Tagged Cost and Quality

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! This week was so busy that I am going to take the unprecedented step and highly recommend you check out our Morning Briefings for the past few days. So many compelling, interesting stories didn’t make the cut for the Breeze, but they’re worth reading.

On to what you may have missed!

Well, this one you probably didn’t miss unless you were in the middle of the woods sans cellphone service: Alabama Gov. Kay Ivey signed legislation that effectively bans all abortions and criminalizes the procedure. The uproar that followed was immediate and ferocious — especially from 2020 Democrats who all but tripped over each other to denounce it as “shameless” and “outrageous” — but is the bill actually the threat to Roe v. Wade that it so dearly wants to be?

The measure is destined for the courts, certainly, but that doesn’t mean it will make it to SCOTUS. One likely outcome: The justices can simply refuse to take it up, leaving in place the lower courts’ decision (which will probably be that the law is unconstitutional). Chief Justice John Roberts is known for favoring incrementalism over sweeping decisions that would overturn nearly 50 years of precedent on a hot-button social issue.

But you need only four votes to get a case on the docket, which has court-watchers eyeing newbie Justice Brett Kavanaugh. His appointment helped galvanize the anti-abortion movement in the first place, but in the past he’s talked seriously about needing a compelling reason to overturn precedent. So far, he has disagreed with the hard conservatives more than people expected. So, the future for Alabama’s law remains uncertain.

What seems more likely is that the high court will instead look to less extreme, but still restrictive state laws (such as bills dictating the disposal of fetal remains and an 18-hour waiting period after state-mandated ultrasound examinations) that are heading toward them even as we speak.

No matter how it plays out, you can pretty much guarantee this is going to be a Big Deal on the campaign trail.

The New York Times: Alabama Aims Squarely at Roe, but the Supreme Court May Prefer Glancing Blows

The Associated Press: Alabama Law Moves Abortion to the Center of 2020 Campaign

The Wall Street Journal: States’ Abortion Curbs Put Supreme Court to the Test

A smattering of the other (dozens and dozens) of thoughtful stories from the past few days:

• What is it like living in a liberal city in the Deep South during times like this?

The New York Times: Abortion and the Future of the New South

• Missouri wants in on the action this week.

KCUR: How Missouri’s Senate Passed a Restrictive Abortion Bill Overnight

• A vote in deep-blue (and very Catholic) Rhode Island was overshadowed by Alabama’s news, but it highlights how nuanced and complicated the issue can be.

Boston Globe: In Rhode Island, Vote on Abortion-Rights Bill Reveals a Complicated State

• A lot of Senate Republicans are trying their best to nope out of this conversation, like “no thank you, not touching that with a 10-foot pole.”

The Hill: Senate Republicans Running Away From Alabama Abortion Law

• And a really handy look at what’s going on at the state level.

The Washington Post: The Widening Gap in Abortion Laws in This Country


House Democrats took advantage of their newfound power by tying a vote on reining in high drug prices to legislation shoring up the health law. The bill is destined to die, of course, but the move forced their Republican colleagues to go on record voting against something that voters care very, very deeply about.

The New York Times: House Passes Legislation Aiming to Shore Up Health Law and Lower Drug Costs

They also foreshadowed a potential subpoena with letters to Attorney General William Barr. Five powerful committee chairmen said that they’ve been asking since April 8 for documents connected to the Justice Department’s decision to stop defending the health law but haven’t received a sufficient response. They’re giving DOJ two more weeks before they consider “alternative means of obtaining compliance.”

Politico: Dems Tee Up New Document Fight With DOJ Over Obamacare

Meanwhile, a new Sunlight Foundation report found that the Trump administration has been systematically altering and eliminating information on the health law that’s on government websites.

Wired: The Trump Admin Is Scrubbing Obamacare From Government Sites


Surprise medical billing is truly the darling of Capitol Hill recently with all the attention it’s getting. Multiple variations of bipartisan duos and groups are working on introducing legislation to combat the issue. The most recent bill unveiled would protect patients from the surprise costs, and let an outside arbitrator settle any disputes between hospitals and insurers. Other proposals have instead favored a rate-setting method to solve payment issues.

The Hill: Bipartisan Senators Unveil Measure to End Surprise Medical Bills

The Hill: Dem House Chairman, Top Republican Release Measure to End Surprise Medical Bills


Attorneys general from 44 states have filed suit against pharma companies over allegations that “the generic drug industry perpetrated a multibillion-dollar fraud on the American people.” The lawsuit implicates 20 pharma firms following an investigation into allegations that the companies sought not only to maintain their “fair share” of the generic drug market through agreements with one another but also to “significantly raise prices on as many drugs as possible.”

The Associated Press: States Bring Price Fixing Suit Against Generic Drug Makers


Washington state took a big step this week in approving the creation of a public option — which would essentially look like a state-sponsored health plan. But now comes the hard part: making it work.

And don’t call it a game changer quite yet, experts say. Even sponsors of the legislation acknowledge the state plans may save consumers only 5-10% on their premiums. Still, the rollout will likely be watched closely as the progressive universal health care push grows stronger.

Politico: 5 Key Questions About the Country’s First Public Option

NPR: Washington State to Create ‘Public Option’ Health Care Plans

(If you feel like you need a refresher on all these terms — join the crowd, amiright? this one from NYT’s Margot Sanger-Katz is great.)


Rural hospitals, which sometimes fight literally hour by hour to afford to stay open, are in a crisis in this country, as evidenced by two amazing pieces this week on what happens to a town when one dies.

“If we aren’t open, where do these people go?” asked one hospital worker in The Washington Post’s coverage.

“They’ll go to the cemetery,” another employee answered. “If we’re not here, these people don’t have time. They’ll die along with this hospital.”

The Washington Post: ‘Who’s Going to Take Care of These People?’

Kaiser Health News: Dealing With Hospital Closure, Pioneer Kansas Town Asks: What Comes Next?

But I found a flicker of hope in a lovely story about how a one-room clinic in North Carolina just marked its 100th year.

North Carolina Health News: One Hundred Years in a Rural Clinic


Think this measles outbreak is big? (It is, by the way!) How about the one in 1990, which had more than 27,000 cases? In the past few months, I’ve read and written about the record 963 cases from 1994 more times than you can count but had no idea that just four years earlier it was that much higher. If you’re as intrigued as I was about how that changed, dive into NPR’s historical look at what exactly was going on at the time, and how public officials made so much progress so quickly.

NPR: How a Measles Outbreak Was Halted in the 1990s


In the miscellaneous file for the week:

• There’s a pretty serious debate going on right now about fair distribution of donated livers. A new rule that went into effect this week and then was immediately blocked by a judge would give the organ to the sickest patient within 500 nautical miles. But advocates in the Midwest and South say that’s unfair.

The Washington Post: Liver Transplant Rules Spark Open Conflict Among Transplant Centers

• The U.S. birth rate has fallen again to the lowest in three decades. Some say that means the sky is falling; others are unconcerned.

The Associated Press: US Births Lowest in 3 Decades Despite Improving Economy

• Despite there being thousands of children in the country with a terminal diagnosis, only three hospice facilities in the U.S. are designed specifically for them.

The New York Times: Where Should a Child Die? Hospice Homes Help Families With the Unimaginable

• Can we learn about trauma from an island of monkeys that was devastated by Hurricane Maria?

The New York Times: Primal Fear: Can Monkeys Help Unlock the Secrets of Trauma?

• Many of our gun safety discussions focus on buying the weapons, but teaching about proper storage can make a bigger difference than you’d necessarily expect.

The New York Times: The Potentially Lifesaving Difference in How a Gun Is Stored


Whew! You made it both through this hefty Breeze and the week itself. Take it easy this weekend as a reward!

Listen: After Its Hospital Closes, A Pioneer Kansas Town Searches For What Comes Next

KHN senior correspondent Sarah Jane Tribble is interviewed on NPR’s “Morning Edition” about the challenges faced by rural communities when their hospitals close. She is spending a year following Fort Scott, Kan., as it copes and recovers from the loss. Listen to the conversation here:

And read the first installment of the series, “No Mercy,” here.

How To Find And Use New Federal Ratings For Rehab Services At Nursing Homes

For the first time, the federal government is shining a spotlight on the quality of rehabilitation care at nursing homes — services used by nearly 2 million older adults each year.

Medicare’s Nursing Home Compare website now includes a “star rating” (a composite measure of quality) for rehab services — skilled nursing care and physical, occupational or speech therapy for people recovering from a hospitalization. The site also breaks out 13 measures of the quality of rehab care, offering a more robust view of facilities’ performance.

Independent experts and industry representatives welcomed the changes, saying they could help seniors make better decisions about where to seek care after a hospital stay. This matters because high-quality care can help older adults regain the ability to live independently, while low-quality care can compromise seniors’ recovery.

“It’s a very positive move,” said David Grabowski, a professor of health care policy at Harvard Medical School. He noted that previous ratings haven’t distinguished between two groups in nursing homes with different characteristics and needs — temporary residents getting short-term rehabilitation and permanent residents too ill or frail to live independently.

