Tagged Health Industry

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Warren y Klobuchar dicen que pueden bajar precios de medicamentos sin ayuda del Congreso

Durante el debate demócrata, las dos mujeres que se postulan para la presidencia prometieron hacer, solas, lo que Washington hasta ahora no ha logrado: bajar los precios de los medicamentos recetados.

Hablando durante el último debate demócrata, la senadora por Massachusetts Elizabeth Warren y la senadora por Minnesota Amy Klobuchar dijeron que, si fueran elegidas presidentas, actuarían de inmediato para reducir directamente el costo de ciertos medicamentos.

Declaraciones importantes ya que provienen de dos senadoras que han patrocinado sus propios proyectos de ley para controlar el aumento vertiginoso de los precios de las drogas recetadas. Y, además, después que el Congreso se pasó el año pasado debatiendo el problema, sin aprobar ninguna legislación significativa para solucionarlo.

“Necesitamos ayudar a la gente todo lo que podamos, lo antes posible”, dijo Warren.

Si bien no dieron detalles sobre qué poderes presidenciales usarían, Warren y Klobuchar dijeron que el presidente ya tiene la autoridad legal para controlar estos precios. De hecho, Klobuchar tiene una lista de 137 cosas que puede hacer como presidente y sin ayuda del Congreso.

Una encuesta de 2019 de la Kaiser Family Foundation halló que, por culpa del costo, cerca del 29% de los estadounidenses no habían tomado sus medicamentos recetados correctamente el año anterior.

Tras haber propuesto una legislación que empoderaría al gobierno federal para fabricar drogas, Warren dijo que actuaría para reducir el precio de la insulina y drogas que tratan el VIH/SIDA.

Su campaña envió por correo electrónico a los reporteros una lista de otras drogas específicas, incluido EpiPen, para ataques severos de asma; Humira, el medicamento contra la artritis reumatoide más vendido, cuyo fabricante ha sido criticado por abusar de las patentes para sofocar a la competencia; y naloxona, un medicamento que revierte los efectos de la sobredosis de opioides.

Klobuchar y el ex alcalde de South Bend, Indiana, Pete Buttigieg, también respaldaron el empoderamiento de Medicare para negociar precios más bajos con los fabricantes de medicamentos: la propuesta en el corazón del plan de medicamentos presentada el año pasado por Nancy Pelosi y otros líderes demócratas de la Cámara de Representantes.

Sin embargo, esa idea es profundamente impopular entre los republicanos del Congreso, quienes la describen como una interferencia del gobierno en el mercado libre. Mientras el proyecto de ley fue aprobado por la Cámara en diciembre, el senador por Kentucky y líder republicano Mitch McConnell, dijo que no permitirá que se vote en el Senado, eliminando sus posibilidades, al menos por ahora.

Klobuchar enfatizó que el verdadero problema es el número de cabilderos farmacéuticos en Capitol Hill, dos por cada miembro del Congreso, dijo.

“¿Cómo podemos realmente romper el dominio corporativo de nuestro gobierno para que podamos aprobar cualquiera de estas cosas?”, se preguntó Tom Steyer, el empresario que fue uno de los seis candidatos demócratas que calificaron para el debate.

Este debate, que se realizó en Des Moines, Iowa, le dio al ex vicepresidente Joe Biden y al senador por Vermont Bernie Sanders otra oportunidad para discutir, aunque sea brevemente, el costo del Medicare para Todos.

Al extenderse sobre cómo pagaría por la revisión de un solo pagador del sistema de atención médica de la nación, Sanders dijo que implicaría un impuesto sobre la renta del 4%, eximiendo los primeros $29,000 del ingreso de un contribuyente para aliviar la carga de la “familia promedio en Estados Unidos”.

“Ahora es el momento de atacar la avaricia y la corrupción de la industria del cuidado de salud, de las compañías farmacéuticas, y finalmente brindar atención médica a todos a través de un programa de pagador único de Medicare para Todos”, dijo Sanders. “No será fácil. Es lo que tenemos que hacer”.

“Puedes hacerlo sin Medicare para Todos”, rebatió Biden. “Puedes llegar al mismo lugar”.

Sin embargo, luego de seis debates dedicados a analizar los detalles del Medicare para Todos, Warren hizo referencia al primer desafío que tienen por delante: una elección general durante la cual el candidato demócrata que gane se postulará contra el presidente Donald Trump, que quiere revocar la Ley de Cuidado de Salud a Bajo Precio (ACA).

Warren dijo que impulsaría su plan para expandir la cobertura a través de un sistema de pagador único, pero también que defendería ACA.

“Y vamos a vencerlo en esto”, agregó.

