerstein, 7/24)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Rural Californians Want Price Relief From GOP Health Bill, But Unlikely To Get It

Aaron Albaugh peered out from under the brim of his cowboy hat, surveying the acres of hayfields in front of him. The fourth-generation rancher has raised about 450 cattle this year, in this remote corner of Lassen County, Calif.

His closest neighbor lives a half-mile away. “And that’s my brother,” Albaugh said.

“If I want to go see a movie, it’s 70 miles, round-trip,” he added. “If I want to go bowling, that’s 100 miles, round-trip.”

Living a half-day’s drive from civilization, you learn to do without, he explained. If your refrigerator breaks, you put your food on ice until the weekend when you can go buy a new one. With health care, it’s the same thing.

“Put a Band-Aid on it,” Albaugh said. “I was raised: ‘You don’t need to cry’ and ‘Suck it up, buttercup.’ That’s the way I still live, and I try to treat my kids the same way.”

For people who were already used to doing without health coverage, it was quite a culture shock when the Affordable Care Act came along and they were told they had to buy it. Residents complained that the premiums and deductibles were too high — and with only two insurers selling plans in their area, there wasn’t enough competition to bring down prices.

Many in this Republican corner of California are looking to the GOP majority in Congress to bring some relief. But for most of them, prices would jump even more under the main proposals the party has served up so far, and fewer services would be covered, according to analyses by the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

“Being told you have to have insurance you can’t afford, and then that doesn’t cover what you need? You are stuck,” said Modoc County resident Althia Cline, who decided to forgo Obamacare coverage — and a surgery she needs to help with her asthma — when she couldn’t find a health plan that her doctors accepted.

Just like the movie theater and the bowling alley, most medical specialists are miles away. In Modoc County, there’s no hospital or birthing center where a woman can have a baby. Tessa Anklin, who lives in Canby, Calif., gave birth to her son and daughter over the border in Oregon, an hour and a half from home.

Anklin makes about $33,000 a year as a dental receptionist. Her husband does seasonal work baling hay and herding cattle at local ranches. While their kids are covered by Medi-Cal, neither parent gets health insurance through work, and before the Affordable Care Act passed, Anklin and her husband did without coverage for a while.

Tessa Anklin says Covered California health plans are too expensive for her family. (April Dembosky/KQED)

Two years ago, they bought a plan through Covered California. Their monthly premium was just $2 a month after the ACA subsidy, but their annual deductible was $10,000.

“We paid for all of our medical services and our prescriptions,” she said. “We had no help until we reached the $10,000 deductible. So really, we had nothing.”

Then, last year, their monthly premium jumped to $600. Anklin said she’s not sure what happened. It’s possible a technical glitch caused them to lose their subsidy. All she knew was that the plan was the same, their household income was the same, and they still faced the same hour-and-a-half drive to see doctors they almost never needed.

Anklin thought of all the other ways they could spend that money.

“It makes the car payment. Almost your mortgage payment. Groceries for at least four months,” she said. “That’s a big difference, when you think about how little you actually use the health coverage.”

That’s the reason they decided to cancel their health plan this year and go without insurance. But they’ll still have to pay a penalty when the next tax season comes around.

“It basically penalizes us one way or the other because we can’t afford the coverage,” she said. “So, that’s kind of difficult — to be that middle-class person.”

Anklin said she’d be happy to see Republicans get rid of Obamacare.

“To me, it’s no good, if you have to force people to pay yet another something out of their paycheck,” she said, “when they’re already trying to survive with what they have.”

But the Republican “repeal and replace” plan wouldn’t make things much better for Anklin and her neighbors. Average premiums in California would double under the   U.S. Senate plan, according to a recent analysis from the Kaiser Family Foundation. Anklin could end up paying roughly $2,000 more per year for the cheapest individual plan than under Obamacare, according to Kaiser’s county-by-county projections.

That’s not the kind of fix she had in mind.

“I’d love that insurance could be more affordable for families that need it, for families that work hard for it,” Anklin said.

With Republican health care plans in flux, Democrats have been more willing to admit to Obamacare’s flaws. The Dems agree that the rising costs of marketplace plans are the chief complaint they hear about, too.

Democrats have also said if the Republican repeal effort fails, they’d be willing to work together on solutions. But it’s not clear the parties could agree on one that would help people like Anklin.

If they can’t, Anklin said, she has no choice but to continue to go without coverage. Financially, it makes sense in the short term, but she still worries about an unforeseen surgery, serious illness or accident.

“If I ever have a problem,” she said, “I know I will be paying for the rest of my life.”

This story is part of a partnership that includes KQED, NPR and Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law


Price Transparency In Medicine Faces Stiff Opposition — From Hospitals And Doctors

COLUMBUS, Ohio — Two years after it passed unanimously in Ohio’s state Legislature, a law meant to inform patients what health care procedures will cost is in a state of suspended animation.

One of the most stringent in a group of similar state laws being proposed across the country, Ohio’s Healthcare Price Transparency Law stipulated that providers had to give patients a “good faith” estimate of what non-emergency services would cost individuals after insurance before they commenced treatment.

But the law didn’t go into force on Jan. 1 as scheduled. And its troubled odyssey illustrates the political and business forces opposing a common-sense but controversial solution to rein in high health care costs for patients: Let patients see prices.

Many patient advocates say such transparency would be helpful for patients, allowing them to shop around for some services to hold down out-of-pocket costs, as well as adjust their household budgets for upcoming health-related outlays at a time of high-deductible plans.

At the Ohio Statehouse, the law’s greatest champion in state government has been Rep. Jim Butler, a Republican and former Navy fighter pilot whose wife is a physician. He authored the legislation and has beat the drum for it since he got the idea in 2013, as he waited for a garage mechanic to repair his car and absorbed the shop’s posted rates for brake jobs, oil changes and tuneups.

Opposition has been formidable, led by the goliath Ohio Hospital Association. It has filed a court injunction that is currently delaying enactment, peppered local news media with editorials, and lobbied Republican Gov. John Kasich, who has eliminated funding that would allow implementation from the latest state budget.

Joining the hospital association in its legal action are a wide range of provider groups including the Ohio State Medical Association, the Ohio Psychological Association, the Ohio Physical Therapy Association, and the Ohio chapters of the American Academy of Pediatrics, the American College of Surgeons, and the American Osteopathic Association.

These groups say that the law, which applies only to elective procedures, is too broad and that forcing providers to create estimates before procedures would slow down patient care. “The only way to even try to comply with the law is to delay care to patients in order to track down information from insurance companies, who may or may not provide the requested information,” wrote Mike Abrams, the president and CEO of the Ohio Hospital Association, in an op-ed in The Columbus Dispatch in January.

But Jerry Friedman, a retired health policy adviser for the Ohio State University Wexner Medical Center, said the opposition doesn’t stem from genuine concern about patients but from a desire to keep the secret rates that providers have negotiated with insurers under wraps. Transparency would mean explaining to consumers why the hospital charged them $1,000 for a test, he said, adding that providers “don’t want to expose this house of cards they’ve built between hospital physician industry and the insurance industry.”

Ohio State Rep. Jim Butler (Chris Stewart/Courtesy of the Dayton Daily News)

Said Butler on his quest to see the law enacted: “The health care industry has a lot of political power and lots of money. It’s hard to fight on behalf of people against this kind of force.”

The law’s next test will come in August, when the first court hearing on the association’s lawsuit is scheduled. The Kasich administration said it couldn’t comment on the law because of the pending litigation.

Greater price transparency has been a popular policy prescription for America’s high health costs, especially at a time when many patients have high-deductible insurance plans and face larger copayments. Upfront estimates exist in other countries, such as Australia and, for patients facing out-of-pocket expenses, in France.

In Massachusetts, patients can get an estimate within two days of admission if they ask for it. Nebraska requires hospitals and surgical centers to provide a list of the average charges for services. New Hampshire has a website where consumers can compare costs.

Hospitals and doctors often oppose such measures. The American Hospital Association’s position is that health plans — not hospitals — are responsible for telling insured patients about their out-of-pocket costs, according to its website.

Aimee Winteregg, 35, of Troy, Ohio, said she would have liked such information before five miscarriages in four years left her buried in unexpected medical bills. She and her husband became first-time parents in November. Though they are well insured, tests and treatment cost the couple $4,000 out-of-pocket, demanded in bills that were sometimes no more descriptive than for “medical service.”

“We don’t want to deal with this, especially when the doctor tells you stress is bad for the pregnancy,” her husband, J.D., said. But imposing greater transparency has been controversial in both the medical industry and among some health care researchers, who say it puts patients in an untenable position.

The transparency law “was written by someone thinking about health care as a TV, and not as health care,” said Sandra Tanenbaum, a professor of health services management and policy at The Ohio State University College of Public Health.

She said people could not shop for procedures as they would for a TV or car repairs, since they often lack information on the quality of doctors and hospitals, and make health care decisions based on much more than cost.

Consumers are more likely to base their decisions on their doctors’ advice, not on cost alone, according to a report from the Health Policy Institute of Ohio.

Only around 10 percent of health care costs are even “shoppable” expenses — procedures that can be scheduled in advance, like an MRI or elective surgery — according to the HPIO.

Regardless, Butler maintains, the health care industry can give consumers better information upfront. “If you really want patients to be empowered, they really need the information,” he said.

In support of such access, Butler has written letters to the Ohio Hospital Association, the Ohio attorney general and the Dayton Daily News, all in defense of the transparency law.

The Ohio Hospital Association, along with seven other Ohio health organizations, went to court last December to block the law, a month before it was supposed to take effect.

Butler said Gov. Kasich’s administration is helping the hospital association stall by not writing regulations, eliminating funding for the law in the state budget, and declining to meet with Butler to discuss it.

State Rep. Michael Henne, also a Republican, has worked with Butler in the Ohio General Assembly on the transparency law. He called Butler a “driver” on the law, noting: “It’s frustrating. You don’t realize how much [influence] special interests have in the process.”

Categories: Cost and Quality, Health Care Costs, Health Industry, Insurance

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Viewpoints: Is Silicon Valley Losing The Lead In Medical Technology?; Doctors And Hand Writing

Here’s a review of editorials and opinions on a range of public health issues.

