PNHP

Anthem Blue Cross learns how to control costs

Anthem Blue Cross learns how to control costs

Cedars-Sinai and UCLA cut from Los Angeles health plan

By Chad Terhune
Los Angeles Times, September 21, 2012
Two of the most prestigious names in Southern California healthcare — Cedars-Sinai and UCLA — are getting shut out of a major insurance plan for being too expensive.
In a bold cost-cutting move, Anthem Blue Cross has eliminated doctors affiliated with the hospitals from a health plan offered to about 60,000 employees and dependents at the cash-strapped city of Los Angeles.
The city opted for Anthem’s plan because it will save $7.6 million in annual premiums next year by excluding physicians from the two institutions known for tending to the Southland’s rich and famous.
“Purchasers are sending a signal that certain prices are just unaffordable,” said David Lansky, chief executive of the Pacific Business Group on Health, which represents large companies such as Walt Disney Co. “We want great teaching and medical research institutions to survive. Whether that should happen by charging everyone in society a higher rate for routine services is more debatable.”
“Implementation of the narrow network was a difficult choice, but one made necessary by the city’s fiscal constraints,” a city spokesman said. Los Angeles is expected to be the biggest employer to offer Anthem’s Select plan.
Officials at Cedars-Sinai and UCLA criticized the rationale for the move, saying the increased costs are tied to their world-class medical research and cutting-edge treatments in areas such as cancer or organ transplants that benefit the entire community.
Thomas Priselac, chief executive of Cedars-Sinai Medical Center, said these exclusions offer a “false economy” because they don’t reduce costs in the healthcare system overall.
“It just pushes the cost onto those who continue getting care at those facilities,” Priselac said. “Secondly, it doesn’t recognize the reason why places like Cedars and UCLA are more expensive than the typical community hospital.”
For its part, UCLA said its hospitals treat a large number of patients in Medi-Cal, the government program for the poor and disabled.
“Other providers don’t have to deal with the expenses UCLA has to deal with,” said Santiago Muñoz, chief strategy officer for the UCLA Health System.
Anthem isn’t alone in pursuing this strategy. Many insurers are aggressively pitching these sharply limited networks, which offer fewer choices and lower-priced doctors and hospitals, as a cost-cutting tool at a time when U.S. health insurance premiums have climbed three times as fast as inflation and wages over the last decade.
Industry giant WellPoint Inc., which owns Anthem Blue Cross in California, offers plans that include as few as 30% of the company’s full list of providers.
http://www.latimes.com/business/la-fi-hospital-costs-20120921,0,4069159,full.story

The explosion in limited-network private insurance plans is taking choice away from more and more patients. The business tools that  private insurers use to control costs are very different from the patient-service tools of a single payer national health program. Not only do the private insurers’ tools restrict patients’ care, but they are also quite ineffective in controlling overall spending, as is demonstrated by the fact that our health care costs are about twice the average of other nations.
Under a single payer system, all legitimate costs are paid by the government and are not linked to specific health plans assigned to different individuals – a very inefficient and fragmented method of financing health care. Using the example of UCLA, there would be no tiers of private coverage and no problem with an underfunded Medicaid program. The hospital costs would be globally budgeted, just as are police and fire departments. Separate, extraordinary costs of research functions would be funded through our National Institutes of Health. Education grants can be provided through the global budgeting process since house staff members are, from a financing perspective, really just low-paid hospital employees.
We need to get WellPoint/Anthem Blue Cross and their ilk out of our health care and out of our lives. Let’s improve our own Medicare program and then provide it for everyone.

Let the buyer beware in a free-market health care system

By Philip Caper, M.D.
Bangor Daily News, Sept. 20, 2012

For the past 30 years or so, a debate about the proper place for competition vs. regulation in our health care system has raged. That debate has now become a central theme in the 2012 presidential race. Democrats favor a regulated system while Republicans favor a more market-driven system, nationally and in Maine.

Americans have the most market-driven health care system in the world. We are now seeing the results. We have the world’s highest health care costs, the highest rates of un- and underinsurance, some of the poorest health outcomes, and an almost universal belief that our health care system is badly broken.

Having a choice of health care providers is very important, since trust is critical to healing. But full-blown market-based competition doesn’t work. It has been known for years that the more doctors and hospitals there are in a region, the higher the costs — a phenomenon known as “provider-induced demand.” The Institute of Medicine recently reported that our system wastes about $750 billion a year, more than 30 percent of our spending. Much is due to an oversupply of some services and technology.

Usually, I am a great fan of competitive markets — where the seller and the buyer each have the same information about prices, features and availability. When it comes to buying a car, washing machine, TV or computer, I go to Consumer Reports or other websites where I can get current and accurate information about the price, quality, availability, reliability and other characteristics of the product I’m interested in. I can also find the opinions of lots of other customers. Then I can decide, usually at my leisure, which features of those products are important to me, how much I want to spend, and when and whether to make my purchase.

Good information is the one indispensable ingredient of competitive markets.

None of this applies to the strange world of health care. I don’t know when I am going to have an injury or illness, what it will be, or what treatment will be recommended. There is vigorous disagreement among even the best-trained doctors about the most effective course of treatment for many conditions. Tests and procedures that have been standard for years can turn out to be more trouble than they are worth. Mammograms, prostate cancer tests and excessive imaging procedures for many patients are the latest examples.

The pricing of health care services is so complicated and irrational that it is impossible to determine in advance what the costs of treatment will be.

What about quality? Although there are efforts in Maine and elsewhere to measure and publish the quality of individual doctors and hospitals, they are very much in their infancy. During a recent personal encounter with the health care system, I found them to be of little use.

As far as shopping for health insurance (as opposed to health care), a recently issued report from Maine’s Consumers for Affordable Healthcare documents the early results of attempts by the Maine Legislature to increase “competition” in the health insurance market. Those results are just what I (and many other experts) predicted. If you’re young and healthy, your costs may go down a little. If you’re older and more likely to be ill, your costs will go up a lot. Instead of encouraging larger pools where risk can be broadly spread, the new pro-competition law goes in the opposite direction by enabling insurers to charge the most vulnerable even more.

