Resource – Page 518

A Different Model — Medical Care in Cuba

By Edward W. Campion, M.D., and Stephen Morrissey, Ph.D.
The New England Journal of Medicine, Jan. 24, 2013

For a visitor from the United States, Cuba is disorienting. American cars are everywhere, but they all date from the 1950s at the latest. Our bank cards, credit cards, and smartphones don’t work. Internet access is virtually nonexistent. And the Cuban health care system also seems unreal. There are too many doctors. Everybody has a family physician. Everything is free, totally free — and not after prior approval or some copay. The whole system seems turned upside down. It is tightly organized, and the first priority is prevention. Although Cuba has limited economic resources, its health care system has solved some problems that ours has not yet managed to address.[1,2]

Family physicians, along with their nurses and other health workers, are responsible for delivering primary care and preventive services to their panel of patients — about 1000 patients per physician in urban areas. All care delivery is organized at the local level, and the patients and their caregivers generally live in the same community. The medical records in cardboard folders are simple and handwritten, not unlike those we used in the United States 50 years ago. But the system is surprisingly information-rich and focused on population health.

All patients are categorized according to level of health risk, from I to IV. Smokers, for example, are in risk category II, and patients with stable, chronic lung disease are in category III. The community clinics report regularly to the district on how many patients they have in each risk category and on the number of patients with conditions such as hypertension (well controlled or not), diabetes, and asthma, as well as immunization status, time since last Pap smear, and pregnancies necessitating prenatal care.

Every patient is visited at home once a year, and those with chronic conditions receive visits more frequently. When necessary, patients can be referred to a district polyclinic for specialty evaluation, but they return to the community team for ongoing treatment. For example, the team is responsible for seeing that a patient with tuberculosis follows the assigned antimicrobial regimen and gets sputum checks. House calls and discussions with family members are common tactics for addressing problems with compliance or follow-up and even for failure to protect against unwanted pregnancy. In an effort to control mosquito-borne infections such as dengue, the local health team goes into homes to conduct inspections and teach people about getting rid of standing water, for example.

This highly structured, prevention-oriented system has produced positive results. Vaccination rates in Cuba are among the highest in the world. The life expectancy of 78 years from birth is virtually identical to that in the United States. The infant mortality rate in Cuba has fallen from more than 80 per 1000 live births in the 1950s to less than 5 per 1000 — lower than the U.S. rate, although the maternal mortality rate remains well above those in developed countries and is in the middle of the range for Caribbean countries.[3,4] Without doubt, the improved health outcomes are largely the result of improvements in nutrition and education, which address the social determinants of health. Cuba’s literacy rate is 99%, and health education is part of the mandatory school curriculum. A recent national program to promote acceptance of men who have sex with men was designed in part to reduce rates of sexually transmitted disease and improve acceptance of and adherence to treatment. Cigarettes can no longer be obtained with monthly ration cards, and smoking rates have decreased, though local health teams say it remains difficult to get smokers to quit. Contraception is free and strongly encouraged. Abortion is legal but is seen as a failure of prevention.

But one should not romanticize Cuban health care. The system is not designed for consumer choice or individual initiatives. There is no alternative, private-payer health system. Physicians get government benefits such as housing and food subsidies, but they are paid only about $20 per month. Their education is free, and they are respected, but they are unlikely to attain personal wealth. Cuba is a country where 80% of the citizens work for the government, and the government manages the budgets. In a community health clinic, signs tell patients how much their free care is actually costing the system but no market forces compel efficiency. Resources are limited, as we learned in meeting with Cuban medical and public health professionals as part of a group of editors from the United States. A nephrologist in Cienfuegos, 160 miles south of Havana, lists 77 patients on dialysis in the province, which on a population basis is about 40% of the current U.S. rate — similar to what the U.S. rate was in 1985. A neurologist reports that his hospital got a CT scanner only 12 years ago. U.S. students who are enrolled in a Cuban medical school say that operating rooms run quickly and efficiently but with very little technology. Access to information through the Internet is minimal. One medical student reports being limited to 30 minutes per week of dial-up access. This limitation, like many of the resource constraints that affect progress, is blamed on the long-standing U.S. economic embargo, but there may be other forces in the central government working against rapid, easy communication among Cubans and with the United States.

As a result of the strict economic embargo, Cuba has developed its own pharmaceutical industry and now not only manufactures most of the medications in its basic pharmacopeia, but also fuels an export industry. Resources have been invested in developing biotechnology expertise to become competitive with advanced countries. There are Cuban academic medical journals in all the major specialties, and the medical leadership is strongly encouraging research, publication, and stronger ties to medicine in other Latin American countries. Cuba’s medical faculties, of which there are now 22, remain steadily focused on primary care, with family medicine required as the first residency for all physicians, even though Cuba now has more than twice as many physicians per capita as the United States.[4] Many of those physicians work outside the country, volunteering for two or more years of service, for which they receive special compensation. In 2008, there were 37,000 Cuban health care providers working in 70 countries around the world.[5] Most are in needy areas where their work is part of Cuban foreign aid, but some are in more developed areas where their work brings financial benefit to the Cuban government (e.g., oil subsidies from Venezuela).

Any visitor can see that Cuba remains far from a developed country in basic infrastructure such as roads, housing, plumbing, and sanitation. Nonetheless, Cubans are beginning to face the same health problems the developed world faces, with increasing rates of coronary disease and obesity and an aging population (11.7% of Cubans are now 65 years of age or older). Their unusual health care system addresses those problems in ways that grew out of Cuba’s peculiar political and economic history, but the system they have created — with a physician for everyone, an early focus on prevention, and clear attention to community health — may inform progress in other countries as well.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

References

1. Keck CW, Reed GA . The curious case of Cuba. Am J Public Health 2012;102:e13-e22
2. Drain PK, Barry M . Fifty years of U.S. embargo: Cuba’s health outcomes and lessons. Science 2010;328:572-573
3. World population prospects, 2011 revision. New York: United Nations (http://esa.un.org/unpd/wpp/Excel-Data/mortality.htm).
4. The world factbook. Washingto
n, DC: Central Intelligence Agency, 2012 (https://www.cia.gov/library/publications/the-world-factbook).
5. Gorry C . Cuban health cooperation turns 45. MEDICC Rev 2008;10:44-47

N Engl J Med 2013; 368:297-299 January 24, 2013 DOI: 10.1056/NEJMp1215226

Two Events, One Argument: The Case for Single-Payer Health Care

Debra Street, Andrew Coates speak in Buffalo

By George Sax
Artvoice (Buffalo, N.Y.), Jan. 24, 2013

Thirty years ago, soon after she arrived in Fort Walton Beach, Florida, from her native Canada, Debra Street found herself in a hospital emergency room with a painful kidney stone problem. This unpleasant situation quickly became more unpleasant, and something of a cultural shock.

