PNHP

Excluding preganancy from insurance risk pools

Excluding preganancy from insurance risk pools

Excluding preganancy from insurance risk pools

Los Angeles Times
August 18, 2004
State Bill Mandates Maternity Coverage
By Marc Lifsher

The measure by Sen. Jackie Speier (D-Hillsborough) would affect a relatively small number of Californians: the 354,000 who get their health insurance outside of employer-provided group plans and don’t buy maternity coverage.

Kaiser Permanente, the state’s largest healthcare provider, thinks maternity care should be part of any basic health service. Slightly smaller rival Blue Cross of California, a subsidiary of WellPoint Health Networks Inc., contends that getting pregnant is a choice and that outlawing the exclusion would drive up insurance costs.

Speier and her supporters say they want to protect women against discrimination and prevent insurance companies from exploiting a legal loophole by covering only certain medical conditions – a practice known as cherry-picking. (Federal law prohibits insurers from excluding maternity benefits from employer health plans, which cover 97% of Californians who have health insurance.)

“If you’re going to tailor healthcare to the individual . everybody’s costs would skyrocket,” Speier said. “The reason that healthcare works now is because we spread the risks over the entire population.”

Although (Gov. Schwarzenegger) hasn’t taken an official position, his insurance advisor, Scott K. Reid, wrote a letter to Speier opposing the bill. “This bill would limit choice in the marketplace and increase costs for consumers who desire a lower-cost insurance product that excludes maternity coverage,” he said.

http://www.latimes.com/business/la-fi-maternity18aug18,1,2163960.story?coll=la-home-business

Comment: Customizing insurance coverage by allowing shoppers to choose from a menu of options for coverage would reduce costs for those who likely would not need the services declined. But for those who are clustered with individuals who have greater specific needs, the costs of the segregated pools would be significantly higher and unaffordable for many. An equitable insurance pool shifts costs from those with greater needs and dilutes those costs amongst the greater number of individuals with much more modest needs.

Segregating higher cost individuals into separate pools is irrational, but assessing financial penalties on pregnant women is inhumane. We should establish our own equitably-funded universal insurance pool and tell Blue Cross/WellPoint to get lost.

State health insurance 'reform' is making matters worse

Another View: State health insurance ‘reform’ is making matters worse
By BURT COHEN
Guest Commentary

WHICH COSTS you more: your mortgage or your health insurance? From talking to many neighbors, I know I’m not the only one whose health insurance premium has long since surpassed my mortgage. This is crazy.

But hang on to your seat. Thanks to a bill sponsored by Sen. Russell Prescott, R-Kingston, it’s going to get much worse. Prescott’s infamous Senate Bill 110, with Gov. Craig Benson’s active support, became law despite overwhelming evidence it would do great harm. Citizens of all political stripes are up in arms, as they should be.

The simple premise of SB 110 was that, by allowing market forces free rein, more health insurance companies would be drawn to New Hampshire, and health insurance costs would drop. My goodness, it didn’t turn out that way. The actual results are that insurance will now be cheaper for the young and healthy (who generally don’t even buy health insurance), but more expensive for the old and sick. Premiums are skyrocketing from 25 percent to 75 percent, or more, for small businesses and families across New Hampshire.

The argument for passing SB 110 was that insurance costs are high, so we’ve got to do something — anything. Well, actually no, not if it makes matters worse. I am reminded of Barbara Tuchman’s perceptive book “The March of Folly,” in which folly is defined as “government pursuit of a policy contrary to the self-interest of the constituency involved . . . a policy which is perceived to be counter-productive in its own time, not merely by hindsight.” SB 110 clearly fits that definition.

It was obvious at the time that SB 110 was about cherry picking. It enables insurance companies to make more money by being more selective in who they underwrite. They can now charge higher rates for small groups according to geographic region, as well as age or health. Any legislation that forces employers in the economically depressed North Country to pay more, shift costs to employees or drop health insurance altogether is completely counter-productive. It is not in our state’s best interest.

The public good is served when the healthy help pay the costs of caring for the sick. And it’s not like we have a choice in getting sick. While it is certainly fair to have bad drivers pay more for insurance, is it fair to charge the sick more for their unchosen predicament? Yet that’s exactly how SB 110 works.

Another odious part of the new law requires employees to fill out the “New Hampshire Family Health Statement” questionnaire. I’ve talked to many employers who hate being forced to ask these invasive questions of their loyal employees. It’s hard to imagine, but thanks to Sen. Prescott’s bill, today our New Hampshire government is prying deep into private personal information. You must list every health problem, and every medication taken by anyone in your family during the past five years. So here we have it: The state of New Hampshire, through SB 110, is now serving the interests of the health insurance industry against the interests of the citizens.

And what about Sen. Prescott’s claim that insurance companies would flood into New Hampshire? According to the Insurance Commission, since the bill became law in January, just one insurance company has come to this state, period. The three or four others who may come had signaled their intent to enter the market prior to SB 110’s passage.

And it’s not just patients who are getting whacked by our insurance mess. Ask your physician what he or she thinks of SB 110. To them it means a huge amount of new paperwork, with no benefit to anybody. Except, of course, the insurers.

Yes, we have to do something. More and more health care providers are coming to the conclusion that it’s time to create a national solution, something like an expanded Medicare system.

