Tagged Medicare

Viewpoints: Rising Medicare Premiums Pinching Budgets; GOP Needs Alternative To Individual Mandate

Medicare Trust Fund Is Not Sustainable Long-Term, HHS Warns

Podcast: ‘What The Health?’ Tax Bill Or Health Bill?

Republican efforts to alter the health law, left for dead in September, came roaring back to life this week as the Senate Finance Committee added a repeal of the “individual mandate” fines for not maintaining health insurance to their tax bill.

In this episode of “What the Health?” Julie Rovner of Kaiser Health News, Sarah Kliff of Vox.com, Joanne Kenen of Politico and Alice Ollstein of Talking Points Memo discuss the other health implications of the tax bill, as well as the current state of the Affordable Care Act.

Among the takeaways from this week’s podcast:

  • The tax bill debate proves that Republicans’ zeal to repeal the Affordable Care Act is never dead. The new congressional efforts to kill the penalties for the health law’s individual mandate could seriously wound the ACA since the mandate helps drive healthy people to buy insurance.
  • One of the most overlooked consequences of the tax debate is that it could trigger a substantial cut in federal spending on Medicare.
  • A $25,000 MRI? That’s what one family paid to go out of their plan’s network to get the hospital they wanted for the procedure for their 3-year-old. Such choices are again drawing complaints about narrow networks of doctors and hospitals available in some health plans.
  • Although they don’t likely say it in front of cameras, many Democrats are relieved at President Donald Trump’s choice to head the Department of Health and Human Services, former HHS official Alex Azar.
  • Federal officials have given 10 states and four territories extra money to keep their Children’s Health Insurance Programs running but it’s not clear what couch they found the money hidden in.
  • And in remembrance of Uwe Reinhardt, a reminder that he always stressed that a health care debate was about more than money – it was about real people.

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

Julie Rovner: Statnews.com’s “This Tennessee insurer doesn’t play by Obamacare’s rules – and the GOP sees it as the future,” by Erin Mershon.

Also: Georgetown University Health Policy Institute’s “What’s Going on in Tennessee? One Possible Reason for Its Affordable Care Act Challenges,” by Kevin Lucia and Sabrina Corlette.

Sarah Kliff: Bloomberg Businessweek’s “How to Make a Fortune on Obamacare,” by Bryan Gruley, Zachary Tracer, and Hannah Recht.

Joanne Kenen: Politico Magazine’s “How Bourbon and Big Data Are Cleaning Up Louisville,” by Arthur Allen.

Alice Ollstein: Talking Points Memo’s “Trump’s Abrupt Policy Shift Fuels Misleading Obamacare Renewal Info,” by Alice Ollstein.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

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Health Care Costs Insurance Medicare Multimedia The Health Law

Perspectives: A New Front For An Old Obamacare War; How Tax Reform Tees Up Medicare Cuts

Perspectives: A New Front For An Old Obamacare War; How Tax Reform Tees Up Medicare Cuts

Bipartisan Bill Seeks To Overturn New Cuts In Some Medicare Drug Payments

Bipartisan Bill Seeks To Overturn New Cuts In Some Medicare Drug Payments

Medicare Seeks Comment On Ways To Cut Costs Of Part D Drugs

Noting that the true price of a drug is often hidden from consumers, Medicare officials requested comments late Thursday on how to use discounts and rebates to help decrease what enrollees pay for prescriptions.

The proposal request, buried in hundreds of pages released late Thursday afternoon, asked for public comment on how to share the rebates and discounts that are negotiated by manufacturers, pharmacists and insurers. Insurers and pharmacy benefit managers, or PBMs, administer Medicare’s Part D drug program and negotiate behind-the-scenes fees and discounts that are often hidden from public view.

Officials at Medicare “are asking: ‘Tell us what you want,’” said Jack Hoadley, a commissioner with the Medicare Payment Advisory Commission and a health policy analyst at Georgetown University. “They are open to ideas both around manufacturer rebates and the pharmacy price concessions.”