Despite their claims to the contrary, insurance companies cannot effectively control health care costs. Price competition among them is really a race to the bottom resulting in skimpier policies with more policyholder costs that are not worth much when the time comes to use them. That’s why we’re seeing more and more bankruptcies due to medical costs filed by people who have health insurance.

Most of this is intuitive for many people. Nevertheless, the myth of the sanctity of free markets in health care keeps on chugging along, despite overwhelming evidence from around the world that they don’t work. That’s why I advocate for a health care system more like Medicare than a free market — sensibly regulated.

The next time somebody tells you we need more competition in health care, just remember that what you’re hearing is the sound of smoke being blown in order to create a smokescreen. What the free marketeers (mostly corporate health care providers who are benefiting from our current system) are really saying is, “Give us your money, and leave us alone.”

When it comes to competition and health care, let the buyer beware.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2012/09/20/health/let-the-buyer-beware-in-a-free-market-health-care-system/print/

Six million will face penalties under the Affordable Care Act

Payments of Penalties for Being Uninsured Under the Affordable Care Act

Congressional Budget Office
September 19, 2012

Beginning in 2014, the Affordable Care Act (comprising Public Law 111-148 and the health care provisions of P.L. 111-152) requires most legal residents of the United States to either obtain health insurance or pay a penalty tax. That penalty will be the greater of: a flat dollar amount per person that rises to $695 in 2016 and is indexed by inflation thereafter (the penalty for children will be half that amount and an overall cap will apply to family payments); or a percentage of the household’s income that rises to 2.5 percent for 2016 and subsequent years (also subject to a cap).

The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have estimated that about 30 million nonelderly residents will be uninsured in 2016, but the majority of them will not be subject to the penalty tax. Unauthorized immigrants, for example, who are prohibited from receiving almost all Medicaid benefits and all subsidies through the insurance exchanges, are exempted from the mandate to obtain health insurance. Others will be subject to the mandate but exempted from the penalty tax—for example, because they will have income low enough that they are not required to file an income tax return, because they are members of Indian tribes, or because the premium they would have to pay would exceed a specified share of their income (initially 8 percent in 2014 and indexed over time). CBO and JCT estimate that between 18 million and 19 million uninsured people in 2016 will qualify for one or more of those exemptions. Of the remaining 11 million to 12 million uninsured people, some individuals will be granted exemptions from the penalty because of hardship, and others will be exempted from the requirement on the basis of their religious beliefs.

After accounting for those who will not be subject to the penalty tax, CBO and JCT now estimate that about 6 million people will pay a penalty because they are uninsured in 2016 (a figure that includes uninsured dependents who have the penalty paid on their behalf) and that total collections will be about $7 billion in 2016 and average about $8 billion per year over the 2017–2022 period. Those estimates differ from projections that CBO and JCT made in April 2010: About two million more uninsured people are now projected to pay the penalty each year, and collections are now expected to be about $3 billion more per year.

Most of the increase—about 85 percent—in the number of people who are expected to pay the penalty tax stems from changes in CBO and JCT’s baseline projections since April 2010, including the effects of legislation enacted since that time, changes in the economic outlook (primarily a higher unemployment rate and lower wages and salaries), and other technical updates. A small share—about 15 percent—of the increase in the number of uninsured people expected to pay the penalty results from the recent Supreme Court decision. As a result of that decision, CBO and JCT now anticipate that some states will not expand their Medicaid programs at all or will not expand coverage to the full extent authorized by the ACA. Such state decisions are projected to increase the number of uninsured, a small percentage of whom will be subject to the penalty tax.

Among the uninsured individuals subject to the penalty tax, many are expected to voluntarily report on their tax returns that they are uninsured and pay the amount owed. However, other individuals will try to avoid payments. Therefore, the estimates presented here account for likely compliance rates, as well as the ability of the Internal Revenue Service (IRS) to administer and collect the penalty.

CBO and JCT have also updated their estimates of the distribution of those penalty tax payments by income category. Table 1 (in PDF available at link) shows how much of those payments are projected to be made by or on behalf of people who are uninsured in 2016 (which the IRS will collect in 2017) in each of several income categories, measured as percentages of the federal poverty level (FPL). In general, households with lower income will be subject to the flat dollar penalty (with adjustments to account for the lower penalty for children and an overall cap on family payments), and households with higher income will owe a percentage of their income. In 2016, households with income that exceeds 400 percent of the FPL are estimated to constitute about one-third of people paying penalties and to account for about two-thirds of the receipts from those penalties.

http://www.cbo.gov/publication/43628

Comment:

By Don McCanne, MD

When it was decided to use the purchase of private plans as the model for insuring everyone, it was clear that the law must include a requirement to purchase plans and that the threat of assessing a penalty would have to be included to ensure compliance, otherwise adverse selection would have driven insurance premiums up even higher than their current intolerable levels. It was also clear that this still wouldn’t ensure universality because of various exceptions and non-compliance.

We now have a reasonably reliable estimate from the Congressional Budget Office that tells us that 30 million people will remain uninsured and that 6 million of them will be assessed penalties. That is a terrible outcome when considering that a single payer system would have covered everyone automatically, obviating the need for penalties.

Some will note that the penalty is not as onerous as it might have been since two-thirds of the total amount will be paid by households with incomes over 400 percent of the federal poverty level. The fact that more lower income households will be exempt from the penalty is hardly a reason to celebrate when considering that the price they do pay is remaining uninsured.