El octavo debate está programado para el 8 de febrero, el primero de tres debates demócratas que se realizarán el próximo mes.

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No Shield From X-Rays: How Science Is Rethinking Lead Aprons

CHICAGO — Patients have come to expect a technician to drape their torsos with a heavy lead apron when they get an X-ray, but new thinking among radiologists and medical physicists is upending the decades-old practice of shielding patients from radiation.

Some hospitals are ditching the ritual of covering reproductive organs and fetuses during imaging exams after prominent medical and scientific groups have said it’s a feel-good measure that can impair the quality of diagnostic tests and sometimes inadvertently increase a patient’s radiation exposure.

The about-face is intended to improve care, but it will require a major effort to reassure regulators, health care workers and the public that it’s better not to shield.

Fear of radiation is entrenched in the collective psyche, and many people are surprised to learn that shielding can cause problems. The movement also has yet to gain much traction among dentists, whose offices perform more than half of all X-rays.

“There’s this big psychological component, not only with patients but with staff,” said Rebecca Marsh, a medical physicist at the University of Colorado Anschutz Medical Campus in Aurora, Colorado, who spoke about shielding at a December forum here at the annual meeting of the Radiological Society of North America. “How do you approach something that is so deeply ingrained in the minds of the health care community and the minds of patients?”

Covering testicles and ovaries during X-rays has been recommended since the 1950s, when studies in fruit flies prompted concern that radiation might damage human DNA and cause birth defects. Only in the past decade did radiology professionals start to reassess the practice, based on changes in imaging technology and a better understanding of radiation’s effects.

Lead shields are difficult to position accurately, so they often miss the target area they are supposed to protect. Even when in the right place, they can inadvertently obscure areas of the body a doctor needs to see — the location of a swallowed object, say — resulting in a need to repeat the imaging process, according to the American Association of Physicists in Medicine, which represents physicists who work in hospitals.

Shields can also cause automatic exposure controls on an X-ray machine to increase radiation to all parts of the body being examined in an effort to “see through” the lead.

Moreover, shielding doesn’t protect against the greatest radiation effect: “scatter,” which occurs when radiation ricochets inside the body, including under the shield, and eventually deposits its energy in tissues.

Still, Dr. Cynthia Rigsby, a radiologist at Chicago’s Ann & Robert H. Lurie Children’s Hospital, called the move away from shielding a “pretty substantial” change. “I don’t think it’s going to happen overnight,” she added.

Sweeping Shift

In April, the physicists’ association recommended that shielding of patients be “discontinued as routine practice.” Its statement was endorsed by several groups, including the American College of Radiology and the Image Gently Alliance, which promotes safe pediatric imaging.

Around the same time, the Food and Drug Administration proposed removing from the federal code a 1970s recommendation to use shielding. A final rule is expected in September.

In the coming year, the National Council on Radiation Protection and Measurements, which gives guidance to regulatory bodies, is expected to release a statement supporting a halt to patient shielding.

However, experts continue to recommend that health care workers in the imaging area protect themselves with leaded barriers as a matter of occupational safety.

Groups in Canada and Australia have endorsed the change, and a movement to abandon lead shields is underway in Great Britain, according to Marsh.

Marsh, who’s helping direct the educational effort, said perhaps a dozen U.S. hospitals have changed their official policies, but “most hospitals are starting to have the conversation.”

Chicago’s Lurie hospital is launching an “Abandon the Shield” campaign to educate staff, patients and caregivers before it stops shielding across the organization this spring, Rigsby said. Shielding is used for most of the 70,000 X-ray procedures performed annually at Lurie in a variety of settings, from orthopedics to the emergency department.

A few miles away, at the University of Chicago Medicine hospitals, the recommendation to stop shielding “came as kind of a shock,” said Dr. Kate Feinstein, chief of pediatric radiology.

Feinstein said it seems contrary to what radiology professionals are taught, and she’s uncertain how it applies to her department, which already takes steps to reduce the chance that a shield will interfere with an exam. “We apply our shields correctly, and our technologists are incredibly well trained,” she said.

Nevertheless, Feinstein said, her department is weighing a halt to routine shielding.

Some hospitals are concerned about violating state regulations. As of last spring, at least 46 states, including Illinois, required shielding of reproductive organs if they are close to the area being examined, unless shielding would interfere with the diagnostic quality of the exam, according to the medical physicists’ association.

Some states are revising their regulations. In some cases, hospitals have applied for waivers or sidestepped state rules by taking the stance that a shield has the potential to affect diagnostic quality anytime it is used, Marsh said.

No Evidence Of Benefit

The amount of radiation needed for an X-ray is about one-twentieth of what it was in the 1950s, and scientists have found no measurable harm to ovaries and testicles of patients from radiation exposure that comes from diagnostic imaging after decades of looking at data.