The Wall Street Journal: Silicon Valley Trails In Medical Tech
People who develop medical technology have long assumed that Silicon Valley would pioneer smartphone-based devices to make Americans fitter and healthier than ever. To some degree, that forecast is coming true: Tech giants are working with doctors and hospitals on highly sophisticated devices — automated radiology, supercomputer-based oncology, fitness-tracker-based analytics — to monitor the sick, provide better automated care, and keep people out of hospitals in the first place. But it turns out the biggest gains from mobile medicine will come from deploying it in poor countries across Africa and Asia. (Michael S. Malone, 7/23)

KevinMD: Doctor, We Can’t Read Your Writing
So to future pharmacists who will read my prescriptions, and other health care professionals who will read my notes: I pledge from here on in to write as neatly as possible within the time constraints allowed, for the safety of my patients, the posterity of cursive writing, and for the sake of my grandfather (who likes reading my blog on his iPad). (Sarah Fraser, 7/23)

USA Today: Veterans Affairs Secretary: VA Health Care Will Not Be Privatized On Our Watch
As a physician, my professional assessment is that the Department of Veterans Affairs has made significant progress over the past six months — but it still requires intensive care. In order to restore the VA’s health, we must strengthen its ability to provide timely and high quality medical care while improving experiences and outcomes for veterans. (David Shulkin, 7/24)

Lexington Herald Leader: A Woman’s Death, Kentucky’s Opioid Crisis
Jenny Fulton’s brief life and brutal death hold important lessons, especially for Kentuckians in positions of public trust. The 27-year-old woman died in 2014 in the Mason County jail where she was sent because she had relapsed into heroin use, violating her parole. Despite widespread recognition that incarceration is not the solution, Kentucky still spends millions of dollars jailing people who have drug use disorders when that money could be better spent on evidence-based treatment. (7/23)

St. Louis Post-Dispatch: Trump Takes A ‘Just Say No’ Approach To Sex Education
In today’s version of “Just Say No,” first lady Nancy Reagan’s approach to drug use in the 1980s, President Donald Trump’s administration is cutting more than $213 million in funding to help prevent teen pregnancy. The move eliminates evidence-based pregnancy prevention and research programs, and family planning services, but leaves money for abstinence-only education. In addition, Trump appointed a prominent abstinence-only advocate as assistant secretary of Health and Human Services. (7/22)

San Jose Mercury News: Reject Climate Change Skeptic For Top Science Post
President Trump’s disdain for science apparently knows no bounds. He has now nominated climate change skeptic Sam Clovis, a talk radio host, to serve as the Department of Agriculture’s chief scientist — a slap in the face of the scientific community and a disservice to those responsible for the integrity of the USDA’s research. (7/23)

Sacramento Bee: California Workers’ Comp System Remains Nation’s Most Expensive
Obviously, working in California is not inherently more dangerous than in other states, and cash benefits to disabled California workers are not out of line, so the enormous cost differential must be rooted in the system itself, which explains why its rules are the subject of constant political infighting. One factor in those costs is what officials say is an enormous amount of fraud, concentrated in Southern California. (Dan Walters,  7/23)

Los Angeles Times: Don’t Believe The American Heart Assn. — Butter, Steak And Coconut Oil Aren’t Likely To Kill You
Last month, the American Heart Assn. once again went after butter, steak and especially coconut oil with this familiar warning: The saturated fats in these foods cause heart disease. The organization’s “presidential advisory” was a fresh look at the science and came in response to a growing number of researchers, including myself, who have pored over this same data in recent years and beg to differ. A rigorous review of the evidence shows that when it comes to heart attacks or mortality, saturated fats are not guilty. (Nina Teicholz, 7/23)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

The Big Picture: The Health Issues We Should Be Discussing; How To Move The Debate Forward

Even as the heated discourse over the future of the Affordable Care Act continues, some people offer their thoughts on the serious issues that are being overlooked and on how bad manners have soured the process.

Boston Globe: The Health Care Debate We Should Be Having
Most of the life expectancy gains of the last century can be chalked up to what we call public health, a catch-all term for those interventions aimed not at a single patient, but at a whole community or the entire population. …Which helps explain the great riddle of American health care: How come we spend more than everyone else, yet generally have worse outcomes? We overspend on medical care and underinvest in public health. (Horowitz, 7/22)

St. Louis Post-Dispatch: Collapse To Compromise: A Better Way To Health Care Reform
Republicans and Democrats disagree about the role of government; the trade-off between individual freedom and societal good; and about money and taxes. These long-standing disagreements play out repeatedly on the national stage, and today, health care is front and center. On our present course, these disagreements will turn our health care system upside down every time we vote to change party control of the White House and the Congress. (Steven H. Lipstein, 7/23)

The Washington Post: The GOP Cannot Fix Itself — Let Alone American Health Care
The inability of a Republican Congress and a Republican president to repeal Obamacare, or even just dial it back, is yet the latest demonstration that Republicans simply aren’t ready to govern. The facile explanation for this is the unresolved division, within the party, between its radical tea party populist wing and its more moderate, business-friendly establishment wing. But the bigger issue is that the party’s elected politicians are unwilling to make the trade-offs that are the essence of what governing is about. (Steven Pearlstein, 7/23)

The Washington Post: How Health Care Controls Us
If we learned anything from the bitter debate over the Affordable Care Act (Obamacare) — which seems doubtful — it is that we cannot discuss health care in a way that is at once compassionate and rational. This is a significant failure, because providing and financing health care have become, over the past half-century, the principal activity of the federal government. (Robert J. Samuelson, 7/23)

Huffington Post: Former CBO Directors Express ‘Strong Objection’ To GOP Attacks On Agency
Every economist who has previously served as director of the Congressional Budget Office has signed a letter registering “strong objection to recent attacks” on the agency. The letter, sent Friday morning and addressed to congressional leaders, does not specify who has been making those attacks. But only one political party is attacking the CBO right now ― and only one party has so brazenly questioned the agency’s methods to draw this kind of response from such a distinguished, bipartisan group of economists. It’s the Republicans, because they don’t like what the CBO has been saying about GOP proposals to repeal the Affordable Care Act. (Jonathan Cohn, 7/21)

Roll Call: How Bad Political Manners Fomented The Health Care Mess
[I]t’s not surprising that a secretive, churlish and entirely-outside-the-normal-channels approach has, from the start, distinguished [Senate Majority Leader Mitch McConnell’s] balky and now repudiated tackling of the defining legislative battle of Trump’s first year. Straightforward legislative etiquette would have required at least a few hearings and legislative markups on health care where Democrats could have gone on record in opposition and Republican skeptics, on the hard right and in the center, could have vented concerns and offered mollifying language — long before spreading anxieties at both ends of the GOP ideological spectrum crippled the bill. (David Hawkings, 7/24)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Committee’s Plan To Shift Money To Veterans’ Choice Program Draws Immediate Backlash

Eight major organizations spoke out against the proposal, saying it was unacceptable privatization of veterans’ health care.

The Associated Press: House Unveils Plan To Fix VA’s Budget Gap As Deadline Looms
A House committee unveiled a disputed plan Friday to allow the Department of Veterans Affairs to shift $2 billion from other programs to cover a sudden budget shortfall that could threaten medical care for thousands of patients in the coming weeks. The proposal by the House Veterans Affairs Committee would provide a six-month funding fix to the department’s Choice program, which offers veterans federally paid medical care outside the VA and is a priority of President Donald Trump. To offset spending, the VA would trim pensions for some veterans and collect fees for housing loans. (Yen, 7/21)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Follow The Money: Drugmakers Deploy Political Cash As Prices And Anger Mount

Two federal investigations — one examining opioid sales, another about a multiple sclerosis drug whose price had soared to $34,000 a vial — were only part of the troubles Mallinckrodt faced as the year began.

The stock of the drugmaker, whose United States headquarters are in St. Louis, was tanking. Wall Street worried that Medicare might reduce the half-billion dollars it was spending yearly on a Mallinckrodt drug with limited evidence of effectiveness.

This year, the company left the industry trade group Pharmaceutical Research and Manufacturers of America, or PhRMA, after the group threatened to kick out companies that did not spend enough on research.

Mallinckrodt, however, has been increasing its spending in another area: It has been writing checks to politicians.

After making meager donations in 2015, the company’s political action committee began raising its contributions for congressional campaigns last year. Lawmakers in both the House and Senate collected $44,000 from Mallinckrodt in 2017’s first quarter, nearly nine times what they got from the company in the same period two years ago.

Mallinckrodt also spent $610,000 lobbying Congress, triple the amount of 2015’s first quarter. The company, which makes pain-control drugs as well as H.P. Acthar, an injectable gel prescribed for multiple sclerosis and other diseases, has lobbied on issues related to opioids, patents, Medicare and other matters, regulatory filings show.

Mallinckrodt is far from unique. This year, a critical and risky one for drug companies, the industry as a whole is ratcheting up campaign donations and its presence on Capitol Hill, a new database compiled by Kaiser Health News shows.

“The stakes are really high right now,” said David Maris, who follows pharmaceutical stocks for Wells Fargo, given that President Donald Trump has joined Democrats to demand action on drug costs.

Mallinckrodt acknowledges that it has increased its political spending to help its particular causes. “We actively participate in the political process on issues that matter to us and our patients,” Rhonda Sciarra, a Mallinckrodt spokeswoman, said by email. “Our PAC’s absolute spend remains small in relation to other companies in our industry.”

Congressional donations from pharmaceutical PACs rose 11 percent in this year’s first quarter, compared with the first three months of 2015 (the comparable point in the previous election cycle), according to a Kaiser Health News analysis. The increase accompanied a spike in pharma lobbying for the period.

Contributions to powerful committee members who handle health policy matters also increased in the face of public anger over the opioid crisis as well as anticipated renewal of legislation that determines the “user fees” companies pay for regulatory drug approval.

A dozen Republican committee heads and ranking Democrats on health-related panels collected $281,600 from pharma-related PACs in the first quarter, up 80 percent from what people in the same positions collected in the first quarter of 2015, the data show. Such initial donations often set the pace for a two-year election cycle, and suggest whom corporate interests are trying to cultivate in a new Congress, with implied promises of more to come, analysts say.

For pharma companies, “now would be the time to give out the money, ahead of a piece of legislation that may come down the road,” said Kent Cooper, a former Federal Election Commission official who has tracked political money for decades. “You want to get your name out there and make a connection with these members’ legislative assistants — so you are known to them and you can get in their door.”

Other drugmakers increasing their congressional donations include AbbVie — whose blockbuster rheumatoid arthritis injection, Humira, faces threats from competition — and Alexion Pharmaceuticals. A six-figure price tag for Soliris, Alexion’s treatment for a rare blood disorder, makes it one of the world’s most expensive drugs.

Pfizer, the No. 2 pharma donor in the first quarter after Sanofi, gave $130,900 to congressional campaigns, three times its contribution for the same period two years ago. So far this year, the company has raised the price of dozens of drugs by an average of 20 percent, The Financial Times reported.

PhRMA, a big giver in the past, has not yet joined individual companies in increasing donations for this election cycle. Congressional campaigns collected $7,000 in the first quarter from PhRMA, which Politico reported had raised member dues to prepare for the drug-price fight. They got $31,500 two years ago.


The totals do not include contributions from individual executives and lobbyists, or donations to leadership PACs. Leadership PACs associated with a particular member of Congress often spend money on other members’ campaigns, as well as on things that a campaign committee cannot finance. Details on contributions to leadership PACs take longer to become available.

Outrage was still bubbling last year over moves by Turing Pharmaceuticals and Mylan to raise prices of cheap-to-make, lifesaving drugs to hundreds of dollars a dose, when the country elected a Republican president who vowed: “I’m going to bring down drug prices.” Nearly 8 in 10 Americans said in a September poll they believed prescription drug prices were unreasonable.

Evidence has grown that pharma companies helped fuel the nation’s addiction and overdose crisis with sales of powerful painkillers, prompting calls for an overhaul. Drug developers are also preparing for renewal of the Prescription Drug User Fee Act, which generates revenue to pay for government review and approval of drugs.

At the same time, drug companies anticipated Republican efforts to repeal and replace the Affordable Care Act, which finances billions in drug sales. That process has stalled in the Senate. All of this gives drugmakers the most powerful incentives in years to cultivate policymakers, analysts say.

Tense politics may also be prompting members of Congress to be energetic about soliciting donations.

“My sense is that Republicans are nervous in the House — especially given the long-term record of the presidential party losing seats in the midterm,” said David Magleby, a political scientist at Brigham Young University who studies campaign finance. “I would be surprised if Republican incumbents across the board aren’t more aggressive in raising money in the first and second quarters.”

In the past six months, Mallinckrodt has come under pressure for both painkiller sales and price increases for non-narcotic drugs. Earlier this month, the Justice Department announced the company would pay $35 million to resolve an investigation into whether it ignored enormous volumes of its oxycodone moving through distributors and pharmacies. Over several years, The Washington Post reported, Mallinckrodt was responsible for two-thirds of all the oxycodone sold in Florida.