New Hampshire’s new experiment is not a solution. It’s a big problem, and it’s getting worse. The fact is that people across America are struggling with health care costs that are out of reach. Allowing cherry picking by the insurers does not help; it causes harm. Prescott’s puzzling plan is no fix at all. It merely makes a bad problem worse. Voters can take this matter into their own hands. Before you cast a vote in November, it would serve you well to ask your Senate or House candidate how he or she feels about repealing SB 110.

Burt Cohen is a Democratic state senator from New Castle.

State health insurance ‘reform’ is making matters worse

Another View: State health insurance ‘reform’ is making matters worse
By BURT COHEN
Guest Commentary

WHICH COSTS you more: your mortgage or your health insurance? From talking to many neighbors, I know I’m not the only one whose health insurance premium has long since surpassed my mortgage. This is crazy.

But hang on to your seat. Thanks to a bill sponsored by Sen. Russell Prescott, R-Kingston, it’s going to get much worse. Prescott’s infamous Senate Bill 110, with Gov. Craig Benson’s active support, became law despite overwhelming evidence it would do great harm. Citizens of all political stripes are up in arms, as they should be.

The simple premise of SB 110 was that, by allowing market forces free rein, more health insurance companies would be drawn to New Hampshire, and health insurance costs would drop. My goodness, it didn’t turn out that way. The actual results are that insurance will now be cheaper for the young and healthy (who generally don’t even buy health insurance), but more expensive for the old and sick. Premiums are skyrocketing from 25 percent to 75 percent, or more, for small businesses and families across New Hampshire.

The argument for passing SB 110 was that insurance costs are high, so we’ve got to do something — anything. Well, actually no, not if it makes matters worse. I am reminded of Barbara Tuchman’s perceptive book “The March of Folly,” in which folly is defined as “government pursuit of a policy contrary to the self-interest of the constituency involved . . . a policy which is perceived to be counter-productive in its own time, not merely by hindsight.” SB 110 clearly fits that definition.

It was obvious at the time that SB 110 was about cherry picking. It enables insurance companies to make more money by being more selective in who they underwrite. They can now charge higher rates for small groups according to geographic region, as well as age or health. Any legislation that forces employers in the economically depressed North Country to pay more, shift costs to employees or drop health insurance altogether is completely counter-productive. It is not in our state’s best interest.

The public good is served when the healthy help pay the costs of caring for the sick. And it’s not like we have a choice in getting sick. While it is certainly fair to have bad drivers pay more for insurance, is it fair to charge the sick more for their unchosen predicament? Yet that’s exactly how SB 110 works.

Another odious part of the new law requires employees to fill out the “New Hampshire Family Health Statement” questionnaire. I’ve talked to many employers who hate being forced to ask these invasive questions of their loyal employees. It’s hard to imagine, but thanks to Sen. Prescott’s bill, today our New Hampshire government is prying deep into private personal information. You must list every health problem, and every medication taken by anyone in your family during the past five years. So here we have it: The state of New Hampshire, through SB 110, is now serving the interests of the health insurance industry against the interests of the citizens.

And what about Sen. Prescott’s claim that insurance companies would flood into New Hampshire? According to the Insurance Commission, since the bill became law in January, just one insurance company has come to this state, period. The three or four others who may come had signaled their intent to enter the market prior to SB 110’s passage.

And it’s not just patients who are getting whacked by our insurance mess. Ask your physician what he or she thinks of SB 110. To them it means a huge amount of new paperwork, with no benefit to anybody. Except, of course, the insurers.

Yes, we have to do something. More and more health care providers are coming to the conclusion that it’s time to create a national solution, something like an expanded Medicare system.

New Hampshire’s new experiment is not a solution. It’s a big problem, and it’s getting worse. The fact is that people across America are struggling with health care costs that are out of reach. Allowing cherry picking by the insurers does not help; it causes harm. Prescott’s puzzling plan is no fix at all. It merely makes a bad problem worse. Voters can take this matter into their own hands. Before you cast a vote in November, it would serve you well to ask your Senate or House candidate how he or she feels about repealing SB 110.

Burt Cohen is a Democratic state senator from New Castle.

A brief history of disease, science and medicine

From the ice age to the genome project
by Michael Kennedy
(Asklepiad Press, 2004)

Discovery of beneficial drugs or other therapy requires some capability for scientific analysis, studying the effects of administration to sick patients and recognizing evidence of improvement. Before such analysis is possible, the natural history of disease and the diagnosis of different maladies must be known. Greek physicians were capable of scientific observation and ancient medicine was mostly a matter of diagnosis and prognostication since useful remedies were few. The physician who was successful was a good observer and able to predict the outcome of the illness. He often took credit for successful outcomes that he had nothing to do with, a characteristic that makes him seem only more modern.

Asklepiad Press:
http://www.asklepiadpress.com/order.htm

Borders/Amazon reviews:

Comment: What does a book on the history of disease and medicine have to do with health care reform? The simple answer is the well acknowledged concept that those who fail to understand the errors of history are doomed to repeat them. But an even greater value of this book is that it provides a clear perspective of the historical basis of our existing health care system.

Understanding that perspective is essential if we expect to design a truly rational system of reform. As a transition into our contemplation of reform, Dr. Kennedy ends his book with a chapter on the economics of medicine.

There is another quality of this book that I should mention. It is truly enjoyable reading. I read it within view of Old Faithful in Yellowstone. I actually missed several eruptions of the geyser because I was so deeply absorbed in the story that Dr. Kennedy has to tell.