Temporary residents are trying to regain the ability to care for themselves and return home as soon as possible, he noted. By contrast, permanent residents aren’t expecting improvements: Their goal is to maintain the best quality of life.

Three separate ratings for the quality of residents’ care now appear on the Nursing Home Compare website: one for overall quality (a composite measure); another one for “short-stay” patients (people who reside in facilities for 100 days or less, getting skilled nursing services and physical, occupational or speech therapy) and a third for “long-stay” patients (people who reside in facilities for more than 100 days).

Ratings for short-stay patients — available for 13,799 nursing homes — vary considerably, according to a Kaiser Health News analysis of data published by the government in late April. Nationally, 30% of nursing homes with a rating received five stars, the highest possible. Another 21% got a four-star rating, signifying above-average care. Twenty percent got three stars, an average performance. Seventeen percent got two stars, a worse-than-average score. And 13% got one star, a bottom-of-the-barrel score. (Altogether, 1,764 nursing homes did not receive ratings for short-stay patients.)

Here’s information about how to find and use the new Nursing Home Compare data, as well as insights from Kaiser Health News’ analysis:

Finding data about rehabilitation. Enter your geographic location on Nursing Home Compare’s home page, and a list of facilities will come up. You can select three at a time to review. Once you’ve done so, hit the “compare now” button at the top of the list. (To see more facilities, you’ll need to repeat the process.)

A new page will appear with several tabs. Click on the one marked “quality of resident care.” The three overall star ratings described above will appear for the facilities you’ve selected.

Below this information, two options are listed on the left side: “short-stay residents” and “long-stay residents.” Click on “short-stay residents.” Now you’ll see 13 measures with actual numbers included (most but not all of the time), as well as state and national averages.

Understanding the star rating. Six measures are used to calculate star ratings for the quality of rehab care for short-stay patients. Two of them concern emergency room visits and rehospitalizations, potential indicators of problematic care. Another two examine how well pain was controlled and bedsores were managed. One measure looks at how many patients became better able to move around on their own, an important element of recovery. Yet another examines the rate at which antipsychotic medications were newly prescribed. (These drugs can have significant side effects and are not recommended for older adults with dementia.)

One measure of great interest to seniors is the percentage of residents who return successfully home after a short nursing home stay. But actual numbers aren’t available on the Nursing Home Compare website this time around: Instead, facilities are listed as below average, average or above average. The national average, reported in April, was 48.6%, indicating room for improvement.

Tracking variations in performance. Some facilities outperform others by large margins on measures of quality of care for short-stay residents. And some facilities have high scores in some areas, but not in others.

For instance, the nursing home at Westminster Village, a high-end continuing care retirement community in Scottsdale, Ariz., had the highest score for rehospitalizations — 39.9% — out of 68 facilities in and around Phoenix. (By contrast, the lowest score in the Phoenix area was 15.4% and the state average was 23.5%.) It also had the highest rate of helping residents improve their ability to move around on their own — 88.6%. (The lowest score was 37.6% and the state average was 63.6%.)

In an email, Lesley Midkiff, marketing director at Westminster Village, said that the facility’s staff is vigilant about sending residents back to the hospital if health issues arise. At the same time, she said, staffers “push the residents just enough to regain independence and recover quickly from their short term stays.” Both priorities have the “residents’ best interest” in mind, she said.

If a facility has an average or low quality score, Dr. David Gifford, a senior vice president at the American Health Care Association, a nursing home industry group, recommended that people look closely at various measures and try to figure out where the institution fell short. Call the facility and ask them to explain, he said. Also, review Nursing Home Compare’s information about staffing and health inspections, Gifford suggested, and visit the facility if possible.

Variations within nursing homes. The newly published Nursing Home Compare data also shows that institutions aren’t always equally adept at caring for short-stay and long-stay residents.

Disparities in facilities’ ratings for short- and long-stay patients are common. Of 13,351 nursing homes that received both ratings, 32% received the same star ratings for the quality of care received by short-stay and long-stay residents. Another 32% of facilities received higher star ratings for short-stay residents, while 36% got higher ratings for long-stay residents. About one-third of the time, these rating categories were one star apart, but in another third of cases, they varied by two or more stars — a significant discrepancy. (This analysis does not include 2,212 nursing homes for which data was missing.)

In Phoenix, Desert Terrace Healthcare Center, which bills itself on its website as the city’s “premier location for short-term rehabilitation and long-term care,” is one such facility. Its quality-of-care rating for short-term residents was two stars, while its rating for long-term residents was five stars. Notably, hospital admissions and ER visits for short-stay patients were higher than the state average, while the portion of short-stay residents whose mobility improved was lower than average.

In an email, Jeremy Bowen, the facility’s administrator, wrote that the facility had a good record of managing pain and bedsores and limiting antipsychotic prescriptions for short-stay patients. Factors such as hospital readmissions depend on community resources and patients’ understanding of their health needs, which are difficult to control, he noted.

Sierra Winds, part of a continuing care community in Peoria, Ariz., has a similar split in quality ratings (two stars for short-stay residents, five stars for long-stay residents). On four of six measures used to calculate star ratings for short-stay residents, it performed worse than the state average.

“Sierra Winds remains committed to providing the highest quality care and services to its residents,” wrote Shannon Brown, the facility’s executive director, in an email. “We are proud of our 4-star rating with CMS [the Centers for Medicare & Medicaid Services].”

That’s the facility’s overall rating (this includes data about staffing and health inspections). But it doesn’t address the split in scores for short-stay and long-stay patients, which raises a red flag and should certainly cause seniors and their families to ask follow-up questions.

“If I’m a patient looking for a place for a short-term rehab stay, I really want to know how patients who look like me did,” said Dr. Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania and a quality-measurement expert.

KHN senior correspondent Jordan Rau contributed to this report.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

‘Living Their Values’: Palliative Care Power Couple Faces Cancer At Home

WASHINGTON, D.C. — In the 18 years that Kathy Brandt and Kim Acquaviva have been together, death has been a constant companion.

It’s the reason they went to work each morning. Acquaviva, a professor of nursing, wrote an acclaimed 2017 book on inclusive end-of-life care for LGBTQ people. Brandt, a nationally known hospice industry leader and consultant, was tapped to write and edit the latest clinical guidelines for quality palliative care.

But in January, the professional became acutely personal: Brandt, 53, was diagnosed with metastatic ovarian cancer and learned she had mere months to live.

“The day she had her scans, as soon as we saw them, I was like, ‘It’s clear what this is,’” recalled Acquaviva, 47, settling beside the couple’s small spaniel, Mitzi, in their sunny living room last month.

“It was definitely shocking,” said Brandt, thin and wan beneath her signature spiky hair. She’d had puzzling intestinal symptoms since last summer, but never suspected it was serious.

Once the initial shock wore off, however, the couple who met while working for a Florida hospice decided to use Brandt’s illness as one more way to educate people about what it means to die.

“It’s what Kim and I have been working on for 30 years. The whole idea of: We need to talk about these issues, we need to get them out of the closet,” Brandt said. “We need to not be scared of death.”

Since her diagnosis with stage 3 ovarian clear cell carcinoma, or OCCC, Brandt and Acquaviva have been public about a controversial decision: Brandt is pursuing aggressive palliative care, forgoing treatments such as chemotherapy or radiation. It’s a choice made by fewer than 2% of patients facing the disease, one study showed.

But OCCC, a rare cancer, is often resistant to chemotherapy. In advanced stages of the disease, like hers, the prognosis is poor.

“Once I read things, it became very clear it would be futile,” said Brandt.

She said she has witnessed many grim cancer deaths during her career and understands the toll chemotherapy takes.

“I want to minimize the time I’m at the doctor,” Brandt said. “If it’s not going to save my life, then why would I go through trying to get an extra month, when that month leading up to it would be terrible?”

The couple — who married in 2010 and have a 19-year-old son, Greyson Acquaviva — have detailed their experience in frequent, frank updates through a GoFundMe site set up by friends to defray medical costs and living expenses. So far, at least 440 people have donated more than $56,000 toward a $100,000 goal.

“I want to minimize the time I’m at the doctor,” says Brandt (right), who was diagnosed with metastatic ovarian cancer in January and is pursuing aggressive palliative care.(Andrew Propp for KHN)

“Everyone initially was just shocked,” said Jon Radulovic, vice president of communications for the National Hospice and Palliative Care Organization, or NHPCO. He worked for a decade with Brandt, whom he describes as “focused and intent, with an unending reservoir of energy.”

“The fact that she and Kim are sharing this experience really openly is making a difference,” he said. In a series of posts and emails about Brandt’s illness, the pair have explained what’s helpful — kind messages, shared memories — and what’s not – unsolicited suggestions about how to “battle” cancer.

“At this time, our family gently asks that you not offer advice about treatment options you think Kathy should consider,” Acquaviva wrote in an email widely circulated to friends and colleagues.

In pursuing aggressive palliative care, Brandt is focused on relieving symptoms like pain, bloating and sleeplessness. Although palliative care can be used along with curative treatments, Brandt said she’s “100% certain” about her decision.