Mallinckrodt denied it violated the law and said the settlement was not an acknowledgment of liability.

In January, it agreed to pay $100 million to settle Federal Trade Commission allegations that a company it bought three years ago had illegally quashed competition, enabling it to raise the price of Acthar, the multiple sclerosis drug, which the FTC said cost only $40 per vial in 2001, to $34,000. Mallinckrodt disputed the agency’s complaint but said it settled to put the matter to rest.

The drug is prescribed to treat a rare form of epilepsy as well as multiple sclerosis and other ailments. Even Mallinckrodt acknowledges that “clinical trials demonstrating the efficacy for Acthar are limited.”

But in part because of price increases, global sales of the drug soared from $123 million in the 2014 fiscal year to $1.2 billion in the 2016 fiscal year. It was Medicare’s most expensive drug per patient in 2015 — $162,371 for the year — and now makes up a third of the company’s revenue.

Company shareholders have worried that Medicare will crack down on sales of Acthar. Mallinckrodt has pledged to keep future price increases for all drugs to single-digit percentages per year, though that could still be well above the current inflation rate of less than 3 percent.

Mallinckrodt’s biggest donations on Capitol Hill, of $5,000 each, went to Ann Wagner, a House member from its home state, Missouri, and Sen. Orrin Hatch, the powerful chairman of the Senate Finance Committee. That amount is the maximum a PAC can give to a campaign committee for each primary and general election.

Ever since it was spun off as an independent company in 2013, Mallinckrodt has made its legal home in Ireland, which allows it to take advantage of lower income tax rates. Hatch favors cutting U.S. corporate taxes to eliminate incentives to make such moves.

Mallinckrodt gave lesser amounts to 16 other congressional campaigns, including that of Paul Ryan, the House speaker. Ryan, who has played down Trump’s attacks on the pharmaceutical industry, was the top recipient of industry money in the first quarter, with $82,750 collected, the data show.

The White House has made no proposals on drug costs. Trump has said little about the issue since January, when he said drug sellers were “getting away with murder.”

Drug companies are hedging their bets, writing checks to individual Democrats and Republicans. With Trump breaking ranks with Republicans to favor reform, “you can’t tell who’s your friend and who’s not,” said Maris, the Wells Fargo analyst. “So you have to go to a ground game — a more one-on-one legislator basis.”

Naema Ahmed contributed to this report.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Categories: Cost and Quality, Health Industry, Pharmaceuticals

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In Appalachia, Two Hospital Giants Seek State-Sanctioned Monopoly

JOHNSON CITY, Tenn. — Looking out a fourth-floor window of his hospital system’s headquarters, Alan Levine can see the Appalachian Mountains that have defined this hardscrabble region for generations.

What gets the CEO’s attention, though, is neither the steep hills in the distance nor one of his Mountain States Health Alliance hospitals across the parking lot. Rather, it’s a nearby shopping center where his main rival ­— Wellmont Health System, which owns seven area hospitals — runs an urgent care and outpatient cancer center. Mountain States offers the same services just up the road.

“Money is being wasted,” Levine said, noting that duplication of medical services is common throughout northeastern Tennessee and southwestern Virginia where Mountain States and Wellmont have been in a health care “arms race” for years, each trying to outduel the other for the doctors and services that will bring in business.

The companies now want to merge, which would create a monopoly on hospital care in a 13-county region that studies have placed among the nation’s least healthy places. The merger’s savings would pay for a range of public health services that they can’t afford now, the companies project. And they are trying to pull it off without Washington regulators’ approval, breaking with hospitals’ usual path to consolidation.

In a typical case, a plan that eliminates so much competition in a market would almost certainly provoke a court battle with the Federal Trade Commission, which enforces antitrust laws and challenges anti-competitive behavior in the health industry.

To avert such a fight, the hospitals are using an obscure legal maneuver available in Tennessee and Virginia and some other states.

The view of mountains is everywhere in Johnson City, Tenn. (Phil Galewitz/KHN)

Generally known as a Certificate of Public Agreement (COPA), the process works like this: If regulators in Virginia and Tennessee agree that the merger is in the public interest, Wellmont and Mountain States would operate as one company under a state-supervised agreement governing key parts of their operations, including setting prices. The states’ approval would prevent the FTC from challenging the merger under federal antitrust law.

Their decisions could come as soon as this month.

In exchange for approval, Mountain States and Wellmont promise to use money saved from the merger to offer mental health and addiction treatment services and attack public health concerns, such as obesity and smoking — areas previously neglected by the systems that don’t increase hospital admissions and bring in big revenue, hospital officials said

“The question that needs to be asked is whether tight state oversight of a monopoly is better than failed competition,” said Robert Berenson, a health policy expert at the Urban Institute.

Little-Used And Rarely Challenged Mechanism

The federal antitrust exemption made possible under a COPA dates to a Supreme Court ruling in the 1940s used only about a dozen times to allow hospital mergers. One was an hour away from here, in Asheville, N.C.

There’s little scholarly research on COPAs’ results.

Last summer, the FTC dropped its challenge to a merger of two West Virginia hospitals after the state adopted a COPA law and permitted the deal.

In recent years, hospital mergers and acquisitions have created behemoth health systems that have used their status to demand high payments from insurers and patients. Studies by health economists have repeatedly found that consolidation means higher prices.

But the same calculus may not apply here and in other regions where a preponderance of patients are poor or uninsured, officials from both Mountain States and Wellmont say.

While President Donald Trump and Republicans in Congress stress the value of free-market principles in health care, both hospitals argue that in their part of Appalachia the market has led to unnecessary spending, driven up health costs and forced them to focus on services that produce the highest profits rather than meet the community’s most pressing health needs. In this deeply conservative region where death rates from cancer and heart disease are among the nation’s highest, the hospitals say only a state-sanctioned monopoly can help them control rising prices and improve their population’s health.

Without their proposed merger, Levine said, both hospital systems would likely have to sell to an out-of-market chain. That would likely eliminate local control of the facilities and could lead to massive layoffs and the closure of hospitals and services, he said. Together, the two hospital systems employ about 17,000 people.

Alan Levine, CEO of Mountain States Health Alliance, outside his Johnson City, Tenn., office. (Phil Galewitz/KHN)

The FTC, which is urging the states to reject the hospitals’ plan, contends the hospitals could form an alliance or take other steps short of a merger to accomplish the benefits they say one will bring. The agency says the hospitals’ market probably would be no worse off if one chain merged with a company outside the area.

Feds Wary Of Promises

The hospitals are making big promises to sell their deal. They say no hospitals would close for at least five years, although some could be converted to specialized health facilities to treat problems such as mental health or drug addiction. After the merger, all qualified doctors would have staff privileges at all hospitals to treat patients. No insurer would pay lower rates than others. The new hospital system would spend at least $160 million over 10 years to improve public health, expand medical research and support graduate medical education for work in rural areas.

The FTC maintains the hospitals’ pledges are unreliable and dismissed them as having “significant shortcomings, gaps and ambiguities” in an analysis filed with state regulators in January.

Levine said the plan is the best deal for the community given the factors that handicap the hospitals. Those include declining populations and Medicare reimbursement rates that are lower here than other parts of the country because of lower average wages. Another concern is the cost of caring for uninsured people — neither Virginia nor Tennessee expanded Medicaid under the health law, which would have lowered uninsured rates.

“Competition is and should be the first choice, but in an area where competition becomes irrational and there are limited choices, there has to be a Plan B. If not this, then what?” he said.

Blue Cross and Blue Shield of Tennessee, the state’s largest health insurer, is not opposing the hospitals’ combination, a spokesman said. But its counterpart in Virginia, Anthem, hasn’t been persuaded.

“Anthem does not believe that there are any commitments that will protect Southwest Virginia and Northeast Tennessee health care consumers from the negative impact of a state-sanctioned monopoly,” the company said in a statement.

Wanted: Better Job Prospects

The proposed COPA has strong support among large employers in the region, including Eastman, a Kingsport, Tenn., chemical company with $9 billion in annual revenue that employs more than 7,000 people locally. “We get local governance, input and control … and that’s a lot better situation for us,” said David Golden, a senior vice president at Eastman.

Still, walking around Johnson City — the region’s largest city with almost 67,000 people — it’s easy to feel an unease among small employers and residents about a merger. Many worry about possible job cuts.

“Eliminating duplication of services means eliminating people,” said Dick Nelson, 60, who runs a coffee and art shop downtown and has lived here for 27 years. “I don’t care how much health care costs because my insurance will pay it,” he said.

In Kingsport, where Wellmont and Mountain States each has a hospital, Thorp is leery about a merger, too. “It’s an economic move, not an enhancement of medical care,” said Thorp, who runs a newsstand downtown. “We pride ourselves here for having good education and health care. They say there won’t be any services or jobs cut, but if that’s the case then what’s the point of the merger?”

Tom Throp owns Wallace News, a staple in downtown Kingsport, Tenn. Of the hospital consolidation plan, he says: “They say there won’t be any services or jobs cut, but if that’s the case then what’s the point of the merger?” (Phil Galewitz/KHN)

Levine said no place better supports the case for a hospital merger than Wise County in southwestern Virginia, a scenic area with about 40,000 people whose three hospitals all operate below half their capacity. Mountain States and Wellmont each own a hospital in Norton, the county seat with 4,000 residents. Despite few patients, the hospitals still bear hard-to-cut costs for buildings, equipment and adequate staffing levels, Levine said.

On a recent weekday morning, Lonesome Pine Hospital, a Wellmont facility in Big Stone Gap, Va., looked nearly deserted. No volunteers or staffers were visible inside its main entrance and fewer than a fifth of its 70 acute-care beds were being used.

A five-minute drive away, Mountain States’ Norton Community Hospital’s 129 beds are about a quarter filled. Its maternity unit delivers fewer than five babies a week. The hospital offers hyperbaric oxygen therapy — a treatment that pays well under Medicare’s reimbursement rates — to help diabetics heal their wounds. But it has no endocrinologists to help diabetics manage their disease to avoid such complications. Despite a high rate of heart disease in the community, there’s no cardiologist on staff.

Whether a state-sanctioned merger will resolve the incongruities — here or in other poor regions — depends on how firmly regulators hold the hospitals to their pre-merger commitments. If the merger plan gets rejected, Mountain States and Wellmont will resume arch-competitive business practices that do not always put community interests first, said Bart Hove, Wellmont’s CEO.

“It’s about competing for the dollar in any way you can and extracting a dollar from your competition,” Hove said. “You do what you can to drive patients to your hospital.”

Categories: Cost and Quality, Health Care Costs, Health Industry

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Viewpoints: The Opioid Epidemic Through The Lens Of Neuroscience; Prognostic Uncertainty, Outcomes And Medical Decisions.

Here’s a review of editorials and opinions on a range of public health issues.