“What we know now is that there is likely no [hereditary] risk at all,” said Dr. Donald Frush, a radiologist at Lucile Packard Children’s Hospital Stanford in Palo Alto, California, who chairs the Image Gently Alliance.

There’s also no evidence that fetuses are harmed by even a relatively high amount of radiation exposure, such as that from a CT scan of the abdomen, Marsh said.

Nevertheless, some patients may insist on shielding. The physicists’ group suggested that when hospitals craft their policies they consider that shielding may “calm and comfort.”

“I don’t think any of us are advocating to never use it,” Frush said.

A Need For Outreach

Public confusion might develop if dentists continue to shield while hospitals don’t. An estimated 275 million medical X-ray exams were performed in the U.S. in 2016, but 320 million dental X-rays were done.

Mahadevappa Mahesh, the chief physicist at Johns Hopkins Hospital, said there’s been less outreach to dentists on the topic. “It’s high time we bring them into the discussion,” he said.

The American Dental Association states abdominal shielding “may not be necessary” but has continued to recommend using lead collars to shield the thyroid “whenever possible.”

But Mahesh, who’s on the board of the physicists’ association, cautioned that lead collars to protect the thyroid may not be helpful and could obscure images taken by newer 3D dental imaging machines.

Contacted for a response, the dental association said its guidance on shielding is under review.

Technologists especially will need support in educating patients and families “so they are not feeling like they are walking into a disastrous conversation,” said Marsh, the medical physicist.

She is doing her part. At the radiology conference, Marsh strummed a banjo and sang her version of the Woody Guthrie ballad “So Long, It’s Been Good to Know Yuh,” with lyrics like: “To get rid of shielding at first may seem strange, but the time is upon us to embrace this change.”

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Warren and Klobuchar Say They Can Lower Drug Prices Without Congress’ Help

On Tuesday, two Democrats running for president promised to do — each by herself — what Washington has so far proven unable to do: lower the prices of prescription drugs.

Speaking during the last Democratic debate before the Iowa caucus on Feb. 3, Sen. Elizabeth Warren of Massachusetts and Sen. Amy Klobuchar of Minnesota said, if elected president, they would each act immediately to directly reduce the cost of certain drugs.

Their declarations, coming from two senators who have sponsored their own bills to control skyrocketing drug prices, stood out after Congress spent last year debating the problem — and failed to pass significant legislation to fix it.

“We need to get as much help to people as we can, as soon as possible,” Warren said.

While they did not elaborate on which presidential powers they would use, Warren and Klobuchar said the president already has the legal authority to rein in drug prices. (Klobuchar actually has a list of 137 things that she could do without Congressional action that include but are not limited to action on drug pricing.)

A 2019 poll from the Kaiser Family Foundation found that, due to cost, about 29% of Americans had not taken a prescription as directed in the previous year.          

Having proposed legislation that would empower the federal government to manufacture drugs itself, Warren said she would act to lower the price of insulin and drugs that treat HIV/AIDS.

Her campaign emailed reporters a list of other targeted drugs, including the EpiPen; Humira, the top-selling rheumatoid arthritis drug whose maker has been criticized for abusing patents to stifle competition; and Naloxone, a drug that reverses the effects of opioid overdose.

Klobuchar and former Mayor Pete Buttigieg of South Bend, Ind., also endorsed empowering Medicare to negotiate lower prices with drugmakers — the proposal at the heart of the drug plan unveiled last year by Speaker Nancy Pelosi and other House Democratic leaders.

However, that idea is deeply unpopular with congressional Republicans, who describe it as government interference in the free market. While the bill passed the House in December, Sen. Mitch McConnell of Kentucky, the Republican leader, has said he will not allow it to get a vote in the Senate, killing its chances, at least for now.

Klobuchar said the real problem is the number of pharmaceutical lobbyists on Capitol Hill — two to every member of Congress, she said. PolitiFact rated this claim Mostly True last year.

“How do we actually break the corporate stranglehold on our government so we can get any of these things passed?” said Tom Steyer, a businessman who was one of the six Democratic candidates to qualify for the debate.

The debate, which took place in Des Moines less than three weeks before voting begins, gave former Vice President Joe Biden and Sen. Bernie Sanders of Vermont another opportunity to spar over the cost of “Medicare for All,” albeit only briefly.

Elaborating on how he would pay for his single-payer overhaul of the nation’s health care system, Sanders said it would involve a 4% income tax, exempting the first $29,000 of a taxpayer’s income to ease the burden on “average family in America.”

“Now is the time to take on the greed and corruption of the health care industry, of the drug companies, and finally provide health care to all through a Medicare for All single-payer program,” Sanders said. “It won’t be easy. It’s what we have to do.”