Six million will face penalties under the Affordable Care Act

Payments of Penalties for Being Uninsured Under the Affordable Care Act

Congressional Budget Office
September 19, 2012
Beginning in 2014, the Affordable Care Act (comprising Public Law 111-148 and the health care provisions of P.L. 111-152) requires most legal residents of the United States to either obtain health insurance or pay a penalty tax. That penalty will be the greater of: a flat dollar amount per person that rises to $695 in 2016 and is indexed by inflation thereafter (the penalty for children will be half that amount and an overall cap will apply to family payments); or a percentage of the household’s income that rises to 2.5 percent for 2016 and subsequent years (also subject to a cap).
The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have estimated that about 30 million nonelderly residents will be uninsured in 2016, but the majority of them will not be subject to the penalty tax. Unauthorized immigrants, for example, who are prohibited from receiving almost all Medicaid benefits and all subsidies through the insurance exchanges, are exempted from the mandate to obtain health insurance. Others will be subject to the mandate but exempted from the penalty tax—for example, because they will have income low enough that they are not required to file an income tax return, because they are members of Indian tribes, or because the premium they would have to pay would exceed a specified share of their income (initially 8 percent in 2014 and indexed over time). CBO and JCT estimate that between 18 million and 19 million uninsured people in 2016 will qualify for one or more of those exemptions. Of the remaining 11 million to 12 million uninsured people, some individuals will be granted exemptions from the penalty because of hardship, and others will be exempted from the requirement on the basis of their religious beliefs.
After accounting for those who will not be subject to the penalty tax, CBO and JCT now estimate that about 6 million people will pay a penalty because they are uninsured in 2016 (a figure that includes uninsured dependents who have the penalty paid on their behalf) and that total collections will be about $7 billion in 2016 and average about $8 billion per year over the 2017–2022 period. Those estimates differ from projections that CBO and JCT made in April 2010: About two million more uninsured people are now projected to pay the penalty each year, and collections are now expected to be about $3 billion more per year.
Most of the increase—about 85 percent—in the number of people who are expected to pay the penalty tax stems from changes in CBO and JCT’s baseline projections since April 2010, including the effects of legislation enacted since that time, changes in the economic outlook (primarily a higher unemployment rate and lower wages and salaries), and other technical updates. A small share—about 15 percent—of the increase in the number of uninsured people expected to pay the penalty results from the recent Supreme Court decision. As a result of that decision, CBO and JCT now anticipate that some states will not expand their Medicaid programs at all or will not expand coverage to the full extent authorized by the ACA. Such state decisions are projected to increase the number of uninsured, a small percentage of whom will be subject to the penalty tax.
Among the uninsured individuals subject to the penalty tax, many are expected to voluntarily report on their tax returns that they are uninsured and pay the amount owed. However, other individuals will try to avoid payments. Therefore, the estimates presented here account for likely compliance rates, as well as the ability of the Internal Revenue Service (IRS) to administer and collect the penalty.
CBO and JCT have also updated their estimates of the distribution of those penalty tax payments by income category. Table 1 (in PDF available at link) shows how much of those payments are projected to be made by or on behalf of people who are uninsured in 2016 (which the IRS will collect in 2017) in each of several income categories, measured as percentages of the federal poverty level (FPL). In general, households with lower income will be subject to the flat dollar penalty (with adjustments to account for the lower penalty for children and an overall cap on family payments), and households with higher income will owe a percentage of their income. In 2016, households with income that exceeds 400 percent of the FPL are estimated to constitute about one-third of people paying penalties and to account for about two-thirds of the receipts from those penalties.
http://www.cbo.gov/publication/43628

When it was decided to use the purchase of private plans as the model for insuring everyone, it was clear that the law must include a requirement to purchase plans and that the threat of assessing a penalty would have to be included to ensure compliance, otherwise adverse selection would have driven insurance premiums up even higher than their current intolerable levels. It was also clear that this still wouldn’t ensure universality because of various exceptions and non-compliance.
We now have a reasonably reliable estimate from the Congressional Budget Office that tells us that 30 million people will remain uninsured and that 6 million of them will be assessed penalties. That is a terrible outcome when considering that a single payer system would have covered everyone automatically, obviating the need for penalties.
Some will note that the penalty is not as onerous as it might have been since two-thirds of the total amount will be paid by households with incomes over 400 percent of the federal poverty level. The fact that more lower income households will be exempt from the penalty is hardly a reason to celebrate when considering that the price they do pay is remaining uninsured.

Big Pharma's Hidden Business Model and How Your Company Funds It

By Donald W. Light
Harvard Business Review, Sept. 12, 2012

Business executives may not know it, but they are wasting billions of their gross profits on ineffective, even harmful drugs in their health plans. That’s one implication of the study Joel Lexchin and I just published in the BMJ (formerly British Medical Journal).

The study assembles considerable evidence about the hidden business model of major pharmaceutical companies: to devote most of their research budget to developing hundreds of drugs that provide few if any advantages over existing drugs and then market them heavily to doctors and patients. As a result, about 80 percent of increased expenditures for drugs goes to paying for these minor variations.

Even worse, testing for harmful side effects is minimal when new drugs are approved by the FDA as “safe.” And only 10-15 percent are clinically superior, according to independent review bodies. So employers and employees end up paying for treating the side effects as well as overpaying for new drugs with few advantages to offset risks of harms. The chances that a newly approved drug will get a severe, black box warning or be withdrawn for serious side effects is about 20 percent over its lifetime.

Drug companies also develop clinically superior new drugs, which enlarge the medicine chest of effective drugs that greatly benefit millions of people. But while they are waiting for the next big breakthrough, companies have to fill their product line with clinically similar drugs to market as “better” than their competitors’ similar drugs. Even new molecules are usually not clinically superior. Equating “innovative” with new molecules misses the point: to develop clinically superior new medicines.

The apparent business model of Big Pharma emphasizes the billions spent at great risk to find “innovative” and “breakthrough” new molecules that must be priced high to recover research costs that have become “unsustainable.” However, revenues have increased six times more than their increased costs for research—hardly “unsustainable.” This handsome return comes from the hidden business model that generates billions in costs for employers and employees.

The FDA approves new drugs as “safe” and “effective” with little evidence that they are either in regular medical practice. In fact, industry-friendly regulations prohibit the FDA from using comparative effectiveness to approve new drugs. That would be un-American because it would jeopardize “innovation” and high-tech research jobs. Of course, the opposite is true: requiring new drugs to be clinically superior would foster true innovation and stop rewarding pseudo-innovation.