Bloomberg: Neuroscience Offers Insights Into The Opioid Epidemic
Most Americans say they’re interested in scientific discoveries, but they may be thinking of the kinds of findings that lead to new gadgets and wonder drugs. When it comes to discoveries about hazards and risks — especially the risks of those wonder drugs — Americans seem more likely to tune out. (Faye Flam, 7/21)

The New England Journal Of Medicine: Managing Uncertainty — Harnessing The Power Of Scenario Planning
Although prognostic certainty remains elusive, many clinicians use statistics to quantify outcomes. We strive to achieve increasing precision with risk calculators and use the best available evidence to report probabilities of discrete complications. Decision aids allow us to share these predictions with patients and facilitate comparison between treatments. Although numbers quantify uncertainty, they offer little guidance to patients for managing this uncertainty. Moreover, these strategies fail to illuminate logical connections between the patient’s current condition, downstream outcomes, and events experienced along the way. (Margaret L. Schwarze and Lauren J. Taylor, 7/20)

The New England Journal Of Medicine: Certain About Dying With Uncertainty
Mrs. C., a woman with whom we’d had a long-standing patient–physician relationship, one of us for over 25 years, died recently in the 87th year of her life. A woman who had always maintained her cheerful spirit even in the midst of quite trying medical setbacks, she was one of our favorite patients. But what made her most special was her perspective on life and death: we learned a lot from her. … when her husband died of a brain tumor about 5 years ago, she witnessed the good and the not-so-good that medicine had to offer. She saw interventions that improved things slightly for a short while but did not provide meaningful and sustained benefit. After he died, we had “the conversation”; we had broached the subject before but had never discussed it in great depth. She knew what she wanted. … We vowed to keep our part of the bargain. If we had only known how hard that would be. (Jeffrey M. Drazen and Maria A. Yialamas, 7/20)

Los Angeles Times: Dear Media: When You Cover Death By Suicide, Do It Thoughtfully
When a family member died by suicide, my parents chose not to tell me his method. They wanted me to remember him as he lived, for both of our sakes. While I didn’t understand their decision at the time, I now see it as one borne out of deep care. I was especially thankful for my parents’ thoughtfulness after reading the media coverage of Linkin Park singer Chester Bennington’s death by suicide this week. (Melissa Batchelor Warnke, 7/21)

The Wall Street Journal: In The Netherlands, The Doctor Will Kill You Now
In 2002 the Netherlands became the first country to legalize euthanasia and physician-assisted suicide for those suffering deadly diseases or in the last stages of life. Not long after the legislation was enacted, eligibility was expanded to include those experiencing psychological suffering or dementia. Today pressure is mounting for the Dutch government to legalize a “euthanasia pill” for those who are not ill, but simply consider their lives to be “full.” (Kees van der Staaij, 7/20)

RealClear Health: Digital Health Hope: Personalized Care Is The Final Frontier
For many health care providers, personalized or precision medicine is the holy grail of their practice. While we have made great gains as new technologies develop, progress in medicine in the past decade has been lacking despite all-time spending highs in research. In order to improve outcomes and make significant progress, physicians must accept change and move toward the more precise approach that personalized medicine affords. Today, medicine revolves around standards of care: the best courses of prevention or treatment for the general population, or the average person on the street—not necessarily what is best for the individual. In personalized medicine, physicians cater medical treatment to a patient based on their particular genetic, environmental and clinical information. This personalized approach results in a more precise treatments that are much more likely to be effective. (Kevin Campbell, 7/21)

St. Louis Post-Dispatch: The U.S. Attorney General Is Stuck In A ‘Reefer Madness’ Time Warp
For reasons that defy understanding, science, public opinion and most state governments, Attorney General Jeff Sessions has decided that cracking down on the use of medical marijuana is a priority. Assuming he survives President Donald Trump’s pique, he wants Congress to roll back rules that prohibit the Justice Department from going around state laws to enforce a federal ban against medical cannabis. As recently as May, Congress reaffirmed that the Justice Department can’t spend money to prevent states from “implementing their own laws that authorize the use, distribution, possession, or cultivation of medical marijuana.” (7/20)

Los Angeles Times: USC Bosses Flunk The Leadership Test Amid Shocking Allegations About Former Medical School Dean
By now you probably know the details. Dr. Carmen Puliafito, a $1.1-million-a-year professor, doctor, dean and big-bucks rainmaker for the University of Southern California, left plenty of time in his busy schedule for extracurricular activities. They included drug-fueled parties with a prostitute, convicted criminals and drug addicts. Los Angeles Times sleuths dug up photos of Puliafito’s exploits in hotel rooms, apartments and even the dean’s office at USC, including a shot of him using a butane torch to light a glass pipe while a female companion smoked heroin. (Steve Lopez, 7/20)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Policy Positions: Health Spending Is ‘The American Way’; What Becomes Of Medicare; And Does Universal Health Care Equal Freedom?

Media outlets explore important health policy questions.

Bloomberg: Spending A Lot On Health Care Is The American Way
The U.S. has some of the most expensive medicine in the world, with health-care spending now almost 18 percent of gross domestic product. But why? And might we hope to get this spending down? Unfortunately, expensive health care is embedded in the American way of life — more specifically, the American desire to live it up with high consumption. (Tyler Cowen, 7/20)

Forbes: How GOP Will Still Carve Up Medicare
The rehashed House GOP budget blueprint wants to reshape Medicare into more of a Medicare Advantage model, which now covers some 19 million Americans. What does that mean? Funding for the guaranteed part of Medicare would be shifted into the privatized scheme. You’d receive a fixed stipend or “premium support” to buy a private policy on an exchange. (John Wasik, 7/19)

USA Today: Dear America, Universal Health Care Is What Real Freedom Looks Like
In 1991, after nearly 10 years of recurring wracking pain in my lower abdomen, I walked into a hospital in Helsinki, Finland. I wasn’t a Finnish citizen and wasn’t, at that time, married to one. I was an American writer visiting my Finnish boyfriend, working temporarily in Helsinki. An admitting nurse listened to my symptoms and guessed my problem — a diagnosis that received preliminary confirmation by ultrasound within the hour. (Anne Korkeakivi, 7/20)

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Research Roundup: Early Hospice Discharges Turn Profits; Integrating Mental Health Care

Each week, KHN compiles a selection of recently released health policy studies and briefs.

Health Affairs: A Positive Association Between Hospice Profit Margin And The Rate At Which Patients Are Discharged Before Death
Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices’ desire to maximize profits drives them to inappropriately discharge patients… Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. (Dolin et. al., 7/1)

Health Affairs: Medicare Advantage Associated With More Racial Disparity Than Traditional Medicare For Hospital Readmissions
We compared racial disparities in thirty-day readmissions between traditional Medicare and Medicare Advantage beneficiaries who underwent one of six major surgeries in New York State in 2013. We found that Medicare Advantage was associated with greater racial disparity, compared to traditional Medicare. After controlling for patient, hospital, and geographic characteristics in a propensity score based approach, we found that in traditional Medicare, black patients were 33 percent more likely than white patients to be readmitted, whereas in Medicare Advantage, black patients were 64 percent more likely than white patients to be readmitted. (Li et. al., 7/1)

RAND: Possible Legal Barriers For PCP Access To Mental Health Treatment Records
Provider and payer groups have endorsed the goal of improving the integration of primary care and behavioral health across a variety of programs and settings… Preliminary investigation found that in almost one third of the states (including large-population states such as Florida, Georgia, Massachusetts, New York, and Texas), primary care physicians (PCPs) may have difficulty accessing mental health treatment records without the patient’s (or his/her guardian/conservator’s) written consent. If a comprehensive legal analysis supports this conclusion, then those advocating integration of behavioral and primary care may need to consider seeking appropriate state legislative solutions. (Rothenberg et. al., 7/19)

New England Journal of Medicine: Implementation Of Medical Homes In Federally Qualified Health Centers 
We examined the achievement of medical-home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients’ experiences, and Medicare expenditures in demonstration sites versus comparison sites… Demonstration sites had higher rates of medical-home recognition and smaller decreases in the number of patients’ visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. (Timbie et. al., 7/20)

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Trump Plan Might Cut Expenses For Some Insured Patients With Chronic Needs

Erin Corbelli takes three medications to treat high blood pressure, depression and an anxiety disorder. Her health plan covers her drugs and specialist visits, but Corbelli and her family must pay a $3,000 annual deductible before the plan starts picking up any of that tab.

Corbelli’s insurance is linked to a health savings account so that she and her husband can put aside money tax-free to help cover their family’s drug and medical expenses. But there’s a hitch: Plans like theirs can’t cover any care for chronic conditions until the deductible is satisfied.

Those out-of-pocket expenses could shrink under a Trump administration draft executive order that would change Internal Revenue Service rules about what care can be covered before the deductible is met in plans linked to health savings accounts, or HSAs.

“It would save us a lot of money,” said Corbelli, 41, who lives in Orlando with her husband and their two children, ages 3 and 5.

Michelle AndrewsInsuring Your Health

Health plans with deductibles of thousands of dollars have become increasingly commonplace. Plans often cover services like generic drugs or doctor visits before consumers have satisfied their deductibles, typically requiring a copayment or coinsurance rather than demanding that consumers pony up the entire amount.

But plans that link to health savings accounts have more restrictions than other high-deductible plans. In addition to minimum deductibles and maximum HSA contribution limits, the plans can’t pay for anything but preventive care before consumers meet a deductible. Under current IRS rules, such preventive care is limited to services such as cancer screenings and immunizations that prevent a disease or condition, called “primary prevention.” With HSA-eligible plans, medical services or medications that prevent an existing chronic condition from getting worse or prevent complications from occurring — called “secondary prevention” — can’t be covered before the deductible is paid.

The Trump administration’s draft executive order, which was first obtained last month by The New York Times and has yet to be issued, would allow such secondary preventive services to be covered.

Under the Affordable Care Act, most health plans, including HSA-eligible plans, are required to cover services recommended by the U.S. Preventive Services Task Force without charging consumers anything for them. That requirement is generally limited to primary prevention.

“We know health savings accounts are here to stay and we’d like to make them better,” said Dr. A. Mark Fendrick, an internist who is director of the University of Michigan’s Center for Value-Based Insurance Design and who has advocated for the change.

If people have diabetes, for example, they need regular eye and foot exams to prevent complications such as blindness and amputations down the road. But HSA plans can’t pay anything toward that care until people satisfy their deductible. “The executive order gives plans the flexibility to do that,” he said.

Similarly, it’s critical to remove obstacles to treatment for people like Corbelli with high blood pressure or heart disease, said Sue Nelson, vice president for federal advocacy at the American Heart Association.

“For people with cardiovascular disease, affordability is their No. 1 concern,” Nelson said.

The draft executive order is short on details, and administration officials would have to determine which new preventive services should be covered pre-deductible. Guidelines from medical specialty boards and quality metrics that many physicians are already being measured against could be used, said Roy Ramthun, president and founder of HSA Consulting Services who led the Treasury Department’s implementation of the HSA program in the early 2000s.

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Back then, they took a conservative approach. “We said we can be more flexible later, but we can’t put the genie back in the bottle,” said Ramthun, who supports expanding preventive services coverage.

Many more employers would offer HSA-eligible plans if the list of services that could be covered pre-deductible were expanded, said Tracy Watts, a senior partner at human resources consultant Mercer. Fifty-three percent of employers with 500 or more workers offer HSA-eligible plans, according to Mercer survey data. Three-quarters of employers put money into their employees’ HSA accounts, she said.

Erin Corbelli’s husband’s employer contributes up to $1,500 every year to their health savings account, which can help cover their pre-deductible costs.

Not everyone is so fortunate. “You’re kind of at the mercy of what your employer can offer and what your disposable income is,” she said.

Republicans have long advocated for the expanded use of health savings accounts as a tax-advantaged way for consumers to get more financial “skin in the game.”

Consumer advocates have been much less enthusiastic, noting that the accounts typically benefit higher-income consumers who have cash to spare.

Still, given the reality of the growing prevalence of high-deductible plans, with or without health savings accounts, it’s a sensible proposal, many say.

“This is not a silver bullet or a solution to the problems that high-deductible plans can pose,” said Lydia Mitts, associate director of affordability initiatives at Families USA, an advocacy group. “But this is a good step in thinking about how we offer access to treatment people need in a timely and affordable way.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Cost and Quality, Insurance, Insuring Your Health

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Viewpoints: The Logistics Of Overlapping Surgeries; ‘A World Without Antibiotics’

Opinion writers offer their thoughts on a range of public health issues.