The next time that you are looking for some escape literature, make it worth your while. Read Mike Kennedy’s book. It will be fun, and it will recharge your enthusiasm for reform.

Canadian drugs aren't the cure

Canadian drugs aren’t the cure
By Robert Kuttner  |  August 18, 2004

THERE IS something quite lunatic about the entire debate on whether to permit imports of drugs from Canada. It’s not as if Canada manufactures drugs more cheaply. Nor are drugs like trees, or bauxite, or hydro power, which just happen to be naturally plentiful in Canada.

No, the cheaper Canadian drugs are the same ones sold at higher prices in the United States, and either exported or licensed for manufacture in Canada.

Why are they cheaper up north? Because Canada has a policy of controlling drug prices through its national health insurance system. As Deborah Stone, a health policy expert at Dartmouth, has observed, it’s not the drugs we should be importing, it’s the policy.

But the pharmaceutical lobby has so much power in the United States that cheaper drug prices are off the political radar screen. In fact, the recent Medicare bill pushed through Congress by the Bush administration explicitly prohibits Medicare, the largest bulk purchaser of pharmaceutical drugs, from negotiating cut-rate bulk prices. A consequence of these sky-high drug prices is that seniors who elect to take the new Medicare drug coverage must pay thousands of dollars out of pocket each year before the coverage fully kicks in. (Senator Kerry, to his credit, would reverse this policy.)

Instead of debating head-on whether the United States should have a national health program like Canada’s, or at least controlled drug prices, the news media have generally accepted the nonsensical premise that the battle is about imports and that the issue is the safety of drugs from Canada. This is the drug industry line, and it’s a complete red herring. In fact, there is no documented case of an American getting sick because of tainted or adulterated drugs brought in from Canada. On the contrary, Canadian safety standards are at least as strict as our own. But Bush appointees at the FDA, as a service to their allies in the pharmaceutical industry, have tried to make the public focus on safety. Why? Because if drug imports from Canada became widespread, the domestic structure of drug overpricing would collapse. Everyone would buy from Canada.

If the administration were not hostile to the idea of drug imports or cheaper drug prices, it would be easy to set up safety spot checks. Indeed, in areas where the administration promotes free trade, it satisfies its safety concerns with spot checks of raw agricultural products imported from countries whose rudimentary sanitary standards are far less sophisticated than Canada’s. To add insult to injury, the administration is actually pressing America’s trading partners who have lower drug prices to raise those prices so that our high prices won’t stick out like a sore thumb and tempt Americans to seek cheaper drugs from abroad.

The drug industry and its friends in the administration contend that the exorbitant prices are necessary to pay for research. You’ve probably seen the TV ads in which an idealistic research scientist at a drug company vows to find a cure for Parkinson’s or Alzheimer’s, mentioning in passing that it costs $800 million to “bring a new drug to market.”

But as author Merrill Goozner documents in his book, “The $800 Million Pill,” much of the money attributed to “research” goes to advertising and copy-cat drugs rather than true breakthroughs, and much of the actual research is financed by taxpayers through the National Institutes of Health). Economist Dean Baker has calculated that only about one dollar in five that US consumers spend on inflated drug prices go to finance drug research. Baker adds up all the money contributed by taxpayers to drug companies through Medicare, Medicare, the Veterans Administration, and NIH. He concludes that it would be more cost-effective to pay for all drug research through government grants and then put the results in the public domain. Manufacturers, as in the case of aspirin, doxycycline, and other off-patent drugs, would then earn only a normal profit, and all drugs would be far cheaper.

Scientists would still innovate. The pioneers of antibiotics weren’t in it to get rich. Nor was Dr. Jonas Salk. Their breakthroughs quickly went into the public domain to help the greatest number at the lowest cost.

It’s charming that the Republican governor of New Hampshire, Craig Benson, is suing the FDA to allow Canadian pharmacies to fill US prescriptions and that congressmen of both parties have sponsored bills to legalize imports. But these worthies are fighting the wrong fight and ducking the real one. Forget Canada. We need a national policy to lower drug prices right here in the USA.

A Medical Emergency in Ireland Shows Strengths of National Health Service

Jerry
Laura&Jerry

A Medical Emergency in Ireland Shows Strengths of National Health Service
By Laura Zimmermann, second year medical student,
Northwestern University Feinberg School of Medicine.

While gingerly treading among the limestone slabs of the Burren in County Clare, Ireland, my 71-year old grandmother fell and broke her hip. While my father retrieved the rented minibus, my siblings and I carried my grandmother, moaning in pain, past grazing cows to the main road. We raced to the ER of the local hospital in Galway, where the staff immediately took her back to the examining area. We waited anxiously in the lobby, worried about her injury, but relieved that she was receiving emergency attention.

As a second-year medical student at Northwestern University, I look back on this traumatic family vacation in the summer of 2000 and recognize a lesson in health care systems. In the United States, where tens of millions of people go without needed care because of the cost, opponents of national health insurance often claim that patients will end up waiting in long lines for sub-par care. However, this is not what happened to my grandmother when she was treated by the Irish national health service.