She was asked how she would pay by an intake interviewer. Street, currently the chair of the sociology department at the University at Buffalo, had no insurance, or job. Her husband had both, but his insurance hadn’t kicked in yet during a probationary period. She had no checks with her name printed on them since the bank hadn’t yet sent them. She had no credit card. “It was a perfect storm” of misfortune, she told a meeting of the League of Women Voters at an Amherst restaurant last Friday. She was told to seek treatment at a “charity hospital” 40 miles away. “I hadn’t thought of this before,” she said. “I’m a Canadian. We get health care.”

And they get it without this kind of scrutiny. The Canadian government is billed for service. Canadians pay for it through premiums or taxes, depending on which province they live in.

Street might encounter a different response today because of a federal law that mandates emergency room treatment without regard for a patient’s fiscal resources. But maybe not. As she pointed out in a telephone interview this week, she might be turned down because hospitals are only required to stabilize emergencies and they judge whether a case is one. They also need not give preventive or longer-term service. (This is true despite the blithe assurance of the Buffalo News’ editors several years ago that everyone is protected by a care “safety net” because of access to emergency rooms. The News was engaging in a long-running opposition to President Barack Obama’s health care proposal and its limited insurance mandate.) None of this would have mattered to Street in Canada. As she said, Canadians get health care, in a single-payer system, where treatment isn’t approved or disallowed by private interests, as in this country.

“In Canada,” she told League members, “corporations don’t make the important decisions about health; public officials do.”

The night before Street spoke, more than 80 people crowded into a basement meeting room at Buffalo’s Lafayette Presbyterian Church for a community forum on “Poverty, Disparities and Healthcare,” organized by the Community Health Worker Network of Buffalo. At least a third of the attendees were young people, a result of outreach to medical students and undergraduates, according to Jessica Bauer Walker, the Network’s director.

The lead speaker was Andrew D. Coates, the newly elected president of Physicians for a National Health Program. Coates is an assistant professor at Albany Medical College and the medical director at an Albany County-owned nursing home. The PNHP is a 18,000-member organization dedicated to the institution of a single-payer system in this country, rather than what it regards as the unwieldy, piecemeal, and inadequate Obamacare program.

Thursday night, in his talk, Coates effectively functioned not only as a physician but also as a political economist, a historian, and a sociologist. For about an hour he deftly sped through data compilations and comparisons, succinctly and sometimes aphoristically commenting on the dismal state of American health care. The poor results of the American system haven’t been a secret for years, although a large portion of the American public has seemed confused about or unaware of the situation, an ignorance created at least in part by powerful political and private interests.

The U.S. ranks at or near the bottom of a list of 20 of the most advanced nations around the world in such categories as infant mortality, incidence of serious illness, and life expectancy. It is at the top in the cost of its system. “Our health delivery systems have created the dismal results and ill-health,” Coates said.

The two central themes of the Coates presentation—and of two co-speakers—were “the social determinants” of health, and the probable failures of Obamacare. There are at least 50 million uninsured Americans, and millions more of the underinsured. This glaring lack accounts for much of the bad outcomes, Coates said. He noted a recent finding by Harvard researchers that there are 45,000 “excess deaths” each year because of a lack of access to medical services.

As to state Medicaid programs, a crucial element of the Obama plan that is supposed to provide for those unable to pay for the insurance policies offered by private companies on the Internet “exchanges” that are to be established, Coates expressed biting skepticism: “Medicaid may be indefensible, but it’s better than nothing.”

It may also prove unavailable. (Dis)qualifying standards are usually stringent and a large number of the 50 states will apparently opt out of Obamacare’s expanded Medicaid with liberalized requirements despite a federal subsidy to them, according to William P. Keefer, a health law practitioner at the Buffalo law firm Phillips, Lytle LLP.

Coates dismissed the prospects of Obamacare insuring a majority of the uninsured. In an interview before the event, he cited a recent Congressional Budget Office projection that there will be 36 million people left out of the program at the end of 2016. The cost of policies offered will be too great for many people, he said. The sector of the population that will benefit the most from Obamacare are corporate interests: insurance, managed care, medical device and pharmaceutical companies. (Last June, USA Today quoted insurance executives who were relieved that the U.S. Supreme Court had sustained the program because it would create an expanded market for them.)

Coates scoffed at so-called market-driven reforms, quoting Harvard professor David Himmelstein: “Consumer-driven plans are driven like cattle are driven.” High co-pays and deductibles cause people with meager resources to deny themselves care, he said. “People delay care, even for heart attacks, one-fifth more if they’re underinsured,” he reported.

Sam Magavern, co-director of the Partnership for the Public Good, told the audience that for all the talk of Buffalo’s extreme poverty, the problem isn’t really the city’s poverty rate: “It’s not poverty, it’s inequality,” he said. The metropolitan area around Buffalo has a poverty rate at the national median. The national health care crisis isn’t due to “lack of resources. It’s the politics of who is willing to pay for what.”

Dr. Myron Glick, founder and chief executive at the nonprofit Jericho Road Family Practice in Buffalo, pointedly recalled how he has marvelled at the new and lavish suburban offices of insurance companies and medical groups he has visited for meetings. And he remembered a prominent cardiologist who declined a referral from Glick because the patient had only Medicaid. “It was the first question he asked,” Glick said. “He said I should send him to the county hospital. ‘They need patients to practice on.’”

Glick said he later saw the doctor at a medical conference. “I hold it against him,” he went on, “but it’s really the system. But the system won’t be changed by altruism.”

“I’m an incrementalist,” Coates said. “I’m not asking for a social revolution, but to get rid of a private-profit health system.” A single-payer system, he said a few minutes later, would “eliminate the most parasitical portion of finance capital” from health care.

Artvoice is Buffalo’s oldest and largest weekly newspaper, providing in-depth coverage of local politics, event information and reviews.

http://artvoice.com/i
ssues/v12n4/week_in_review/case_for_single_payer

Managed care needs a better watchdog

The Star Tribune failed that role in a story about UnitedHealth

By Kip Sullivan
Star Tribune (Minneapolis), Jan. 23, 2013

So UnitedHealth Group has figured out a way to cut Medicare’s costs “without cutting services”? That is how the Star Tribune characterized the organization’s self-serving claims in a recent story (“UnitedHealth says Medicare can save big without big cuts,” Jan. 20).

The Star Tribune has long had a policy of clearly distinguishing advertisements from news reporting. That policy was violated by the story on United, which characterized the firm’s claims as a fresh perspective in the debate about how to cut Medicare’s costs. In fact, United and every other large health insurance company has been peddling similar hype for decades.

The reader had to wade through 15 paragraphs to find a dissenting view, expressed by the Congressional Budget Office. The Star Tribune relegated the CBO’s views to this single sentence: “The Congressional Budget Office … tends to downplay or even ignore numbers like the ones UnitedHealth now offers, experts said.” It would have been helpful if the article had gone on to explain why.