Since companies test their own products—an obvious conflict of interest—they naturally design clinical trials to maximize evidence that they are beneficial and minimize evidence they are harmful. For example, they randomly sample from a pool that excludes people most likely to have adverse reactions, like patients with two or more health problems, women, children, and minorities. Many trials run for only a few months, long enough to gather evidence of a drug’s main effects but too short to pick up evidence of many harmful reactions.

Then drug companies retain teams of science writers and editors to shape the published medical literature in order to persuade doctors that new drugs are more effective and safer than they are. Systematic reviews find that sponsored scientific articles almost always conclude the company’s drug is better. Negative results are usually not published at all. Employees and their physicians thus get biased information about biased trials. At Harvard’s Edmond J. Safra Center for Ethics, some fellows study how these institutional practices corrupt medical science and clinical practice.

The bottom line is that prescription drugs have become the 4th leading cause of death and a leading cause of hospitalizations, accidents, and falls. See “The Risks of Prescription Drugs” (Columbia 2010). These cost employers even more in hidden ways. Most of the estimated 50 million adverse side effects suffered by Americans each year are minor: nausea, headaches, muscle and joint pain, itchiness and rashes, dizziness, depression, and feeling tired. But these decrease productivity and compromise good judgment on the job and off.

Driving all this are employers paying top dollar for new drugs that are little or no better than much cheaper, well-established drugs. Employers hold the key to sending clear market signals to Big Pharma—pay no more than generics for no better clinical value, a bit more for a bit more value, and only a lot more for significantly more value. The point is not to cut prices but to price to reward better patient outcomes.

It’s so obvious, and employers think they are managing drug costs through their pharmacy benefit managers (PBMs) and insurers. But PBMs and insurers profit from costs increasing, even as they talk a good game of holding down costs. And they do not draw on international review bodies to inform employers about the many new drugs with little added value.

No PBM (a uniquely American middleman who takes his cut) is doing what the Germans are doing for their employers—assessing the marginal gain of new drugs and paying only for greater value. The European trade association for pharmaceutical companies cries foul: how dare the new German agency for better value compare new patented drugs with older generics! But why not? Isn’t the point to see if the new ones are better than the old ones in the same class that cost a fraction as much?—How dare the new Germany agency undermine innovative research! But paying more only for better products is good business practice and rewards true innovation instead of pseudo-innovation.

Senator Bernie Sanders of Vermont has another proposal: reward research teams or companies with a large sum directly and quickly if they develop superior drugs for unmet needs and buy out the IP rights so that all drugs can be available at low generic prices from the start. It speeds up the innovation cycle (which otherwise has to wait for sales at patent-protected high prices), and it keeps health care costs down. Lower costs, more true innovation.

Donald W. Light is a resident fellow at the Edmond J. Safra Center for Ethics, Harvard University, and professor of comparative health care at the University of Medicine and Dentistry of New Jersey.

http://blogs.hbr.org/cs/2012/09/big_pharmas_hidden_business_model_and_how_your_company_funds_it.html

The BMJ article that professor Light refers to is titled “Pharmaceutical research and development: what do we get for all that money?” published on Aug. 7, 2012. BMJ 2012;345:e4348

Big Pharma’s Hidden Business Model and How Your Company Funds It

By Donald W. Light
Harvard Business Review, Sept. 12, 2012

Business executives may not know it, but they are wasting billions of their gross profits on ineffective, even harmful drugs in their health plans. That’s one implication of the study Joel Lexchin and I just published in the BMJ (formerly British Medical Journal).

The study assembles considerable evidence about the hidden business model of major pharmaceutical companies: to devote most of their research budget to developing hundreds of drugs that provide few if any advantages over existing drugs and then market them heavily to doctors and patients. As a result, about 80 percent of increased expenditures for drugs goes to paying for these minor variations.

Even worse, testing for harmful side effects is minimal when new drugs are approved by the FDA as “safe.” And only 10-15 percent are clinically superior, according to independent review bodies. So employers and employees end up paying for treating the side effects as well as overpaying for new drugs with few advantages to offset risks of harms. The chances that a newly approved drug will get a severe, black box warning or be withdrawn for serious side effects is about 20 percent over its lifetime.

Drug companies also develop clinically superior new drugs, which enlarge the medicine chest of effective drugs that greatly benefit millions of people. But while they are waiting for the next big breakthrough, companies have to fill their product line with clinically similar drugs to market as “better” than their competitors’ similar drugs. Even new molecules are usually not clinically superior. Equating “innovative” with new molecules misses the point: to develop clinically superior new medicines.

The apparent business model of Big Pharma emphasizes the billions spent at great risk to find “innovative” and “breakthrough” new molecules that must be priced high to recover research costs that have become “unsustainable.” However, revenues have increased six times more than their increased costs for research—hardly “unsustainable.” This handsome return comes from the hidden business model that generates billions in costs for employers and employees.

The FDA approves new drugs as “safe” and “effective” with little evidence that they are either in regular medical practice. In fact, industry-friendly regulations prohibit the FDA from using comparative effectiveness to approve new drugs. That would be un-American because it would jeopardize “innovation” and high-tech research jobs. Of course, the opposite is true: requiring new drugs to be clinically superior would foster true innovation and stop rewarding pseudo-innovation.

Since companies test their own products—an obvious conflict of interest—they naturally design clinical trials to maximize evidence that they are beneficial and minimize evidence they are harmful. For example, they randomly sample from a pool that excludes people most likely to have adverse reactions, like patients with two or more health problems, women, children, and minorities. Many trials run for only a few months, long enough to gather evidence of a drug’s main effects but too short to pick up evidence of many harmful reactions.

Then drug companies retain teams of science writers and editors to shape the published medical literature in order to persuade doctors that new drugs are more effective and safer than they are. Systematic reviews find that sponsored scientific articles almost always conclude the company’s drug is better. Negative results are usually not published at all. Employees and their physicians thus get biased information about biased trials. At Harvard’s Edmond J. Safra Center for Ethics, some fellows study how these institutional practices corrupt medical science and clinical practice.