Some friends and family have had trouble accepting that choice, Acquaviva said. One cousin sent a message saying: “You don’t realize it, but you’re strong enough to do chemo.” An acquaintance showed up with fresh carrot juice, insisting that drinking 5 pounds of the juice daily would cure Brandt’s disease.

“I let her know really clearly that it wouldn’t,” Acquaviva said.

Even Brandt’s surgeon, a highly rated specialist, pushed back.

“Her oncologist is truly exceptional and I think she has had some struggles with this,” Acquaviva said. “I said, ‘Kathy’s really clear that she doesn’t want chemo and she said: ‘I can’t just let her kill herself.’”

Despite their extensive experience with hospice and palliative care, Brandt and Acquaviva say they’ve had to remain firm to have her wishes honored. It underscores the difficulty that cancer patients without their expertise may face.

“The default is, you’re going to fight with chemo,” Acquaviva said. “I would love to see clinicians and oncologists presenting patients with choices.”

At Sibley Memorial Hospital in Washington, D.C., where Brandt underwent the surgery that confirmed her diagnosis, Nicole Ollis is her palliative care nurse practitioner. She said Brandt and Acquaviva are not her typical clients.

“Kathy is probably my youngest patient who has been so confident not to move forward with treatment,” she said. “She would be my most educated patient when it comes to maximizing quality of life.”

Soon, however, Brandt will seek care from a new team of palliative specialists. Two weeks before Brandt’s diagnosis, Acquaviva accepted a new job: an endowed professorship at the University of Virginia School of Nursing.

Despite her illness, Brandt insisted Acquaviva take the post. “In the midst of dying, you’ve got to have, if at all possible, something to look forward to. I’m looking forward to it for Kim.”

Acquaviva and Brandt have been together for 18 years and married in 2010. Acquaviva (left), a professor of nursing, wrote an acclaimed 2017 book on inclusive end-of-life care for LGBTQ people. Brandt (right), a nationally known hospice industry leader and consultant, was tapped to write and edit the latest clinical guidelines for quality palliative care.(Andrew Propp for KHN)

They’ve just sold the home they owned for a decade in D.C. and bought a new place in Charlottesville, Va. Greyson finished his freshman year at Emerson College in Boston, where his moms proudly note he won two awards in a student film festival.

Acquaviva’s new colleagues are poised to welcome her — and to care for Brandt in whatever way she needs, said Susan Kools, associate dean for diversity and inclusion at the UVA nursing school.

“These are women who are living their values,” she said. “Instead of treating this news as a bitter twist of fate, they’re embracing their values as palliative care professionals.”

Dozens of people have sent cards, posts and emails praising Brandt and Acquaviva for being brave in sharing their story at a time of such personal hardship. But Brandt said raising awareness about choices for dying patients has always been the legacy she’d like to leave.

“The story of palliative care is still being written,” she said. “It’s so underutilized and it can be so life-changing for people, and there are so many things that block people’s access to it.”

Walmart Charts New Course By Steering Workers To High-Quality Imaging Centers

Walmart Inc., the nation’s largest private employer, is worried that too many of its workers are having health conditions misdiagnosed, leading to unnecessary surgery and wasted health spending.

The issue crystallized for Walmart officials when they discovered about half of the company’s workers who went to the Mayo Clinic and other specialized hospitals for back surgery in the past few years turned out to not need those operations. They were either misdiagnosed by their doctor or needed only non-surgical treatment.

A key issue: Their diagnostic imaging, such as CT scans and MRIs, had high error rates, said Lisa Woods, senior director of benefits design for Walmart.

So the company, whose health plans cover 1.1 million U.S. employees and dependents, has recommended since March that workers use one of 800 imaging centers identified as providing high-quality care. That list was developed for Walmart by Covera Health, a New York City-based health analytics company that uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments.

Although Walmart and other large employers in recent years have been steering workers to medical centers with proven track records for specific procedures such as transplants, the retail giant is believed to be the first to prod workers to use specific imaging providers based on diagnostic accuracy — not price, said employer health experts.

“A quality MRI or CT scan can improve the accuracy of diagnoses early in the care journey, helping create the correct treatment plan with the best opportunity for recovery,” said Woods. “The goal is to give associates the best chance to get better, and that starts with the right diagnosis.”

Walmart employees are not required to use those 800 centers, but if they don’t use one that is available near them, they will have to pay additional cost sharing. Company officials advise workers that they could have more accurate results if they opt for the specified centers.

Studies show a 3% to 5% error rate each workday in a typical radiology practice, but some academic research has found mistakes on advanced images such as CT scans and MRIs can reach up to 30% of diagnoses. Although not every mistake affects patient care, with millions of CT scans and MRIs done each year in the United States, such mistakes can have a significant impact.

“There’s no question that there are a lot of errors that occur,” said Dr. Vijay Rao, chairwoman of radiology at the Thomas Jefferson University Hospital in Philadelphia.

Errors at imaging centers can happen for many reasons, including the radiologist not devoting enough time to reading each image, Rao said. The average radiologist typically has only seconds to read each image, she said. “It’s just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen,” she added.

Other pitfalls: the technician not positioning the patient correctly in the imaging machine or a radiologist not having sufficient expertise or experience, Rao said.

Employers and insurers typically do little to help patients identify which radiology practices provide the most accurate results. Instead, employers have been focused on the cost of imaging tests. Some employers or insurers require plan members to use free-standing outpatient centers rather than those based in hospitals, which tend to be more expensive.

Woods said Walmart found that deficiencies and variation in imaging services affected employees nationwide. “Unfortunately, it is all over the country. It’s everywhere,” she said.

Walmart’s new imaging strategy is aligned with its efforts over the past decade to direct employees to select hospitals for high-cost health procedures. Since 2013, Walmart has been sending workers and their dependents to select hospitals across the country where it believes they can get better results for spine surgery, heart surgery, joint replacement, weight loss surgery, transplants and certain cancers.

As part of its “Centers of Excellence” program, the Bentonville, Ark.-based retail giant picks up the tab for the surgeries and all related travel expenses for patients on the company’s health insurance plan, including a caregiver.

Sampling Imaging Centers’ Work

Covera has collected information on thousands of hospital-based and outpatient imaging facilities starting with its previous business work in the workers’ compensation field.

“Our primary interest is understanding which radiologist or radiology practices are achieving the highest level of diagnostic accuracy for their patients,” said Dan Elgort, Covera’s chief data science officer.

Covera has independent radiologists evaluate a sampling of patient care data on imaging centers to determine facilities’ error rates. It uses statistical modeling along with information on each center’s equipment, physicians and use of industry-accepted patient protocols to determine the facilities’ rates of accuracy.

Covera expects to have about 1,500 imaging centers in the program by year’s end, said CEO Ron Vianu.

There are about 4,000 outpatient imaging centers in the United States, not counting thousands of hospital-based facilities, he estimated.

As a condition for participating in the program, each of the imaging centers has agreed to routinely send a sampling of their patients’ images and reports to Covera.

Vianu said studies have shown that radiologists frequently offer different diagnoses based on the same image taken during an MRI or CT scan. Among explanations are that some radiologists are better at analyzing certain types of images — like those of the brain or bones — and sometimes radiologists read images from exams they have less experience with, he said.

Vianu noted that most consumers give little thought to where to get an MRI or CT scan, and usually go where their doctors send them, the closest facility or, increasingly, the one that offers the lowest price. “Most people think of diagnostic imaging as a commodity, and that’s a mistake,” he said.

Rao applauded the effort by Walmart and Covera to identify imaging facilities likely to provide the most accurate reports. “I am sure centers that are worried about their quality will not be happy, but most quality operations would welcome something like this,” she said.

Few Guides For Consumers

Consumers have little way to distinguish the quality of care from one imaging center to the next. The American College of Radiology has an accreditation program but does not evaluate diagnostic quality.

“We would love to have more robust … measurements” than what is currently available, said Dr. Geraldine McGinty, chair of the college’s board of chancellors.

Facilities typically conduct peer reviews of their radiologists’ patient reports, but there is no public reporting of such results, she said.

Covera officials said they have worked with Walmart for nearly two years to demonstrate they could improve the quality of diagnostic care its employees receive. Part of the process has included reviewing a sample of Walmart employees’ health records to see where changes in imaging services could have caught potential problems.

Covera said the centers in its network were chosen based on quality and price was not a factor.

In an effort to curtail unnecessary tests, Walmart, like many large employers and insurers, requires its insured members to get authorization before getting CT scans and MRIs.

“Walmart is on the leading edge of focusing on quality of diagnostic imaging,” said Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led health care think tank and advocacy group.

But Mark Stolper, executive vice president of Los Angeles-based RadNet, which owns 335 imaging centers nationally, questions how Covera has enough data to compare facilities. “This would be the first time,” he said, “I have seen or heard of a company trying to narrow a network of imaging centers that is based on quality instead of price.”

Woods said that even though the new imaging strategy is not based on financial concerns, it could pay dividends down the road.

“It’s been demonstrated time and time again that high quality ends up being more economical in the long run because inappropriate care is avoided, and patients do better,” she said.