“You can do it without Medicare for All,” Biden said. “You can get to the same place.”

After six debates spent parsing the details of Medicare for All, though, Warren referenced what comes next: a general election during which the Democratic nominee will run against President Donald Trump, a Republican who wants to repeal the Affordable Care Act.

Warren said she would push her plan to expand coverage through a single-payer system — but also that she would defend the Affordable Care Act.

“I’ll take our side of the argument any day,” she said. “We’re going to beat him on this.”

The eighth debate is scheduled for Feb. 8, the first of three Democratic debates next month.

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Sanders Targets Health Industry’ Profits. Are His Figures Right?

At the January Democratic debate, Vermont Sen. Bernie Sanders zeroed in on the question of profits in the health care industry.

Under “Medicare for All,” he said, “We end the $100 billion a year that the health care industry makes.”

It’s a huge number, and one that Sanders has cited before. So we decided to look closer.

The Math

The Sanders campaign shared its math, and it’s comprehensive. 

The $100 billion total comes from adding the 2018 net revenues — as disclosed by the companies — for 10 pharmaceutical companies and 10 companies that work in health insurance. 

We redid the numbers. Sanders is correct: The total net revenues, or profits, these companies posted in 2018 comes to just more than $100 billion – $100.96 billion, in fact. We also spoke to three independent health economists, who all told us that the math checks out.

There are a couple of wrinkles to consider. Some of the companies included — Johnson & Johnson, for instance — do more than just health care. Those other services likely affect their bottom lines.

But more importantly, $100 billion is likely an underestimate, experts told us.

For one thing, there are more than just 10 pharmaceutical companies, and more than 10 insurance companies, noted Robert Berenson, a health economist at the Urban Institute. Many more exist — even if they are smaller and post smaller profits.

And this figure looks at pharmaceutical companies and insurance companies, but it doesn’t include the biggest source of health care profits: hospitals and physicians.

“You could ask the same questions of health systems and not-for-profit hospitals who are raising prices at a steady clip,” said Ellen Meara, a professor of health economics at the Harvard T.H. Chan School of Public Health. “If you’re going to go after industry, you need to go after the whole system and say prices are a problem everywhere.”

If anything, Berenson said, that makes Sanders’ point stronger. After all, $100 billion is a small proportion of the trillions spent annually via national health expenditures. When you factor in hospital margins, the number grows significantly.

So, Medicare For All?

Sanders suggested that Medicare for All would “end” the $100 billion per year profits reaped by the health care industry.

The proposal would certainly give Washington the power to do that. 

“If you had Medicare for All, you have a single payer that would be paying lower prices,” Meara said. 

That means lower prices and profits for pharmaceuticals, lower margins for insurers

and lower prices for hospitals and health systems. 

That could bring tradeoffs: for instance, fewer people choosing to practice medicine. But, Meara noted, the number supports Sanders’ larger thesis. “There’s room to pay less.”

Other health reform plans — including letting Medicare negotiate drug prices, or a government-sponsored public option, such as the plan backed by former Vice President Joe Biden and former South Bend, Indiana, Mayor Pete Buttigieg — could also have this effect. 

But, Berenson noted, having only one insurer, and having it be publicly funded, would likely have a greater impact.

“I could whack pharmaceutical companies, and I don’t need Medicare for All to do it, but I do need Medicare prices for All to deal with what the real profits are — whether you call them profits or not — which is hospitals.”

Our Ruling

Sanders said Medicare for All would “end the $100 billion a year that the health care industry makes.”

The math holds up. If anything, it’s an underestimate because it doesn’t include one of the largest sources of health care profits: hospitals, health systems and physicians. We rate it True.

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Loopholes Limit New California Law To Guard Against Lofty Air Ambulance Bills

Kathleen Hoechlin lost control as she crested a small jump on her final ski run of the day at California’s Mammoth Mountain two years ago. She landed hard on her back, crushing one of the vertebra in her lower spine “like a Cheerio,” she said.

An air ambulance flew Hoechlin, then 32, to an airport near Loma Linda University Medical Center in Southern California’s Inland Empire. There she underwent emergency 12-hour surgery to remove bone fragments and replace the crushed vertebra with a metal cage that was fused to the rest of her spine with rods and screws to provide structure and stability.

Hoechlin was still in intensive care when her husband, Matt, got the bill for the 300-mile air ambulance ride. The total: $97,269. The company wasn’t in their health plan’s network of providers, and the PPO plan they had through Matt’s job agreed to pay just $17,569.

The Hoechlins were on the hook for the $79,700 balance.

“It was just shocking,” said Hoechlin, who worked as a business analyst project manager in Highland, California. “I was just focused on, ‘Am I going to be able to walk again?’ I thought I was going to have a heart attack when he told me.”