The bottom line is that prescription drugs have become the 4th leading cause of death and a leading cause of hospitalizations, accidents, and falls. See “The Risks of Prescription Drugs” (Columbia 2010). These cost employers even more in hidden ways. Most of the estimated 50 million adverse side effects suffered by Americans each year are minor: nausea, headaches, muscle and joint pain, itchiness and rashes, dizziness, depression, and feeling tired. But these decrease productivity and compromise good judgment on the job and off.

Driving all this are employers paying top dollar for new drugs that are little or no better than much cheaper, well-established drugs. Employers hold the key to sending clear market signals to Big Pharma—pay no more than generics for no better clinical value, a bit more for a bit more value, and only a lot more for significantly more value. The point is not to cut prices but to price to reward better patient outcomes.

It’s so obvious, and employers think they are managing drug costs through their pharmacy benefit managers (PBMs) and insurers. But PBMs and insurers profit from costs increasing, even as they talk a good game of holding down costs. And they do not draw on international review bodies to inform employers about the many new drugs with little added value.

No PBM (a uniquely American middleman who takes his cut) is doing what the Germans are doing for their employers—assessing the marginal gain of new drugs and paying only for greater value. The European trade association for pharmaceutical companies cries foul: how dare the new German agency for better value compare new patented drugs with older generics! But why not? Isn’t the point to see if the new ones are better than the old ones in the same class that cost a fraction as much?—How dare the new Germany agency undermine innovative research! But paying more only for better products is good business practice and rewards true innovation instead of pseudo-innovation.

Senator Bernie Sanders of Vermont has another proposal: reward research teams or companies with a large sum directly and quickly if they develop superior drugs for unmet needs and buy out the IP rights so that all drugs can be available at low generic prices from the start. It speeds up the innovation cycle (which otherwise has to wait for sales at patent-protected high prices), and it keeps health care costs down. Lower costs, more true innovation.

Donald W. Light is a resident fellow at the Edmond J. Safra Center for Ethics, Harvard University, and professor of comparative health care at the University of Medicine and Dentistry of New Jersey.

http://blogs.hbr.org/cs/2012/09/big_pharmas_hidden_business_model_and_how_your_company_funds_it.html

The BMJ article that professor Light refers to is titled “Pharmaceutical research and development: what do we get for all that money?” published on Aug. 7, 2012. BMJ 2012;345:e4348

Medicare's failure to protect personal finances

Out-of-Pocket Spending in the Last Five Years of Life

By Amy S. Kelley, Kathleen McGarry, Sean Fahle, Samuel M. Marshall, Qingling Du and Jonathan S. Skinner
Journal of General Internal Medicine, September 5, 2012

Abstract

Background
 
A key objective of the Medicare program is to reduce risk of financial catastrophe due to out-of-pocket healthcare expenditures. Yet little is known about cumulative financial risks arising from out-of-pocket healthcare expenditures faced by older adults, particularly near the end of life.

Design

Using the nationally representative Health and Retirement Study (HRS) cohort, we conducted retrospective analyses of Medicare beneficiaries’ total out-of-pocket healthcare expenditures over the last 5 years of life.

Participants
 
We identified HRS decedents between 2002 and 2008; defined a 5 year study period using each subject’s date of death; and excluded those without Medicare coverage at the beginning of this period (n = 3,209).

Main Measures

We examined total out-of-pocket healthcare expenditures in the last 5 years of life and expenditures as a percentage of baseline household assets. We then stratified results by marital status and cause of death. All measurements were adjusted for inflation to 2008 US dollars.

Results

Average out-of-pocket expenditures in the 5 years prior to death were $38,688 for individuals and $51,030 for couples in which one spouse dies. Spending was highly skewed, with the median and 90th percentile equal to $22,885 and $89,106, respectively, for individuals, and $39,759 and $94,823, respectively, for couples. Overall, 25% of subjects’ expenditures exceeded baseline total household assets, and 43% of subjects’ spending surpassed their non-housing assets. Among those survived by a spouse, 10% exceeded total baseline assets and 24% exceeded non-housing assets. By cause of death, average spending ranged from $31,069 for gastrointestinal disease and $66,155 for Alzheimer’s disease.

Conclusion
 
Despite Medicare coverage, elderly households face considerable financial risk from out-of-pocket healthcare expenses at the end of life. Disease-related differences in this risk complicate efforts to anticipate or plan for health-related expenditures in the last 5 years of life.

http://www.springerlink.com/content/427m88565153p76k/

And…

Grappling With Details of Medicare Proposals

By Roni Caryn Rabin
The New York Times, September 17, 2012

The (Medicare reform) proposals keep changing, and some are short on details. No one is certain what health care costs will be in the coming years.

Still, it’s clear the proposed changes would shift costs from the federal government to retirees. “All scenarios will require seniors to pay more,” said Robert Moffit, senior fellow at the Heritage Foundation, a conservative research organization in Washington. To think otherwise, he said, “is a fantasy.”

http://well.blogs.nytimes.com/2012/09/17/grappling-with-details-of-medicare-proposals/

Comment: 

By Don McCanne, MD

In spite of having Medicare coverage, out-of-pocket health care expenditures can be devastating for seniors. Current proposals to reduce government entitlement spending on Medicare would shift even more costs to our seniors.

Premium support voucher proposals for Medicare would create a defined contribution which would shift more costs to all Medicare beneficiaries, when only the wealthier could afford the increase. That won’t work.

Since many already can’t pay their current out-of-pocket costs, proposals have been advanced to index costs to income by charging higher premiums, higher cost sharing and/or reducing benefits for the wealthier. That process has already begun with Part B and Part D premiums now based on income. That risks reducing support by the politically connected affluent, which could clear the way for enactment of destructive government policies, especially if the conservatives gained control. The threat from the liberals is bad enough.