The reason is that CBO requires supporting evidence before it will report back to Congress that a health care reform proposal will save money. The evidence the CBO looks for is not news releases and “studies” from health insurance companies but papers based on the principles of science and published in peer-reviewed journals. To date, the scientific literature does not support the cost-containment claims made by United and the rest of the managed-care insurance industry.

Neither the CBO nor professional journals are infallible. But they have no financial stake in the debate.

United thinks “private success stories need to drive public reforms.” In other words, that self-serving anecdotes from the health insurance industry should mean more to lawmakers than the scientific literature does. How does the state’s largest newspaper let such nonsense go unexamined?

Minnesota badly needs the equivalent of a CBO. I urge the Star Tribune to consider playing the role. That would require regular reporting on the evidence for the cost-containment claims made for “payment reform,” “pay for performance,” “report cards,” “bundled payments,” “disease management,” and the other health care reform fads collectively known as “managed care.”

Here are two questions to investigate:

First, how can United claim to have discovered methods that will lower Medicare costs when the health insurance industry, including United, has a long track record of raising, not lowering, Medicare’s costs? A steady stream of research has shown that it costs more to insure seniors through health insurance companies than it does through the traditional fee-for-service (FFS) Medicare program.

The current name for the private-sector branch of Medicare is Medicare Advantage (MA). The Medicare Payment Advisory Commission, which is very sympathetic to managed care, had this to say in a recent report to Congress: “Currently, Medicare spends more under the MA program for similar beneficiaries than it does under FFS.”

The second question to investigate is United’s claim that “health improvement programs such as diabetes prevention and weight control could save $53 billion” for Medicare and Medicaid. The peer-reviewed literature on this claim currently supports the opposite conclusion — that the cost of administering “disease management” programs in general, and diabetes and obesity prevention programs in particular, exceeds the savings in medical costs achieved by these programs.

There are a few exceptions to this rule, but diabetes and obesity are not among them. It remains possible that such programs targeted at a very small number of diabetics and overweight people (for example, those who are highly motivated to get well) will someday prove to save more than they cost the health care system, but in that event the total savings will be small compared with total health care spending.

The Star Tribune is capable of good reporting on managed-care hype. It has done so infrequently in the past. But it needs to do so regularly.

Kip Sullivan is a member of the steering committee of Physicians for a National Health Program, Minnesota chapter.

http://m.startribune.com/opinion/?id=188131581&c=y

Profit-Driven Health Care

By Leonard Rodberg
The New York Times, Letters, Jan. 21, 2013

Re “Health Care and Profits, a Poor Mix,” by Eduardo Porter (Economic Scene, Jan. 9):

The way we Americans provide health care is actually far worse than Mr. Porter suggests. It is not just that for-profit health insurance is more costly and less efficient than the nonprofit or government alternatives; it is inherently contradictory. The more health care the insurance companies provide — the more they respond to the needs of patients — the less profit they make. That’s why they cherry-pick the healthy and avoid the sick. That’s why we patients face denials and delays when we try to receive care.

The results are predictable; we have some of the worst health statistics of any advanced country. Other countries make health care a government responsibility, with the result that their people are healthier and they spend far less.

When will we learn, as your headline suggested, that health care and profits don’t mix?

Leonard Rodberg is a professor and chairman of the urban studies department, Queens College, CUNY. He resides in Flushing, Queens.

http://www.nytimes.com/2013/01/22/opinion/profit-driven-health-care.html?ref=opinion

The second managed care revolution

HMO-Like Plans May Be Poised To Make Comeback In Online Insurance Markets

By Julie Appleby
Kaiser Health News, January 22, 2013

It’s back to the future for insurers, which plan to sharply limit the choice of doctors and hospitals in some policies marketed to consumers under the health law, starting next fall.

Such plans, similar to the HMOs of old, fell into disfavor with consumers in the 1980s and 1990s, when they rebelled against a lack of choice.

But limited network plans — which have begun a comeback among employers looking to slow rising premiums — are expected to play a prominent role in new online markets, called exchanges, where individuals and small businesses will shop for coverage starting Oct. 1. That trend worries consumer advocates, who fear skimpy networks could translate into inadequate care or big bills for those who develop complicated health problems.

Because such policies can offer lower premiums, insurers are betting they will appeal to some consumers, especially younger and healthier people who might see little need for more expensive policies.

Insurers, who are currently designing their plans for next fall, “will start with as tight a network control as they can,” says Ana Gupte, a managed care analyst with Sanford Bernstein.

Plans may also benefit from offering such policies because they are less attractive to those with medical problems, who can no longer be turned away beginning in January 2014.

Driven by consumer and employer demand for lower-cost plans, insurers are already rolling out narrow network policies that have shaved premiums 10 percent or more. A recent survey by benefit firm Mercer found that 23 percent of large employers offered such plans this year, usually among a choice of plans, up from 14 percent in 2011.

Many policies that currently offer a limited network of doctors and hospitals generally allow patients to go to out-of-network providers, with whom they do not have negotiated prices. But patients who seek such care face significant co-payments, which often start at 30 percent of the bill and can go as high as 50 percent.

It is often hard for consumers to figure out how much they might be charged if they go out of network, says Lynn Quincy, senior policy analyst at Consumers Union, publisher of Consumer Reports magazine. In addition to meeting separate annual deductibles for out-of-network care, patients can be “balance-billed” by doctors or hospitals for the difference between what the insurer pays them and their total charges.

That doesn’t change under the federal health law, so consumers could be left on the hook for tens of thousands of dollars.

http://www.kaiserhealthnews.org/Stories/2013/January/23/HMO-limited-networks-comeback-in-exchanges.aspx

Comment:

By Don McCanne, M.D.

So we didn’t get single payer, but at least we got a bill that brought us an end to insurance company abuses, so they say. But did we really?

Most people purchasing plans through the insurance exchanges will select plans with lower premiums which means the bronze and silver plans that have actuarial values of 60 or 70 percent. To achieve these low values, the plans will require large deductibles and other cost sharing – expenses that may not be affordable for many who actually need health care.

This article and others have reported on the strategy of insurers to rely more heavily on “narrow network” plans – plans that greatly limit your choice of health care professionals and institutions. Obtaining care outside of the network can result in greater cost sharing plus balance-billing for charges that normally would be disallowed. Current networks are already restrictive enough, but these new super skimpy networks will leave patients even more dissatisfied than they were at the peak of the managed care revolution. And we thought we got away from that.

Although insurers would be prohibited from deliberately excluding more costly, sicker patients, the very design of these plans motivates the healthy to buy them and the sick to shun them. Thus cherry picking and lemon dropping will still be with us, even if not overt.

Can you imagine the celebrations in the board rooms of the insurance and pharmaceutical firms? Officers and directors dancing around the table Don McNeill-style, singing, “Happy days are here again!”