JAMA: The Evolving Story Of Overlapping Surgery
In December 2015, a Boston Globe investigation of Massachusetts General Hospital (MGH) sparked investigations into concurrent and overlapping surgery. Overlapping surgery refers to operations performed by the same primary surgeon such that the start of one surgery overlaps with the end of another. A qualified practitioner finishes noncritical aspects of the first operation while the primary surgeon moves to the next operation. This is distinct from concurrent surgery, in which “critical parts” of operations for which the primary surgeon is responsible occur during the same time. There is general agreement that concurrent surgery is ethically unacceptable and is prohibited for teaching hospitals under the Medicare Conditions of Participation. Overlapping surgery is common, ranging from having trainees open and close incisions to delegating all aspects of the operation except the critical parts. (Michelle M. Mello and Edward H. Livingston, 7/18)

Real Clear Health: A World Without Antibiotics
Imagine a world without antibiotics. A simple cut or scrape could become life-threatening. Childbirth would be much more dangerous, for both mother and child. We could return to tuberculosis the old-fashioned way: with just a dose of fresh air. If we don’t get antibiotic resistance under control, this world could become our reality again. (Tanya Parish, 7/20)

JAMA Forum: A Bipartisan “Moonshot” In Health: Improving Care For High-Need Patients
Drawing comparisons to a “moonshot” in health care is usually reserved for breakthroughs like curing cancer. Perhaps less hyperbolic, though no less impactful, is the idea of transforming care for high-need patients—people with multiple, and often interconnected, medical, social, and behavioral health needs. Better care for these patients is also a promising approach to reining in health care costs, a bipartisan health policy priority. ( Dave A. Chokshi, 7/19)

JAMA: The Role Of Patient Engagement In Addressing Parents’ Perceptions About Immunizations
Vaccines are frequently cited as one of the greatest successes in the history of public health. The World Health Organization estimates that vaccines for diphtheria, pertussis, tetanus, and measles save between 2 million and 3 million lives annually. However, in recent years, parental resistance toward childhood vaccinations has increased.1 Many parents have become concerned and distrusting of scientific evidence about vaccinations. As a result, cases of vaccine-preventable diseases have reemerged in the United States and other countries. Unvaccinated and undervaccinated individuals are susceptible to disease and increase the risk of transmitting diseases even to those who are fully vaccinated. (Mary C. Politi, Katherine M. Jones and Sydney E. Philpott, 7/18)

USA Today: Congress, Stand Up For Nature Conservation So Nature Can Keep Sustaining Us
Earlier this month, my wife Tracy and I explored on horseback for three days the Big South Fork National River and Recreation Area — a gem of the national park system in east Tennessee. As we rode the trails, experiencing the gently flowing creeks, the quiet wooded paths, the inspiring sounds of birds and kids playing along the way, we delightfully soaked up the present, reflected fondly on the past and what it took to make our experience possible, but also worried about the future. (Bill Frist, 7/18)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Cruz Plan Gets Thumbs Up From HHS But Thumbs Down From Most Everyone Else

Contradicting the opinion of most policy experts, a draft report from the Trump administration forecasts better enrollment and lower premiums for everyone who buys their own health insurance if a controversial amendment proposed by Sen. Ted Cruz of Texas were to become law.

The draft surfaced just as Republican senators were lunching with President Donald Trump on Wednesday to talk about the next steps in the health care debate.

“The Republicans never discuss how good their healthcare bill is, & it will get even better at lunchtime,” tweeted Trump, before the group convened.

But findings from the draft report drew immediate criticism from health policy experts as opaque and misleading.

“The details get a bit dicey,” said Craig Garthwaite, director of the health care program at Northwestern University’s Kellogg School of Management. “No one I’ve talked to thinks [the analysis] is well done.”

The forecasts in a 22draft analysis by the Department of Health and Human Services are exactly opposite from what many experts forecast.

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Still, the HHS analysis did provide some insight into how HHS envisioned that the Cruz plan, part of the Senate bill that appeared to die this week, could have worked. Particularly notable: The analysis assumes annual deductibles of $12,000, which means consumers would have to pay that amount — which is far higher than allowed under the ACA — before most benefits are covered.

On Wednesday, health care developments continued to unfold at a breakneck pace, and with a zigzagging trajectory, when the Senate Budget Committee posted on its website yet another bill. This one is an updated version of the 2015 “repeal and delay” bill, which is likely the measure the Senate will consider next week if a vote to start debate succeeds.

It would repeal all of the taxes that paid for the Affordable Care Act’s benefits, roll back the expansion of Medicaid (but not cap the underlying program), nullify the requirement for most people to have insurance and rescind the financial aid for low- and moderate-income Americans.

Late in the afternoon, the Congressional Budget Office released an updated estimate of an earlier analysis concluding that the new “repeal and delay” measure could result in 32 million fewer Americans having coverage and premiums doubling by 2026. By 2020, according to CBO, “about half the nation’s population would live in areas having no insurer participating in the non-group market.” The new bill does not include the Cruz amendment, the subject of the HHS report.

Opposition to the Cruz amendment from powerful health care sectors, like the insurance industry, is cited as one reason why the Senate was unable to muster enough votes to move the whole Senate bill forward for debate this week.

Last Friday, the insurance industry trade lobby sent a harsh warning to Congress, saying the Cruz amendment “is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage.”

Today, the HHS report took a very different view.

First reported in the right-leaning Washington Examiner, it forecasts far more people covered by insurance in 2024 if the Cruz plan were adopted, as compared with how many would be insured under the Affordable Care Act.

It also projects premiums would fall, both in plans that meet all the rules of the ACA, and in plans Cruz proposes, which would not have to follow the rules. The Cruz plans would have lower premiums, however, because they could come with far fewer benefits — and could reject people with medical problems or charge them more.

Insurers and actuaries said the Cruz proposal would result in a segmented market, with younger and healthier people drawn to the skimpier, less expensive plans. That, in turn, would leave older or sicker enrollees in the ACA-compliant plans, causing their premiums to spiral upward.

But the analysis by HHS shows premium costs for ACA-compliant plans would go down by more than $250 a month in 2024 when compared with what they would be under current law. The Cruz plans would be super cheap, at under $200 a month under the rosiest scenario outlined.

Experts today immediately pounced on the department’s methods — in as much as they could be determined, since the full report was not released.

(HHS did not respond to requests for comment or for the release of the full report.)

For starters, the draft report, they say, compares premiums for a 40-year-old with the “weighted average” of all people of all ages purchasing ACA plans now.

“It’s not apples to apples,” said Matt Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Innovation in Health Policy.

It cited its own “proprietary model” used to determine how many people would switch from ACA plans to the new Cruz plans, without spelling out its assumptions. Not including such details is highly unusual and makes the results difficult to analyze, said Garthwaite, adding: “There’s nothing in this that gives me any hope that the entire report will be any more accurate, complete or unbiased.”

Meanwhile, over lunch at the White House, President Trump asked senators to skip all or part of their August recess in order to work on another proposal to repeal and replace the ACA. He promised premiums that would be significantly lower, without citing details on how that would occur.

Categories: Cost and Quality, Repeal And Replace Watch, The Health Law

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Fraud And Billing Mistakes Cost Medicare — And Taxpayers — Tens Of Billions Last Year

Federal health officials made more than $16 billion in improper payments to private Medicare Advantage health plans last year and need to crack down on billing errors by the insurers, a top congressional auditor testified Wednesday.

James Cosgrove, who directs health care reviews for the Government Accountability Office, told the House Ways and Means oversight subcommittee that the Medicare Advantage improper payment rate was 10 percent in 2016, which comes to $16.2 billion.

Adding in the overpayments for standard Medicare programs, the tally for last year approached $60 billion — which is almost twice as much as the National Institutes of Health spends on medical research each year.

“Fundamental changes are necessary” to improve how the federal Centers for Medicare and Medicaid Services ferrets out billing mistakes and recoups overpayments from health insurers, he said.

Medicare serves about 56 million people, both those 65 and older and disabled people of any age. About 19 million have chosen to enroll in Medicare Advantage plans as an alternative to standard Medicare.

Federal officials predict the Medicare Advantage option will grow further as massive numbers of baby boomers retire in coming years.

Standard Medicare has a similar problem making accurate payments to doctors, hospitals and other health care providers, according to statistics presented at the hearing. Standard Medicare’s payment error rate was cited at 11 percent, or $41 billion for 2016.

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Last week, Attorney General Jeff Sessions announced the arrest of 412 people, some 100 doctors among them, in a scattershot of health care fraud schemes that allegedly ripped off the government for about $1.3 billion, mostly from Medicare.

CMS official Jonathan Morse said that the “largest contributors” to billing mistakes in standard Medicare were claims from home health care and inpatient rehabilitation facilities.

Some lawmakers appeared frustrated that CMS cannot say for sure how much of the “improper payments” in both Medicare options are caused by fraud. The agency uses the term broadly to cover billing fraud, waste and abuse, as well as simply overcharges and underpayments.

“When trying to understand how much fraud is in Medicare, the answer is simply we don’t know,” subcommittee Chairman Vern Buchanan (R-Fla.) said.

Yet he added that “it doesn’t take a big percentage [of fraud] to get a giant number” of dollars.

CMS official Morse did little to clear up any confusion over billing mistakes. In his written testimony, he said that improper payments are “most often payments for which there is no or insufficient supporting documentation to determine whether the service … was medically necessary.”

In his testimony, GAO official Cosgrove focused on the Medicare Advantage program. He took aim at a little-known government audit process called Risk Adjustment Data Validation, or RADV. These audits require health plans to submit a sample of patient records for review.

Cosgrove said that the RADV audits take too long to complete and failed to focus on health plans with the greatest potential for recovery of overcharges. He also said that CMS officials had not done enough to make sure the payment data they use are accurate. As a result, “the soundness of billions of dollars in Medicare expenditures remains unsubstantiated,” according to written testimony.

The GAO, the watchdog arm of Congress, has previously criticized CMS for its failure to ferret out overcharges in Medicare Advantage. In an April report, GAO found that CMS has spent about $117 million on the Medicare Advantage audits since 2010 but recouped just under $14 million in total.

Payment errors and overcharges by Medicare Advantage plans were the subject of a lengthy investigation by Kaiser Health News and the Center for Public Integrity. Federal officials have struggled for years to weed out billing irregularities by Medicare Advantage plans, according to CMS records obtained through a Freedom of Information Act lawsuit filed by the Center for Public Integrity.

The investigation found that Medicare Advantage payment errors result mostly from flaws in a billing formula called a risk score. Congress expected risk scores would pay higher amounts for sicker patients and less for people in good health when it began phasing in the billing scales in 2004.

But since then, a wide range of CMS audits and other reviews have found that Medicare wastes billions of tax dollars annually because some health plans inflate risk scores by exaggerating how sick their patients are. One CMS memo made public through the FOIA lawsuit referred to risk-based payments as essentially an “honor system,” with few audits to curtail fraud and abuse.

Even when RADV audits have detected widespread overpayments, CMS officials have failed to recoup money after years of haggling with the health plans.

In January, Kaiser Health News reported that Medicare had potentially overpaid five Medicare Advantage health plans by $128 million in 2007, but under pressure from the insurance industry collected just $3.4 million and settled the cases.

Morse testified on Wednesday that CMS is still in the process of completing appeals of RADV audits from 2007. He said that payment errors have been calculated for 2011 and that reviews for 2012 and 2013 were underway.

These results are years behind schedule, according to CMS documents, which show the results were expected in early 2014. In the past, officials have said that they expected to collect as much as $370 million from the 2011 audits.