Requests for comments are open until Jan. 16 and, Hoadley said, it may be a challenge to institute any changes before 2020. But other parts of the proposed rule are more likely to take effect sooner. Those include:

  • Allowing enrollees to buy drugs at the pharmacy they prefer, by revising participation rules to motivate more local pharmacies to participate in the program.
  • Lowering drug costs by allowing for midyear changes to prescription drug formularies when a generic becomes available.
  • Treating lower-cost drugs called biosimilars, such as cancer drug Zarxio, the same as generics when determining how much they cost out-of-pocket.

While the request for information on the fees and discounts is not yet a proposal, pressure has been building for the administration to take action.

Earlier this year, the Centers for Medicare & Medicaid Services (CMS) released a fact sheet that set the stage for change, describing how the fees kept Medicare Part D and monthly premiums lower but translated to higher out-of-pocket spending by enrollees and increased costs to the program overall.

Supporters of a rule change say they want the fees disclosed and for them to be applied to what enrollees pay for their drugs. However, there are questions about how the rule would work and whether it would drive up premium prices for Medicare Part D plans.

“There’s a potential to bring about the price reductions at the point of sale,” Hoadley said. “That might come at the expense of higher premiums. Money is going to move from one pot to another.”

In the proposal out Thursday, CMS writes that when manufacturer rebates and pharmacy price concessions are not reflected at the point of sale, Medicare enrollees might get a break with lower premiums but “end up paying a larger share of the actual cost of a drug.”

Congress has also raised concerns, sending letters to CMS officials asking about transparency, sharing the discounts with enrollees and introducing related legislation.

When Sen. Chuck Grassley (R-Iowa) and 10 other senators sent a letter in July to the agency asking for more transparency in the fees, CMS Administrator Seema Verma responded last month that they were analyzing the issue.

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

Related Topics

Cost and Quality Medicare Pharmaceuticals

State Highlights: In Ill., Feds Investigate Cook Co. Health System Security Lapse; Survey Grades Patient Safety At San Francisco Hospitals

Media outlets report on news from Illinois, California, Massachusetts, Arkansas, Texas and Ohio.

San Francisco Chronicle: How Safe Is Your Hospital? Survey Grades SF-Area Medical Centers
About 1,000 patients die in the United States each day because of preventable hospital errors, according to the Leapfrog Group, a national nonprofit organization that compiles an annual survey on hospital performance. The Leapfrog Hospital Safety Grade assigns letter grades to hospitals based on their record of patient safety. … We wanted to see how local hospitals compare on safety issues, so we chose those in a 25-mile radius of downtown San Francisco. Of 26 hospitals, seven received A’s, seven earned B’s, another seven got C’s and five were marked D’s. (Moffitt, 11/14)

Boston Globe: Beth Israel Deaconess To Build 10-Story Patient Building
Beth Israel Deaconess Medical Center plans to construct a new 10-story patient care building, its largest such project in more than 20 years. The building in Boston’s Longwood Medical Area would house private patient rooms, operating rooms, and imaging facilities, and it would include a rooftop landing pad for medical helicopters, according to a letter hospital officials filed with the Boston Planning & Development Agency. The building would have 345,000 square feet of space and would be located on the western end of the hospital campus. (Dayal McCluskey, 11/14)

The Associated Press: Appeals Court Won’t Reconsider Planned Parenthood Defunding
A federal appeals court said Monday it won’t reconsider a ruling that Arkansas can block Medicaid funding to Planned Parenthood, setting up a potential showdown over defunding efforts by conservative states over videos secretly recorded by an anti-abortion group. The 8th U.S. Circuit Court of Appeals denied a request by three Planned Parenthood Great Plains patients to reconsider a three-judge panel’s decision upholding the state’s defunding decision. (11/13)

Boston Globe: Catholics Split Over Petition Drives At Churches
A controversy is brewing at local churches between Catholics whose faith guides their politics and those who favor a wall between church and state, after the archbishop of Boston said late last month that political signature drives are permissible on church property. Mary Collins, who has attended Marlborough’s Immaculate Conception Parish for 15 years, said she was “startled” when it was announced last Sunday that some parishioners would gather signatures in the church lobby after Mass for a measure that would prohibit funding abortions with state dollars. (Fox, Capelouto and Guerra, 11/13)

Texas Tribune: Health Clinic Provides Free Abortions To 85 Women Affected By Hurricane Harvey
Whole Woman’s Health provided free abortions to 85 women affected by Hurricane Harvey, the clinic said Monday. The procedures, which took place at the clinic’s Austin and San Antonio locations, were offered for free to Harvey victims during September. A dozen other women received free consultations through the clinic but did not have abortions performed. (Platoff, 11/13)