The second managed care revolution

HMO-Like Plans May Be Poised To Make Comeback In Online Insurance Markets

By Julie Appleby
Kaiser Health News, January 22, 2013
It’s back to the future for insurers, which plan to sharply limit the choice of doctors and hospitals in some policies marketed to consumers under the health law, starting next fall.
Such plans, similar to the HMOs of old, fell into disfavor with consumers in the 1980s and 1990s, when they rebelled against a lack of choice.
But limited network plans — which have begun a comeback among employers looking to slow rising premiums — are expected to play a prominent role in new online markets, called exchanges, where individuals and small businesses will shop for coverage starting Oct. 1. That trend worries consumer advocates, who fear skimpy networks could translate into inadequate care or big bills for those who develop complicated health problems.
Because such policies can offer lower premiums, insurers are betting they will appeal to some consumers, especially younger and healthier people who might see little need for more expensive policies.
Insurers, who are currently designing their plans for next fall, “will start with as tight a network control as they can,” says Ana Gupte, a managed care analyst with Sanford Bernstein.
Plans may also benefit from offering such policies because they are less attractive to those with medical problems, who can no longer be turned away beginning in January 2014.
Driven by consumer and employer demand for lower-cost plans, insurers are already rolling out narrow network policies that have shaved premiums 10 percent or more. A recent survey by benefit firm Mercer found that 23 percent of large employers offered such plans this year, usually among a choice of plans, up from 14 percent in 2011.
Many policies that currently offer a limited network of doctors and hospitals generally allow patients to go to out-of-network providers, with whom they do not have negotiated prices. But patients who seek such care face significant co-payments, which often start at 30 percent of the bill and can go as high as 50 percent.
It is often hard for consumers to figure out how much they might be charged if they go out of network, says Lynn Quincy, senior policy analyst at Consumers Union, publisher of Consumer Reports magazine. In addition to meeting separate annual deductibles for out-of-network care, patients can be “balance-billed” by doctors or hospitals for the difference between what the insurer pays them and their total charges.
That doesn’t change under the federal health law, so consumers could be left on the hook for tens of thousands of dollars.
http://www.kaiserhealthnews.org/Stories/2013/January/23/HMO-limited-netw…

So we didn’t get single payer, but at least we got a bill that brought us an end to insurance company abuses, so they say. But did we really?
Most people purchasing plans through the insurance exchanges will select plans with lower premiums which means the bronze and silver plans that have actuarial values of 60 or 70 percent. To achieve these low values, the plans will require large deductibles and other cost sharing – expenses that may not be affordable for many who actually need health care.
This article and others have reported on the strategy of insurers to rely more heavily on “narrow network” plans – plans that greatly limit your choice of health care professionals and institutions. Obtaining care outside of the network can result in greater cost sharing plus balance-billing for charges that normally would be disallowed. Current networks are already restrictive enough, but these new super skimpy networks will leave patients even more dissatisfied than they were at the peak of the managed care revolution. And we thought we got away from that.
Although insurers would be prohibited from deliberately excluding more costly, sicker patients, the very design of these plans motivates the healthy to buy them and the sick to shun them. Thus cherry picking and lemon dropping will still be with us, even if not overt.
Can you imagine the celebrations in the board rooms of the insurance and pharmaceutical firms? Officers and directors dancing around the table Don McNeill-style, singing, “Happy days are here again!”

Proposed Rule on Medicaid Premiums and Cost Sharing

A Proposed Rule by the Centers for Medicare & Medicaid Services

Federal Register, January 22, 2013

Medicaid, Children’s Health Insurance Programs, and Exchanges: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eligibility and Enrollment for Exchanges, Medicaid and CHIP, and Medicaid Premiums and Cost Sharing

This proposed rule would implement provisions of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act), and the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).

IV. Medicaid Premiums and Cost Sharing

A. Background

Section 1916 of the Act describes long-standing requirements for cost sharing, which apply broadly to all individuals who are not specifically exempted. Such cost sharing is limited to “nominal” amounts. Section 1916 of the Act also establishes authority for states to impose premiums on specific groups of beneficiaries with family income above 150 percent of the federal poverty level (FPL). The Deficit Reduction Act of 2005 (DRA) established a new section 1916A of the Act, which gives states additional flexibility, allowing for alternative premiums and cost sharing, beyond what is allowed under section 1916 of the Act, for somewhat higher income beneficiaries. Such alternative cost sharing may be targeted to specific groups of beneficiaries and payment may be required as a condition of providing services. Alternative premiums and cost sharing imposed under section 1916A of the Act, cannot exceed five percent of family income.

B. Provisions of Proposed Rule

2. Update to Maximum Nominal Cost Sharing (§ 447.52)

Under the authority granted under sections 1916(a)(3) and (b)(3) of the Act for the Secretary to define nominal cost sharing, at § 447.52(b) we propose to revise the maximum amount of nominal cost sharing for outpatient services, which may be imposed on beneficiaries with incomes below 100 percent of the FPL.

To simplify the rules, we propose to remove the state payment as the basis for the cost sharing charge and replace it with a flat $4 maximum allowable charge for outpatient services.

Current rules permit cost sharing for institutional care, up to 50 percent of the cost for the first day of care, for individuals with incomes below 100 percent of the FPL. We are not proposing a change but are considering alternatives for the maximum allowable cost sharing related to an inpatient stay because this is a relatively high cost for very low income people and not a service that consumers have the ability to avoid or prevent. Options under consideration include the $4 maximum applied to outpatient services, $50, or $100, which would encompass the majority of hospital cost sharing currently in effect

3. Higher Cost Sharing Permitted for Individuals With Incomes Above 100 Percent of the FPL (§ 447.52)

Proposed § 447.52 consolidates the requirements for cost sharing established under sections 1916 and 1916A of the Act. Under the statute, states may impose cost sharing at higher than nominal levels for nonexempt individuals with incomes at or above 100 percent of the FPL. Section 1916A provides that states may establish cost sharing for nonexempt services, other than drugs and ED services, up to 10 percent of the cost paid by the state for such services, for individuals with incomes between 100 and 150 percent of the FPL.

4. Cost Sharing for Drugs (§ 447.53)

To provide additional flexibility to states, and to further encourage the use of preferred drugs, we are proposing to define nominal for this purpose so as to allow cost sharing of up to $8 for non-preferred drugs for individuals with income equal to or less than 150 percent of the FPL or who are otherwise exempt from cost sharing. States will have the flexibility to apply differential cost sharing for preferred and non-preferred drugs in whatever manner they consider most effective. For example, a state may charge $2 for preferred and $6 for non-preferred drugs or $0 for preferred and $8 for non-preferred drugs.

For individuals with family income above 150 percent of the FPL, per section 1916A(c) of the Act, cost sharing for non-preferred drugs may not exceed 20 percent of the cost the agency pays for the drug.