My grandmother was diagnosed with a complete fracture of the femur. Her leg was, in effect, detached from her body. Less than twenty-four hours later, we greeted my grandmother, fresh out of surgery. Both she and my entire family were relieved when told she would need ten days to recover before she could leave Galway hospital. My grandmother stayed in a pleasant hospital room called “the Sun Room,” and quickly made friends with her roommates and nurses. Her doctor was “just the nicest man.” Altogether, the hospital provided my Grandmother with emergency care, orthopedic surgery, physical therapy, nursing care, and a lovely hospital room for ten days. Within a few months of arriving home, my Grandmother’s recovery was complete, and she walked without assistance.

Given the amount and quality of the care my grandmother received, the entire family was shocked when the bill arrived. The Irish health service charged my grandmother’s insurance company $6,100 for all the care she received in Ireland. According to Blue Cross/Blue Shield, a U.S. hospital would charge about $35,000, including only four days of hospitalization, and not including emergency treatment.

My grandmother’s care in the Irish national health service was swift, compassionate, high-quality, and effective. “The experience was as good as it could have been considering I broke a bone,” my grandmother says. Unfortunately, my grandmother broke her other femur three years later. That hip still hurts her, while her “Irish hip,” she likes to note, is just fine. Her share of the bill for her care, at a hospital in Illinois, despite having extra coverage on top of her Medicare coverage, was not only more than the entire bill in Ireland, but the bills were so very confusing, they took a lot of my parents’ time to straighten out.

I hope to provide the best care for all of my future patients, not just the wealthy and well-insured ones. Also, patients should not have to face financial ruin in addition to illness. Over a million Americans go bankrupt over medical bills every year, despite the fact that 75 percent of them have health insurance.
The United States has a lot to learn about health care from County Galway, Ireland. Just ask my grandmother, “Jerry.”

Canadian drugs aren’t the cure

Canadian drugs aren’t the cure
By Robert Kuttner  |  August 18, 2004

THERE IS something quite lunatic about the entire debate on whether to permit imports of drugs from Canada. It’s not as if Canada manufactures drugs more cheaply. Nor are drugs like trees, or bauxite, or hydro power, which just happen to be naturally plentiful in Canada.

No, the cheaper Canadian drugs are the same ones sold at higher prices in the United States, and either exported or licensed for manufacture in Canada.

Why are they cheaper up north? Because Canada has a policy of controlling drug prices through its national health insurance system. As Deborah Stone, a health policy expert at Dartmouth, has observed, it’s not the drugs we should be importing, it’s the policy.

But the pharmaceutical lobby has so much power in the United States that cheaper drug prices are off the political radar screen. In fact, the recent Medicare bill pushed through Congress by the Bush administration explicitly prohibits Medicare, the largest bulk purchaser of pharmaceutical drugs, from negotiating cut-rate bulk prices. A consequence of these sky-high drug prices is that seniors who elect to take the new Medicare drug coverage must pay thousands of dollars out of pocket each year before the coverage fully kicks in. (Senator Kerry, to his credit, would reverse this policy.)

Instead of debating head-on whether the United States should have a national health program like Canada’s, or at least controlled drug prices, the news media have generally accepted the nonsensical premise that the battle is about imports and that the issue is the safety of drugs from Canada. This is the drug industry line, and it’s a complete red herring. In fact, there is no documented case of an American getting sick because of tainted or adulterated drugs brought in from Canada. On the contrary, Canadian safety standards are at least as strict as our own. But Bush appointees at the FDA, as a service to their allies in the pharmaceutical industry, have tried to make the public focus on safety. Why? Because if drug imports from Canada became widespread, the domestic structure of drug overpricing would collapse. Everyone would buy from Canada.

If the administration were not hostile to the idea of drug imports or cheaper drug prices, it would be easy to set up safety spot checks. Indeed, in areas where the administration promotes free trade, it satisfies its safety concerns with spot checks of raw agricultural products imported from countries whose rudimentary sanitary standards are far less sophisticated than Canada’s. To add insult to injury, the administration is actually pressing America’s trading partners who have lower drug prices to raise those prices so that our high prices won’t stick out like a sore thumb and tempt Americans to seek cheaper drugs from abroad.

The drug industry and its friends in the administration contend that the exorbitant prices are necessary to pay for research. You’ve probably seen the TV ads in which an idealistic research scientist at a drug company vows to find a cure for Parkinson’s or Alzheimer’s, mentioning in passing that it costs $800 million to “bring a new drug to market.”

But as author Merrill Goozner documents in his book, “The $800 Million Pill,” much of the money attributed to “research” goes to advertising and copy-cat drugs rather than true breakthroughs, and much of the actual research is financed by taxpayers through the National Institutes of Health). Economist Dean Baker has calculated that only about one dollar in five that US consumers spend on inflated drug prices go to finance drug research. Baker adds up all the money contributed by taxpayers to drug companies through Medicare, Medicare, the Veterans Administration, and NIH. He concludes that it would be more cost-effective to pay for all drug research through government grants and then put the results in the public domain. Manufacturers, as in the case of aspirin, doxycycline, and other off-patent drugs, would then earn only a normal profit, and all drugs would be far cheaper.

Scientists would still innovate. The pioneers of antibiotics weren’t in it to get rich. Nor was Dr. Jonas Salk. Their breakthroughs quickly went into the public domain to help the greatest number at the lowest cost.

It’s charming that the Republican governor of New Hampshire, Craig Benson, is suing the FDA to allow Canadian pharmacies to fill US prescriptions and that congressmen of both parties have sponsored bills to legalize imports. But these worthies are fighting the wrong fight and ducking the real one. Forget Canada. We need a national policy to lower drug prices right here in the USA.