Morse said on Wednesday he didn’t know when the 2011 audit results would be released. “Hopefully soon,” he said after the hearing. “I actually don’t know.”

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Categories: Cost and Quality, Health Industry, Medicare

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Perspectives: A Nonprofit Drug Company? It’s Not As Wild An Idea As It Seems

Read recent commentaries about drug-cost issues.

The New York Times: Escaping Big Pharma’s Pricing With Patent-Free Drugs
How’s this for a great deal? The United States government funded research and development of a new vaccine against Zika. But the Army, which paid a French pharmaceutical manufacturer for its development, is planning to grant exclusive rights to the vaccine to the manufacturer, Sanofi Pasteur, along with paying Sanofi up to $173 million. (Fran Quigley, 7/18)

Stat: Importing Drugs From Other Countries Undermines Safety
The Food and Drug Administration was established to ensure the safety of food and medicines sold in the United States. That original charter seems to be ignored by the advocates of drug importation, who brush aside legitimate safety concerns to advance a political agenda. (Jim Greenwood, 7/14)

The New England Journal Of Medicine: The Economics Of Indication-Based Drug Pricing
Pharmaceutical treatments and medical devices often have varying effectiveness depending on the indication for which they’re used: in oncology, for instance, response to a treatment varies with the type of tumor and stage of disease. The advent and proliferation of precision medicine in which biomarkers — whether genomic, proteomic, or structural — identify patients likely to receive greater treatment benefits only increase the range of variability in the effectiveness of the same product. (Amitabh Chandra and Craig Garthwaite, 7/13)

Bloomberg: Trump’s New Drug-Pricing Move Won’t Cut Prices
We’ve come a long way from President Donald Trump telling the pharmaceutical industry it was getting away with murder. His administration’s Center for Medicaid and Medicaid Services (CMS) on Thursday proposed deep cuts to reimbursement rates for the 340B drug-discount program, which mandates big price cuts for “safety-net” hospitals that treat a lot of poor patients. (Max Nisen, 7/14)

Stat: The Art Of The Deal? Why A Money-Back Guarantee For Drugs Is A Bad Idea
President Trump likes to boast that he mastered the “art of the deal.” But one option his administration is considering to encourage lower drug prices, which surfaced in a recent draft executive order, may not be much of a deal for consumers. The concept has a clunky name — value-based pricing — but it’s fairly simple. One increasingly popular version works like this: A drug maker refunds some money to an insurer if its medicine fails to improve patient health or prevent a costly incident, such as a heart attack. (Ed Silverman, 7/17)

The New England Journal Of Medicine: Targeting Unconscionable Prescription-Drug Prices — Maryland’s Anti–Price-Gouging Law
Why, in the early 21st century, are so many drugs that were cheaply available in the 20th century becoming prohibitively expensive? The past few years have seen a series of dramatic price hikes on essential off-patent medications, from albendazole to albuterol, digoxin to naloxone, Daraprim to EpiPen. In the storm of allegations and indignation that has followed each of these revelations, one explanation has remained consistent. To paraphrase Senators Susan Collins (R-ME) and Claire McCaskill (D-MO), who were the chair and the ranking member of the Senate Special Committee on Aging, firms that corner the market on off-patent medications and raise prices wildly often do so simply because they can. When the committee issued a 130-page report last December documenting the parallel strategies used by firms to engage in monopolistic price gouging on older essential drugs, the senators pointed out that these actions, though arguably unethical, have so far not been found to be illegal. (Jeremy A. Greene and William V. Padula,, 7/13)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

More And More, States Are Becoming Battleground For Drug Pricing War

News outlets report on stories related to pharmaceutical pricing.

The Wall Street Journal: Drug Prices Under Fire, In The States
All eyes are on Washington as the Senate grapples with health care legislation. Investors in drug companies should give some attention to state capitals, where a wave of bills designed to limit drug price increases are under consideration. Maryland is the first of about 30 states weighing such bills to pass a new law on drug pricing. The law, scheduled to take effect in October, outlaws “excessive” price hikes on generics and gives Maryland’s attorney general sweeping powers to roll back price hikes and fine companies for violations. Bills with similar enforcement mechanisms have been introduced in several other states, including New York, Missouri, Massachusetts, Maine, and Rhode Island. (Grant, 7/12)

Stat: Sanofi Denies Rejecting Army Request For A Fair Price On A Zika Vaccine
In a series of letters to the U.S. Army and several senators, Sanofi is denying that it rejected so-called fair pricing for a Zika virus vaccine that the company is developing with American taxpayer funds. The missives were sent as a growing number of federal and state lawmakers push the U.S. Army to negotiate a more favorable agreement with Sanofi, which is one of the world’s largest vaccine makers and has already received a $43 million U.S. research grant. (Silverman, 7/17)

Stat: Hurt By A Drug? You Can File Suit In California If A Clinical Trial Took Place There
Last month, the U.S. Supreme Court made it more difficult for people who file product-liability lawsuits against drug makers to engage in “forum shopping,” a practice in which someone files a lawsuit in a state where courts are seen as more hospitable to consumers. In that closely watched case, the court ruled hundreds of out-of-state plaintiffs failed to demonstrate a sufficient connection between injuries they allegedly suffered from a Bristol-Myers Squibb drug and company activities in California. The state has been a favorite venue for such suits, but the court noted the plaintiffs did not buy or ingest the drug there, and Bristol-Myers is not headquartered there. (Silverman, 7/18)

CQ Roll Call: Generics Could Get A Boost In Bid To Rein In Prescription Prices
The most talked about strategies to bring down sky-high drug costs involve letting the government more aggressively negotiate prices with manufacturers and permitting the importation of lower-cost drugs from abroad. But neither idea has sufficient support on Capitol Hill to move this year. That’s why, for now, the only likely bipartisan solutions that could move the needle on drug prices involve promoting competition from lower-cost generic drugs. When a drug’s patent expires, it opens the door for other companies to copy it. Since the generic makers don’t have to recoup the research costs, they can offer much lower prices. Still, while policy improvements now under consideration in Congress could help, they’re not a panacea. (Siddons, 7/17)

ProPublica: The Myth Of Drug Expiration Dates
The dates on drug labels are simply the point up to which the Food and Drug Administration and pharmaceutical companies guarantee their effectiveness, typically at two or three years. But the dates don’t necessarily mean they’re ineffective immediately after they “expire” — just that there’s no incentive for drugmakers to study whether they could still be usable. (Allen, 7/18)

Stat: What Are You Taking? Most-Prescribed Drugs Across The Nation Last Year
More than 4.4 billion prescriptions were filled in the United States last year, and the top 10 were all written for drugs now available in generic versions of pricier brand-name originals. Nearly half of all Americans are prescribed a drug at any given time. The most common ones, as you might expect, treat the most common chronic conditions — managing high blood pressure, for example, or controlling diabetes. Painkillers are also on the list, carrying with them the risk of substance abuse. But there are some surprises, too. (Blau, 7/19)

Stat: Trying A New Tack: Delivering Insulin To The Liver To Control Type 1 Diabetes
Type 1 diabetics, armed with glucose meters and insulin pens, are caught in a delicate high-wire act. Too much glucose wreaks havoc on nerves and blood vessels, while too little causes dizziness and nausea. A Cleveland biotech company is trying to change that by delivering insulin to the liver, where it naturally goes. (Woosen, 7/17)

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In Massachusetts, Proposed Medicaid Cuts Put Kids’ Health Care At Risk

The U.S Senate’s plan to replace Obamacare, now in limbo, would cut funding for Medicaid and other health insurance subsidies by more than $1 billion a year within five years. That has many lawmakers, doctors, hospitals and patients across Massachusetts in a state of alarm.

“Where in this bill is the protection for children?” asked Dr. Jonathan Davis, the chief of newborn medicine at Tufts Medical Center, as he stood in the hospital’s NICU among babies who weighed as little as 1 pound. Roughly 60 percent of babies in the Tufts NICU are covered by Medicaid.

Davis paused in front of an incubator that held a tiny girl, just a few days old, who weighed 2.5 pounds. Her little lungs pumped several times a second.

“The fact is, she’s in room air, so she’s breathing entirely on her own — which is great,” Davis said.

Doctors and nurses work round-the-clock to give this baby and her roommates the best possible start. But it’s unclear whether Tufts could provide this care for free if the baby or her mom didn’t qualify for Medicaid. Davis said they also need good health coverage after they leave the hospital.

“Because if those children don’t go home to get great primary care, follow-up, early intervention and support, all those gains that could potentially have been made are going to be lost,” Davis said.

That threat seems real under the Senate health care bill, said Audrey Shelto, president of the Blue Cross Blue Shield of Massachusetts Foundation.

“It is even more devastating than the House bill for low-income and vulnerable populations,” Shelto said.

That’s because as of 2025, the Senate would tie spending for each person on Medicaid to a standard inflation rate, instead of the rate of medical inflation, which is usually higher. In Massachusetts, lots of lawmakers — Democrats and Republicans — are frustrated, if not angry.

State Rep. Jeff Sánchez, House chair of the Joint Committee on Health Care Financing, reviewed the details on his way to a health care conference.

“They talked about repeal and replace,” he said. “This is more like search and destroy — because fewer people are going to get coverage that they need, and people will pay more out of pocket.”

Sánchez says Massachusetts has a longstanding practice of making kids a priority and has enhanced MassHealth to make sure kids in low-income families get the care they need.

“Nobody’s clear on what’s the future of that program,” he said. “Everything is up in the air.”

Sánchez’s co-chair, state Sen. James Welch, has called the U.S. Senate bill “class warfare” because it would take money from poor kids and their moms and give it to wealthy adults in the form of tax cuts. But Welch says the state won’t have any good options if Massachusetts has to make up $1.4 billion in federal health care cuts in the future.

“Do you raise taxes somewhere? Do you cut back on eligibilities? Do you cut back on benefits? Tough decisions are going to have to be made,” Welch said. “But health coverage that children are currently receiving — we’ll fight tooth and nail to make sure that continues.”

Eileen McAnneny, president of the Massachusetts Taxpayers Foundation, says the state should cut health care spending before any talk of raising taxes or moving people off Medicaid. But McAnneny says MassHealth, the state’s Medicaid program, is growing faster than the state can manage. About 60 cents of every new tax dollar goes to MassHealth.

“So we have to reduce the cost of the MassHealth program, or the state will deliver MassHealth services and few others because it will consume a lot of our resources,” McAnneny says.

For kids, there is one bright spot in the Senate health plan that is not in the House Obamacare replacement bill: About 20 percent of children who qualify for Medicaid because they are severely disabled would be exempt from the cuts.

Kayla Klein, of West Roxbury, is watching what Congress is doing closely. She tugs at the appliquéd dog on the front of her 2-year-old son Robbie’s T-shirt.

“Right, Robs? Where’s your port?” she asks, playfully.

Robbie’s T-shirt hides a central line port through which he gets medicine every day that he needs to stay healthy; he has the blood-clotting disorder hemophilia.

Robbie makes his mom and dad, Joel Klein, laugh a lot. But they’re also very worried. Hemophilia medications can be terribly expensive, and the Kleins are both school teachers, without hefty salaries. Robbie has private insurance through his parents to cover most of the cost, and Medicaid fills in the gaps, for now.

The Kleins want to make sure members of Congress understand the decisions they’re making are really important.

“Our futures and our livelihood are hanging in the balance,” Joel Klein says.

“It makes you feel very fragile. It makes you feel like you aren’t empowered when your child’s life is at stake,” Kayla Klein adds.