NPR: AARP Foundation Sues Nursing Home To Stop Illegal Evictions
A California judge could decide Tuesday if Gloria Single will be reunited with her husband, Bill. She’s 83 years old. He’s 93. The two have been married for 30 years. They lived in the same nursing home until last March, when Gloria Single was evicted without warning. Her situation isn’t unique. Nationwide, eviction is the leading complaint about nursing homes. In California last year, more than 1,500 nursing home residents complained that they were discharged involuntarily. That’s an increase of 73 percent since 2011. (Jaffe, 11/13)

The Associated Press: CA Doctor’s License Suspended After 2 Patient Deaths
The board’s ruling says one of the patients experienced respiratory arrest after waking up from breast augmentation surgery in 2013 and died after being taken to a hospital. It says another patient’s 2013 death was “likely due to ‘trauma’ caused by the surgical procedure.” Yoho’s attorney, Albert Garcia, said that the women died from fat embolisms but he decided to settle with the medical board. (11/13)

The Associated Press: Man: Psychiatric Hospital Staff Tormented, Kicked Brother
A man who says his brother was abused repeatedly by staff at Connecticut’s only maximum-security psychiatric hospital urged lawmakers on Monday to look more deeply into the case and make changes at the state-run facility. Al Shehadi said he came forward to give a name to the victim at the center of internal and criminal investigations, to tell his brother’s story and to “encourage this committee to continue to investigate what happened.” (11/13)

Fresno Bee: They Went To A Plastic Surgeon To Improve Their Looks, But Wound Up Dead
The state medical board has ordered a 30-day suspension for a Visalia plastic surgeon accused of gross negligence and incompetence in the treatment of four patients, including two women who died in 2013. Dr. Robert Alan Yoho, who has had offices in Pasadena and Visalia, cannot practice medicine from Nov. 19 through Dec. 16 under the disciplinary order by the Medical Board of California. The suspension was part of a five-year probation the board imposed. (Anderson, 11/13)

Cincinnati Enquirer: Cincinnati-Based Chemed Pays $75M To Settle Medicare Lawsuit
Chemed has paid the U.S. government a record $75 million to settle lawsuits claiming the hospice care provider submitted false claims to Medicare. The settlement resolves allegations that between 2002 and 2013 Chemed subsidiary Vitas knowingly submitted or caused to be submitted false claims to Medicare for services to hospice patients who were not terminally ill. (Coolidge, 11/13)

KQED: A Food Community Unites To Pay Local Farmers And Feed Fire Evacuees Nourishing, Home-Cooked Meals
On the first Friday after the North Bay fires swept through Sonoma County, displacing an estimated 100,000 people, Tim Page drove from San Francisco to the Salvation Army in Sonoma County with 2,000 fresh, chef-made breakfasts, courtesy of SF Fights Fire, stacked in the back of his company van. The trip was the first of many made over the next two weeks by Page and his employees at F.E.E.D. Sonoma, a micro-regional produce aggregation and distribution food hub in Sebastopol that functions as a conduit between dozens of small, organic farms and chefs and restaurants across the Bay Area. (Clark, 11/13)

KQED: Benicia Still Looking for Answers from Valero Six Months After Refinery Outage
When a massive refinery outage sent flames, black smoke and toxic gas shooting into the sky from Valero’s Benicia plant last spring, the city’s mayor said the local government had little information about what was going on. Days later Mayor Elizabeth Patterson called for the city to develop regulations that would give Benicia more oversight over the oil giant it hosts. She proposed regulations similar to those in Contra Costa County, home to several refineries, that require oil refining facilities to undergo safety audits and share their risk management plans. … But six months after one the Bay Area’s worst refinery malfunctions in the last five years, the refinery oversight measure has not moved through the City Council. (Goldberg, 11/14)

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

State Highlights: In Ill., Feds Investigate Cook Co. Health System Security Lapse; Survey Grades Patient Safety At San Francisco Hospitals

Data Is Starting To Pull Curtain Back On Health Costs, But There’s Still A Long Way To Go

Experts hope the extra transparency, though, will change Americans’ behavior as consumers. In other news on medical costs, the toll of the Las Vegas shooting, Medicare billing and virtual doctors.