A California law that took effect Jan. 1 aims to protect consumers from such enormous bills for out-of-network air ambulance services. The measure limits what consumers owe if they’re transported by an air ambulance that’s not part of their insurance network to the amount that they’d be charged if they used an in-network provider. The health plan and the air ambulance provider must then work out payment between themselves.

But the new law won’t protect consumers like Hoechlin, whose health plan isn’t regulated by the state. Matt’s employer pays its workers’ medical claims directly rather than buying state-regulated insurance, a common arrangement called “self-funding.” Self-funded plans are regulated by the federal government and generally not subject to state health insurance laws.

In this regard, the new air ambulance law is like laws in California and other states that protect consumers from surprise medical bills: They don’t apply to residents in federally regulated health plans. Those plans cover about two-thirds of people who get insurance through their jobs nationwide.

In California, that translates to nearly 6 million people.

Federal legislation is the best solution for those consumers, experts say. One of the leading bills before Congress to address surprise medical bills includes air ambulance charges. But that, and other measures, are up in the air, although members of Congress say they are working to reach an accord this year.

Another legal wrinkle affects even consumers with health plans the state does oversee. Under the federal Airline Deregulation Act of 1978, states aren’t permitted to regulate the “rates, routes, or services” of air carriers, including air ambulances. It’s unclear whether the California law, which doesn’t spell out a payment rate for a health plan, would be preempted by federal law if challenged in court, according to legal experts.

“It’s a very big step in balance billing, but it’s not a definitive one,” said Samuel Chang, a health policy researcher at the Source on Healthcare Price and Competition, a project of the University of California-Hastings.

Although people rarely need to be transported by a helicopter or airplane for medical care, it’s often an emergency when they do, and they’re unable to shop for an in-network provider, even if their health plan offers one. According to a federal Government Accountability Office analysis of air ambulance private insurance claims, 69% of air ambulance transports were out of network in 2017.

The median price charged in 2017 was $36,400 for a transport by helicopter and $40,600 by plane, according to the report. If an insurer doesn’t have a contract with an air ambulance provider, the air ambulance company may bill the consumer for whatever the insurer doesn’t pay, a practice known as balance billing.

“The air ambulance issue is such a big deal because it’s just such an eye-popping bill,” said Yasmin Peled, the policy and legislative advocate at Health Access California, a consumer advocacy group.

Air ambulance providers defend their charges, saying the rates offered by commercial insurance companies barely cover their costs. And public insurance programs often pay even less.

“Seven out of 10 of our transports are Medicare, Medicaid or uninsured,” said Doug Flanders, director of communications and government affairs at Air Methods, a large air ambulance company that provides services in 48 states, including California. Medicare pays Air Methods an average of $5,998 per transport, and Medicaid payments are typically half of that, Flanders said via email. That presents a “huge financial challenge,” he said.

In recent years, Air Methods has focused on joining the networks of some major insurers, including Blue Shield of California and Anthem Blue Cross of California, Flanders said. In addition to protecting patients, being in network “stabilizes operations and eases the administrative burden of the claims processing procedures created by insurers,” he said.

For the past several years, reimbursements by Medi-Cal, the state’s Medicaid program, for air ambulance services have been bolstered by funds collected from penalties for traffic violations. But the penalty was slated to sunset in 2020. Under the new California law, the state will extend supplemental funding of Medi-Cal payments for air ambulance services until 2022. Without that agreement, the rates would have reverted to much lower 1993 levels.

With the higher Medi-Cal rates, the industry supported the bill, including the prohibition on balance billing. In fact, the California Association of Air Medical Services sponsored the bill, although it didn’t respond to requests for comment.

In contrast, when other states have tried to prohibit air ambulance balance billing, the companies have often successfully challenged those laws on the grounds that the federal Airline Deregulation Act of 1978 prohibits state rate setting, according to Erin Fuse Brown, an associate law professor at Georgia State University who has studied air ambulance billing.

Legal experts say California’s approach may thread the needle where other states have failed.

“I do think the state has a pretty tolerable argument here that they are not regulating rates,” said Christen Linke Young, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy. “They are telling the air ambulance providers who they can go to to get paid, but they’re ultimately not telling the amount that is getting paid.”

Kathleen Hoechlin and her husband, who now live in Riverside, California, eventually negotiated the amount they owed down to $20,000, arguing to the air ambulance firm that by tapping their savings and using money from a GoFundMe campaign, that was all they could afford.

She is now able to walk with only a slight limp. But she continues to deal with severe pain due to nerve damage. She recently underwent a fourth surgery to implant a spinal cord stimulator to interrupt the pain signal to her brain.