On the other hand, lower income individuals could be given support beyond that of Medicare. Again, that is already happening through the dual-eligible program for both Medicare and Medicaid. The risk is that the dual-eligible program would be considered a welfare program for the poor, and would be budgeted accordingly. That is already happening as the federal and state governments are well along in the process of herding these victims into underfunded, low quality, private Medicaid managed care programs (see https://pnhp.org/news/2012/september/herding-dual-eligibles-into-low-quality-plans).

Obviously Medicare needs a lot of improvement before we convert it into a single payer national health program. We need to go in the opposite direction from where the politicians currently are headed. Instead of slashing it under the budget hawks’ call for cutting back on entitlements, we need to expand its coverage so that it doesn’t leave anyone with the devastating out-of-pocket expenses associated with complex and prolonged medical care.

Even though more would be spent through the Medicare program (i.e., through the tax system), the efficiencies of single payer would not increase our total health care costs, and, more importantly, would slow future health care cost increases to sustainable levels. It’s not that we can’t afford to expand Medicare; it’s that we can’t afford not to.

Medicare’s failure to protect personal finances

Out-of-Pocket Spending in the Last Five Years of Life

By Amy S. Kelley, Kathleen McGarry, Sean Fahle, Samuel M. Marshall, Qingling Du and Jonathan S. Skinner
Journal of General Internal Medicine, September 5, 2012

Abstract

Background
 
A key objective of the Medicare program is to reduce risk of financial catastrophe due to out-of-pocket healthcare expenditures. Yet little is known about cumulative financial risks arising from out-of-pocket healthcare expenditures faced by older adults, particularly near the end of life.

Design

Using the nationally representative Health and Retirement Study (HRS) cohort, we conducted retrospective analyses of Medicare beneficiaries’ total out-of-pocket healthcare expenditures over the last 5 years of life.

Participants
 
We identified HRS decedents between 2002 and 2008; defined a 5 year study period using each subject’s date of death; and excluded those without Medicare coverage at the beginning of this period (n = 3,209).

Main Measures

We examined total out-of-pocket healthcare expenditures in the last 5 years of life and expenditures as a percentage of baseline household assets. We then stratified results by marital status and cause of death. All measurements were adjusted for inflation to 2008 US dollars.

Results

Average out-of-pocket expenditures in the 5 years prior to death were $38,688 for individuals and $51,030 for couples in which one spouse dies. Spending was highly skewed, with the median and 90th percentile equal to $22,885 and $89,106, respectively, for individuals, and $39,759 and $94,823, respectively, for couples. Overall, 25% of subjects’ expenditures exceeded baseline total household assets, and 43% of subjects’ spending surpassed their non-housing assets. Among those survived by a spouse, 10% exceeded total baseline assets and 24% exceeded non-housing assets. By cause of death, average spending ranged from $31,069 for gastrointestinal disease and $66,155 for Alzheimer’s disease.

Conclusion
 
Despite Medicare coverage, elderly households face considerable financial risk from out-of-pocket healthcare expenses at the end of life. Disease-related differences in this risk complicate efforts to anticipate or plan for health-related expenditures in the last 5 years of life.

http://www.springerlink.com/content/427m88565153p76k/

And…

Grappling With Details of Medicare Proposals

By Roni Caryn Rabin
The New York Times, September 17, 2012

The (Medicare reform) proposals keep changing, and some are short on details. No one is certain what health care costs will be in the coming years.

Still, it’s clear the proposed changes would shift costs from the federal government to retirees. “All scenarios will require seniors to pay more,” said Robert Moffit, senior fellow at the Heritage Foundation, a conservative research organization in Washington. To think otherwise, he said, “is a fantasy.”

http://well.blogs.nytimes.com/2012/09/17/grappling-with-details-of-medicare-proposals/

Comment: 

By Don McCanne, MD

In spite of having Medicare coverage, out-of-pocket health care expenditures can be devastating for seniors. Current proposals to reduce government entitlement spending on Medicare would shift even more costs to our seniors.

Premium support voucher proposals for Medicare would create a defined contribution which would shift more costs to all Medicare beneficiaries, when only the wealthier could afford the increase. That won’t work.

Since many already can’t pay their current out-of-pocket costs, proposals have been advanced to index costs to income by charging higher premiums, higher cost sharing and/or reducing benefits for the wealthier. That process has already begun with Part B and Part D premiums now based on income. That risks reducing support by the politically connected affluent, which could clear the way for enactment of destructive government policies, especially if the conservatives gained control. The threat from the liberals is bad enough.

On the other hand, lower income individuals could be given support beyond that of Medicare. Again, that is already happening through the dual-eligible program for both Medicare and Medicaid. The risk is that the dual-eligible program would be considered a welfare program for the poor, and would be budgeted accordingly. That is already happening as the federal and state governments are well along in the process of herding these victims into underfunded, low quality, private Medicaid managed care programs (see https://www.pnhp.org/news/2012/september/herding-dual-eligibles-into-low-quality-plans).

Obviously Medicare needs a lot of improvement before we convert it into a single payer national health program. We need to go in the opposite direction from where the politicians currently are headed. Instead of slashing it under the budget hawks’ call for cutting back on entitlements, we need to expand its coverage so that it doesn’t leave anyone with the devastating out-of-pocket expenses associated with complex and prolonged medical care.

Even though more would be spent through the Medicare program (i.e., through the tax system), the efficiencies of single payer would not increase our total health care costs, and, more importantly, would slow future health care cost increases to sustainable levels. It’s not that we can’t afford to expand Medicare; it’s that we can’t afford not to.

Raise the eligibility age for Medicare? No, the price is too high

By Aaron E. Carroll, M.D.
The Wall Street Journal, Sept. 18, 2012

Whenever a debate begins on how to cut Medicare spending, someone “sensibly” suggests raising the eligibility age to 67 from 65. The reasons for this are always presented as obvious “facts”:

People are living so much longer than they did when Medicare was enacted that it only makes sense to raise the age at which Medicare begins; with other safety nets and programs in place, only relatively wealthy people would be affected; and, of course, it would save a whole lot of money.