Georgia Health News: Are Our Health Care Prices Not As Reasonable As We Thought?
The prices of health care services have long been opaque to the average person. Individuals often don’t know whether they are being overcharged or not. But recent efforts by health insurers, state legislatures and private firms have begun to reveal more information about the cost of care for consumers. Still, the picture is not always crystal clear. As comparative information on health care prices has become more available in recent years, Atlanta and Georgia typically rank below the national averages. But a new comparison of hospital outpatient costs shows the opposite about metro Atlanta — with its hospitals ranking above the national average, and indeed among the most costly in the nation. (Miller, 11/13)

Bloomberg: Las Vegas Massacre May Add More Than $1 Billion To Insurer Costs
The deadliest mass shooting in modern U.S. history is adding to soaring costs for insurance companies, which are already taking a beating this year from an onslaught of hurricanes, earthquakes and wildfires. The industry may have to shell out more than $1 billion for the Las Vegas massacre, insurance executives say. Acts of a solo gunman, who killed almost 60 people and injured about 500 others when he fired into the crowd of a country music festival last month from his Mandalay Bay hotel room, have resulted in multiple lawsuits. Victims have accused the hotel and its owner, MGM Resorts International, and concert promoter Live Nation Entertainment Inc., of failing to protect people at the event. (Levitt and Vasak, 11/10)

CBS News: Medicare Billing: Hospital “Observation” Can Cost You
Although Medicare doesn’t cover general custodial nursing home care — such as help with daily living, administering medicine, etc. — it does pay for prescribed follow-up treatment in a skilled nursing facility with specialized care. To qualify for this benefit, though, Medicare patients must have previously stayed in a hospital for three days, not counting the day of discharge. Because [Mary] Higgins had been in the hospital five days, she and [Regina] Titus figured everything was all set. Except for one big problem: Higgins was admitted to the hospital under “observation” status. (Konrad, 11/13)

Milwaukee Journal Sentinel: Virtual Doctor Visits Offer Patients A Convenient, Low-Cost Option
Twice this year, Wendy Harrop has gotten medical care that normally would have meant a trip to an urgent care clinic. The first time was for a sinus infection, the second for a spider bite. Both times she got the care she needed — and saved time and money. The service she used enables anyone to get medical care for simple conditions from a doctor or a nurse practitioner by telephone or, better still, by video chat using a computer, tablet or smartphone. … Harrop’s experience shows why telehealth, particularly so-called virtual visits, is on its way to becoming an integral part of primary care. (Boulton, 11/13)

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

Data Is Starting To Pull Curtain Back On Health Costs, But There’s Still A Long Way To Go

Experts hope the extra transparency, though, will change Americans behavior as consumers. In other news on medical costs, the toll of the Las Vegas shooting, Medicare billing and virtual doctors.

Georgia Health News: Are Our Health Care Prices Not As Reasonable As We Thought?
The prices of health care services have long been opaque to the average person. Individuals often don’t know whether they are being overcharged or not. But recent efforts by health insurers, state legislatures and private firms have begun to reveal more information about the cost of care for consumers. Still, the picture is not always crystal clear. As comparative information on health care prices has become more available in recent years, Atlanta and Georgia typically rank below the national averages. But a new comparison of hospital outpatient costs shows the opposite about metro Atlanta — with its hospitals ranking above the national average, and indeed among the most costly in the nation. (Miller, 11/13)

Bloomberg: Las Vegas Massacre May Add More Than $1 Billion To Insurer Costs
The deadliest mass shooting in modern U.S. history is adding to soaring costs for insurance companies, which are already taking a beating this year from an onslaught of hurricanes, earthquakes and wildfires. The industry may have to shell out more than $1 billion for the Las Vegas massacre, insurance executives say. Acts of a solo gunman, who killed almost 60 people and injured about 500 others when he fired into the crowd of a country music festival last month from his Mandalay Bay hotel room, have resulted in multiple lawsuits. Victims have accused the hotel and its owner, MGM Resorts International, and concert promoter Live Nation Entertainment Inc., of failing to protect people at the event. (Levitt and Vasak, 11/10)