“When you look at the bigger picture, at the total amount, we’re feeling very fortunate,” she said.

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

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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! In things I’ve learned today that I can’t stop thinking about: We apparently carry fat in our tongues? And you can lose it like any other fat on your body. This feels like something I should have known as a human, and yet I somehow managed 30-plus years without this information. Anyway, now that everyone is thinking too much about their tongues, let’s head to the news.

Democrats have asked the Supreme Court to expedite the case on the constitutionality of the health law, pushing for a ruling on the case during this term. This might seem paradoxical — as the lower courts have ruled against the ACA — but, as you Breeze readers know, the move is politically savvy. The health law is more popular than ever, and Democrats have been owning that advantage. If they can keep the Republicans’ attack on the legislation in the front of voters’ minds heading into the 2020 elections, there could be a repeat of the blue-wave midterms.

SCOTUS gave the Trump administration and Republicans until today to respond. (As of press time, they haven’t yet.)

The New York Times: Democrats Ask Supreme Court for Quick Decision on Obamacare


In a pretty harsh reality check, a new study this week found that a popular idea for cutting health spending doesn’t pan out when you look at the data. The strategy is based on identifying the hardest-to-treat, most expensive patients and better coordinating their care. But, despite the hype, the method didn’t cut hospital readmissions for those patients. The study highlights once again what we all know: Health care is complicated. And hyped-up promises to cut costs that sound too good to be true too often are.

Kudos to the evangelists of the method, though, for acknowledging it doesn’t work. “We could have coasted on the publicity we were getting,” said Dr. Jeffrey Brenner, a family physician in New Jersey who founded the program that was studied. “It’s my life’s work. So, of course, you’re upset and sad.”

The New York Times: These Patients Are Hard to Treat

The administrative costs of running a single-payer system in Canada come in at $551 per person per year. That seems like a lot, right? That’s what I thought, too, until I saw the total for Americans, which is *drum roll* $2,497 per year.

Los Angeles Times: U.S. Health System Costs Four Times More to Run Than Canada’s


California Gov. Gavin Newsom has proposed that California get into the drug-selling business — generic drugs, that is. The theory behind it is to increase competition and drive down prices. But despite generics accounting for 90% of the prescriptions filled in the country, they aren’t really the problem when talking high drug prices. It’s uncommon for those types of meds to only have one player in the marketplace, so pricing already tends to be competitive. For the average person, Newsom’s plan wouldn’t make much of a dent.

Los Angeles Times: Q&A: What You Need to Know About Gov. Newsom’s Drug Plan for California

But a strategy some people are hoping would make a difference is the VA model. The troubled federal agency might not have many bright spots these days, but patients who get prescriptions through Veterans Affairs are less likely than other insured Americans to skip doses and less likely to delay filling prescriptions because they were unable to afford them. What’s more, the program seems to curb racial disparities in accessing meds.

Stat: The VA Approach to Buying Drugs Means Patients Are Less Likely to Skip Medications Due to Cost

Mark your calendar: The annual J.P. Morgan Healthcare Conference runs through next week, and, as it nears, Stat looks back at the past 20 years of the event and how it has shaped the health care world. What emerges is a story of heroes and villains, booms and busts, sensational scandals, drinks and deals, flaring tempers and foolish predictions, and far more drama than anyone could expect from health care industry executives.

Stat: The Ghosts of JPMs Past: How 20 Years of Deals Have Shaped Health Care


In the latest sign that red-state resistance against Medicaid expansion is fading, Kansas Democratic Gov. Laura Kelly fulfilled a campaign promise by reaching a deal with Kansas Senate Republican Leader Jim Denning after a years-long impasse between the state’s two parties. Denning is eyeing a tough reelection race for next year — which could make the decision all the more notable.

The Wichita Eagle: Kansas Governor Kelly, Senate GOP Leader Reach Medicaid Deal


In a rare glimpse of good news, cancer death rates plummeted dramatically over a one-year period in the largest drop ever seen in national cancer statistics dating to 1930. The reason? Advancements in lung cancer treatments.

The Associated Press: Cancer Group Finds Biggest One-Year Drop in U.S. Death Rate

The back-and-forth over whether baby powder can be linked to ovarian cancer is the debate that launched 1,000 lawsuits (plus a couple of thousand more). A big study, however, tries to put the matter to rest. Research — that was deemed “overall reassuring” — now shows there is no strong connection between the two.

The Associated Press: Big Study Finds No Strong Sign Linking Baby Powder & Cancer


In the never-ending finger-pointing game that signals a reckoning in the opioid crisis, major drugstore chains like CVS and Walgreens are saying, “Nuh-uh, not our fault!” Instead, they say, doctors are to blame. Who are pharmacists to question doctors’ orders? The counter-argument, of course, is that when you’re filling prescriptions that equate to thousands of pain pills per person in a town you’re serving, it might be expected that someone would raise a red flag. Just maybe.