Newsom Changes Course On Plan To Pay For Immigrant Health Coverage

Gov. Gavin Newsom’s administration Friday reversed course on his plan to divert public health dollars from several counties to help provide health coverage to young adults who are in the country illegally.

The administration heeded the alarm sounded by Sacramento, Placer, Santa Barbara and Stanislaus counties, which had warned that the governor’s plan would compromise their ability to cope with surging rates of sexually transmitted diseases and, in some cases, measles outbreaks.

“The Administration has subsequently reevaluated this proposal due to the potential negative impacts to public health activities in these counties,” Vivek Viswanathan, chief deputy director of the state Department of Finance, wrote in a letter Friday to the chairs of the state Assembly and Senate Budget Committees.

Sacramento County, for example, estimates it would have lost roughly $7.5 million  that goes toward operating its STD clinic and paying communicable disease investigators. It warned that without the money, it would have to close the STD clinic and cut its own health services for undocumented immigrants of all ages.

“The public health dollars being restored make a big difference particularly at a time we have measles,” Dr. Peter Beilenson, Sacramento County Health Services Director, told California Healthline Friday. “We’re thrilled. It’s a great thing for the patients that we’re serving.”

This year, there have been 44 confirmed cases of measles in California as of May 8, three of them in Sacramento County. Public health officials also are struggling to address record rates of sexually transmitted diseases, with more than 300,000 cases of gonorrhea, chlamydia and syphilis reported in California in 2017.

On Thursday, when Newsom unveiled his revised budget — one that still included the plan to divert money from the four counties — he announced it would cost less to cover young adult unauthorized immigrants next year than previously estimated.

Because the state would have to delay the implementation date by six months to address IT issues, he said, it would cost $98 million to cover them in 2019-20, a significant drop from his original forecast of $260 million. The number of people expected to enroll also has dropped from 138,000 to 106,000.

The lower cost estimate means the administration won’t need to divert money from those four counties. What it does need, it will take from a special state budget reserve fund, said Department of Finance spokesman H.D. Palmer.

Newsom still plans to divert state money from 35 mostly small and rural counties, funds that currently pay for health services for uninsured residents, including undocumented immigrants, Palmer said.

Those counties participate in something called the County Medical Services Program, which has a $300 million budget surplus, Newsom noted at his budget briefing Thursday.

“That’s more than enough to address their issues,” Newsom said.

He also noted that his budget includes $40 million to combat infectious diseases.

Legislators are crafting their own budget proposals and have held dozens of hearings examining Newsom’s plan. The governor and lawmakers have until June 15 to negotiate a final budget, so it’s not yet clear which proposals will be included.

Placer County, which has reported three measles cases this year, praised Newsom’s change of heart.

“I appreciate the governor listening to some of the potential impacts it could have on public health and realizing that, in this time in California, we need to be making investments,” said Jeff Brown, director of Placer County’s Health and Human Services Department.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

State Highlights: Washington Health Spending Law For Native American Groups Called Promising; Citing Abuses, 5 More Former Ohio State Students File Lawsuit Against Team Doctor

Media outlets report on news from Washington, Ohio, Illinois, Maryland, Connecticut, Arizona, Georgia, California, New York, Minnesota, North Carolina, Utah, New Hampshire, Massachusetts, Iowa and Arkansas.

Doctors, Hospitals And Insurers Don Their Armor As They Prepare For A Fight Over Surprise Medical Bills

President Donald Trump added fuel to the fire over surprise medical bills last week when he called on Congress to take action on the issue, which has become a top concern for voters. Lawmakers are fully on board, but the question remains about who will pick up the extra costs if not patients. The powerful industries that any legislation could impact are gearing up for a battle. Other news from Capitol Hill focuses on a single-payer hearing and site-neutral pay regulation.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! As if those sky-high medical bills weren’t bad enough, apparently California teachers also must pay substitutes to cover for them — even while undergoing treatment for breast cancer.

Which is the perfect segue into what you may have missed this week (almost like I planned it).

President Donald Trump waded into the turf wars among doctors, hospitals and insurers Thursday when he called for an end to surprise medical bills. The issue has been gaining attention across the country as stories about $48,512 cat bites and $109,000 heart attacks resonate with voters who are sick of paying an arm, a leg and a mortgage for health care even when they have insurance.

It’s not exactly a controversial issue — it’s listed as a top concern among voters, and lawmakers are lining up in droves to sign their names to any potential legislation. But, as is often the case with health care costs, the devil’s in the details. The costs don’t just disappear because the president doesn’t want patients to have to pay them. Physician groups tend to favor arbitration, while insurers argue that method is flawed because it still relies on bill charges. Instead, the industry wants set prices, with rates in line with what they would consider reasonable for the procedures. Each side hates the other’s opinion. So … good luck to the lawmakers who have to balance those two big interest groups!

The New York Times: Trump Said He Wanted to Work With Democrats on Surprise Medical Bills. Then He Attacked Democrats.

(FWIW: Two stories of the patients who were featured at the White House event were previously highlighted in KHN and NPR’s “Bill of the Month” series. Check them out here.)


Kicking off a veritable blitz of bills, House Democrats voted on legislation that would ban the Trump administration from granting states waivers for health law regulations. Over the next couple of weeks, Dems are expected to go hard on their campaign promises to shore up the bruised and battered health law. Some of the topics of those bills: short-term “junk insurance” plans, outreach funding, “reinsurance” payments, drug rebates and more.

The New York Times: With Insurance Bill Passage, House Democrats Begin Health Care Blitz

Speaking of waivers, Tennessee is set to ask for one to shift its Medicaid program into a block grant model. Block grants — aka Republicans’ longtime dream system — as an idea have a long history riddled with controversy and criticism, and the request, if granted, is all but certain to draw a court challenge. Now the question is: How far is CMS ready to go in pushing the envelope on Medicaid changes? Especially when other waivers are getting knocked down left and right in court?

Modern Healthcare: Tennessee Will Test CMS’ Willingness to Block-Grant Medicaid

Meanwhile, the Trump administration is proposing a change to the formula to calculate poverty. That may seem fairly dry, but since government assistance (like Medicaid and food stamps) is tied to that line, millions could lose health care coverage and/or have to go hungry.

The New York Times: Trump Administration Seeks to Redefine Formula for Calculating Poverty


Pharma companies are going to start to have to include list prices in their TV ads under a new rule that’s central to the Trump administration’s war on high drug costs. While most people think, in general, it’s a good step, many doubt it will accomplish much. It’s not as if sick consumers can then go negotiate a different price, as they would with cars.

As Ben Wakana, the executive director of Patients for Affordable Drug Prices, told NPR: “Drug companies have been shamed about their price increases for years. They appear to be completely comfortable with the shame as long as it is bringing them in the billions of dollars a year that they make from their outrageous prices.”

NPR: New Rule for Drugmakers: Disclose Drugs’ List Prices in TV Ads

Drug prices were a hot topic this week (and most weeks, amiright?), with the Senate Finance Committee holding a hearing on the idea of setting an international price index. Other countries set lower prices and “we look like chumps,” said Sen. John Kennedy (R-La.).

Modern Healthcare: GOP Senators Warn Drug Price Controls Could Come

And, yup, there’s still more news: Despite HHS Secretary Alex Azar’s concerns about safety, Trump backed Florida’s plan to import drugs from other countries. The kicker here: Florida will surely be a battleground state in the 2020 election, and drug prices routinely top voters’ list of concerns. The potential for a winning talking point is huge.

The Associated Press: Trump Backs Fla. Plan to Import Lower-Cost Meds From Abroad


In somewhat tangential news, Gilead announced it will donate its drug that reduces the risk of HIV transmission for up to 200,000 people a year. The price of the life-changing medication has long been a barrier to the goal of ending HIV transmissions, and many advocates were thrilled with the decision. Still, others were disappointed, saying that will cover only a fifth of what the country needs.

The Associated Press: Drugmaker Will Donate Meds for US Push to End HIV Epidemic

But everyone was cheering a new study out of Europe. Out of nearly 1,000 gay male couples where one partner had HIV and was taking antiretroviral drugs, there were zero cases of HIV transmission even without the use of condoms.

Reuters: AIDS Drugs Prevent Sexual Transmission of HIV in Gay Men


Fed up with the strategy to slowly chip away at abortion rights, Alabama lawmakers are poised to go all in. The legislation (which was almost up for a vote this week, but was delayed because of a ruckus over rape and incest amendments) would effectively ban all abortions and criminalize the act of performing the procedure. The supporters of the bill aren’t being coy at all about their intention: They want to challenge Roe v. Wade with a simple, “clean bill” on the legality of abortions.

The New York Times: As States Race to Limit Abortions, Alabama Goes Further, Seeking to Outlaw Most of Them

And over in Georgia, abortion rights advocates have one message to Republican Gov. Brian Kemp, who just signed a heartbeat bill: “We will see you, sir, in court.”