CBS News: Medicare Billing: Hospital “Observation” Can Cost You
Although Medicare doesn’t cover general custodial nursing home care — such as help with daily living, administering medicine, etc. — it does pay for prescribed follow-up treatment in a skilled nursing facility with specialized care. To qualify for this benefit, though, Medicare patients must have previously stayed in a hospital for three days, not counting the day of discharge. Because [Mary] Higgins had been in the hospital five days, she and [Regina] Titus figured everything was all set. Except for one big problem: Higgins was admitted to the hospital under “observation” status. (Konrad, 11/13)

Milwaukee Journal Sentinel: Virtual Doctor Visits Offer Patients A Convenient, Low-Cost Option
Twice this year, Wendy Harrop has gotten medical care that normally would have meant a trip to an urgent care clinic. The first time was for a sinus infection, the second for a spider bite. Both times she got the care she needed — and saved time and money. The service she used enables anyone to get medical care for simple conditions from a doctor or a nurse practitioner by telephone or, better still, by video chat using a computer, tablet or smartphone. … Harrop’s experience shows why telehealth, particularly so-called virtual visits, is on its way to becoming an integral part of primary care. (Boulton, 11/13)

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

Trump Administration Chips Away At Initiatives That Base Payments On Quality Over Quantity

Experts have said that paying doctors for quality care instead of just the number of appointments they take would help rein in burgeoning medical costs. But the Trump administration wants to slow efforts to shift toward that model.

The New York Times: Trump Health Agency Challenges Consensus On Reducing Costs
For several decades, a consensus has grown that reining in the United States’ $3.2 trillion annual medical bill begins with changing the way doctors are paid: Instead of compensating them for every appointment, service and procedure, they should be paid based on the quality of their care. The Obama administration used the authority of the Affordable Care Act to aggressively advance this idea, but many doctors chafed at the scope and speed of its experiments to change the way Medicare pays for everything from primary care to cancer treatment. Now, the Trump administration is siding with doctors — making a series of regulatory changes that slow or shrink some of these initiatives and let many doctors delay adopting the new system. (Goodnough and Zernike, 11/12)

In other news —

The Wall Street Journal: Fewer Return Visits To The Hospital, But Higher Rates Of Death, Study Finds
The Affordable Care Act required Medicare to penalize hospitals with high numbers of heart failure patients who returned for treatment shortly after discharge. New research shows that penalty was associated with fewer readmissions, but also higher rates of death among that patient group. The researchers said the study results, being published in JAMA Cardiology, can’t show cause and effect, but “support the possibility that the [penalty] has had the unintended consequence of increased mortality in patients hospitalized with heart failure.” (Evans, 11/12)

Modern Healthcare: Redesigning Hospitals With Patient Experience In Mind
The clinics are flanked by an atrium, a cafe and a library with an outdoor deck. Their main concourses are dotted with furnished alcoves. One thing they don’t have: designated waiting rooms. That’s because patients at the clinics in the Health Transformation Building at Dell Medical School, part of UT Health Austin, can either go straight to their rooms, if available, or if they arrive early, to any of those decidedly non-institutional spaces, where in the future they’ll be buzzed via a smartphone app. (Arndt, 11/11)

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

Viewpoints: Veterans Day Thoughts On Vets’ Health Care; GOP’s Tax-Reform Secret: Success Is Tied To Medicare Cuts

A selection of opinions on health care from around the country.

USA Today: On Veterans Day, A VA Doctor Shares Praise And Hope
Perhaps this is the inevitable conclusion for someone only reading news headlines about the Department of Veterans Affairs, but I am honored to be a VA doctor. The other day, I was in a Lyft car (I am writing from San Francisco, after all.) chatting with the driver when I mentioned I work at the VA. He immediately opened up and shared that he was an Iraq War veteran and told me all about his primary care doctor at the VA and the support he received as he transitioned back to civilian life. He thanked me for my service to the veterans. I thanked him for his service to our country. This is the VA that I know, the VA that our country should be proud of. (Megha Garg, 11/10)