Experts say that by bringing up the doctors and providers, the drugstore chains could also be trying to complicate the case further, in hopes of mitigating some damage to themselves.

The Washington Post: Major Drugstore Chains Sue Doctors in Sprawling Federal Opioid Case


In the miscellaneous file for the week:

— You’ve heard of ambulance-chasing lawyers, but what about ambulance-chasing doctors? It’s becoming a growing practice for doctors to promise plaintiffs in personal-injury cases free upfront care with the hope of cashing in when the settlement comes. While the strategy is legal and doesn’t technically violate any ethical rules, it still seems a little off — and can also leave patients with big bills if their lawsuits don’t go as planned.

The Wall Street Journal: Who Wins in a Personal-Injury Lawsuit? It Can Be the Doctor

— Public health experts are warily watching the development of a pneumonia-like illness in China, with echoes of the SARS outbreak not distant enough not to draw comparison and concern.

The New York Times: China Identifies New Virus Causing Pneumonia-Like Illness

— As we continue to watch suicide rates skyrocket, experts scramble to figure out what can be done to halt the disturbing rise. Now, research suggests hope could come from an interesting strategy: raising the minimum wage by just $1.

NPR: For Suicide Prevention, Try Raising the Minimum Wage, Research Suggests

— A truism that has emerged for me over my decade-plus in journalism is that where there’s a catastrophe or disaster, there is someone who stands to gain something. In this case, it’s the windfall that will come to hospitals if the flu season is as bad as predicted.

Bloomberg: Record 2019-2020 Flu Season May Be Good for Hospitals


On that cheerful note, that’s it from me. Have a great weekend!

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High-Deductible Plans Jeopardize Financial Health Of Patients And Rural Hospitals

Kristie Flowers had been sick with the flu for four or five days in July before the 52-year-old registered nurse from Genoa, Colo., acknowledged she needed to go to the ER.

At Lincoln Community Hospital, about 10 miles from her home on the Eastern Plains of Colorado, doctors quickly diagnosed her with pneumonia and sepsis. Her right lung had completely filled with fluid, and Flowers needed much more intensive care than the 15-bed hospital could provide.

Doctors stabilized Flowers and transferred her by ambulance about 80 miles away to St. Francis Medical Center in Colorado Springs. There, doctors put her on a ventilator for 10 days as they slowly nursed her back to health. After two weeks, she returned to Lincoln Community Hospital for another week of rehab before going home.

After her insurance plan had paid its share, Flowers owed $8,000 in medical bills. A big chunk represented the $3,500 deductible from her employer-sponsored health plan. Never one to let the bills pile up, Flowers went to the bank and took out an $8,000 loan to pay off her medical tab.

Plans with annual deductibles of $3,000, $5,000 or even $10,000 have become commonplace since the implementation of the Affordable Care Act as insurers look for ways to keep monthly premiums to a minimum. But in rural areas, where high-deductible plans are even more prevalent and incomes tend to be lower than in urban areas, patients often struggle to pay those deductibles.

That has hit patients like Flowers hard as they grapple with medical debt when emergencies happen — but small rural hospitals like Lincoln Community are suffering, too. These facilities often stabilize critically ill patients and then transfer them to larger regional or urban hospitals for more definitive care.

But when the hospitals submit their claims, bills from the first site of care generally get applied to a patient’s deductible. And if patients can’t afford to cover that amount, those hospitals often don’t get paid, even as the larger urban hospitals where patients were transferred get close to full payment from the health plan.

“As soon as we send them to the city, those things start being paid by the insurance company,” said Kevin Stansbury, CEO of Lincoln Community, “while we’re still chasing the patient around for collections.”

The result is financial headaches for patients and a substantial rise in the amount of uncollectible “bad debt” written off by all hospitals during the past few years. According to the Healthcare Financial Management Association, hospital bad debt increased by $617 million to nearly $56.5 billion between 2015 and 2018. More hospitals, especially those in rural areas, are left teetering financially.

At least 120 rural hospitals nationwide have shut down in the past decade. Without changes, advocates say,     more will close, leaving patients such as Flowers in remote areas far from access to immediate emergency care.

Shopping On Premiums

According to the nonprofit National Rural Health Association, bad debt for rural hospitals has gone up about 50% since the passage of the Affordable Care Act in 2010.

“People in rural America were buying plans maybe for the first time, but buying plans they couldn’t afford,” said Maggie Elehwany, the group’s vice president for government affairs and policy. The plans “seemed to make sense at the time, until they got sick.”