The problem is that all of these things are wrong. Raising the eligibility age is a bad idea.

Disparity in Longevity

It’s a bad idea because it’s a regressive way to cut Medicare. Life expectancy at age 65 has gone up over the past four decades, but it hasn’t gone up equally. A 2007 study showed that while earners in the top half of incomes saw life expectancy at 65 increase more than five years since 1977, earners in the bottom half saw an increase of barely more than a year. So raising the eligibility age likely will result in a significant number of people receiving less years of Medicare overall than people did when the program was enacted. We’re punishing the poor, not correcting for improved health and longevity.

It’s a bad idea because it will raise the number of uninsured dramatically. Stating the obvious, if the Affordable Care Act is repealed and nothing replaces it, then most of those 65- and 66-year-olds won’t be able to get affordable insurance unless they’re employed. Many aren’t.

Even with the law, though, many will become uninsured. The Congressional Budget Office estimates that 95% of affected seniors will be able to get coverage from an employer or through the ACA. But some who qualify for Medicaid will fail to enroll. Some won’t be able to buy health insurance, even with government subsidies. According to estimates from the Kaiser Family Foundation, half of the affected seniors would have incomes too high to qualify for exchange subsidies, and since insurance companies can charge the elderly more under the ACA, their premiums could reach up to $12,000 annually for an individual. Many won’t be able to afford that. Yes, seniors making up to 300% of the federal poverty line may end up paying less, but that’s only one-third of the affected group. The other two-thirds will pay more.

It’s a bad idea because it will be bad for health. Studies have shown that uninsured adults nearly eligible for Medicare often forgo care until they get Medicare and then use more care once they get in. Looking carefully at people just before and after they turn 65, researchers found that uninsured adults with hypertension, heart disease, stroke or diabetes all had significant improvements in health after they got Medicare. Delaying eligibility means delaying these improvements.

It’s a bad idea because it will cost America money, not save it. This is the hardest reason to swallow, but it’s true. The CBO estimates that raising the eligibility age would save the federal government $148 billion through 2021. But that figure doesn’t take into account all the new spending that would occur.

New Spending

The Kaiser Family Foundation examined what would happen in 2014 alone if this idea was put into effect. Washington would see $24 billion in Medicare savings. But it also would see a rise of about $9 billion in Medicaid spending and another $9 billion in subsidy spending, which would reduce the overall savings to about $5.7 billion.

But all those 65- and 66-year-olds need insurance. Those who get it through their jobs would cost employers another $4.5 billion. Others would go to the exchanges. But, ironically, removing these people from the Medicare risk pool and adding them to the exchanges makes both groups less healthy, so everyone’s premiums would go up. This would cost all Americans another $2.5 billion. States have to cover a portion of the new Medicaid spending. That’s $700 million. Finally, there are the out-of-pocket costs to seniors, which may rise by $3.7 billion.

So to save the federal government $5.7 billion, the rest of America has to cough up $11.4 billion. That makes no sense.

As for the idea that encouraging seniors to stay in the workforce longer would boost productivity and make up for some of that pain, I suggest the opposite may be true. We don’t have enough jobs to go around now. By holding on to jobs, seniors would prevent businesses from hiring younger workers, who are cheaper to employ.

Raising the eligibility age is a bad idea. We need a better one.

Dr. Carroll is associate professor of pediatrics and the associate director of Children’s Health Services Research at the Indiana University School of Medicine. He is also the director of the Center for Health Policy and Professionalism Research. Email him at reports@wsj.com.

http://online.wsj.com/article/SB10000872396390443864204577623700185012824.html?KEYWORDS=carroll+the+price+is+too+high+medicare

Single-payer health care still best solution

By John Raffensperger, M.D.
The News-Press (Fort Myers, Fla.), Sept. 18, 2012

Fishing is one of the main reasons people come to Southwest Florida. Most of us need a guide to find the fish.

One morning recently, I met my guide at Blind Pass on Sanibel and set off to fish the mangroves and sand holes. He found the right spot and we caught a few fish. During a lull, our conversation turned to health care. Neither of us had health insurance.

My guide, being self-employed, could not pay for health insurance, which would cost more than the mortgage on his home. He was most concerned about how he would pay for a catastrophic event, a situation he had already met when his wife had two major operations.

We both agreed that Obamacare would help people in his situation, but that a single-payer system would be a better solution.

During 40 years of pediatric surgical practice, I became angry when the insurance companies and HMOs refused to pay for a child’s admission to the hospital the day before an operation. They also insisted on children being discharged while they were still in pain and in danger of complications such as bleeding. A child with a corrected birth defect would later be considered to have a “pre-existing condition” and could not get health insurance.

I was particularly incensed by the multimillion-dollar salaries given to executives in the health care industry, investor profit, advertising and bribes to politicians.

The need for extensive paperwork to meet the demands of insurance companies translates into many more employees in doctors’ offices and hospitals. The high overhead in doctors’ practices partly explains why I paid several thousand dollars to specialists for the removal of two small skin cancers—a procedure than any intern could do in a half hour or so.

For-profit-hospitals further aggravate our medical delivery system.

Two recent stories about HCA, the giant healthcare company, partly owned by Bain Capital, illustrate the unscrupulous practices the industry will use to inflate profit. The Aug. 7 story “Hospital chain inquiry cited unnecessary cardiac work” in The New York Times told how HCA physicians performed unnecessary coronary artery operations to bolster profits. An Aug. 15 story in the same paper revealed shoddy care that caused complications such as bed sores. Oh! We must not forget that in the year 2000, when Governor Rick Scott was the chief executive of the company, HCA was forced to settle a huge fraud case involving over-billing of Medicare.