Health Care Cost Containment or Consumer Rip-Off? 

Pharmacy Benefit Managers: Health Care Cost Containment or Consumer Rip-Off? 
Corporate Truth Squad Alert #12 – August 13, 2004

Prescription drug prices are the fastest growing segment of runaway health care costs – increasing at double-digit rates over the last seven years, according to the Kaiser Family Foundation.  Consumers, especially older Americans, are paying ever-higher prices with no end in sight.  And a July 2004 study concluded that the cost of prescription drugs has risen so sharply that the average share of income (or the drug cost burden) spent by individuals on prescription drugs has increased from .8% in 1990 to 1.2% in 1998, accelerating to 1.8% in 2002.

Pharmacy Benefit Managers (PBMs), greatly impact access to and the costs of prescription drugs. They are an outgrowth of the managed care industry intended to keep drug costs down and to ensure quality of care, use their buying power to negotiate rebates from drug manufacturers and discounts from retail pharmacies.  But there are new and troubling questions about what PBMs do with those savings.  Are the savings being passed on to consumers or used to ensure the highest quality of drugs?  Or are they being used to enrich PBMs?

What’s At Stake?
The stakes are enormous. PBMs administer and manage prescription drug benefit programs for a wide range of clients – HMOs, employers, preferred provider organizations, Medicaid and other state programs, and other health plans. PBMs play a major role in the purchasing and distribution of drugs.  They purchase drugs in huge volumes through a large network, negotiating rebates from the drug manufacturers and discounts from retail pharmacies, and process hundreds-of-millions of pharmaceutical claims a year.  At the same time, however, they also run their own mail-order service centers.

State governments have a particular interest in the practices of PBMs as they increasingly use the bulk purchasing power of Medicaid beneficiaries, the uninsured or other groups in their state to negotiate lower drug prices. But since PBMs administer these programs, states may not be reaping the full savings of their market power.

And, PBMs will play a major role as administrators of the new prescription drug provisions in the 2003 Medicare Modernization and Improvement Act. A September 2003 study concluded that PBM self-dealing could cost the Medicare program and beneficiaries as much as $30 billion from 2004 to 2013.
 
According to the Centers for Medicare and Medicaid Services, spending for prescription drugs in America totaled $162.4 billion in 2002.  That’s four times higher than total spending since 1990.  PBMs have enormous power in this lucrative arrangement.  The New York Times reported on January 5, 2002 that there are 60 PBMs in America administering drug plans for about 200 million consumers – equaling 84% of individuals who have health insurance. 
 
Case Study:  Do PBMs Profit at Expense of Their Clients and Consumers?
Recent state investigations and several lawsuits have begun to raise the question of who benefits the most from PBMs.  Do PBMs keep the savings they negotiate for their own profits rather than passing them on to consumers?  Do they pad their profits by steering consumers to more costly drugs instead of the highest quality drugs at the lowest cost? 

Although 60 PBMs administer drug plans nationwide, three companies (Caremark, Express Scripts, and Medco) control close to half of the business.  According to financial data submitted by these three companies, they enjoyed billion dollar earnings in 2003.  Caremark had revenues of $9.1 billion managing more than 114 million prescriptions.  Advance PCS recently merged with Caremark, but before the merger rolled up $14 billion in annual revenues and managed 502 million prescriptions.  Express Scripts had $13 billion in revenues and processed more than 410 million pharmacy claims.  Medco had revenues of $34 billion and administered 532 million prescriptions. 
 
A pilot study conducted for the Journal of the American Pharmacists Association found wide gaps between what a PBM pays a pharmacy for a drug and what it bills the end user.  While the study concluded that PBMs average a $5 to $10 markup on generic and brand name drug transactions, it also found some much larger gaps, including one case in which a PBM billed an employer $215 for a generic stomach medicine, Ranitidine, but only paid the pharmacy $15 for the drug. 

In addition, PBMs may be using financial incentives to choose which drugs they offer.  One study found that drug companies pay rebates to PBMs for placing their products on special usage lists called formularies.  PBMs typically retain up to 30% of the manufacturers’ rebates, so they have an incentive to swap for drugs that pay higher rebates even if the drug costs the end user more. 
 
State Investigations Raise Questions about PBM Business Practices

The business practices of all three major PBMs are being investigated by a number of states around the country. On July 28, 2004, the St. Louis Post-Dispatch reported that twenty states are investigating Express Scripts, one of the nation’s largest PBMs.  The article also indicated that 19 other states are seeking documents related to a wide range of its business practices.  Since then, New York has also filed suit against them, alleging the company breached its contract with the state and broke other civil laws. The New York state litigation is centered on the practice of switching patients from one drug to another in order to boost its own profits.  In April, Medco, another large PBM, agreed to a $29 million settlement with 20 states, including New York, from litigation alleging the same abuses.  According to an August 5, 2004 article in the Kaiser Daily Health Policy Report, “Caremark Rx announced last month that it is being investigated by attorneys general from 19 states . . . .” On August 12, the Wall Street Journal reported that an additional four states had requested information about how Caremark Rx (which subsumed Advance PCS on March 24, 2004) is meeting requirements of their consumer protection laws.