5. Cost Sharing for Emergency Department Services (§ 447.54)

In order to make it easier for states to utilize existing flexibilities to reduce non-emergency use of the ED, at § 447.54(a) we propose to allow cost sharing of up to $8 for non-emergency use of the ED no waiver will be required.

For individuals with family income above 150 percent of the FPL, per section 1916A(e) of the Act, there is no limit on the cost sharing that may be imposed for non-emergency use of the ED.

If an emergency condition does not exist, § 447.54(d) includes the requirements for hospital screening and referral currently codified at § 447.80(b)(2), to ensure that beneficiaries have appropriate access to other sources of care, before cost sharing is imposed. Hospitals must assess the individual clinically, identify an accessible and available alternative provider with lesser cost sharing, and establish a referral to coordinate scheduling. Examples of accessible alternative providers are those that are located within close proximity, accessible via public transportation, open extended hours, and able to serve individuals with LEP and disabilities.

5. Premiums (§ 447.55)

At proposed § 447.55, we consolidate and simplify the requirements for premiums established under sections 1916 and 1916A of the Act. Proposed § 447.56(a) describes the option to impose premiums on individuals with family income above 150 percent of the FPL, as established under section 1916A of the Act, while paragraphs (a)(1) through (a)(5) describe the options to impose premiums for specific populations as established under section 1916 of the Act. Except for the minor revisions described below, we are not seeking to change current policy related to premiums.

At § 447.55(a)(5), we propose to revise requirements related to premiums imposed on medically needy individuals whose income is under 150 percent of the FPL. We removed the current income-related scale currently at § 447.52(b) and instead would provide states with the flexibility to determine their own sliding scale for establishing premiums for the medically needy up to maximum of $20 instead of the $19 in current regulation.

VII. Regulatory Impact Analysis

C. Estimated Impact of the Medicaid Premiums and Cost Sharing Provisions

1. Overall Impact

Based on our policy analysis, we do not anticipate significant costs or savings from these proposed changes at the program level given the targeted nature of the cost sharing. We believe these proposed policies would encourage less costly care and decreased use of unnecessary services, which may reduce state and federal costs for the specified services.

2. Anticipated Effects

As states better understand their options for imposing premiums and cost sharing, more states may take advantage of existing flexibilities, such as cost sharing of up to 20 percent of the cost of the service, and the option of allowing providers to deny services for unpaid cost sharing, both of which are targeted to somewhat higher income beneficiaries. Research has shown that higher-than-nominal cost sharing on very low-income individuals can have an adverse impact on access to servi
ces by discouraging or preventing such individuals from seeking needed care. However, such impacts are not likely to result from the changes proposed here as they are largely focused on services where there are more appropriate and less costly alternatives. Increased cost sharing may have a negative impact on providers, as uncollected cost sharing reduces provider reimbursement, to the extent that the beneficiary cannot or does not pay the cost sharing and services are nonetheless provided. Under the DRA provisions and this proposed rule, however, states may minimize this impact by allowing providers to deny services for failure to pay the required cost sharing in certain circumstances.

https://www.federalregister.gov/articles/2013/01/22/2013-00659/medicaid-childrens-health-insurance-programs-and-exchanges-essential-health-benefits-in-alternative#h-186

Comment:

By Don McCanne, M.D.

Admittedly, there was some effort to target the cost sharing to encourage more appropriate and less costly alternatives, but permitting states to require up to five percent of family income for out-of-pocket costs is truly unaffordable for most of these families.

This shows how much traction the make-them-shop-with-their-own-money crowd has gained – the moral hazard freaks who are hazardous to our health care morals. There are more effective and humane means of controlling health care costs, single payer being the most obvious. We do not need to erect financial barriers that can impair access to beneficial services, for the poor or for anyone else.

Perhaps the most disturbing statement in this Proposed Rule is the following: States may allow providers “to deny services for failure to pay the required cost sharing in certain circumstances.” Deny services for failure to pay “nominal” cost sharing?! What does that say about health care justice in America?