Senate leaders say they expect to vote on their health care bill before their August recess. It’s not clear whether the bill has the votes to pass.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

Categories: Cost and Quality, Insurance, Medicaid, Repeal And Replace Watch, States, The Health Law

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5 Ways GOP Reforms Could Change Your Health Plan Options

One of the fiercest complaints about the Affordable Care Act is that it imposed a government mandate on consumers to purchase coverage with a broad and specific set of benefits — including maternity care, mental health treatment and limits on out-of-pocket costs — whether they wanted those benefits or not.

More choice is always better, critics argued. But what if choice trumps protection?

With the latest Senate bill — drafted solely by Republicans and now in limbo, even collapsing, as four GOP Senators have now expressed opposition — that question is again at the heart of the debate and central to the potential changes for consumers.

“I think choice is great when it comes to buying cell phones or pizza slices,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “It’s a very different thing in insurance. None of us is immune from someday becoming one of those sick people. Insurance is supposed to protect us from unpredictable risk.”

One bill provision, dubbed the “Cruz amendment,” for backer Texas Sen. Ted Cruz, would allow insurers to offer plans stripped of most of the ACA’s requirements so long as they also offer some policies that do meet those rules.

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The provision aims to win support from conservatives who want lower premiums, which would be achieved with the more limited benefit package. But it’s not so simple. Consumers would have to weigh the tradeoffs between price and their somewhat unpredictable future needs.

“This is the fundamental divide,” said Christopher Condeluci, an attorney and former counsel to the Senate Finance Committee.

“You are taking a risk in purchasing a less comprehensive plan because you never know what’s going to happen. But, if you feel this is the right type of plan, then you should have ability to make that economic and risk decision.”

ACA supporters, though, see high value in the strong consumer safeguards.

The ACA, they say, rescued consumers left wanting by some of the choices on the individual market. Before the ACA, some policies had very limited coverage, not covering hospitalization, for example, or paying only small amounts toward doctor visits, tests or drugs.

Sometimes consumers were misled by insurers or agents about the breadth of coverage. Sometimes they were just confused and didn’t realize the limits until after the medical problem occurred — their most vulnerable point — leaving some on the hook for hefty medical costs.

The ACA’s comprehensive benefit rules, supporters say, may add to premium costs, but protect consumers from making bad choices — deliberately or inadvertently — that could result in tens of thousands in unpaid medical bills or no treatment altogether.

The next steps in the Senate’s consideration of the GOP health plan are now uncertain as Sen. John McCain (R-Ariz), a key GOP vote, recovers from surgery and the intra-party fissures emerge.

McCain issued a statement urging that the chamber return to “regular order, hold hearings, receive input from members of both parties” to produce the legislation. But Majority Leader Mitch McConnell (R-Ky.) signaled his intent to hold a vote to repeal the health law with a two year delay. As the discussion continues from this point, here are five things you should know about how this marketplace provision could play out:

1. Premiums would be lower, but maybe not for you.

Because they would cover less, premiums on such policies would be lower for healthy people. That’s how the market was before the ACA passed, when insurers could reject people with preexisting medical conditions in most states.

The ACA barred that practice, so insurers generally raised everyone’s rates to cover those who were ill. Premium increases were softened for consumers who received subsidies to purchase ACA coverage, but really hit people with incomes of more than $48,000 and who are not eligible for subsidies.

Still, the Cruz plan might not lower premiums for everyone.

Insurers could use a person’s health — including their claims history and genetic profile — to set rates, a move barred in ACA plans. They could also outright reject people deemed too risky or sick. People with medical conditions — or those that develop them while covered — could be charged far more than those without. And the Senate bill doesn’t offer consumers help in buying the plans. Federal subsidies cannot be used to purchase the Cruz amendment plans.

2. Coverage would be less generous.

Because the plans would not have to include the ACA’s ten “essential health benefits” — hospital care and prescription drugs among them — consumers could end up paying those expenses themselves.

Those costs could be high, as insurers could also forego the ACA’s annual out-of-pocket caps, which this year are $7,150 for individual coverage and $14,300 for family plans.

The policies cannot set annual or lifetime dollar limits on care, but under the Cruz amendment, insurers could use deductibles or other out-of-pocket costs to achieve a similar goal: shifting more costs to consumers. For example, chemotherapy might have unlimited annual coverage, but only after a huge deductible — say $10,000 or $20,000 — is met.

3. It would create essentially two different markets.

Insurers could offer Cruz amendment plans, so long as they also offered at least one gold level, one silver level and one “benchmark” plan that meets the ACA rules. But there’s nothing saying they would have to actively market those plans.

Most policy experts fear the result would be market segmentation — a siphoning off of the healthiest people into Cruz plans. “The attempt here is to turn what we know as Obamacare today into a high-risk pool,” said Robert Laszewski, an insurance industry consultant.

Then what would happen? Premium costs could rise rapidly for people in the ACA plans and, at the same time, subsidies for consumers purchasing those plans would become less generous for many, particularly older people.

Even the insurers’ trade lobby has sounded alarm about the Cruz approach, sending a letter last week to Senate Majority Leader Mitch McConnell (R-Ky.) and Democratic Leader Chuck Schumer (D-N.Y.) that called it “simply unworkable in any form.”

4. You might be temporarily barred from broader coverage.

Because the plans won’t be considered “creditable coverage,” consumers who buy one and then decide to switch to a plan that is consistent with ACA rules might face a penalty of having to wait six months for that coverage to begin. That lockout period aims to keep people from jumping in and out of comprehensive coverage.

Here’s how that would work: Someone with a stripped down plan gets cancer and wants to switch to coverage that is more generous. Under the current proposal, that person might have to wait six months, which could complicate if not threaten their cancer treatment.

Some experts read the proposal as appearing to offer a small exception to that six-month lockout — but only if consumers don’t have a single-day gap between the day their Cruz amendment policy expires and the new ACA-compliant plan kicks in.

“People would have the freedom to choose, but the difference between the choices and the consequences of those choices are extraordinary,” said Laszewski, a longtime critic of the ACA who has blasted the proposed Senate replacement. “Do they roll the dice with their health and hope they never get sick?”

5. They are different from “catastrophic plans.”

The bill would also expand eligibility for coverage known as catastrophic plans. These are not the same as the Cruz amendment plans. Catastrophic plans include the broader array of ACA benefits. They also allow three doctor visits annually exempt from the deductible.

At the same time, however, their deductibles are higher than any of the other types of ACA plans sold, equal to those previously mentioned annual out-of-pocket limits. So far, they haven’t been terribly popular. They are currently limited to people age 30 and younger, with a few other exceptions. The Senate bill would make them available to all ages — and allow subsidies to be used to purchase them.

Categories: Cost and Quality, Repeal And Replace Watch, The Health Law

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Analysis: Senate’s Latest Health Blueprint Cuts Costs At The Expense Of Chronically Ill

The latest Senate health proposal reins in costs by effectively splitting the individual insurance market, with healthy people diverted into stripped-down plans and chronically ill individuals left with pricey and potentially out-of-reach options, insurance analysts said.

This draft — a fresh attempt by the Republican Party to undo the Affordable Care Act — injects more uncertainty into plans for people with preexisting conditions such as cancer, asthma, diabetes or other long-term ailments. Those people, insured through ACA marketplaces now, could be more isolated than in an earlier version of the Senate bill.

For such patients, “I would be pretty nervous,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “You will have separate pools — one that only healthy people can get into and one for you. That pool is liable to get increasingly expensive — in fact, very expensive over time.”

The two biggest insurer trade groups went further on Friday, saying in an unusually strong-worded letter that “millions of more individuals will become uninsured” if the proposal becomes law.

Plans sold to individuals and families through the Obamacare exchanges cover some 10 million people, many with chronic disease.

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A draft bill released Thursday added a proposal from Texas Sen. Ted Cruz that would let insurers sell health coverage outside the ACA exchanges with no provisions for prescription drugs, mental illness, hospitalization or almost any other benefit.

Such plans would be far cheaper than comprehensive coverage and almost certainly draw younger, healthier people away from high-benefit insurance, analysts said.

Without healthy customers subsidizing the sick, premiums and other costs would soar for plans that accept chronically ill patients, experts said. The Senate draft includes $70 billion over a decade to help pay those costs, but it’s far from clear that would be enough.

Insurers were struggling last week to grasp the implications of the legislation, studded with ambiguous language. One big takeaway: The Senate’s version of health care would undermine historical assumptions and drastically shift risk in the individual market.

Letting carriers sell low-cost, low-benefit plans to healthy consumers “is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage for people currently enrolled in the individual market,” America’s Health Insurance Plans and the Blue Cross Blue Shield Association, two lobbying groups, said in a Friday letter to the Senate.

The Republicans are nowhere near success with this plan. Already two of the 52 Republican senators — Kentucky conservative Rand Paul and Maine moderate Susan Collins — have said they won’t support the bill. One more defection would sink it, and a delay caused by the surgery of Arizona Republican John McCain gives opponents more time to build resistance.

Senate leaders had scheduled a vote for this week but postponed it to give McCain time to recover from treatment of a blood clot near his eye.

Meanwhile, the nonpartisan Congressional Budget Office is likely to issue its assessment of the bill this week. The CBO had said an earlier Senate bill would increase the number of people without health insurance by 22 million by 2026.

The Republican plan offers a freer insurance market — something the party has long favored — while purporting to protect those with existing illness. Insurers selling stripped-down plans would be required to also offer traditional Obamacare plans covering preexisting conditions.

You will have separate pools — one that only healthy people can get into and one for you.

Sabrina Corlette, Georgetown University’s Health Policy Institute

But such coverage risks becoming a high-cost ghetto for the chronically ill, experts said. It would likely become unattractive to carriers and unaffordable to members who could face paying thousands of dollars for premiums and thousands more out-of-pocket before coverage kicks in.

Even though insurers selling unregulated plans would be required to offer full-coverage plans to all comers, they could limit their risk with time-tested maneuvers to repel the sick, said Ana Gupte, who follows health care stocks for Leerink Partners.

“They usually find ways to minimize enrollment” such as jacking up premiums or cutting broker commissions for certain coverage, she said.

Nor would there likely be much choice in high-benefit Obamacare plans, she said. Under the Senate bill, carriers seeking to sell skimpy coverage would have to offer only one high-benefit “gold” plan and a medium-benefit “silver” plan as traditionally sold under the Affordable Care Act.

Even then, the legislation would allow state officials to alter Obamacare standards for out-of-pocket maximums and essential health benefits.

That even could allow richer plans intended for the chronically ill to drop coverage of prescription drugs, mental illness, maternity care or other items.

The bill includes two measures intended to keep costs in high-benefit Obamacare plans from spiking out of control. One is the $70 billion in federal subsidies to help cover the expense of the pool of sick people.

“It seems to me it’s not nearly enough” to keep plans affordable for those with chronic illness, said Timothy Jost, emeritus law professor at Washington and Lee University and an expert on health reform.

The other is a six-month waiting period for applicants wanting to buy full coverage who don’t already have it.

That’s supposed to induce healthy people to buy high-coverage plans and help subsidize the sick. Otherwise they risk a coverage gap if they become gravely ill or hurt, raising the chance they would have to pay thousands out-of-pocket for any unexpected medical expense.

But that incentive to buy comprehensive coverage is far weaker than Obamacare’s mandate, which fined people for not having insurance, Jost said. The Republicans’ bills would scrap the mandate.

“I just don’t think it’s going to be terribly effective,” he said.

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law

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Calif. Hits Nerve By Singling Out Cardiac Surgeons With Higher Patient Death Rates

Michael Koumjian, a heart surgeon for nearly three decades, said he considered treating the sickest patients a badge of honor. The San Diego doctor was frequently called upon to operate on those who had multiple illnesses or who’d undergone CPR before arriving at the hospital.