State Attorneys General are stepping in to investigate PBM abuses even though PBMs are not comprehensively regulated by state or federal agencies.  Unlike pharmacies, no states require licensing for PBMs – except when they dispense medication directly through mail-order activities.  Also, states don’t regulate PBMs through their insurance regulations as they do the managed care industry. 

As questions have arisen regarding possible conflict of interests in the dual roles PBMs play, the National Legislative Association (NLA) on Prescription Drug Prices – currently comprised of 10 states – has decided to work towards the formation of an independent non-partisan Pharmacy Benefit Administer that will “facilitate aggregating the purchasing power of states, businesses, and individuals.”

Consumer Advocates Join the Fight to Reduce Rx Drug Prices

The Prescription Access Litigation (PAL) Project has joined forces with the American Federation of State, County and Municipal Employees (AFSCME) to sue the four largest PBMs in the nation, charging they are responsible for higher prescription drug costs.  The four PBMs named in the lawsuit are Advance PCS; Caremark Rx, Inc.; Express Scripts; and Medco Health.  The April 2003 complaint alleges that these four companies pocket savings on their drug purchases instead of passing them on to health plans and their members. According to the lawsuit, the PBMs have “willfully contributed to escalating drug costs, and have failed in their fiduciary duty to those client health plans.”

In addition, PAL has joined with the AARP Foundation Litigation and the Legal Counsel for the Elderly in a friend of the court (amicus) brief supporting the District of Columbia’s efforts to regulate PBMs and make them more accountable.  The amicus brief describes the enormous power that PBMs have:
PBMs do not manufacture, distribute, prescribe, or ultimately even pay for prescription drugs, yet they often determine what drug a patient will receive and at what price.

PBMs have consistently refused to disclose their pricing structures and the deals they negotiate with drug companies.  According to AARP and the Legal Counsel for the Elderly, studies have shown more transparency would save consumers money:
What seems clear from this navigation of the PBM maze is that prescription benefit plan sponsors (either private employers or government entities) should insist on full disclosure of cash flows to and through the PBM that is administering their drug benefit.  Without this level of scrutiny, the plan sponsor cannot be sure if its PBM is providing good service for a fair price or is acting primarily in its own interest.

The PBM industry successfully fought back efforts to include strong transparency provisions in the new Medicare law, according to the Corporate Research Project of Good Jobs First. (See “Cost Cutters or Con Artists? Pharmacy Benefit Managers Under Fire,” Corporate Research E-Letter No. 42, December 2003) Instead, Congress adopted a weaker provision, requiring that the Federal Trade Commission study whether PBMs will have a conflict of interest in providing the new Medicare prescription drug benefit through their own mail order pharmacies, thereby resulting in increased Medicare spending. 

For more information about this alert, the Corporate Truth Squad Campaign, or for a PDF version of this document, please call Helen Gonzales, USAction Policy Director, at 202-624-1730.

Highlights of the Health Care for All Ohioans Act

Highlights of the Health Care for All Ohioans Act

1. The Health Care for All Ohioans Act, referred to here as “the Plan,” provides coverage for the full range of inpatient and outpatient hospital care, preventive care, mental health, vision, hearing, prescription drugs, dental, emergency services, rehabilitation services, hospice care, home care, health maintenance care, medical supplies, and all other necessary medical services as determined by any state licensed, certified, or registered health care practitioner. It provides timely emergency health care services in each county, including hospital care and triage, and necessary transportation in each county to access covered health care services.

2. Coverage will be provided regardless of income or employment status and there will be no exclusions for pre-existing conditions.

3. There will be no copayments or deductibles.

4. Patients will have free choice of health care providers and hospitals. People who today lack coverage will be able to see doctors and other providers when needed, and will benefit from preventive care and early intervention.

5. Payments to health care providers for all covered services will be made from a single public fund, called the Ohio Health Care Fund. The Plan will be funded by payroll taxes paid by employers, a gross receipts tax on businesses, personal tax increases limited ONLY to those earning more than $87,900 annually, $11.6 billion in administrative cost savings, and funds from government sources.

6. Since health care bills will be paid from a single public fund, insurance companies will no longer have a role in the system and the billions of dollars in profits they take from it will go instead for patient care.

7. Workers under collective bargaining agreements will enjoy the same benefits as everyone else. If benefits under these agreements are less than what the Plan provides, employers must pay the cost of increasing benefits to the level of the Plan, with the employers paying all the premiums, co-payments and deductibles; or the employer and the union may renegotiate and begin coverage under the Plan immediately. The Plan will automatically cover workers when their collective bargaining agreements expire.

8. Public employers — on a state, county, school district and municipal level — will pay much less for employees’ health care coverage than they do today, since their payroll tax for health care will not exceed 3.85% of the total payroll. Private employers who today provide benefits will also save because the combination of the payroll tax and the gross receipts tax on businesses, which is not to exceed 3%, is much less than what many of these employers and businesses pay today for health care coverage for their employees.

9. Workers employed by health insurance companies and others who lose jobs as a result of the changes brought about by the Health Care for All Ohioans Act will receive, at public expense, retraining and financial assistance for up to two years. Many of these workers will be able to find employment in the public sector implementing the new Plan.

10. There will be a marked reduction in physicians’ costs for billing since payment for services rendered will come from one public fund, not 1500 private insurers. And payment will be guaranteed from that public fund. Malpractice insurance will also be less expensive since medical bills will no longer be part of jury awards.