The Associated Press: Opponents of Georgia Abortion Ban Promise Court Challenge


On a sad note: Legendary New York Times reporter Robert Pear passed away this week from complications of a stroke. Although I did not have the pleasure of meeting or working with him, his byline became a familiar friend of mine. He has shaped my world for the past several years with the stories he continuously broke. It is a loss for journalism, for health care and for the people he helped through the light he shined on Washington.

His last story is a perfect example of that: looking at legislation that carried promises of helping people with preexisting conditions but failed to live up to them.

The New York Times: Robert Pear, Who Covered Washington for 45 Years, Dies at 69

The New York Times: Republicans Offer Health Care Bills to Protect Patients (and Themselves)


In the miscellaneous files of the week:

• Traditionally, HHS has received, on average, one complaint related to “conscience” violations from health care workers per year. Last year, that rose to 343. What on earth happened? (Hint: It does not mean the problem actually worsened.)

NPR: Why Are Health Care Workers’ Religious and Moral Conscience Complaints Rising?

• It might seem like the anti-vaccination movement is a new phenomenon spurred on by social media, but there’s a long history of resistance in the country. And it’s not as random as it might appear at first. Usually, it’s tied to time periods that are marked by great resentment toward government.

Los Angeles Times: Why the Measles Outbreak Has Roots in Today’s Political Polarization

• Stories about student heroes stopping mass shooters and dying in the process highlight just how grim our reality has become as young people find themselves thrust into violence.

The New York Times: Colorado School Shooting Victim Died Trying to Stop the Gunman

• Not only is the United States’ maternal mortality rate abysmal, a new study finds that many of those deaths — 60%! — are preventable. What’s more, African American and American Indian/Alaska Native women are three times more likely to die from pregnancy and childbirth than white women.

USA Today: Pregnancy and Childbirth Deaths Are Largely Preventable, CDC Says

• Beneath the bright, tantalizing promises of the stem cell industry (targeted at the most desperate patients) festers a dark underbelly of greed and profit.

ProPublica: The Birth-Tissue Profiteers


Have a great weekend, and remember, as National Nurses Week wraps up, to hug (or otherwise appropriately thank) the nurses in your life. Their job can be quite tough.

Is It A Feminist Right To Want More Sex? One Company Thinks A Pill Is The Answer

Studies have never defined a “normal” level of sexual desire. Despite that, there’s a website and an online quiz to help you decide if you’ve got a problem. Called “Right to Desire,” it brands libido as a feminist “right,” and its home page offers the defiant, in-your-face prompt: “Yes, I want my desire back.”

Click a few boxes and you’re instantly directed to a remedy (and an online doctor to prescribe it): a pill called Addyi from Sprout Pharmaceuticals.

“This particular product should not have been approved by FDA, but it was, and it is not a product that adds value to women’s lives,” said Susan Wood, assistant commissioner for women’s health at the Food and Drug Administration from 2000 to 2005.

She added: “There isn’t an actual market.”

The effort, called a “disease awareness” campaign, troubles critics because it attempts to define low sexual desire as a widespread disease that is treatable with a pill. Although doctors recognize that there is (perhaps) a condition called Hypoactive Sexual Desire Disorder, many of the studies defining HSDD were sponsored by the drugmaker. Almost all doctors on the 2016 consensus panel that defined HSDD were consultants or on Sprout’s advisory board.

To further complicate matters, in the studies that led to Addyi’s approval, results were not terribly impressive. And, for those who would simply like a little more sex in their lives, is it worth a $400-a-month pill?

Enter the latest sales pitch, which encourages women to stand up for their rights. The new campaign taps into emotional issues that have long been staples of women’s equality movements, like the right to equal access to health care, the idea that women’s issues should be taken as seriously as men’s, including women in conversations about their health and valuing women as sexual beings.

“To hear our language co-opted” is upsetting, Cindy Pearson, the executive director of the National Women’s Health Network, said in an interview. “It’s really bittersweet to see it co-opted to sell, and sell a product that isn’t that good.”

Addyi — also known as flibanserin — first gained FDA approval in 2015 after a long and contentious fight. It’s often called the “female Viagra” because it’s related to sex, but Addyi and erectile dysfunction meds are quite different.

While impotence medications work by directing blood to the genitals and are taken before sex, Addyi is taken nightly and works in the brain to increase desire.

In fact, it was originally developed to be an antidepressant, but its clinical-trial performance fell short. Along the way, researchers noticed that subjects reported having some increase in sexual desire.

“Addyi is believed to work on the part of the brain involved in sexual motivation and response, though its exact mechanism of action is not fully understood,” the official website reads.

Even during drug trials, Addyi’s effectiveness was questioned. On average, women who took it reported one increased sexually gratifying experience every other month, and that was only after the subjects began recording their experiences monthly instead of daily.

There are also concerns about side effects like dangerously low blood pressure, fainting, severe drowsiness and insomnia.

The FDA rejected Addyi twice before it went before a public advisory council, where patients, doctors and women’s groups (some funded by the manufacturer, according to industry researchers) testified in favor of the drug.

In the old days, drugmakers developed drugs for known diseases. Now drugs come looking for a market.

It’s difficult to pinpoint the number of women who report a persistent lack of sexual desire. Even the findings of studies sponsored by the drugmaker vary widely. Such complaints also tend to be more common among post-menopausal women — a group for whom the drug is not approved.

Experts say it’s difficult to get an accurate picture of the problem medically known as low libido because it has so many possible causes — depression, poor body image, fatigue, stress, pregnancy and menopause. Even in the Sprout-sponsored study, many women who were distressed about their low sexual desire ascribed it to “relationship issues.”

“You take something that can occur from a wide range of reasons, some of which have nothing to do with physiological or medical problems, and you turn it into a medical problem, you give it a name and you sell a product to get rid of it,” said Diana Zuckerman, the president of the National Center for Health Research.

Rather than turn to a costly, silver-bullet medication approach, complaints like sexual dysfunction and low desire often need to be addressed by mental health professionals, sexual health professionals or people with more time and training than general practitioners, Zuckerman said.

Anyway, Addyi’s labeling expressly notes it is not approved for use by women whose low libido is caused by problems in their relationship, menopause, childbirth, medical issues, other medications they are taking or mental illness.

While Wood said she thought Sprout would like to market Addyi to “almost all women,” there’s a “tiny subset of women who suffer from HSDD.”

“And there’s not a big a market of people who actually suffer from this diagnosable condition that could benefit from a medical treatment,” Wood added.

Addyi’s labeling expressly notes it is not approved for use by women whose low libido is caused by problems in their relationship, menopause, childbirth, medical issues, other medications they are taking or mental illness.(Screenshot from addyi.com)

“Right to Desire” brands itself as a movement for women who are struggling with HSDD. The campaign is heavy on social media, with a strong Facebook presence that includes Funny or Die videos, date night “hacks” and testimonials from patients and doctors. There was a #RightToDesire “girls’ night out” Twitter party featuring several mommy bloggers and giveaways.

It’s not the first time feminism has been used to sell a product, but it’s still frustrating for women’s health activists who have been working for years to get their issues taken seriously.

At the time, a coalition of groups — some venerated women’s rights groups and some that were formed and funded by the pharmaceutical industry — known as “Even the Score” pushed for the drug’s approval and found traction. The rallying cry was the idea that 26 drugs had been approved for male sexual dysfunction and none for women.

“I believe [the FDA] found it hard to keep the product off the market when they were being accused of being sexist,” Wood said.

“They got, in my view, sort of bamboozled by that argument,” she added.

Forty-eight hours after Addyi was approved, Sprout sold it to Valeant, now under the umbrella of Bausch Health Companies, for around $1 billion.

And it flopped. According to Wood, that’s because the drug didn’t work, came with safety concerns and wasn’t covered by many insurance plans. Addyi cost around $800 a month for a daily pill, which may account for why at its peak in March 2016 only 1,600 prescriptions were written for it.

In 2017, Valeant gave up on Addyi, turning it back over to Sprout, which is now trying again to make the drug a sensation. As part of the arrangement, according to press reports, Sprout did not have to pay an upfront fee and, among other parts of the deal, agreed to pay Valeant, now Bausch, royalties on sales of the drug, though early indications say it still isn’t successful.

“We will receive royalties once they make a milestone,” Arthur Shannon, senior vice president and head of investor relations and communications for Bausch, wrote in an email. “We have not received any royalties thus far.”

The deal paved the way for a lower price tag — cut in half — and this trendy pop-feminist ad campaign.

Sprout did not make its CEO available for an interview.

Originally, the drug’s labeling included a prohibition on drinking alcohol while on the medication. This caution, though, resulted from a study whose participants were mostly men.

This spring, Sprout funded two new studies to show Addyi was safe to consume with alcohol, but the FDA kept the “black box” warning in place with one change — the alcohol prohibition is restricted to two hours before and at least eight hours after taking it.

“Now is the time to lend your voice and demand gender equality when it comes to sexual health,” the Facebook page declares as it directs visitors to a Change.org petition to get benefits managers to cover the drug. It also asserts that it’s “time to address women’s sexual health beyond reproduction alone.” It even quotes Eleanor Roosevelt.