Proposed Rule on Medicaid Premiums and Cost Sharing

A Proposed Rule by the Centers for Medicare & Medicaid Services

Federal Register, January 22, 2013
Medicaid, Children’s Health Insurance Programs, and Exchanges: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eligibility and Enrollment for Exchanges, Medicaid and CHIP, and Medicaid Premiums and Cost Sharing
This proposed rule would implement provisions of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act), and the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).
IV. Medicaid Premiums and Cost Sharing
A. Background
Section 1916 of the Act describes long-standing requirements for cost sharing, which apply broadly to all individuals who are not specifically exempted. Such cost sharing is limited to “nominal” amounts. Section 1916 of the Act also establishes authority for states to impose premiums on specific groups of beneficiaries with family income above 150 percent of the federal poverty level (FPL). The Deficit Reduction Act of 2005 (DRA) established a new section 1916A of the Act, which gives states additional flexibility, allowing for alternative premiums and cost sharing, beyond what is allowed under section 1916 of the Act, for somewhat higher income beneficiaries. Such alternative cost sharing may be targeted to specific groups of beneficiaries and payment may be required as a condition of providing services. Alternative premiums and cost sharing imposed under section 1916A of the Act, cannot exceed five percent of family income.
B. Provisions of Proposed Rule
2. Update to Maximum Nominal Cost Sharing (§ 447.52)
Under the authority granted under sections 1916(a)(3) and (b)(3) of the Act for the Secretary to define nominal cost sharing, at § 447.52(b) we propose to revise the maximum amount of nominal cost sharing for outpatient services, which may be imposed on beneficiaries with incomes below 100 percent of the FPL.
To simplify the rules, we propose to remove the state payment as the basis for the cost sharing charge and replace it with a flat $4 maximum allowable charge for outpatient services.
Current rules permit cost sharing for institutional care, up to 50 percent of the cost for the first day of care, for individuals with incomes below 100 percent of the FPL. We are not proposing a change but are considering alternatives for the maximum allowable cost sharing related to an inpatient stay because this is a relatively high cost for very low income people and not a service that consumers have the ability to avoid or prevent. Options under consideration include the $4 maximum applied to outpatient services, $50, or $100, which would encompass the majority of hospital cost sharing currently in effect
3. Higher Cost Sharing Permitted for Individuals With Incomes Above 100 Percent of the FPL (§ 447.52)
Proposed § 447.52 consolidates the requirements for cost sharing established under sections 1916 and 1916A of the Act. Under the statute, states may impose cost sharing at higher than nominal levels for nonexempt individuals with incomes at or above 100 percent of the FPL. Section 1916A provides that states may establish cost sharing for nonexempt services, other than drugs and ED services, up to 10 percent of the cost paid by the state for such services, for individuals with incomes between 100 and 150 percent of the FPL.
4. Cost Sharing for Drugs (§ 447.53)
To provide additional flexibility to states, and to further encourage the use of preferred drugs, we are proposing to define nominal for this purpose so as to allow cost sharing of up to $8 for non-preferred drugs for individuals with income equal to or less than 150 percent of the FPL or who are otherwise exempt from cost sharing. States will have the flexibility to apply differential cost sharing for preferred and non-preferred drugs in whatever manner they consider most effective. For example, a state may charge $2 for preferred and $6 for non-preferred drugs or $0 for preferred and $8 for non-preferred drugs.
For individuals with family income above 150 percent of the FPL, per section 1916A(c) of the Act, cost sharing for non-preferred drugs may not exceed 20 percent of the cost the agency pays for the drug.
5. Cost Sharing for Emergency Department Services (§ 447.54)
In order to make it easier for states to utilize existing flexibilities to reduce non-emergency use of the ED, at § 447.54(a) we propose to allow cost sharing of up to $8 for non-emergency use of the ED no waiver will be required.
For individuals with family income above 150 percent of the FPL, per section 1916A(e) of the Act, there is no limit on the cost sharing that may be imposed for non-emergency use of the ED.
If an emergency condition does not exist, § 447.54(d) includes the requirements for hospital screening and referral currently codified at § 447.80(b)(2), to ensure that beneficiaries have appropriate access to other sources of care, before cost sharing is imposed. Hospitals must assess the individual clinically, identify an accessible and available alternative provider with lesser cost sharing, and establish a referral to coordinate scheduling. Examples of accessible alternative providers are those that are located within close proximity, accessible via public transportation, open extended hours, and able to serve individuals with LEP and disabilities.
5. Premiums (§ 447.55)
At proposed § 447.55, we consolidate and simplify the requirements for premiums established under sections 1916 and 1916A of the Act. Proposed § 447.56(a) describes the option to impose premiums on individuals with family income above 150 percent of the FPL, as established under section 1916A of the Act, while paragraphs (a)(1) through (a)(5) describe the options to impose premiums for specific populations as established under section 1916 of the Act. Except for the minor revisions described below, we are not seeking to change current policy related to premiums.
At § 447.55(a)(5), we propose to revise requirements related to premiums imposed on medically needy individuals whose income is under 150 percent of the FPL. We removed the current income-related scale currently at § 447.52(b) and instead would provide states with the flexibility to determine their own sliding scale for establishing premiums for the medically needy up to maximum of $20 instead of the $19 in current regulation.
VII. Regulatory Impact Analysis
C. Estimated Impact of the Medicaid Premiums and Cost Sharing Provisions
1. Overall Impact
Based on our policy analysis, we do not anticipate significant costs or savings from these proposed changes at the program level given the targeted nature of the cost sharing. We believe these proposed policies would encourage less costly care and decreased use of unnecessary services, which may reduce state and federal costs for the specified services.
2. Anticipated Effects
As states better understand their options for imposing premiums and cost sharing, more states may take advantage of existing flexibilities, such as cost sharing of up to 20 percent of the cost of the service, and the option of allowing providers to deny services for unpaid cost sharing, both of which are targeted to somewhat higher income beneficiaries. Research has shown that higher-than-nominal cost sharing on very low-income individuals can have an adverse impact on access to services by discouraging or preventing such individuals from seeking needed care. However, such impacts are not likely to result from the changes proposed here as they are largely focused on services where there are more appropriate and less costly alternatives. Increased cost sharing may have a negative impact on providers, as uncollected cost sharing reduces provider reimbursement, to the extent that the beneficiary cannot or does not pay the cost sharing and services are nonetheless provided. Under the DRA provisions and this proposed rule, however, states may minimize this impact by allowing providers to deny services for failure to pay the required cost sharing in certain circumstances.
https://www.federalregister.gov/articles/2013/01/22/2013-00659/medicaid-…

Why do patients go on the Medicaid program? Because they’re dirt poor, that’s why. To even bring up a discussion of premiums and cost sharing on these down-and-out people represents the ultimate of bureaucratic insensitivity.
Admittedly, there was some effort to target the cost sharing to encourage more appropriate and less costly alternatives, but permitting states to require up to five percent of family income for out-of-pocket costs is truly unaffordable for most of these families.
This shows how much traction the make-them-shop-with-their-own-money crowd has gained – the moral hazard freaks who are hazardous to our health care morals. There are more effective and humane means of controlling health care costs, single payer being the most obvious. We do not need to erect financial barriers that can impair access to beneficial services, for the poor or for anyone else.
Perhaps the most disturbing statement in this Proposed Rule is the following: States may allow providers “to deny services for failure to pay the required cost sharing in certain circumstances.” Deny services for failure to pay “nominal” cost sharing?! What does that say about health care justice in America?

Baucus/Hatch taxpayer gift to Amgen

Fiscal Footnote: Big Senate Gift to Drug Maker

By Eric Lipton and Kevin Sack
The New York Times, January 19, 2013

Just two weeks after pleading guilty in a major federal fraud case, Amgen, the world’s largest biotechnology firm, scored a largely unnoticed coup on Capitol Hill: Lawmakers inserted a paragraph into the “fiscal cliff” bill that did not mention the company by name but strongly favored one of its drugs.

The language buried in Section 632 of the law delays a set of Medicare price restraints on a class of drugs that includes Sensipar, a lucrative Amgen pill used by kidney dialysis patients.

The provision gives Amgen an additional two years to sell Sensipar without government controls. The news was so welcome that the company’s chief executive quickly relayed it to investment analysts. But it is projected to cost Medicare up to $500 million over that period.

Supporters of the delay, primarily leaders of the Senate Finance Committee who have long benefited from Amgen’s political largess, said it was necessary to allow regulators to prepare properly for the pricing change.

But critics, including several Congressional aides who were stunned to find the measure in the final bill, pointed out that Amgen had already won a previous two-year delay, and they depicted a second one as an unnecessary giveaway.

Amgen has deep financial and political ties to lawmakers like Senate Minority Leader Mitch McConnell, Republican of Kentucky, and Senators Max Baucus, Democrat of Montana, and Orrin G. Hatch, Republican of Utah, who hold heavy sway over Medicare payment policy as the leaders of the Finance Committee.

Amgen’s success also shows that even a significant federal criminal investigation may pose little threat to a company’s influence on Capitol Hill. On Dec. 19, as Congressional negotiations over the fiscal bill reached a frenzy, Amgen pleaded guilty to marketing one of its anti-anemia drugs, Aranesp, illegally. It agreed to pay criminal and civil penalties totaling $762 million, a record settlement for a biotechnology company, according to the Justice Department.

Amgen, whose headquarters is near Los Angeles and which had $15.6 billion in revenue in 2011, has a deep bench of Washington lobbyists that includes Jeff Forbes, the former chief of staff to Mr. Baucus; Hunter Bates, the former chief of staff for Mr. McConnell; and Tony Podesta, whose fast-growing lobbying firm has unusually close ties to the White House.