Issued by Single-Payer Action Network Ohio (SPAN Ohio)

Click here to see the table based on annual incomes

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Click to view list of endorsers

Canadian health care better than we think

Canadian health care better than we think
By Dave Zweifel
August 16, 2004

Thanks to years of propaganda from the giant corporations with a vested interest in the U.S. health system, Americans have a somewhat jaundiced view of Canada’s national health insurance program.

We’re told that Canadians have to wait for simple procedures and that there are huge waiting lines for surgery. Doctors aren’t compensated adequately. We’ve been told that so often that we think it’s true. Almost all of it, however, is false.

The Canadian plan sometimes is short of money as government there, like here, is constantly under pressure to make cuts. But Canada’s single-payer program functions much better than our system. We spend an incredible $1.6 trillion for health care every year under our convoluted system, but still have 45 million citizens without any coverage. At a minimum in Canada everyone has health care and at a much lesser cost.

Pat Cornwell, one of this column’s regular readers, sent me an article written by a Canadian doctor after he and a group of colleagues spent some time working in our U.S. health system. Suffice it to say that America’s health insurers and drug companies aren’t passing the article around.

It was printed recently in Public Citizen’s health letter to underscore how messed up our health system has become.

“I just don’t get it,” the Canadian doc began. “Health care in America and the present debate regarding its reform don’t make any sense to me – no way. Even now, with a year’s stateside experience under my belt, I am still utterly baffled by what seems to be incompatibility between apparent fundamentals of the U.S. health care system and its professed goal of improving American health.

“Many Americans have tried diligently to explain their system to us but we’re still perplexed. And to compound perplexity, even while we were struggling to understand the American system of health care delivery, we were challenged from every side to defend the Canadian one. This was not totally unexpected, but the overload of misinformation among Americans about Canadian health care definitely was.”

He goes on to question why Americans have this compulsion to link health care and employment.

“What does being employed have to do with need for health care? Don’t the jobless also get sick?” he asked. “It seems to me that if you are so unlucky as to become ill enough to require health care, this may limit your opportunities for current or future employment.”

The doctor also wonders why the U.S. system has separate health programs for different groups: “gold-plated plans for the affluent, more meager plans for the less well-off, Medicaid for the poor (some of the poor, to be strictly accurate), Medicare for the elderly and disabled?”

But what perplexes him most about the U.S. system is why Americans don’t demand that adequate health care be defined as a universal human right.

“America has led the world in establishing ‘rights’ to many things … is it not time for a ‘right’ to adequate health care, extended to and enjoyed by all?” he wrote.

Dave Zweifel is editor of The Capital Times. E-mail: dzweifel@madison.com.

About Dave

Dave Zweifel has been editor of The Capital Times since 1983. A native of New Glarus, Wis. and a graduate of the University of Wisconsin-Madison, his life-long goal was to be the editor of this newspaper. He has had more luck achieving that than his other fondest hope — watching the Chicago Cubs win the World Series. He served for many years as president of the Wisconsin Freedom of Information Council and served two years as a juror for the Pulitzer Prizes.

Investor ownership in hospitals signals "the triumph of greed"

Last February in City Council chambers, the Bloomington community came together behind Bloomington Hospital and against the concept of a private for-profit competing hospital in our community. The idea was defeated, but it has not died. Dr. Tiwari and unnamed other backers now threaten to build their new hospital in the county where there are no zoning restrictions to stop them. What was a bad idea in the winter is still a bad idea this summer.

In Canada, where their medical system is privately run but financed by the government like our Medicare, there has been talk of trying to improve efficiency and reduce cost by building some for-profit hospitals, and so a group of researchers from McMaster University in Ontario, along with other investigators from throughout Canada, recently published a thorough review of all the printed literature from the U.S. experience where for-profit and not-for-profit hospitals were concerned. Their study, published in the Canadian Medical Journal June 8, showed that patients at for-profit hospitals had higher mortality and higher costs than at not-for-profit hospitals. An editorial accompanied it, written by renowned Harvard researchers Drs. Steffie Woolhandler and David Himmelstein, and it applies to our local situation.

Woolhandler and Himmelstein start by pointing out that “some aspects of life are too precious, intimate or corruptible to entrust to the market. We prohibit selling kidneys and buying wives or judges.” But private investment in health care has been expanding. “In the United States, investor-owned firms have come to dominate renal dialysis, nursing home care, inpatient psychiatric and rehabilitation facilities and health maintenance organizations (HMOs). They have made significant inroads among acute care hospitals (now owning about 13 percent of such facilities), as well as outpatient surgical centers, home care agencies and even hospices. The for-profit barbarians are at the gates.”
It seems so intuitively obvious that if hospitals compete, then prices should come down. Statistics from the Indiana Hospital Association don’t bear that out, with hospital charges in Bedford and Terre Haute, towns with two competing hospitals, considerably higher than those at Bloomington Hospital. The Harvard doctors point out that those who favor for-profit health care argue that the profit motive optimizes care and minimizes costs. But the findings of the study didn’t bear that out. “Why does investor ownership increase costs?” they ask. “Investor-owned hospitals are profit maximizers, not cost minimizers. Strategies that bolster profitability often worsen efficiency and drive up costs. Columbia/HCA, the largest hospital firm in the United States, has paid the U.S. government $1.7 billion in settlements for fraud, the payment of kickbacks to physicians and overbilling of Medicare. … When Columbia/HCA’s CEO resigned in the face of fraud investigations, he left with a $10 million severance package and $324 million in company stock.”