JAMA: Transforming The Military Health System
The Military Health System (MHS) is one of the largest health systems in the United States, delivering health services to 9.4 million eligible patients in nearly 700 military hospitals and clinics around the world as well as through the TRICARE health plan. … The National Defense Authorization Act for Fiscal Year 2017 directs changes to existing management structures, enabling the MHS to collectively transform into an integrated system of readiness and health. … This Viewpoint describes the strategic logic of a transformation that Sen John McCain (R, Arizona) stated was the “Most sweeping overhaul of the [MHS] in a generation.” (David J. Smith, Raquel C. Bono and Bryce J. Slinger, 11/9)

Reuters: For U.S. Republicans, Tax Reform Math Hinges On Cutting Medicare
A 2018 budget blueprint approved by Congress late last month would reduce Medicare spending by $473 billion over 10 years compared with the current baseline projection, and proposes $1.3 trillion in cuts to Medicaid, various Affordable Care Act (ACA) tax credits and cost sharing subsidies and other health spending. Republicans need the spending reductions to make room for $1.5 trillion in tax cuts, mostly for corporations and wealthy households. The budget plan does not include the specifics on how these cuts will be achieved. (Mark Miller, 11/9)

The New England Journal Of Medicine: Explaining Sluggish Savings Under Accountable Care
Despite aggressive targets set by Medicare for the spread of value-based payment arrangements and widespread agreement on the importance of delivery-system reform, progress toward lower spending growth and a transformed delivery system has been slow. Accountable care organizations (ACOs) are a prime example: nearly 1000 organizations operate as ACOs, but they have generated limited savings. Even in the third year of Medicare ACO contracts, fewer than half of ACOs received a bonus for reducing spending. To guide policy and help providers succeed, it would be useful to understand why so few ACOs are achieving savings. Data-driven empirical work on ACO performance has yielded few insights into the specific characteristics of ACOs that lead to success. We believe it would be helpful to consider how economic and organizational theories might explain early results from the ACO experiment. (Valerie A. Lewis, Elliott S. Fisher and Carrie H. Colla, 11/8)

Axios: How The Elections Could Put The Brakes On Anti-ACA Plans
The most important issue in an election is sometimes, but seldom, the factor that actually determines the outcome of the election. That’s what we saw happen in Virginia this week. Health was the top issue in the Virginia race, according to exit polls, but it was only one of many factors that drove the election. The bottom line: The election may have been more of a referendum on President Trump than health care — but the results in Virginia and in the Maine referendum on Medicaid expansion will still have a practical impact on what happens next, including the appetite for Affordable Care Act repeal and for cutting Medicaid to pay for tax cuts. (Drew Altman, 11/10)

The New York Times: Medicaid Is Great, but Rural Maine Needs Hospitals, Too
This week Maine voted to become the 32nd state to expand Medicaid despite opposition by Gov. Paul LePage, who had vetoed five previous expansion bills passed by the state legislature and has now threatened to block the results of the ballot initiative. Unless Mr. LePage succeeds, about 80,000 more Mainers will be eligible for coverage, a victory in an unsettling year for health care in America. With the Affordable Care Act under constant threat from the Trump administration and out-of-pocket costs rising faster than wages, health care topped the list of the most important issues facing Americans this year. (Zak Ringelstein, 11/9)

Lexington Herald Leader: Em’s Dead. Read This And You Won’t Feel So Hot Either.
But he eventually succumbed to that final straw that broke his back. Em was dead. And when I gave my best friend his last good-bye and spoke his eulogy, we all missed those days of doing what a patient needed, rather than what a bureaucrat wanted. We knew, if Em could speak, he might regret that phrase.“Joe, that’s just the way life is.” Em died. We lost him in a blizzard of records, finances, trivialities, computerized slowdowns with decreased productivity, and the fact that our patient/friends had now just become patients. For Em, you see, was the first letter of my beloved . . . Medicine. (Joseph P. Bark, 11/10)

The New England Journal Of Medicine: Health Care Professionals And Law Enforcement
Health care professionals generally have a respectful, sometimes even friendly, attitude toward law enforcement. We may feel we’re on the same team as the police when we’re treating victims of crime, and police may be called to protect us from people who seek to harm us in the hospital. Some health care professionals in emergency departments or intensive care units may have frequent interactions with police officers who are investigating alleged crimes. But the relationship may be profoundly tested when health care professionals refuse demands from law enforcement that conflict with what we understand to be our professional obligations. These conflicts may arise when law-enforcement officers prevent clinicians from having confidential discussions with patients, demand inappropriate restraints for patients that severely impede examination and treatment, or demand that health care personnel draw specimens from patients or retrieve evidence in an invasive manner from those who refuse or are unable to consent because they lack decision-making capacity due to delirium, confusion, or unconsciousness. (Arthur R. Derse, 11/8)