In some cases, the company’s former employees have found important posts inside the Capitol. They include Dan Todd, one of Mr. Hatch’s top Finance Committee staff members on health and Medicare policy, who worked as a health policy analyst for Amgen’s government affairs office from 2005 to 2009. Mr. Todd, who joined Mr. Hatch’s staff in 2011, was directly involved in negotiating the dialysis components of the fiscal bill, and he met with “all the stakeholders,” Mr. Hatch’s spokeswoman said, not disputing when asked that this included Amgen lobbyists.

Aides to the senators said some heavy donors had won and others had lost in the Medicare negotiations — proof that the legislative outcome was based on the merits. “What is the best policy for Montanans and people across the country lies at the heart of every decision Chairman Baucus makes,” said Meaghan Smith, a spokeswoman for Mr. Baucus. “It’s as simple as that.”

http://www.nytimes.com/2013/01/20/us/medicare-pricing-delay-is-political-win-for-amgen-drug-maker.html

Comment:

By Don McCanne, MD

Of course, Sen. Baucus is not alone in accepting payment in exchange for favorable legislation. All members of Congress have fundraising challenges. If you check OpenSecrets.org, you will find that most members of Congress are tainted, though they vary in their egregiousness.

Who is ultimately to blame? We elect these people. Health care justice doesn’t stand a chance when displaced by the power of greed and corruption, and we simply turn our backs on it.

Medicare pricing delay is political win for drug maker

By Eric Lipton and Kevin Sack
The New York Times, Jan. 19, 2013

WASHINGTON — Just two weeks after pleading guilty in a major federal fraud case, Amgen, the world’s largest biotechnology firm, scored a largely unnoticed coup on Capitol Hill: Lawmakers inserted a paragraph into the “fiscal cliff” bill that did not mention the company by name but strongly favored one of its drugs.

The language buried in Section 632 of the law delays a set of Medicare price restraints on a class of drugs that includes Sensipar, a lucrative Amgen pill used by kidney dialysis patients.

Amgen, which has a small army of 74 lobbyists in the capital, was the only company to argue aggressively for the delay, according to several Congressional aides of both parties.

“That is why we are in the trouble we are in,” said Dennis J. Cotter, a health policy researcher who studies the cost and efficacy of dialysis drugs. “Everybody is carving out their own turf and getting it protected, and we pass the bill on to the taxpayer.”

The provision’s inclusion in the legislation to avert the tax increases and spending cuts that made up the so-called fiscal cliff shows the enduring power of special interests in Washington, even as Congress faces a critical test of its ability to balance the budget.

It also has worked hard to build close ties with the Obama administration, with its lobbyists showing up more than a dozen times since 2009 on logs of visits to the White House, although a company official said Saturday that it had not appealed to the administration during the debate over the fiscal legislation.

Aides to Mr. Hatch and Mr. Baucus, and a spokeswoman for Amgen, said the delay would give the Medicare system and medical providers the time they needed to accommodate other complicated changes in how federal reimbursements for kidney care were determined.

“Sometimes when you try to do too much and too quickly, you screw up,” said Antonia Ferrier, a spokeswoman for Mr. Hatch. The goal, an Amgen spokeswoman said in a written statement, is “to ensure that quality of care is not compromised for dialysis patients.”

But the measure runs counter to a five-year effort in Washington to control the enormous expense of dialysis for the Medicare program by reversing incentives to overprescribe medication.

Amgen’s employees and political action committee have distributed nearly $5 million in contributions to political candidates and committees since 2007, including $67,750 to Mr. Baucus, the Finance Committee chairman, and $59,000 to Mr. Hatch, the committee’s ranking Republican. They gave an additional $73,000 to Mr. McConnell, some of it at a fund-raising event for him that it helped sponsor in December while the debate over the fiscal legislation was under way. More than $141,000 has also gone from Amgen employees to President Obama’s campaigns.

What distinguishes the company’s efforts in Washington is the diversity and intensity of its public policy campaigns. Amgen and its foundation have directed hundreds of thousands of dollars in charitable contributions to influential groups like the Congressional Black Caucus and to lesser-known groups like the Utah Families Foundation, which was founded by Mr. Hatch and brings the senator positive coverage in his state’s news media.

Amgen has sent large donations to Glacier PAC, sponsored by Mr. Baucus in Montana, and OrrinPAC, a political action committee controlled by Mr. Hatch in Utah.

And when Mr. Hatch faced a rare primary challenge last year, a nonprofit group calling itself Freedom Path sponsored advertisements in Utah that attacked his opponent, an effort that tax records released in November show was financed in large part by the Pharmaceutical Research and Manufacturers of America, a trade group that includes Amgen.

For years, Amgen used its clout in Washington to lobby for generous Medicare payments for its blockbuster drug, Epogen, which fends off anemia in dialysis patients.

The Medicare program covers most costs associated with treating severe renal disease, regardless of a patient’s age, and the dialysis market continues to grow steadily. In 2010, the government’s kidney program was spending $1.9 billion on injectable anti-anemia drugs like Epogen.

But nearly a decade ago, evidence started to surface that questioned the effectiveness and safety of Epogen at the levels being used.

Researchers found that Medicare’s practice of reimbursing providers with separate payments for the drugs and for dialysis treatments encouraged overprescription because the providers made healthy profits with each dose. They also found that high doses posed cardiovascular risks to patients.

Congress reversed the incentive in 2008 by requiring Medicare to pay a single, bundled rate for a dialysis treatment and related medications starting in 2011. With providers potentially profiting more by prescribing less Epogen, use of dialysis drugs dropped by nearly 25 percent.

But the blow was softened for Amgen and other kidney care companies with a few favors from Congress. Among them was a two-year delay in the inclusion of certain oral drugs, Sensipar among them, in the new bundled payment system. That meant demand for Sensipar would not decline and Amgen would maintain control over pricing.

With that two-year exclusion set to expire in 2014, Amgen’s lobbyists began making rounds again o
n Capitol Hill last fall. In private meetings with staff members of the House Ways and Means and Senate Finance Committees, they argued for another two-year delay, several Congressional aides said.

Committee staff members had been meeting regularly in Room S-124 of the Capitol to negotiate a package of Medicare cuts needed to prevent a large scheduled reduction in doctors’ fees. The kidney program was on the table because a new report by the Government Accountability Office had found that Medicare had overpaid for dialysis by up to $880 million in 2011.

The discussions about cutting dialysis reimbursement began late last fall with little focus on a delay for oral drugs, but it was eventually endorsed by leading staff members for Mr. Baucus and Mr. Hatch, Congressional aides said.

Aides to the senators said the delay made sense because the Government Accountability Office had warned in early 2011 that federal regulators should take care in setting compensation levels for the drugs.

But others on Capitol Hill saw no justification for further delay.

“It is disappointing,” said a Democratic Congressional aide who declined to be named because of the issue’s sensitivity, “since the status quo encourages prescribing of oral drugs based on financial incentives rather than on best clinical practices.”