Himmelstein and Woolhandler go on to ask: “Why do for-profit firms that offer inferior products at inflated prices survive in the market? Several prerequisites for the competitive free market described in textbooks are absent in health care. First, it is absurd to think that frail elderly and seriously ill patients, who consume the most care, can act as informed consumers (i.e., comparison-shop, reduce demand when suppliers raise prices or accurately appraise quality). Even less vulnerable patients can have difficulty gauging whether a hospital’s luxurious appurtenances bespeak good care. Second, the ‘product’ of health care is notoriously difficult to evaluate, even for sophisticated buyers like government.”
I cannot say it any better than Drs. Himmelstein and Woolhandler. Their article ends with a message that could have been written specifically for Bloomington:
“For-profit specialty hospitals have blossomed across the United States. Most of these new hospitals duplicate services available at nearby not-for-profit general hospitals, but the newcomers avoid money-losing programs such as geriatric care and emergency departments (a common entry point for uninsured patients). The profits accrue to the investors, the losses to the not-for-profit hospitals, and the total costs to society rise through the unnecessary duplication of expensive facilities. Behind false claims of efficiency lies a much uglier truth. Investor-owned care embodies a new value system that severs the community roots and Samaritan traditions of hospitals, makes physicians and nurses into instruments of investors, and views patients as commodities. Investor ownership marks the triumph of greed.”

Investor ownership in hospitals signals “the triumph of greed”

Last February in City Council chambers, the Bloomington community came together behind Bloomington Hospital and against the concept of a private for-profit competing hospital in our community. The idea was defeated, but it has not died. Dr. Tiwari and unnamed other backers now threaten to build their new hospital in the county where there are no zoning restrictions to stop them. What was a bad idea in the winter is still a bad idea this summer.

In Canada, where their medical system is privately run but financed by the government like our Medicare, there has been talk of trying to improve efficiency and reduce cost by building some for-profit hospitals, and so a group of researchers from McMaster University in Ontario, along with other investigators from throughout Canada, recently published a thorough review of all the printed literature from the U.S. experience where for-profit and not-for-profit hospitals were concerned. Their study, published in the Canadian Medical Journal June 8, showed that patients at for-profit hospitals had higher mortality and higher costs than at not-for-profit hospitals. An editorial accompanied it, written by renowned Harvard researchers Drs. Steffie Woolhandler and David Himmelstein, and it applies to our local situation.

Woolhandler and Himmelstein start by pointing out that “some aspects of life are too precious, intimate or corruptible to entrust to the market. We prohibit selling kidneys and buying wives or judges.” But private investment in health care has been expanding. “In the United States, investor-owned firms have come to dominate renal dialysis, nursing home care, inpatient psychiatric and rehabilitation facilities and health maintenance organizations (HMOs). They have made significant inroads among acute care hospitals (now owning about 13 percent of such facilities), as well as outpatient surgical centers, home care agencies and even hospices. The for-profit barbarians are at the gates.”
It seems so intuitively obvious that if hospitals compete, then prices should come down. Statistics from the Indiana Hospital Association don’t bear that out, with hospital charges in Bedford and Terre Haute, towns with two competing hospitals, considerably higher than those at Bloomington Hospital. The Harvard doctors point out that those who favor for-profit health care argue that the profit motive optimizes care and minimizes costs. But the findings of the study didn’t bear that out. “Why does investor ownership increase costs?” they ask. “Investor-owned hospitals are profit maximizers, not cost minimizers. Strategies that bolster profitability often worsen efficiency and drive up costs. Columbia/HCA, the largest hospital firm in the United States, has paid the U.S. government $1.7 billion in settlements for fraud, the payment of kickbacks to physicians and overbilling of Medicare. … When Columbia/HCA’s CEO resigned in the face of fraud investigations, he left with a $10 million severance package and $324 million in company stock.”

Himmelstein and Woolhandler go on to ask: “Why do for-profit firms that offer inferior products at inflated prices survive in the market? Several prerequisites for the competitive free market described in textbooks are absent in health care. First, it is absurd to think that frail elderly and seriously ill patients, who consume the most care, can act as informed consumers (i.e., comparison-shop, reduce demand when suppliers raise prices or accurately appraise quality). Even less vulnerable patients can have difficulty gauging whether a hospital’s luxurious appurtenances bespeak good care. Second, the ‘product’ of health care is notoriously difficult to evaluate, even for sophisticated buyers like government.”
I cannot say it any better than Drs. Himmelstein and Woolhandler. Their article ends with a message that could have been written specifically for Bloomington:
“For-profit specialty hospitals have blossomed across the United States. Most of these new hospitals duplicate services available at nearby not-for-profit general hospitals, but the newcomers avoid money-losing programs such as geriatric care and emergency departments (a common entry point for uninsured patients). The profits accrue to the investors, the losses to the not-for-profit hospitals, and the total costs to society rise through the unnecessary duplication of expensive facilities. Behind false claims of efficiency lies a much uglier truth. Investor-owned care embodies a new value system that severs the community roots and Samaritan traditions of hospitals, makes physicians and nurses into instruments of investors, and views patients as commodities. Investor ownership marks the triumph of greed.”