The Des Moines Register: After Four DUIs And Two Prison Stays, Now-Sober Lawyer Fights For Her Practice
As a student in the 1980s, Sandra Suarez was president of the Brody Middle School “Just Say No” club. It was named for former First Lady Nancy Reagan’s admonition to reject drugs and alcohol. It made perfect sense to the young Cuban-American girl, who had an alcoholic father and had witnessed what she calls “some of the ugliest things that no child should have to see.” She was so keen to get far away that she chose a college in Washington state. Her father stopped drinking after she left. Rekha Basu, 11/9)

The New York Times: Facebook Is Ignoring Anti-Abortion Fake News
Last year, just weeks before the election, an article from a site called Mad World News began circulating around Facebook. The headline read “Before Applauding Hillary’s Abortion Remarks, Know the One Fact She Ignored.” In the article, the writer says she wants to expose Hillary Clinton’s lies about late-term abortions. She argues that a baby never needs to be aborted to save a mother’s life but doesn’t cite any sources or studies, and presents anecdotes and opinion as fact. Midway through the story, she shares an illustration of what she calls a “Partial-Birth Procedure” — a procedure banned in the United States. In it, she describes how a doctor “jams scissors into the baby’s skull” and how “the child’s brains are sucked out.” (Rossalyn Warren, 11/10)

The New England Journal Of Medicine: The Promise, Growth, And Reality Of Mobile Health — Another Data-Free Zone
The use of mobile communication technologies to improve the health of individuals and populations — dubbed “mobile health,” or “mHealth” — has grown dramatically since 2008, when the term mHealth became widely used. The excitement over the use of mHealth technology especially in low- and middle-income countries (LMICs) stems from the recognition that mobile phones have penetrated the market like no other technology. There are more than 5 billion wireless communication subscribers, and more than 70% of them are in LMICs1 (though the subscription rate in low-income countries is 60% overall, and much lower in rural areas). Moreover, commercial wireless signals reach 85% or more of the world’s population, extending much farther than the electrical grid. (Amira Roess, 11/8)

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

Pressure Builds To Cut Medicare Patients In On Prescription Deals

Medicare enrollees, who have watched their out-of-pocket spending on prescription drugs climb in recent years, might be in for a break.

Federal officials are exploring how beneficiaries could get a share of certain behind-the-scenes fees and discounts negotiated by insurers and pharmacy benefit managers, or PBMs, who together administer Medicare’s Part D drug program. Supporters say this could help enrollees by reducing the price tag of their prescription drugs and slow their approach to the coverage gap in the Part D program.

The Centers for Medicare & Medicaid Services (CMS) could disclose the fees to the public and apply them to what enrollees pay for their drugs. However, there’s no guarantee that such an approach would be included in a proposed rule change that could land any day, according to several experts familiar with the discussions.

“It’s obvious something has to be done about this. This is causing higher drug prices for patients and taxpayers,” Rep. Earl “Buddy” Carter (R-Ga.), a pharmacist, said this week.

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While Medicare itself cannot negotiate drug prices, the health insurers and PBMs have long been able to negotiate with manufacturers who are willing to pay rebates and other discounts so their products win a good spot on a health plan’s list of approved drugs.

Federal officials described these fees in a January fact sheet as direct and indirect remuneration, or DIR fees.

In recent years, pharmacies and specialty pharmacies have also begun paying fees to PBMs. These fees, which are different than the rebates and discounts offered by manufacturers, can be controversial, in part, because they are retroactive or “clawed back” from the pharmacies.

The controversy is also part of the reason advocates, such as pharmacy organizations, have lobbied for this kind of policy change.

PBMs have long contended that they help contain costs and are improving drug availability rather than driving up prices.

Pressure has been building for the administration to take action. Earlier this year, the federal agency’s fact sheet set the stage for change, describing how the fees kept Medicare Part D monthly premiums lower but translated to higher out-of-pocket spending by enrollees and increased costs to the program overall.