“[Sprout is] definitely appropriating all that language, making it seem like a feminist issue,” said Dr. Steven Woloshin, a professor at the Dartmouth Institute. “This is an issue that involves women, but that doesn’t mean that taking this drug is something you should do because you’re a feminist.”

Podcast: KHN’s ‘What The Health?’ ‘Conscience’ Rules, Rx Prices and Still More Medicare


Can’t see the audio player? Click here to listen on SoundCloud.


In a new set of rules, the Trump administration wants to let not just doctors but almost any health care worker or organization decline to provide, participate in or refer patients for any health service that violates their conscience or religion.

Also this week, the Trump administration is ordering prescription drugmakers to include list prices in their television ads for nearly all products.

And there’s yet another entry in the growing group of bills aimed at overhauling the nation’s health system. This one is “Medicare for America.”

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Jen Haberkorn of the Los Angeles Times and Alice Miranda Ollstein of Politico.

Also, Rovner interviews Joan Biskupic, author of “The Chief: The Life and Turbulent Times of Chief Justice John Roberts.” Biskupic talks about the behind-the-scenes negotiations that led to the 2012 decision upholding the constitutionality of the Affordable Care Act.

Among the takeaways from this week’s podcast:

  • Robert Pear, who died this week, was the dean of health policy reporters and will be remembered not just for the many front-page stories he produced for The New York Times, but also as a generous and kind colleague who helped mentor many reporters new to the beat.
  • The Trump administration’s announcement last week of new regulations to protect health care workers from having to do anything they believe violates their religious beliefs is a stronger policy than past Republicans have adopted. But it follows other efforts to expand past conservative policies, such as the current administration’s more stringent Title X family planning rules.
  • The administration’s new rule requiring drugmakers to add list prices to their TV ads could confuse some consumers, since few of them actually pay that price. Their insurers often negotiate better prices, and other factors, such as geography and type of pharmacy, affect the consumer’s bottom line.
  • President Donald Trump this week told Health and Human Services officials to work with Florida on its plan to import drugs from Canada to take advantage of lower prices there. HHS Secretary Alex Azar said he would see if it can be done without jeopardizing the safety of the drugs. That is the rub that his predecessors have used to stop importation efforts, dating to the 1990s.
  • The increasing interest in Democratic proposals such as “Medicare for All,” which would set up a government-run health care system, and “Medicare for America,” which would offer a government-run option for consumers and businesses, suggests that a public option is not the political hot potato it was during the debate setting up the ACA. It’s also not clear whether consumers are ready to give up their current insurance.
  • Tennessee is getting ready to ask federal officials for a major change in its Medicaid system. The state wants to switch to a block grant, in which its federal funding would be limited but would come with much more flexibility for spending. The proposal is likely to end up in court because advocates for the poor argue the change would cut off services to some people and would violate laws that have defined Medicaid.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: CNBC’s “Insiders Describe Aggressive Growth Tactics at uBiome, the Health Start-Up Raided by the FBI Last Week,” by Christina Farr, and “Health Tech Start-Up uBiome Suspends Clinical Operations Following FBI Raid,” by Christina Farr and Angelica LaVito

Joanne Kenen: ProPublica and the New Yorker’s “The Birth-Tissue Profiteers,” by Caroline Chen

Jen Haberkorn: The Los Angeles Times’ “Health Insurance Deductibles Soar, Leaving Americans With Unaffordable Bills,” by Noam N. Levey

Alice Miranda Ollstein: Bloomberg News’ “Trump May Redefine Poverty, Cutting Americans From Welfare Rolls,” by Justin Sink

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle Play or Spotify.

Price Check On Drug Ads: Would Revealing Costs Help Patients Control Spending?

[Editor’s note: The Trump administration on May 8 finalized its rule requiring drugmakers to include price information in television ads for any products that cost $35 or more a month or spanning a typical course of therapy. The move comes amid growing federal and state interest in price transparency, although whether it will result in lower prices is uncertain. Here’s a story originally published on June 6, 2018 that explores some of the issues.]

President Donald Trump wants to control spending on drugs. One of his big ideas: include prices in advertisements, just like warnings about side effects.

That’s not as simple as it sounds.

Apart from legal questions about whether the Food and Drug Administration has the authority to require pricing in ads, other uncertainties arise.

For example, what is the right number to use?

There is a dizzying array of ways to look at drug prices, including average wholesale and average sales prices.

And dosage factors in. Would the price be pegged to a monthly cost? A per-dose cost? Or, even more inscrutable, a “unit cost,” which may not equal a single dose?

A final complication: The prices likely would not be what most consumers actually pay.

Most patients with insurance typically shell out either a flat-dollar copayment or a percentage of the drug’s cost. Some patients get coupons that can reduce their cost to zero.

An FDA working group is currently studying these issues.

Still, we wondered how drug prices pinned to ads might look, hypothetically.

We picked the top 10 most-advertised drugs by spending, courtesy of a list from Kantar Media, which advises clients on advertising and tracks spending, and showed how much each drug company spent last year on those ads. Another consulting group, Connecture, then figured the typical monthly costs, based on average wholesale prices. Those costs are based on typical dosages.

Here’s what we found:

Drug: Humira
Company: AbbVie
Monthly cost: $5,846.44
Typical regimen: 40 mg every other week by injection
2017 advertising: $429 million
Treats: Rheumatoid arthritis, chronic plaque psoriasis, Crohn’s disease

Drug: Lyrica
Company: Pfizer
Monthly cost: $1,070.15
Typical regimen: 300 mg per day in pill form
2017 advertising: $350 million
Treats: Fibromyalgia, diabetic nerve pain, spinal cord injury nerve pain and pain after shingles

Drug: Xeljanz
Company: Pfizer
Monthly cost: $4,914.77
Typical regimen: 5 mg twice daily in pill form
2017 advertising: $273 million
Treats: Rheumatoid arthritis, psoriatic arthritis

Drug: Eliquis
Company: Bristol-Myers Squibb
Monthly cost: $502.84
Typical regimen: 5 mg twice daily in pill form
2017 advertising: $227 million
Treats: Prevention of stroke and blood clots

Drug: Keytruda
Company: Merck
Monthly cost: $8,369.36
Typical regimen: 200 mg every three weeks by infusion
2017 advertising: $209 million
Treats: Melanoma, non-small cell lung cancer and other cancers

Drug: Taltz
Company: Eli Lilly
Monthly cost: $6,193.92
Typical regimen: 80 mg every four weeks by injection
2017 advertising: $207 million
Treats: Plaque psoriasis, active psoriatic arthritis

Drug: Chantix
Company: Pfizer
Monthly cost: $515.89
Typical regimen: 1 mg twice daily in pill form
2017 advertising: $207 million
Treats: Aid in smoking cessation

Drug: Trulicity
Company: Eli Lilly
Monthly cost: $876.24
Typical regimen: 0.75 mg once weekly by injection
2017 advertising: $195 million
Treats: Type 2 diabetes

Drug: Cosentyx
Company: Novartis
Monthly cost: $11,309.72
Typical regimen: 300 mg every four weeks by injection
2017 advertising: $174 million
Treats: Plaque psoriasis, psoriatic arthritis, ankylosing spondylitis

Drug: Entresto
Company: Novartis
Monthly cost: $555.91
Typical regimen: 97 mg/103 mg twice daily in pill form
2017 advertising: $159 million
Treats: Chronic heart failure
Sources: Kantar Media, Connecture

Graphic presentation by producer Lydia Zuraw.


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

Mississippi Prison Reforms Have Been Touted As A Model To Follow, But In Reality They’ve Been Mostly Broken Promises

Mississippi vowed to take steps to help prisoners better prepare for life outside bars, send offenders to drug courts for treatment rather than to prison, and to help keep offenders guilty of technical probation violations from returning to prison, among other things. But none of that has happened.

The Money And Politics Of Prescription Drugs: What You Need To Know

If there’s one area of health care where Republicans and Democrats might strike a deal, it’s prescription drugs.

President Donald Trump has floated a plan to cut drug prices. Democratic and Republican ideas abound in Congress, where lawmakers have put more than 40 bills on the table. In 2018, 39 states passed 94 laws targeting pricing and costs. Florida’s House recently approved a move backed by the state’s Republican governor to allow imports from Canada. So far, Vermont is the only state to take that step.

Why do prescription drugs draw so much attention? Because millions of Americans rely on them, and 8 out of 10 say the cost is “unreasonable.”

America spends about $460 billion a year on these drugs, roughly as much as the combined revenues of the top three car makers.

That spending flows mainly in two ways: retail drugs sold at pharmacies, and drugs provided by doctors and other clinicians at hospitals, outpatient clinics and long-term care centers. Retail drugs account for about 10% of all health care spending. The doctor-administered drugs add about another 6% to 7%.

Tracking the money challenges the savviest of analysts. Between the drugmakers and the patients lie an array of middlemen, who end up masking the true prices through discounts to one another and rebates to patients.

Here are a few benchmarks to help you navigate the realm of prescription drugs.