Part of the problem is that consumers primarily shop based on monthly premiums, and insurance plans can lower the monthly premiums they charge by increasing deductibles and copays. Some consumers take the gamble that they’ll stay healthy and won’t get stuck paying the high deductible. But others simply may not understand they are typically responsible for the full deductible before their insurance kicks in to cover the rest of their bills.

In many rural counties, consumers shopping on their state’s health insurance exchange had little choice. This year, about 10% of enrollees, living in 25% of counties, many of them heavily rural, will have access to just one insurer in their local Affordable Care Act marketplaces, according to a Kaiser Family Foundation analysis. (KHN is an editorially independent program of the foundation.)

“The exchanges have never worked the way they were envisioned,” Elehwany said. “The goal was you go on your computer and it’s going to be like buying an airline ticket, and just shopping around for what makes sense for you. There’s no shopping in rural America. You have one choice.”

In Colorado, for example, the average deductible in 2017 was nearly $5,800 for a bronze-level plan. According to an analysis by the Colorado Center on Law & Policy, 1 in 4 Coloradans would not be able to afford to pay that deductible over the course of a year. The ability to pay was even worse in rural areas.

Mark Holmes, director of the North Carolina Rural Health Research and Policy Analysis Center, said that incomes are generally lower in rural areas than elsewhere, and that higher-income rural residents are more likely to travel to an urban hospital than to stay local. Lower-income rural residents, meanwhile, generally go to their local hospital, he said, but they are less likely to be able to meet a high deductible.

Rural residents are also less likely to be covered by employer-sponsored plans and, therefore, more likely to face high deductibles than their urban counterparts.

“They may never pay us,” said Stella Worley, CEO of the 25-bed Keefe Memorial Hospital in Cheyenne Wells, Colo., near the Kansas line. “They get transferred onto high level of care and the other hospital gets paid. We get paid nothing — a lot.”

Worley recalled one patient who had been treated and transferred to a larger hospital. Keefe Memorial wrote off $14,000 in total charges. The patient was billed $1,000 for his deductible and never paid it. Eventually, the unpaid bill went to a collection agency, which takes a 30% cut if it ever collects the fee.

For many rural residents, paying a monthly premium and still facing thousands of dollars in out-of-pocket costs can feel like having no insurance at all. As a result, patients avoid seeking primary care services that could solve minor problems before they devolve into major health issues with much higher costs.

“Some of the people I know in our community trying to get insurance for their employees had a $10,000 deductible, which is really catastrophic insurance,” said Rob Santilli, CEO of Gunnison Valley Health, in Gunnison, Colo. “It’s not going to help them, and it immediately puts them into bad debt with the first instance when they need coverage.”

To be sure, non-rural hospitals have also seen an increase in bad debt. But most city hospitals are part of a larger health system and can weather the storm better than small, independent rural hospitals operating on razor-thin margins.

Colorado has so far avoided the rural hospital closures that have plagued other states. Nonetheless, 22 rural hospitals in Colorado operated in the red last year, according to Michelle Mills, CEO of the Colorado Rural Health Center. That’s double the number in 2018.

“We’re definitely at a tipping point,” Mills said.

Finding Solutions

Hospital and rural health groups across Colorado are lobbying for changes in insurance plan designs to circumvent the impact from high-deductible plans. Lincoln Community’s Stansbury suggested that primary care services, which help keep rural hospitals afloat and patients healthy, should be exempt from the deductible to encourage patients to keep up with their care.

Another option would be simplifying billing so insurance plans would pay hospital and doctor bills directly and send patients a single bill of what they owe. That approach would solve a common complaint from patients who struggle to reconcile multiple bills from various hospitals, doctors and other health care providers that stem from a single episode of care. It would also shift the burden of collecting the patient’s portion of the bill to insurance companies, and protect the hospitals against uncollectible bad debt, leveling the playing field for the rural hospitals.

The Colorado Hospital Association is working with several state legislators to propose that sort of billing structure during the 2020 legislative session. Stansbury said the approach would also allow rural hospitals to focus on patient care rather than trying to collect payments.

“We just don’t have the expertise for billing,” he said. “We do it badly.”

The National Rural Health Association favors requiring insurance plans that offer Medicare and Medicaid plans in rural areas to also offer exchange plans in those counties. If rural consumers had more options, they might be able to avoid high-deductible plans.

That could minimize bad debt for rural hospitals and pay dividends far beyond health care, Elehwany said.

“When you’ve got a small rural hospital and it closes, it’s a nail in the coffin of that rural community,” she said. “How are you going to attract a business? How are you going to keep your school if you don’t have physicians? In rural America, health care is really part of the whole infrastructure of the community.”

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