In early October, Carter led a group of more than 50 House members in a letter urging Medicare to dedicate a share of the fees to reducing the price paid by Part D beneficiaries when they buy a drug. Also in the House, Rep. Morgan Griffith (R-Va.) introduced a related bill.

On the Senate side, Chuck Grassley (R-Iowa) and 10 other senators sent a letter in July to CMS Administrator Seema Verma as well as officials at the Department of Health and Human Services asking for more transparency in the fees — which could lead to a drop in soaring drug prices if patients get a share of the action.

A response from Verma last month notes that the agency is analyzing how altering DIR requirements would affect Part D beneficiary premiums — a key point that muted previous political conversations.

But advocates say the tone of discussions with the agency and on Capitol Hill have changed this year. That’s partly because Medicare beneficiaries have become more vocal about their rising out-of-pocket costs, increasing scrutiny of these fees.

Ellen Miller, a 70-year-old Medicare enrollee in New York City’s borough of Queens, sent a letter to the Trump administration demanding lower drug prices. Miller’s prescription prices went up this year, sending her into the Medicare “doughnut hole” by April, compared with October in 2016. With coverage, Miller pays about $200 a month for several prescriptions that help her cope with COPD, or chronic obstructive pulmonary disease, as well as another chronic illness.

In the doughnut hole, where coverage drops until catastrophic coverage kicks in, her out-of-pocket costs climb to $600 a month.

It’s “ridiculous, and that doesn’t count my medical bills,” Miller said.

The number of Medicare Part D enrollees with high out-of-pocket costs, like Miller, is on the rise. And in 2015, 3.6 million Medicare Part D enrollees had drug spending above the program’s catastrophic threshold of $7,062, according to a report released this week by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Supporters of the rule change say making the fees more transparent and applying them to what enrollees pay would provide relief for beneficiaries like Miller.

The Pharmaceutical Care Management Association (PCMA), which represents the PBMs who negotiate the rebates and discounts, says changing the fees would endanger the Part D program.

“In Medicare Part D, you have one of the most successful programs in health care,” said Mark Merritt, president and chief executive of PCMA. “Why anybody would choose to destabilize the program is beyond me.”

CMS declined to comment on a vague reference to a pending rule change, which was posted in September.

For now, though, according to the CMS fact sheet, the fees pose two compounding problems for seniors and the agency:

  • Enrollees pay more out-of-pocket for each drug, causing them to reach the program’s coverage gap quicker. In 2018, the so-called doughnut hole begins once an enrollee spends $3,750 out-of-pocket and ends at $5,000, and then catastrophic coverage begins.
  • Medicare, thus taxpayers, pays more for each beneficiary. Once enrollees reach the threshold for catastrophic coverage, Medicare pays the bulk cost of the drugs.

CVS Health, one of the nation’s top three PBMs, released a statement in February calling the fees part of a pay-for-performance program that helps improve patient care. The fees, CVS noted, are fully disclosed and help drive down how much Medicare pays plans that help run the program.

“CVS Health is not profiting from this program,” the company noted.

Express Scripts, also among the nation’s top three PBMs, agreed that the fees lower costs and give incentives for the pharmacies to deliver quality care. As for criticism from the pharmacies, Jennifer Luddy, director of corporate communications for the company, said, “We’re not administering fees in a way that penalizes a pharmacy over something they cannot control.”

Regardless, even if a rule is changed or a law is passed, there is some question as to how easily the fees can translate into lower costs for seniors, in part because the negotiations are so complicated.

When the Medicare Payment Advisory Commission, which provides guidance to Congress, discussed the negotiations in September, Commissioner Jack Hoadley thanked the presenters and said, “In my eyes, what you’ve revealed is a real maze of financial … entanglements.”

Tara O’Neill Hayes, deputy director of health care policy at the conservative American Action Forum, said passing on the discounts and fees to beneficiaries when they buy the drug could be difficult because costs crystallize only after a sale has occurred.

“They can’t be known,” said Hayes, who created an illustration of the negotiations.

“There’s money flowing many different ways between many different stakeholders,” Hayes said.

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

Categories: Cost and Quality, Medicare, Pharmaceuticals

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