Out-Of-Pocket Costs

With all the focus on affordability, it’s worth noting that about a third of all retail prescriptions come at no cost to the patient. Another half have an out-of-pocket cost of under $10. In recent years, the average out-of-pocket cost has fallen from about $10 to a bit over $8.

There are several reasons, including company rebates, better drug cost protections through the Affordable Care Act, and greater use of generic drugs, which are cheaper than brand-name drugs protected by patent.

But just because the pressure has eased on average doesn’t mean the financial burden isn’t intense for the relative few. A small number of people and prescriptions accounted for a huge share of the estimated total out-of-pocket costs of $57.8 billion in 2017.

The Federal Bill Grows

Even if most individuals are cushioned from rising drug prices, taxpayers, through the federal government, are not. Spending skyrocketed after the Medicare Part D prescription drug benefit took effect in 2006 and has continued to rise rapidly since.

U.S. Drug Prices Are Higher

One reason states such as Florida are interested in importing drugs from Canada is many drugs are cheaper there. The Commonwealth Fund, a New York-based health policy group, compared a basket of common drugs (of the retail sort) in the United States and several other countries. Using the American cost as a benchmark of 100, it calculated the cost in Canada, the United Kingdom, France, Germany, Switzerland and Australia.

Germany was the closest match to the American price tag, but Canada, the U.K. and Australia were all about half the cost.

Other studies reached the same general result. The U.S. Health and Human Services Department looked at the top 27 Part B drugs (physician-administered drugs) and found that for 20 prices were higher in the United States. A Canadian-American research team looked at spending on primary care drugs in America and 10 other nations, including all of the ones in the Commonwealth study. It found U.S. spending was about twice as high as the average elsewhere.

Broadly, the United States spends more on drugs because prices for many drugs are higher, and patients, usually on the advice of a doctor, take newer, high-cost drugs.

Follow The Money

One of the reasons the prescription drug market poses a challenge to lawmakers is because it has many moving parts. On the payer side, there are patients, the government and employers. On the receiving end are drugmakers, wholesalers, health care plans, pharmacies and pharmacy benefit managers, which are firms that negotiate prices on behalf of payers.

The money moves around a lot, but policy analyst Allan Coukell at the Pew Charitable Trusts modeled the flow among all the players to estimate how much money ended up with each one. For 2016, the drugmakers were the top gainers, with $204 billion (on the retail side), but the pharmacies also did well with about a quarter of the total.

Lobbying

Ever since the passage of the Medicare Part D prescription drug benefit, pharmaceutical companies have invested heavily in lobbying. There was a spike in 2009 as Congress debated the Affordable Care Act, but after a short dip, spending rose again and now stands at $281 million, about where it was nearly a decade ago.

No industry group spends more on lobbying — by a long shot. The insurance industry came in a distant second at $158 million on lobbying last year.

The drug industry can’t ignore the big proposals in Washington that could change the landscape, said Georgetown University researcher Jack Hoadley.

Both Democrats and Republicans, including the White House, have bills to peg American prices to prices in Japan and Europe.

There are bills to let the government negotiate directly with drug companies to reduce prices in the Medicare program. Among the public, that approach enjoys broad bipartisan support, with 80% of Republicans and 90% of Democrats in favor.

“The fact that the administration, congressional Republicans and Democrats are all talking about drug prices is putting all stakeholders on edge,” Hoadley said.

Drug Industry Patents Go Under Senate Judiciary Committee’s Microscope

Congress isn’t making much headway in finding a solution to the problem of soaring prescription drug prices, but lawmakers from both parties are tinkering on the edges with legislation that aims to increase competition among drugmakers.

A comprehensive piece of drug-pricing legislation is a high priority for Senate Finance Committee Chairman Chuck Grassley, (R-Iowa) and Sen. Ron Wyden (D-Ore.). And it could be introduced by mid-June, according to congressional staff.

But while that is hashed out, a slate of options to reform drug patents is working its way through the Senate Judiciary Committee, which had a hearing Tuesday featuring academics, patient advocates and a representative from the pharmaceutical industry. Their mission: to increase competition without decreasing innovation in the industry.

“I think we’re dangerously close to building a bipartisanship consensus around change,” Sen. Dick Durbin (D-Ill.), said during the hearing.

The four proposed bills share a common goal: avoiding some of the thorny issues around drug pricing, like whether the government will set drug prices or negotiate with manufacturers on what federal programs will pay. Instead, the patent reform proposals get at the ways branded drug manufacturers use patents, and the legal monopolies that are granted with patents, to keep lower-priced generic competitors from reaching patients.

“A package of patent reforms are important because they fix systemic problems that allow prices to go up and keep them high,” testified David Mitchell, the president of Patients for Affordable Drugs, a Washington, D.C.-based advocacy group focused on lowering prescription drug prices.

Sen. John Cornyn (R-Texas) offered specific examples of drugs that have benefited from  system issues, including Humira, an expensive drug for arthritis and psoriasis that is protected by 136 patents.

That’s called a “patent thicket,” because it prevents a generic alternative from entering the market for more years — in this case, until 2023 for a drug first approved for use in the United States in 2002. “Is there anyone on the panel who’d like to defend the status quo?” he asked.

“There is no way a biosimilar can deal with a hundred patents,” testified Michael Carrier, a professor at Rutgers Law School. “This is an abuse of the system.”

Among the proposed bills, the Stop STALLING (“Stop Significant and Time-wasting Abuse Limiting Legitimate Innovation of New Generics”) Act, is the bipartisan brainchild of Sen. Amy Klobuchar (D-Minn.) and Grassley. The bill is supposed to put a stop to “sham” citizen petitions to the FDA. Critics say these petitions are often introduced by drugmakers under the guise of patient advocacy to slow FDA approval of new generic medicines. “Nearly every one of these citizen petitions is brought by a brand company. None are filed by individuals. I love the legislation. I would go even stronger,” Carrier said.

Grassley is also the lead sponsor on the bipartisan Prescription Pricing for the People Act of 2019. It directs the Federal Trade Commission to investigate mergers of pharmacy benefit managers, the middlemen that negotiate between drugmakers and health plans.

Klobuchar and Grassley teamed up again on another measure, the Preserve Access to Affordable Generics and Biosimilars Act, which they  say would end “anti-competitive behavior” — specifically, deals struck between branded companies and generic companies to keep a generic, or a biosimilar, off the market. Klobuchar,  a Democratic presidential candidate, has frequently discussed her opposition to this practice on the campaign trail.

James Stansel — the executive vice president and general counsel of the Pharmaceutical Research and Manufacturers of America, a drug industry trade group, and the lone voice of the pharmaceutical industry on the panel — cautioned against moving too aggressively on this point. “We want to make sure we don’t do something that’s anti-competitive in the hopes it would be pro-competitive,” he said.

There’s also the CREATES (“Creating and Restoring Equal Access to Equivalent Samples”) Act, introduced by Sen. Patrick Leahy (D-Vt.) with 31 bipartisan co-sponsors and endorsed by nearly every witness on Tuesday’s panel. It’s supposed to crack down on branded companies that refuse to sell samples of their drugs to generic companies, a necessary step to increasing the number of generics on the market.

Versions of all four of those bills have also been introduced in the House and advanced out of the House Judiciary Committee.

“The American people are being played for chumps,” said Sen. John Kennedy (R-La.). “Just chumps. And it’s got to stop.”

Feds Want To Show Health Care Costs On Your Phone, But That Could Take Years

Federal officials are proposing new regulations that for the first time could allow patients to compare prices charged by various hospitals and other health care providers using data sent to their smartphones.

Donald Rucker, who coordinates health information technology policy for the Department of Health and Human Services, said he expects that the rules, first proposed in March, will give patients new power to shop for care based on price and quality.

Consumers have long sought more knowledge about health care prices, but administration officials cautioned it could take two years or more for it to appear in a user-friendly form on a phone app. Many specifics, including how patients would make sense of complex pricing policies for purchasing health care and insurance and assessing quality via an app, remain unclear.

Rucker said in remarks prepared for a Senate Health, Education, Labor & Pensions Committee hearing Tuesday that patients “have few ways if any to anticipate or plan for costs, lower or compare costs, and, importantly, measure their quality of care or coverage relative to the price they pay.”

The Trump administration proposal comes amid growing outrage from patients hit with seemingly exorbitant “surprise” medical bills. One study found that these bills — which are for amounts far more than the patient anticipated or for care not covered by insurance — have bedeviled more than half of American adults.

The Senate committee is reviewing regulations proposed under the 21st Century Cures Act, a law passed in 2016 to promote innovation in health care.

Dr. Kate Goodrich, the chief medical officer for the federal government’s Centers for Medicare & Medicare Services, said the agency wants every American to have an electronic health record (EHR) that will follow them as they move through the health care system, “giving them the data they need to make the best decisions for themselves and their families.”

Everyone, Goodrich said in her prepared statement to the committee, “should be able, without special effort or advanced technical skills, to see, obtain, and use all electronically available information that is relevant to their health care, and choices — of plans, providers, and specific treatment options.”