I have visited children’s hospitals in Canada, Cuba, Great Britain, Slovakia, China and Mexico, countries that are blessed with government-run health care systems. The doctors in all of these hospitals provided excellent care at low cost. Especially, in Canada, the research, teaching and patient care is equal to and in some cases superior to that given in our country. Even, 20 years ago, the surgeons in Cuba and Slovakia, communist countries, were performing open heart operations, kidney transplants and other complicated operations with great skill.

We should have a single-payer system to care for life-threatening conditions, but patients should be responsible for a portion of the costs, depending on their means. Patients should pay for most of the costs of “comfort” procedures such as joint replacements so the elderly can continue to play tennis.

The elimination of advertising by the entire health care industry including physicians and hospitals would reduce costs. Independent panels to resolve malpractice issues would also go a long ways to reduce the costs of care. The referral of patients with complex diseases to academic hospitals will further improve care and reduce costs.

Dr. John Raffensperger, is former surgeon in chief, Children’s Memorial Hospital, Chicago. He lives on Sanibel Island.

http://www.news-press.com/article/20120919/OPINION/309190008/1075/Guest-opinion-Single-payer-health-care-still-best-solution?odyssey=nav|head

Medicare's failure to protect personal finances

Out-of-Pocket Spending in the Last Five Years of Life

By Amy S. Kelley, Kathleen McGarry, Sean Fahle, Samuel M. Marshall, Qingling Du and Jonathan S. Skinner
Journal of General Internal Medicine, September 5, 2012
Abstract
Background
A key objective of the Medicare program is to reduce risk of financial catastrophe due to out-of-pocket healthcare expenditures. Yet little is known about cumulative financial risks arising from out-of-pocket healthcare expenditures faced by older adults, particularly near the end of life.
Design
Using the nationally representative Health and Retirement Study (HRS) cohort, we conducted retrospective analyses of Medicare beneficiaries’ total out-of-pocket healthcare expenditures over the last 5 years of life.
Participants
We identified HRS decedents between 2002 and 2008; defined a 5 year study period using each subject’s date of death; and excluded those without Medicare coverage at the beginning of this period (n = 3,209).
Main Measures
We examined total out-of-pocket healthcare expenditures in the last 5 years of life and expenditures as a percentage of baseline household assets. We then stratified results by marital status and cause of death. All measurements were adjusted for inflation to 2008 US dollars.
Results
Average out-of-pocket expenditures in the 5 years prior to death were $38,688 for individuals and $51,030 for couples in which one spouse dies. Spending was highly skewed, with the median and 90th percentile equal to $22,885 and $89,106, respectively, for individuals, and $39,759 and $94,823, respectively, for couples. Overall, 25% of subjects’ expenditures exceeded baseline total household assets, and 43% of subjects’ spending surpassed their non-housing assets. Among those survived by a spouse, 10% exceeded total baseline assets and 24% exceeded non-housing assets. By cause of death, average spending ranged from $31,069 for gastrointestinal disease and $66,155 for Alzheimer’s disease.
Conclusion
Despite Medicare coverage, elderly households face considerable financial risk from out-of-pocket healthcare expenses at the end of life. Disease-related differences in this risk complicate efforts to anticipate or plan for health-related expenditures in the last 5 years of life.
http://www.springerlink.com/content/427m88565153p76k/

And…

Grappling With Details of Medicare Proposals

By Roni Caryn Rabin
The New York Times, September 17, 2012
The (Medicare reform) proposals keep changing, and some are short on details. No one is certain what health care costs will be in the coming years.
Still, it’s clear the proposed changes would shift costs from the federal government to retirees. “All scenarios will require seniors to pay more,” said Robert Moffit, senior fellow at the Heritage Foundation, a conservative research organization in Washington. To think otherwise, he said, “is a fantasy.”
http://well.blogs.nytimes.com/2012/09/17/grappling-with-details-of-medicare-proposals/

In spite of having Medicare coverage, out-of-pocket health care expenditures can be devastating for seniors. Current proposals to reduce government entitlement spending on Medicare would shift even more costs to our seniors.
Premium support voucher proposals for Medicare would create a defined contribution which would shift more costs to all Medicare beneficiaries, when only the wealthier could afford the increase. That won’t work.
Since many already can’t pay their current out-of-pocket costs, proposals have been advanced to index costs to income by charging higher premiums, higher cost sharing and/or reducing benefits for the wealthier. That process has already begun with Part B and Part D premiums now based on income. That risks reducing support by the politically connected affluent, which could clear the way for enactment of destructive government policies, especially if the conservatives gained control. The threat from the liberals is bad enough.
On the other hand, lower income individuals could be given support beyond that of Medicare. Again, that is already happening through the dual-eligible program for both Medicare and Medicaid. The risk is that the dual-eligible program would be considered a welfare program for the poor, and would be budgeted accordingly. That is already happening as the federal and state governments are well along in the process of herding these victims into underfunded, low quality, private Medicaid managed care programs (see https://pnhp.org/news/2012/september/herding-dual-eligibles-into-low-…).
Obviously Medicare needs a lot of improvement before we convert it into a single payer national health program. We need to go in the opposite direction from where the politicians currently are headed. Instead of slashing it under the budget hawks’ call for cutting back on entitlements, we need to expand its coverage so that it doesn’t leave anyone with the devastating out-of-pocket expenses associated with complex and prolonged medical care.
Even though more would be spent through the Medicare program (i.e., through the tax system), the efficiencies of single payer would not increase our total health care costs, and, more importantly, would slow future health care cost increases to sustainable levels. It’s not that we can’t afford to expand Medicare; it’s that we can’t afford not to.

'Occupy: for patients, not profits': OWS marks 1-year anniversary

By Mario Tama
Getty Images, Sept. 17, 2012

NEW YORK — Laurie Wen, with Physicians for a National Health Program (L) and Dr. Magni Hamso, M.D., both affiliated with Occupy Wall Street, are arrested in the Financial District while protesting Wall Street influence in health care on September 17, 2012, in New York City. Today is the one-year anniversary of Occupy Wall Street and various actions and events are taking place throughout the day. (Photo by Mario Tama/Getty Images) Copyright © 2012 Getty Images. All rights reserved.