Mr. Hatch’s spokeswoman, Ms. Ferrier, said the involvement of Mr. Todd, the former Amgen employee, had not been inappropriate and that dozens of staff members on Capitol Hill handled matters that might benefit former employers.

“They have to leave their previous lives behind,” Ms. Ferrier said. “And Dan has done just that.”

After the House was sidelined late in the fiscal negotiations, the Senate gained control of the final bill-writing process, and the provision requested by Amgen was inserted into the legislation by Senate staff members.

Aides to Mr. Baucus and Mr. Hatch emphasized that the White House and Senate leadership, including Mr. McConnell, had the final word on the bill.

A spokesman for Mr. McConnell praised the parts of the legislation related to Medicare, while a White House spokesman declined to comment, saying the matter was decided by players on Capitol Hill.

Many lobbyists and Congressional aides said they first learned of the language when the final bill was posted publicly, only hours before being approved. It called for cutting $4.9 billion over 10 years by lowering Medicare payments for dialysis, but left hundreds of millions on the table by extending the oral drug delay.

At this point, opponents had no way to challenge the provision, as there was a single vote on the entire fiscal package. Mr. Baucus and Mr. Hatch voted in favor.

http://www.nytimes.com/2013/01/20/us/medicare-pricing-delay-is-political-win-for-amgen-drug-maker.html

Create Medicare for all

By Harvey Fernbach, M.D.
The Washington Post, Letters, Jan. 21, 2013

Harold Meyerson [“America flunks its checkup,” op-ed, Jan. 16], citing the recent report of the Institute of Medicine, provides an excellent commentary on the failings of our health-care system — failings that will, in too many cases, persist under the Affordable Care Act. While Mr. Meyerson’s diagnosis of the problem hits a home run, however, his prescription for a remedy unfortunately stops at third base.

Until we establish an “improved Medicare for all” — a single-payer system that ends the flagrant waste, inefficiency and injustice associated with the private insurance industry — we won’t get to home plate. As the institute’s report makes plain, such systems are more equitable, economical and user-friendly for patients, practitioners and businesses than are our current arrangements, even as they deliver better medical outcomes.

In 2009, a majority of Americans told pollsters that they wanted the simplicity, portability, increased choice of doctors and peace of mind that an improved Medicare for all would bring. Why should we settle for less?

Harvey Fernbach, M.D., M.P.H., is co-director of the District of Columbia chapter of Physicians for a National Health Program. He resides in College Park, Md.

http://www.washingtonpost.com/opinions/create-medicare-for-all/2013/01/21/f1906f66-6185-11e2-8f16-7b37a1341b04_story.html

Baucus/Hatch taxpayer gift to Amgen

Fiscal Footnote: Big Senate Gift to Drug Maker

By Eric Lipton and Kevin Sack
The New York Times, January 19, 2013
Just two weeks after pleading guilty in a major federal fraud case, Amgen, the world’s largest biotechnology firm, scored a largely unnoticed coup on Capitol Hill: Lawmakers inserted a paragraph into the “fiscal cliff” bill that did not mention the company by name but strongly favored one of its drugs.
The language buried in Section 632 of the law delays a set of Medicare price restraints on a class of drugs that includes Sensipar, a lucrative Amgen pill used by kidney dialysis patients.
The provision gives Amgen an additional two years to sell Sensipar without government controls. The news was so welcome that the company’s chief executive quickly relayed it to investment analysts. But it is projected to cost Medicare up to $500 million over that period.
Supporters of the delay, primarily leaders of the Senate Finance Committee who have long benefited from Amgen’s political largess, said it was necessary to allow regulators to prepare properly for the pricing change.
But critics, including several Congressional aides who were stunned to find the measure in the final bill, pointed out that Amgen had already won a previous two-year delay, and they depicted a second one as an unnecessary giveaway.
Amgen has deep financial and political ties to lawmakers like Senate Minority Leader Mitch McConnell, Republican of Kentucky, and Senators Max Baucus, Democrat of Montana, and Orrin G. Hatch, Republican of Utah, who hold heavy sway over Medicare payment policy as the leaders of the Finance Committee.
Amgen’s success also shows that even a significant federal criminal investigation may pose little threat to a company’s influence on Capitol Hill. On Dec. 19, as Congressional negotiations over the fiscal bill reached a frenzy, Amgen pleaded guilty to marketing one of its anti-anemia drugs, Aranesp, illegally. It agreed to pay criminal and civil penalties totaling $762 million, a record settlement for a biotechnology company, according to the Justice Department.
Amgen, whose headquarters is near Los Angeles and which had $15.6 billion in revenue in 2011, has a deep bench of Washington lobbyists that includes Jeff Forbes, the former chief of staff to Mr. Baucus; Hunter Bates, the former chief of staff for Mr. McConnell; and Tony Podesta, whose fast-growing lobbying firm has unusually close ties to the White House.
In some cases, the company’s former employees have found important posts inside the Capitol. They include Dan Todd, one of Mr. Hatch’s top Finance Committee staff members on health and Medicare policy, who worked as a health policy analyst for Amgen’s government affairs office from 2005 to 2009. Mr. Todd, who joined Mr. Hatch’s staff in 2011, was directly involved in negotiating the dialysis components of the fiscal bill, and he met with “all the stakeholders,” Mr. Hatch’s spokeswoman said, not disputing when asked that this included Amgen lobbyists.
Aides to the senators said some heavy donors had won and others had lost in the Medicare negotiations — proof that the legislative outcome was based on the merits. “What is the best policy for Montanans and people across the country lies at the heart of every decision Chairman Baucus makes,” said Meaghan Smith, a spokeswoman for Mr. Baucus. “It’s as simple as that.”
http://www.nytimes.com/2013/01/20/us/medicare-pricing-delay-is-political…

With appropriate anger, we can point our fingers toward Sen. Baucus and his colleagues for their involvement in this corrupt half billion dollar taxpayer gift to Amgen, a biotechnology company that has already paid over three-quarters of a billion dollars in penalties for prior criminal acts to which they pled guilty. Sen. Baucus especially deserves our ire since he led the process in bringing us the Affordable Care Act – an act that was designed specifically to serve the financial interests of the private insurance and pharmaceutical industries, at a consequential cost to patients and taxpayers.
Of course, Sen. Baucus is not alone in accepting payment in exchange for favorable legislation. All members of Congress have fundraising challenges. If you check OpenSecrets.org, you will find that most members of Congress are tainted, though they vary in their egregiousness.
Who is ultimately to blame? We elect these people. Health care justice doesn’t stand a chance when displaced by the power of greed and corruption, and we simply turn our backs on it.

Comment:

HMO-Like Plans May Be Poised To Make Comeback In Online Insurance Markets

Comment:

A Proposed Rule by the Centers for Medicare & Medicaid Services

Comment:

Fiscal Footnote: Big Senate Gift to Drug Maker

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