Meeting these goals could prove to be a tall order. For well over a decade, federal officials have struggled to set up a digital records network capable of widespread sharing of medical data and patient records. In 2004, President George W. Bush said he hoped to have a digital record for most Americans within five years. In early 2009, the Obama administration picked up the challenge and funneled billions of dollars in economic stimulus money into a campaign to help doctors and hospitals buy the software needed to replace paper medical files.

Critics argue that poor oversight over the stimulus spending and objectives has saddled many doctors and hospitals with flawed software that typically cannot share information across health networks as promised. It has also caused new types of errors that compromise the safety of patients.

Botched Operation,” a recent investigation published by Kaiser Health News and Fortune, found that the federal government has spent more than $36 billion on the EHR initiative. Thousands of reports of deaths, injuries and near misses linked to digital systems have piled up in databases over the past decade — while many patients have reported difficulties getting copies of their complete electronic files, the investigation found.

Despite the slow progress, federal officials remain optimistic that digital records will save the nation billions of dollars while reducing medical errors, unnecessary medical testing and other waste — and encouraging more Americans to take a bigger role in managing their health care by comparing prices.

But Sen. Lamar Alexander, R-Tenn., the committee’s chairman, said the results would have been better had officials not rushed out the stimulus plan. “I am especially interested in getting where we want to go with input from doctors, hospitals, vendors, and insurers, so we have less confusion, make the fewest possible mistakes, and make sure we don’t set some kind of unrealistic timeline,” he said in a statement.

Anger over the lack of easy access to health care has dominated public comments on the proposed regulation posted on a government website.

“The proposed policy to mandate disclosure of health care pricing by hospitals, insurance companies, etc. is one of the most important in American history. That is not hyperbolic,” one anonymous commenter wrote, adding: “The only way to save money on healthcare in America is to never receive it.”

A Boat Crushed His Face, Then Plastic Surgeons Hit Him With $167,000 In Bills

Bob Ensor didn’t see the boom swinging violently toward him as he cleaned a sailboat in dry dock on a spring day two years ago. But he heard the crack as it hit him in the face.

He was transported by ambulance to an in-network hospital near his home in Middletown, N.J., where initial X-rays showed his nose was broken as were several bones of his left eye socket. The emergency physician summoned the on-call plastic surgeon, who admitted him to the hospital and scheduled him for surgery the next day.

Shortly before surgery, the doctor introduced Ensor to a second plastic surgeon who would assist in the 90-minute procedure. Entering through Ensor’s nose, the physicians realigned his facial bones, temporarily sewing Ensor’s left eye shut so that the lids would stay in place as the bones knitted back together.

Six weeks later, as Ensor, then 65, continued to make an uneventful recovery, a collection agency called to inquire how he and his wife planned to pay the $71,729 bill for the assistant surgeon. Ensor’s company health plan had denied payment because the surgeon wasn’t part of its contracted physician network.

There was more bad news. Ensor received notice that the health plan wouldn’t cover the $95,885 charged by the first plastic surgeon either because he also was out-of-network.

“The hospital knew these doctors were out-of-network and didn’t bother to tell us,” said his wife, Linda Ensor, noting they faced more than $167,000 in charges. “We were panicked.”

Riverview Medical Center in Red Bank, N.J., where Ensor was treated, said that it “empathizes with patients who are trying to navigate the complexity of the health care billing system” and that transparency in billing has not always been optimal for emergency department patients.

As surprise out-of-network billing becomes a politically charged issue, Americans want the federal government to take action. In an April survey, more than three-quarters of consumers said the government should protect them from such bills, according to the Kaiser Family Foundation’s monthly health tracking poll. (KHN is an editorially independent program of the foundation.)

An analysis of insurance claims from more than 350 commercial carriers found that plastic and maxillofacial surgeons billed out-of-network more frequently than any other type of specialist in an inpatient setting. Examining hospital admissions in 2016, researchers at Johns Hopkins Bloomberg School of Public Health found that plastic and maxillofacial surgeons billed their services out-of-network 23% of the time, more than any of the other 50 specialties analyzed.

That leaves patients like Ensor, whose care requires plastic or maxillofacial surgery, extremely vulnerable. It also catches patients off guard: When a parent brings in a child with a cut and a triage nurse asks if they’d prefer a plastic surgeon, many reflexively answer “yes” not understanding whether there is an actual need nor anticipating the charges.

According to one survey of emergency department directors at more than 440 hospitals, 81% reported they had inadequate plastic surgery coverage, a higher percentage than reported shortages of any other type of surgical specialty.

The reasons these specialists are such frequent out-of-network billers are fairly straightforward.

Many plastic surgeons don’t participate in health plans because they have flexibility other physicians may not have — their practices often focus on elective cosmetic procedures like nose reshaping and breast augmentation that patients pay for on their own.

Also, general surgeons and heart surgeons generally want to maintain good relations with the hospitals — and be on call for the ER  — since the ER is a source of patient referrals and their patients often require inpatient care. In contrast, plastic surgeons often operate at outpatient centers.

“Fortunately for some plastic surgeons with alternative revenue streams, they don’t need to participate with insurance companies,” said Dr. Gregory Greco, the board vice president for health policy and advocacy of the American Society of Plastic Surgeons, who has a solo practice in New Jersey and Manhattan. Greco participates in the employee plans at the institutions where he has hospital privileges, but he doesn’t accept other insurance plans.

The society did not respond to a request for information regarding the percentage of plastic surgeons who participate in insurance networks.

That can spell trouble in emergency care. Under the federal Emergency Medical Treatment and Labor Act (EMTALA), hospital emergency departments are required to screen and stabilize any patient who walks through the door, whether or not they can afford to pay. Hospitals often rely on a roster of on-call specialists to treat emergency patients, but studies show many specialists are reluctant to be on call, and low rates of insurance reimbursements may play a role in those decisions.

Data from a New York state program to arbitrate surprise medical bills — a 2015 state law holds patients harmless for such charges — highlights the scope of the problem with plastic surgery coverage.

Emergency care involving out-of-network plastic surgery services was by far the most common type of bill reviewed, according to figures from the state Department of Financial Services. By late 2018, there had been 543 decisions regarding such bills, compared with 335 for emergency physician care and 263 for orthopedists.

In New York, the surprise billing law has discouraged plastic surgeons from charging extremely high fees for out-of-network work, said Dr. Andrew Kleinman, a plastic surgeon in suburban New York City who is a former president of the Medical Society of the State of New York. Under the program, which uses a process called “baseball arbitration,” the insurer and provider each submits a proposed dollar amount and the arbitrator picks one.

“Baseball arbitration gives the physician an incentive not to bill an outrageous rate because they’re going to lose,” Kleinman said. If a doctor charges $20,000 for services provided, but the insurer offers $500, “the insurer will win every time,” he said.

More than two dozen states have passed laws that address surprise bills to some extent — although they do not protect the many patients covered by plans regulated by national rules. Congress is debating measures that would address surprise bills at the national level.

Dr. Meghan Candee of Salt Lake City was stunned when a plastic surgeon charged her insurance company more than $25,000 for a single stitch after daughter Maeve cut her face in a fall.(Courtesy of Meghan Candee)

In the meantime, patients remain vulnerable. Dr. Meghan Candee was visiting family in Riverhead, N.Y., last summer when her daughter, who was 4 at the time, fell against a wooden bench and got a small cut underneath her left eyebrow. Candee, a pediatric neurologist in Salt Lake City, took her to the emergency department nearby, where she opted for a plastic surgeon, who put in a single stitch, without any sedation.

Candee paid the $100 copayment for the emergency department visit and took the stitch out herself five days later.

A few weeks later, Candee’s insurer sent a $25,175 check to pass on to the out-of-network plastic surgeon, who had charged that amount for his work.

Assuming there was an error, Candee called the plastic surgeon’s billing office but was told the amount was correct. Even though she wasn’t herself on the hook, Candee was “outraged.”

“This is why people have issues with physicians, and they think most of us are out there trying to get money,” she said.

In New York, the average out-of-network charge at a hospital or other setting for an injury like Candee’s daughter’s — a simple repair of a superficial wound on the face that is 2.5 centimeters or less in length — is $438.01, according to FAIR Health, a national, independent nonprofit organization that collects and manages an extensive database of insurance claims. In the Great Neck/Port Washington area of Long Island, the area with the highest charges for that repair nationwide, the average charge is $1,067.25.

Patients should know that a plastic surgeon may not be covered in-network and is not necessary in many cases. “It’s not uncommon for a family to say they would like a plastic surgeon,” said Dr. William Jaquis, president-elect of the American College of Emergency Physicians. “But, in the vast majority of cases, a well-trained emergency physician can do most of the repairs.” A plastic surgeon makes sense when there’s extensive, deep-tissue damage and the skin is not cleanly torn, especially on the face, he said. A dog bite or an eye socket injury like Ensor’s is a classic example.

Luckily for the Ensors, the sailing club stepped in to take up his case with the out-of-network plastic surgeons. Since sailing club members were required to volunteer on work projects to keep membership costs in check, the club’s insurer agreed to cover the accident as a workers’ compensation case. It paid 100% of the outstanding bill.