Recently, however, Koumjian received some unwelcome recognition: He was identified in a public database of California heart surgeons as one of seven with a higher-than-average death rate for patients who underwent a common bypass procedure.

“If you are willing to give people a shot and their only chance is surgery, then you are going to have more deaths and be criticized,” said Koumjian, whose risk-adjusted death rate was 7.5 per 100 surgeries in 2014-15. “The surgeons that worry about their stats just don’t take those cases.”

Now, Koumjian said he is reconsidering taking such complicated cases because he can’t afford to continue being labeled a “bad surgeon.”

California is one of a handful of states — including New York, Pennsylvania and New Jersey — that publicly reports surgeons’ names and risk-adjusted death rates on a procedure known as the “isolated coronary artery bypass graft.” The practice is controversial: Proponents argue transparency improves quality and informs consumers. Critics say it deters surgeons from accepting complex cases and can unfairly tarnish doctors’ records.

“This is a hotly debated issue,” said Ralph Brindis, a cardiologist and professor at UC-San Francisco who chairs the advisory panel for the state report. “But to me, the pros of public reporting outweigh the negatives. I think consumers deserve to have a right to that information.”

Prompted by a state law, the Office of Statewide Health Planning and Development began issuing the reports in 2003 and produces them every two years. Outcomes from the bypass procedure had long been used as one of several measures of hospital quality. But that marked the first time physician names were attached — and the bypass is still the only procedure for which such physician-specific reports are released publicly in California.

California’s law was sponsored by consumer advocates, who argued that publicly listing the names of outlier surgeons in New York had appeared to bring about a significant drop in death rates from the bypass procedure. State officials say it has worked here as well: The rate declined from 2.91 to 1.97 deaths per 100 surgeries from 2003 to 2014.

“Providing the results back to the surgeons, facilities and the public overall results in higher quality performance for everybody,” said Holly Hoegh, manager of the clinical data unit at the state’s health planning and development office.

Since the state began issuing the reports, the number of surgeons with significantly higher death rates than the state average has ranged from six to 12, and none has made the list twice. The most recent report, released in May, is based on surgeries performed in 2013 and 2014.

In this year’s report, the seven surgeons with above-average death rates — out of 271 surgeons listed — include several veterans in the field. Among them were Daniel Pellegrini, chief of inpatient quality at Kaiser Permanente San Francisco and John M. Robertson, director of thoracic and cardiovascular surgery at Providence Saint John’s Health Center in Santa Monica. Most defended their records, arguing that some of the deaths shouldn’t have been counted or that the death rates didn’t represent the totality of their careers. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

“For the lion’s share of my career, my numbers were good and I’m very proud of them,” said Pellegrini. “I don’t think this is reflective of my work overall. I do think that’s reflective that I was willing to take on tough cases.”

During the two years covered in the report, Pellegrini performed 69 surgeries and four patients died. That brought his risk-adjusted rate to 11.48 deaths per 100, above the state average of 2.13 per 100 in that period.

Pellegrini said he supports public reporting, but he argues the calculations don’t fully take the varying complexity of the cases into account and that a couple of bad outcomes can skew the rates.

Robertson said in a written statement that he had three very “complex and challenging” cases involving patients who came to the hospital with “extraordinary complications and additional unrelated conditions.” They were among five deaths out of 71 patients during the reporting period, giving him an adjusted rate of 9.75 per 100 surgeries.

“While I appreciate independent oversight, it’s important for consumers to realize that two years of data do not illustrate overall results,” Robertson said. “Every single patient is different.”

The rates are calculated based on a nationally recognized method that includes deaths occurring during hospitalization, regardless of how long the stay, or anytime within 30 days after the surgery, regardless of the venue. All licensed hospitals must report the data to the state.

State officials said that providing surgeons’ names can help consumers make choices about who they want to operate on them, assuming it’s not an emergency.

“It is important for patients to be involved in their own health care, and we are trying to work more and more on getting this information in an easy-to-use format for the man on the street,” said Hoegh, of the state’s health planning and development office.

No minimum number of surgeries is needed to calculate a rate, but the results must be statistically significant and are risk-adjusted to account for varying levels of illness or frailty among patients, Hoegh said.

She acknowledged that “a risk model can never capture all the risk” and said her office is always trying to improve its approach.

Surgeons sometimes file appeals — arguing, for example, that the risk was improperly calculated or that the death was unrelated to the surgery. The appeals can result in adjustments to a rate, Hoegh said.

Despite the controversy it generates, the public reporting is supported by the California Society of Thoracic Surgeons, the professional association representing the surgeons. No one wants to be on the list, but “transparency is always a good thing,” said Junaid Khan, president of the society and director of cardiovascular surgery at Alta Bates Summit Medical Center in the Bay Area.

“The purpose of the list is not to be punitive,” said Khan. “It’s not to embarrass anybody. It is to help improve quality.”

Khan added that he believes outcomes of other heart procedures, such as angioplasty, should also be publicly reported.

Consumers Union, which sponsored the bill that led to the cardiac surgeon reports, supports expanding doctor-specific reporting to include a variety of other procedures — for example, birth outcomes, which could be valuable for expectant parents as they look for a doctor.

“Consumers are really hungry for physician-specific information,” said Betsy Imholz, the advocacy group’s special projects director. And, she added, “care that people receive actually improves once the data is made public.”

But efforts to expand reporting by name are likely to hit opposition. Officials in Massachusetts, who had been reporting bypass outcomes for individual doctors, stopped doing it in 2013. Surgeons supported reporting to improve outcomes, but they were concerned that they were being identified publicly as outliers when they really were just taking on difficult cases, said Daniel Engelman, president of the Massachusetts Society of Thoracic Surgeons.

“Cardiac surgeons said, ‘Enough is enough. We can’t risk being in the papers as outliers,’” Engelman said.

Engelman said the surgeons cited research from New York showing that public reporting may have led surgeons to turn away high-risk patients. Hoegh said research has not uncovered any such evidence in California.

In addition to Koumjian, Robertson and Pellegrini, the physicians in California with higher-than-average rates were Philip Faraci, Eli R. Capouya, Alexander R. Marmureanu, Yousef M. Odeh. Capouya declined to comment.

Faraci, 75, said his rate (8.34 per 100) was based on four deaths out of 33 surgeries, not enough to calculate death rates, he said. Faraci, who is semi-retired, said he wasn’t too worried about the rating, though. “I have been in practice for over 30 years and I have never been published as a below-average surgeon before,” he said.

Odeh, 45, performed 10 surgeries and had two deaths while at Presbyterian Intercommunity Hospital in Whittier, resulting in a mortality rate of 26.17 per 100. “It was my first job out of residency, and I didn’t have much guidance,” Odeh said. “That’s a recipe for disaster.”

Odeh said those two years don’t reflect his skills as a surgeon, adding that he has done hundreds of surgeries since then without incident.

Marmureanu, who operates at several Los Angeles-area hospitals, had a mortality rate of 18.04 based on three deaths among 22 cases. “I do the most complicated cases in town,” he said, adding that one of the patients died later after being hit by a car.

“Hospital patients don’t care” about the report. he said. “Nobody pays attention to this data other than journalists.”

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

Categories: Cost and Quality, Health Industry

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Health Insurers Try Paying More Upfront To Pay Less Later

Michael McBrayer of St. Paul, Minn., needs to pay a lot attention to his health.

“I give myself shots multiple times a day, as well as controlling my diet and exercise,” he said.

Ten years ago, McBrayer learned he has Type 1 diabetes. Now he knows he faces dire consequences if he fails to control his blood sugar.

“Kidney failure, blindness, heart disease — all those things are looming out there,” he said.

McBrayer has health insurance through his wife’s employer, the state of Minnesota. It’s a HealthPartners plan that charges extra to employers — in this case, the state — to cover diabetes care. So for the past several years, McBrayer’s plan has paid for everything he needs to keep his diabetes in check. He doesn’t spend a dime on supplies.

Diabetes, high blood pressure and other chronic conditions account for the vast majority of health spending in the U.S., according to the Centers for Disease Control and Prevention. Almost half of American adults have at least one chronic physical or mental health condition, and spending on those adds up to some $2.3 trillion a year.

Some health plans are beginning to offer free maintenance care for people with chronic health problems, hoping that spending a little more early on will save a lot of money in the long run.

“We’ve been trying to change the health care conversation in the United States from how much we spend to how well we spend,” said Dr. Mark Fendrick, head of the University of Michigan’s Center for Value-Based Insurance Design.

He said it makes both medical and economic sense to make properly managing chronic conditions affordable.

“I want the health insurance plan my patients have to charge my patients the least for the services that are going to make them healthier,” he said. “Let’s allow those to be covered on a pre-deductible basis; you’re not leaving the patients paying 100 percent of the cost.”

That may seem like common sense, but health plans have been running hard in the opposite direction. Consumers are on the hook for a rapidly increasing amount of their health costs — in large part to try to curb health costs.

But corporate buyers of health insurance are starting to realize that people may be putting off necessary care, says Mike Thompson, who runs the National Alliance of Healthcare Purchaser Coalitions. The organization advises around 12,000 organizations that buy health plans for tens of millions of Americans. He said those who provide insurance need to take a thoughtful look at what they pay for and what consumers should pay for.

“So that people are more prudent on discretionary care but are more compliant with the care they need and certainly the care they need to stay healthy,” Thompson said.

If people have to pay out-of-pocket for care they might not need, they might think twice, but their day-to-day health needs are taken care of.

One major obstacle to this approach, known as “value-based health insurance,” is an IRS rule that does not allow free maintenance care for chronic conditions for the 20 million Americans with health savings account-qualified, high-deductible insurance.

Michael McBrayer tests his blood sugar before eating lunch. He gets supplies he needs to manage diabetes for free as part of a deal between his employer and health insurer. (Evan Frost/MPR News)

The enhanced insurance benefit that pays for all McBrayer’s Type 1 diabetes maintenance is paying off for state taxpayers, according to HealthPartners, his provider.

That program has helped quadruple the number of diabetes patients with optimal care, saving the state about $1 million on medical services since its inception almost 10 years ago, said Dan Rehrauer, a program manager at HealthPartners.

“We’ve shown that we’ve reduced hospitalization and emergency department utilization, which is exactly what we want to see,” Rehrauer said. “You’ve got a healthy employee and that results in not ending up in the hospital [which saves] money.”

This story is part of a partnership that includes MPR News, NPR and Kaiser Health News.

Categories: Cost and Quality, Health Care Costs, Insurance

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Impact Debated Of Large Nurses Strike At Boston-Area Tufts Medical Center

The hospital is telling patients that care quality has not suffered as a result of the walkout by its nurses union. But studies indicate that such work stoppages can have negative consequences.

Boston Globe: In Tufts Nurse Strike, Some Worry About Patient Care
Tufts Medical Center has gone to great lengths to reassure patients during this week’s strike by nurses, but there is some evidence that medical care can suffer when nurses walk the picket line. One of the few studies examining this question found that more patients die and are readmitted to the hospital during nurses’ strikes. (Kowalczyk and Arnett, 7/13)

Boston Globe: Tufts Medical CEO: Calm Tone, Tough Stance In Nurses Strike
Union leaders say Wagner and other Tufts executives are the ones doing the bullying by denying nurses the compensation and better working conditions they deserve. The strike began after the union and the hospital failed to agree on wages, benefits, and staffing levels for the more than 1,200 unionized nurses at Tufts. (Dayal McCluskey, 7/14)

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